Alberto Vandelli

Prospective validation of a proposal for diagnosis and management of patients attending the emergency department for mild head injury

Background: In mild head injury, predictors to select patients for computed tomography (CT) and/or to plan proper management are needed. The strength of evidence of published recommendations is insufficient for current use. We assessed the diagnostic accuracy and the clinical validity of the proposal of the Neurotraumatology Committee of the World Federation of Neurosurgical Societies on mild head injury from an emergency department perspective. Methods: In a three year period, 5578 adolescent and adult subjects were prospectively recruited and managed according to the proposed protocol. Outcome measures were: (a) any post-traumatic lesion; (b) need for neurosurgical intervention; (c) unfavourable outcome (death, permanent vegetative state or severe disability) after six months. The predictive value of a model based on five variables (Glasgow coma score, clinical findings, risk factors, neurological deficits, and skull fracture) was tested by logistic regression analysis. Findings: At first CT evaluation 327 patients (5.9%) had intracranial post-traumatic lesions. In 16 cases (0.3%) previously undiagnosed lesions were detected after re-evaluation within seven days. Neurosurgical intervention was needed in 71 patients (1.3%) and an unfavourable outcome occurred in 39 cases (0.7%). The area under the ROC curve of the variables in predicting post-traumatic lesions was 0.906 (0.009) (sensitivity 70.0%, specificity 94.1% at best cut off), neurosurgical intervention was 0.926 (0.016) (sensitivity 81.7%, specificity 94.1%), and unfavourable outcome was 0.953 (0.014) (sensitivity 88.1%, specificity 95.1%). Interpretation: The variables prove highly accurate in the prediction of clinically meaningful outcomes, when applied to a consecutive set of patients with mild head injury in the clinical setting of a 1st level emergency department.

Early predictors of unfavourable outcome in subjects with moderate head injury in the emergency department

Background: Subjects with moderate head injury are a particular challenge for the emergency physician. They represent a heterogeneous population of subjects with large variability in injury severity, clinical course and outcome. We aimed to determine the early predictors of outcome of subjects with moderate head injury admitted to an Emergency Department (ED) of a general hospital linked via telemedicine to the Regional Neurosurgical Centre. Patients and methods: We reviewed, prospectively, 12 675 subjects attending the ED of a General Hospital between 1999 and 2005 for head injury. A total of 309 cases (2.4%) with an admission Glasgow Coma Scale (GCS) 9–13 were identified as having moderate head injury. The main outcome measure was an unfavourable outcome at 6 months after injury. The predictive value of a model based on main entry variables was evaluated by logistic regression analysis. Findings: 64.7% of subjects had a computed tomographic scan that was positive for intracranial injury, 16.5% needed a neurosurgical intervention, 14.6% had an unfavourable outcome at 6 months (death, permanent vegetative state, permanent severe disability). Six variables (basal skull fracture, subarachnoid haemorrhage, coagulopathy, subdural haematoma, modified Marshall category and GCS) predicted an unfavourable outcome at 6 months. This combination of variables predicts the 6-month outcome with high sensitivity (95.6%) and specificity (86.0%). Interpretation: A group of selected variables proves highly accurate in the prediction of unfavourable outcome at 6 months, when applied to subjects admitted to an ED of a General Hospital with moderate head injury.

Positive blood alcohol concentration and road accidents. A prospective study in an Italian emergency department

Study objective: To examine if a positive blood alcohol concentration (BAC) at the time of crash (≥0.50 g/l), independently of any clinical evidence and laboratory results indicating acute alcohol intoxication, is associated with specific features of patients involved, specific types of injury, and characteristics of the accident. Methods: In this prospective cohort study, the BAC was measured in adult patients who had been injured and who were admitted to an Italian emergency department within four hours after a road accident. Altogether 2354 trauma patients were included between January to December 1998 out of 2856 eligible subjects. Results: BAC exceeded 0.50 g/l in 425 subjects (18.1%), but was in a toxic range (>1.00 g/l) in only 179 subjects (7.6%). BAC positivity was significantly more common in men, in young subjects, in subjects driving cars or trucks, and in persons involved in a crash during night time and at weekends. It was associated with higher trauma severity, but no differences were found in injury body distribution according to vehicle type. In multivariate logistic regression analysis, the risk of a positive BAC in injured patients at the time of crash was independently associated with night time (odds ratio: 3.48; 95% confidence intervals: 2.46 to 4.91), male sex (3.08 (2.36 to 4.01)), weekend nights (1.21 (1.05 to 1.41)), and age (0.92 (0.86 to 0.99) per decades). Conclusion: In injured patients after a road accident, a BAC at the time of crash in a non-toxic range (≥0.50 g/l) is associated with specific characteristics of crash, as well as increased risk of higher trauma severity. More careful monitoring is needed in young men during weekend nights for highest risk of BAC positivity after a road accident.

Observational approach to subjects with mild-to-moderate head injury and initial non-neurosurgical lesions.

Background: The model of care for patients with mild-to-moderate head injury and CT-detected lesions that do not require an immediate intervention is a matter of debate. This study compared the effects on outcome of a model based either on observation in a neurosurgical unit (NSU) or in a peripheral hospital (PH), making use of neurosurgical expertise via a teleradiology system. Patients and methods: The investigation reviewed the data that was prospectively collected in 865 cases with mild-to-moderate head injury and positive CT scan, not needing immediate neurosurgical evacuation. Outcome was determined at 6 months. The predictive value of location of observation on outcome was evaluated by logistic regression, after adjustment for the propensity score to the type of observation (calculated on main entry variables). Findings: 700 subjects had a mild head injury, 105 had a moderate injury with GCS 13–11 and 60 with Glasgow Coma Scale (GCS) 10–9. Only 152/865 subjects (17.6%) were admitted to a NSU. During observation, neurosurgery was necessary in 117 cases (13.5%), 74/152 (48.7%) NSU-observed patients and 43/713 (6.0%; p<0.001) PH-observed cases. The outcome was unfavourable in 18% of the NSU cases versus 10% of the PH cases (p = 0.143). After correction for propensity, no significant differences were found between models of observation (NSU vs. PH; odds ratio, 0.92; 95% confidence interval, 0.49 to 1.75). Interpretation: A model of care based on observation in PH with neurosurgical consult by teleradiology system, repeat CT scanning and transfer time 30–60 min to a NSU is not detrimental for subjects with initial non-neurosurgical lesions after mild-to-moderate head injury.

Predicting intracranial lesions by antiplatelet agents in subjects with mild head injury

Background The effect of pre-injury antiplatelet treatment in the risk of intracranial lesions in subjects after mild head injury (Glasgow Coma Scale (GCS) 14–15) is uncertain. Methods The potential risk was determined, considering its increasing use in guidelines on cardiovascular disease prevention, and ageing of the trauma population in Europe. Patients The interaction of antiplatelet therapy with the prediction variables of main decision aids was analysed in 14 288 consecutive adolescent and adult subjects with mild head injury. Measurements Any intracranial lesion at CT scan was selected as an outcome measure in a multivariable logistic regression analysis. Results Intracranial lesions were demonstrated in 880 cases (6.2%), with an unfavourable outcome at 6 months in 86 (0.6%). Antiplatelet drugs were recorded in 10% of the entire cohort (24.7% in the group over 65 years). They increased the risk of intracranial lesions in the univariate analysis (OR 2.6; 95% CI 2.2 to 3.1), interacting with age in the multivariate analysis (antiplatelet OR 2.7 (1.9 to 3.7); age ≥75 years 1.4 (1.0 to 1.9)). The inclusion of these two variables with those included in previous decision aids for CT scanning (GCS, neurodeficit, post-traumatic seizures, suspected skull fracture, vomiting, loss of consciousness, coagulopathy) predicted intracranial lesions with a sensitivity of 99.7% (95% CI 98.9 to 99.8) and a specificity of 54.0% (95% CI 53.1 to 54.8), with a CT ordering rate of 49.3% (undetermined events 0.2:1000). Interpretation Antiplatelet drugs need to be considered in future prediction models on mild head injury, considering their increasing use and progressive ageing of the trauma population.

Coagulopathy and NICE recommendations for patients with mild head injury

Management of patients with mild head injury (MHI) is open to debate.1 In the last few years, there has been a trend towards earlier diagnosis, implying an extensive use of computed tomography (CT), rather than admission and observation. The National Institute for Clinical Excellence (NICE) has recently proposed new evidence based recommendations on all steps of the management of patients with MHI.2 In the diagnostic algorithm, coagulopathy (history of bleeding, clotting disorder, or current treatment with warfarin) is not considered a predictor variable necessitating early CT in subjects without loss of consciousness (LOC) or amnesia since injury. This statement conflicts with previous guidelines, where history of coagulopathy, independently of symptoms, indicated CT.3 Since 1999, all cases with MHI attending the Emergency Department of our district hospital have been treated and registered in a comprehensive database according to predefined procedures.3 Our criteria for CT and/or hospital admission are wider than the NICE criteria; in particular, there is routine detailing of NICE variables, but in addition, all subjects with coagulopathy have an early CT, independently of symptoms and signs after injury. This provides the opportunity to determine the risk related to coagulopathy and the accuracy of the NICE recommendations. We analysed the data of 7955 consecutive …

Which type of observation for patients with high-risk mild head injury and negative computed tomography?

Objective: Current guidelines suggest hospital admission followed by home monitoring for high-risk patients with mild head injury and negative computed tomography scan. We tested early home monitoring under the care of a competent observer. Methods: A total of 1480 patients with mild head injury and negative computed tomography scan were prospectively studied. Based on clinical status and available home caretakers, patients were managed by in-hospital observation (n=646) or early home monitoring (n=834). Outcome measures were: (1) the detection of previously undiagnosed post-traumatic intracranial injury; (2) neurosurgical intervention; and (3) unfavourable outcome (death, permanent vegetative state or severe disability). Results: In the in-hospital arm, nine cases (1.4%) developed intracranial injuries (in three after discharge). In the early home-monitoring arm, six patients (0.7%) had a previously undiagnosed lesion after re-admission (P=0.773 versus in-hospital arm). No patients with previously undiagnosed intracranial injuries had a neurosurgical intervention. After 6 months, five patients had died in the home monitoring arm (0.8%) versus eight (1.0%) in the in-hospital arm (P=0.785). No permanent disability or vegetative state was observed. Conclusion: Early home monitoring may be safely proposed to selected ‘high-risk’ patients, with an early negative computed tomography scan, normal clinical examination and feasible home monitoring.

The changing face of mild head injury: Temporal trends and patterns in adolescents and adults from 1997 to 2008

OBJECTIVE To explore the temporal trend of incidence, causes of injury and main characteristics of adolescent and adult subjects with mild head injury (MHI). DESIGN This study had a retrospective design. SETTING The study was conducted in a longitudinal database of an Italian Emergency Department (ED). PARTICIPANTS The study comprised 19124 consecutive subjects who visited and were managed within 24 h from the event, according to a predefined protocol for MHI from 1997 to 2008. MAIN OUTCOME MEASURES Incidence, demography, cause of injury and characteristics of any post-traumatic intracranial lesion within 7 days from MHI. RESULTS The number of subjects with MHI decreased from 2019 per year (1997-1999) to 1232 per year (2006-2008; P for linear trend <0.001), without differences in the total number of subjects visited in the ED. The decrease was observed in all age-decades, in particular, in subjects in the age ranges of 20-29 and 30-39 years. Over time, the age of subjects with MHI lost a bimodal distribution, and the mean age increased from 43 (25-69) years (median (interquartile range)) in 1997-1999 to 56 (33-78) years in 2006-2008 (P<0.001). The prevalence of falls increased from 36.5% to 55.0%, whereas crashes fell from 53.2% to 31.9%. The incidence of subdural haematoma (SDH) and epidural haematoma (EDH) did not change over time, whereas traumatic subarachnoid haemorrhage (t-SAH) and intra-cerebral haematoma/brain contusion (ICH) increased (from 0.7% to 1.9% and from 2.5% to 3.2%; P for trend: <0.001 for both. CONCLUSIONS The incidence and the clinical characteristics of MHI subjects are rapidly changing in our setting. These data need to be considered in defining the effectiveness of preventive measures and deciding resource allocation.

A combined HPLC-immunoenzymatic comprehensive screening for suspected drug poisoning in the emergency department

Objective: To review the results of a comprehensive drug screening as first line diagnostic tool in patients attending an emergency department for suspected drug poisoning. Methods: A comprehensive drug screening was carried out in plasma or urine, or both, of 310 patients combining an HPLC multidrug profiling system and a fluorescence polarisation immunoassay. Results: In 64.2% of cases the screening confirmed the diagnosis of drug poisoning, in 13.9% suspected drugs were measurable at non-toxic concentrations, and in 21.9% no drugs were found. The suspected drugs were fully confirmed in a minority of cases, (symptomatic patients: 28.2% compared with asymptomatic: 16.5%). Symptomatic patients were less likely to have at least one suspected drug (29.6% compared with 57.7%; p<0.001), and more likely to have at least one unsuspected drug found at analysis (17.4% compared with 3.1%; p = 0.005). In 5% of patients, asymptomatic when first observed, one or more unsuspected drugs were found. In 6 of 29 patients, with suspected poisoning of an unspecified drug, the screening identified the specific drug and excluded acute intoxication in the remaining cases. Conclusion: A rapid comprehensive drug screening adds to the diagnosis of patients with suspected drug poisoning, identifying unsuspected drugs in symptomatic patients and excluding drugs in asymptomatic subjects.

Analysis of different decision aids for clinical use in pediatric head injury in an emergency department of a general hospital.

INTRODUCTION The diagnostic algorithm in children with head injury remains uncertain. The National Emergency X-Radiography Utilization Study II (NEXUS II) recently proposed a new decision aid. We analyzed the data prospectively recorded in a local database to evaluate the sensitivity and specificity of the variables proposed by NEXUS II, by comparing with an Italian proposal. METHODS The clinical data of 2,391 children with head injury (0-10 years old) were prospectively collected, for an 8-year period. Any posttraumatic intracranial lesion was selected as the main outcome. The predictive ability of the selected variables was tested by the area under the receiver operating characteristic (ROC) curve. RESULTS Eighteen of the 2,391 children (0.7%) showed the presence of intracranial lesions on computed tomography scan; neurosurgical intervention was needed in only one subject and an unfavorable outcome at 6-month follow-up occurred in only two subjects. The ability to correctly predict intracranial lesions was higher for the Italian proposal (ROC area, 0.896; 95% confidence interval, 0.887-0.904) than the NEXUS II (ROC area, 0.741; 95% confidence interval, 0.666-0.817; Fishers exact test; p<0.001). The individual variables of the Italian proposal were both more sensitive (100% vs. 89%) and more specific (79% vs. 59%). No lesions remained undiagnosed by the variables considered in the Italian proposal, whereas two cases with lesions would have been missed by the NEXUS II rule. CONCLUSIONS In our setting, the variables selected by the Italian proposal had higher discriminating capacity for intracranial lesions than those proposed by the NEXUS II rule, in children with head injury. These results should be considered in children with head injury attending an emergency department of a general hospital.