Computed tomography scans of the head for adult patients with minor head injury: are clinical decision rules a necessary evil?

• Published in: Singapore medical journal
• Main Authors: Tan, Desmond Wei, Lim, Annabelle Mei En, Ong, Daniel Yuxuan, Peng, Li Lee, Chan, Yiong Huak, Ibrahim, Irwani, Kuan, Win Sen
• Format: Journal Article
• Language: English
• Published: Singapore 25.05.2017
• Subjects: head injuries; guideline adherence; clinical decision rule
• ISSN: 0037-5675

This study aimed to evaluate compliance with and performance of the Canadian Computed Tomography Head Rule (CCHR), and its applicability in the local adult population with minor head injury. We conducted a retrospective study of consecutive patients who presented to the adult emergency department (ED) with minor head injury over six months. Data on predictor variables indicated in the CCHR was collected and compliance with the CCHR assessed by comparing the recommendations for head computed tomography (CT) scans to its actual usage. In total, 349 patients satisfied the inclusion criteria. Common mechanisms of injury were falls (59.3%), motor vehicle crashes (16.9%) and assault (12.0%). There were 249 (71.3%) patients who underwent head CT, yielding 42 (12.0%) clinically significant findings. 1 (0.3%) patient required neurosurgical intervention. Head CT was recommended according to CCHR for 209 (59.9%) patients. Compliance with the CCHR was 71.3%. Among the noncompliant group, head CT was overperformed for 20.1% and underperformed for 8.6% of patients. Multivariate logistic regression analysis revealed the absence of retrograde amnesia (odds ratio [OR] 4.1, 95% confidence interval [CI] 1.8-9.7) to be associated with noncompliance to the CCHR. Factors associated with underperformance were absence of motor vehicle crashes as a mechanism of injury (OR 6.6, 95% CI 1.2-36.3) and absence of headache (OR 10.8, 95% CI 1.3-87.4). Compliance with the CCHR for adult patients with minor head injury remains low in the ED. A qualitative review of physicians' practices and patients' preferences may be carried out to evaluate reasons for noncompliance.