Will Neuroimaging Reveal a Severe Intracranial Injury in This Adult With Minor Head Trauma?

Easter, Joshua S.; Haukoos, Jason S.; Meehan, William P.; Novack, Victor; Edlow, Jonathan A.

doi:10.1001/jama.2015.16316

Cited by 67 publications

(70 citation statements)

References 39 publications

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“…Of note, the New Orleans Criteria included slightly different characteristics: age > 60 years, intoxication, headache, any vomiting, seizure, amnesia, visible trauma above clavicle. But the Canadian CT Head Rule was more accurate than the New Orleans Criteria in all but one study . This is consistent with the likelihood ratios of each test element from Table .…”

Section: Benefits Of Using Likelihood Ratios In Clinical Settingssupporting

confidence: 80%

“…The majority of these patients are well‐appearing, and the physician must determine if neuroimaging is necessary. Numerous studies have addressed this question, and a recent meta‐analysis pooled data from 14 studies to examine what factors among patients with minor head trauma were associated with severe intracranial injury, defined as requiring prompt neurosurgical intervention . Table lists clinically meaningful likelihood ratios from several high‐quality studies.…”

Section: Benefits Of Using Likelihood Ratios In Clinical Settingsmentioning

confidence: 99%

“…Is a positive likelihood ratio useful in guiding management? Based on meta‐analysis of more than 23,000 patients with minor head trauma, the baseline risk of severe intracranial injury is approximately 7% . Using 7% as the pretest probability for the patient, it is possible to estimate the posttest probability by the 3 risk factors from the triage note: pedestrian struck, age > 65 years, coagulopathy yields a combined ( LR+ ) = (3)(2.3)(2.2) = 15 (Figure A).…”

Section: Benefits Of Using Likelihood Ratios In Clinical Settingsmentioning

confidence: 99%

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Likelihood Ratios for the Emergency Physician

Peng

Coyle

2018

Academic Emergency Medicine

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The concept of likelihood ratios was introduced more than 40 years ago, yet this powerful metric has still not seen wider application or discussion in the medical decision-making process. There is concern that clinicians-in-training are still being taught an oversimplified approach to diagnostic test performance and have limited exposure to likelihood ratios. Even for those familiar with likelihood ratios, they might perceive them as mathematically cumbersome in application, if not difficult to determine for a particular disease process. This article takes a conceptual approach to likelihood ratios and applies them to two clinical settings: 1) severe intracranial injury after minor head trauma and 2) suspected pulmonary embolism with shortness of breath. Likelihood ratios are the most appropriate metric for efficient rational clinical examination and can prevent unnecessary and wasteful treatments and procedures.

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Section: Benefits Of Using Likelihood Ratios In Clinical Settingssupporting

confidence: 80%

Section: Benefits Of Using Likelihood Ratios In Clinical Settingsmentioning

confidence: 99%

Section: Benefits Of Using Likelihood Ratios In Clinical Settingsmentioning

confidence: 99%

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Likelihood Ratios for the Emergency Physician

Peng

Coyle

2018

Academic Emergency Medicine

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“…First, the studies in which the scores were developed limited inclusion to patients with LOC or amnesia, implying that patients without these signs are not at risk of having significant injuries. In contrast, the absence of these features does not exclude intracranial injuries [6, 18]. We, therefore, did not restrict inclusion to patients with LOC or amnesia, and in fact, in the present study, about 8% of the patients with a discrepancy between initially assumed and actual injury severity neither had LOC nor amnesia.…”

Section: Discussionmentioning

confidence: 74%

“…Healthcare providers need to determine which patients require additional diagnostics and monitoring, and who can be discharged safely. Patients with apparently minor injuries at the first presentation may turn out to be more severely injured than initially assumed and/or assessed [6]. Failure to identify such patients during the initial assessment can result in under-treatment and constitutes a serious threat to patient safety.…”

Section: Introductionmentioning

confidence: 99%

Discrepancy between the initial assessment of injury severity and post hoc determination of injury severity in patients with apparently mild traumatic brain injury: a retrospective multicenter cohort analysis

Bossers¹,

Pol

Ophuis³

et al. 2017

Eur J Trauma Emerg Surg

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PurposeTraumatic brain injury (TBI) is a major cause of trauma-related visits to emergency departments (ED). Determination of monitoring requirements of patients with apparently mild TBI is challenging. Patients may turn out to be more severely injured than initially assumed, and failure to identify these patients constitutes a serious threat to patient safety. We, therefore, aimed to identify clinical risk factors for more severe injuries in patients with apparently mild TBI.MethodsIn a retrospective cohort analysis performed at two level I trauma centers, 808 patients aged ≥ 16 presenting to the ED with head trauma and a Glasgow Coma Scale (GCS) score 13–15 who received a head CT scan were studied. Discrepancies between the initial TBI severity as determined by GCS and severity as determined post hoc by the Head Abbreviated Injury Score were assessed. Multiple logistic regression was used to identify risk factors of such discrepancies.Results104 (12.9%) patients were more severely injured than initially classified. A GCS < 15 at presentation (GCS 13: OR 6.2, [95% CI 3.8–9.9]; GCS 14: OR 2.7, [2.0–3.7]), an SpO2 < 90% (OR 5.4, [1.2–23.4]), loss of consciousness (OR 2.3, [1.5–3.5]), absence of equal and reactive pupils (OR 2.1, [1.6–2.7]), transport by ambulance (OR 2.0, [1.7–2.4]), and use of anticoagulant drugs (OR 1.2, [1.1–1.3]) were independent risk factors of more severe injury.ConclusionsSix risk factors of more severe injury in patients presenting with apparently mild TBI were identified. Patients with any of these factors should be thoroughly monitored for signs of neurologic deterioration.

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Data Error

2017

JAMA

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professional society's imprimatur andthe appearance of quantitation inherent in an alphanumeric rating system may convey the impression of an action that is thoroughly evidence-based and ought to be performed, despite any number of layers of equivocation that might be deployed as a hedge against that impression. To risk a tautology, we advocate that guidelines provide guidance. The National Academy of Medicine (formerly the Institute of Medicine) confronted this issue directly 27 years ago in its initial 1990 report on practice guidelines: "When the evidence is extremely strong and professional judgment is virtually unanimous, the guideline may be treated as a standard of practice permitting few if any exceptions. When the evidence is equivocal, the guideline may only identify currently acceptable practice options." 1 We agree that the use of clinical practice guidelines for inculpatory purposes strays from the intent of the framers. Practice guidelines afford opportunity for extraction of divergent statements that, when used selectively to infer a standard of care in a court of law, may be construed as supporting conclusions that are frankly incorrect. Intermediate-grade recommendations are particularly prone to such interpretations, as they appear to lend support to actions that may only be applicable to a minority of patients. We think that it is best for clinical guidelines to call out uncertainty explicitly when it exists and to deem such recommendations as the purview of the treating physician in the exercise of his or her clinical judgment. Although practice guidelines were conceived to bring rigor to clinical judgment, it would be a mistake to conclude that the current body of scientific knowledge is sufficient to govern clinical practice in areas of sparse or conflicting evidence.

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Will Neuroimaging Reveal a Severe Intracranial Injury in This Adult With Minor Head Trauma?

Cited by 67 publications

References 39 publications

Likelihood Ratios for the Emergency Physician

Likelihood Ratios for the Emergency Physician

Discrepancy between the initial assessment of injury severity and post hoc determination of injury severity in patients with apparently mild traumatic brain injury: a retrospective multicenter cohort analysis

Data Error

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