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Will Neuroimaging Reveal a Severe Intracranial Injury in This Adult With Minor Head Trauma? Interview With Joshua S. Easter, MD, MSc
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Will Neuroimaging Reveal a Severe Intracranial Injury in This Adult With Minor Head Trauma? Interview With Joshua S. Easter, MD, MSc
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>> Clinicians are asked to evaluate minor head trauma all the time. And when they do it, they usually get a CT scan to make sure there's nothing seriously wrong. But CT scans aren't risk free and scanning everybody with minor head trauma when very few patients have a clinically important injury is not a good strategy. So let me ask you, what would you do for these patients? >> So I was walking down Michigan Avenue. It was really cold outside and there was a lot of ice on the sidewalk. I don't know how I did it but I slipped and fell right on my head.
[Background Music] >> I was at the gym and I was playing basketball. I was playing with this larger guy and he shoved me pretty hard and I hit the ground. I fell pretty hard and the first thing that hit was my head. >> So I remember that the whole thing, especially the sound my head made when it hit the sidewalk. It sounded like someone had slapped a watermelon.
>> It was the weirdest thing. I passed out for just a couple seconds but I got back up and got right back in the game. >> So, I didn't pass out or anything but I threw up all over the sidewalk right there and it was really embarrassing. A couple people came and helped me up and someone called a cab. They took me to the hospital and when I got there, I threw up again. >> So I think four hours later, I started feeling this really bad headache on the left side of my head where I hit the ground and I actually was feeling a pretty large bump underneath my scalp.
>> I didn't realize it at the time but I had a cut on my forehead about an inch long. >> When you have patients like this in front of you, you have to decide a few things. Does the patient have minor and not major head trauma? If they've got minor trauma, do they need a head CT or do they not need a head CT? When they leave the emergency room, what do you tell them they should be looking for in case you've missed something? Finally, what's the medical malpractice liability associated with not getting a CT scan?
How do you protect yourself against losing a malpractice case should you evaluate a patient with minor head trauma and choose not to get a CT scan? These are the questions that we're going to address in this podcast. Hello. This is Ed Livingston, Deputy Editor of Clinical Reviews and Education for JAMA. In today's JAMAevidence podcast, we cover the topic of neuroimaging for head trauma. This is based on a Rational Clinical Examination article published in the December 22, 2015 issue of JAMA. [ Music ] Minor head trauma is distinct from moderate or major head trauma.
Each of these gets treated differently. Moderate and major head trauma clearly need neuroimaging and some form of an intervention. That's not the case for minor head trauma. The author of The Rational Clinical Examination article on head trauma, Dr. Joshua Easter, Assistant Professor of Emergency Medicine at the University of Virginia, explains. >> Severe head injuries happen when a patient experiences trauma to their head and after the initial blow has a persistent alteration in their level of alertness associated with a Glasgow coma scale score of less than nine.
These patients are at high risk of having intracranial injuries. And there is little question after they're stabilized initially that they need emergent neuroimaging. The next category in this spectrum would be moderate head injury. Like severe head injury, these patients also have persistent alterations in their level of alertness that would be clear on a physician's exam after an initial blow to their head. They have Glasgow coma scale scores between nine and 12 and they're also at relatively high risk of having intracranial injuries and need emergent neuroimaging.
In contrast, minor or sometimes called mild head injury represents a patient who has a blow to their head and after that blow has a minimal alteration in their level of alertness. They have a Glasgow coma scale score of between 13 to 15 and concussion would be a subset of this category as well. >> The Glasgow coma scale is meant to classify the level of consciousness of patients with head trauma. It goes from zero to 15 and it's based on three major clinical features Eye opening, motor response, and verbal response.
If you open your eyes spontaneously, you get a Glasgow coma score of four and if they don't open at all, it's a one. If you're completely oriented, you get a Glasgow coma of five. And if you can't generate any verbal response at all, it's a one. If you can obey all commands, you get a six. If you can't obey any commands, you get a one. Parenthetically, this command scale is what I use to evaluate clinical interns. Minor head trauma includes patients who have a Glasgow coma score of 13, 14, or 15.
A Glasgow coma score of 15 pretty much means that you've got some head trauma, nothing else is wrong with you and you're pretty much normal. [Background Music] One of the vexing problems in managing patients with minor head trauma is deciding if they need a CT scan or not. CT scans are easy to get. Every emergency room has got one but not all of the two and a half million patients who suffer from head trauma needs a CT scan. The question is, how do you decide who doesn't need one.
[ Music ] This question was addressed in the head trauma Rational Clinical Examination article. We decided that minor head trauma involves having a head injury associated with a patient who pretty much looks normal, and has a Glasgow coma score between 13 and 15. One aspect of this assessment is examination of the head. Again, Dr. Easter. >> There are multiple different things which could indicate that a patient has a skull fracture.
The simplest would be that they have a large laceration to their scalp and you're able to look in and see the skull and you see a break in the integrity of the skull through the open wound. Other potential signs that you could see a skull fracture would be being able to palpate it with your fingers. So you're running your hand along the edge of the skull and you feel a divot or a break again in the integrity of the skull, which is suggestive that there could be a fracture at that location.
And then there are other signs which could be suggestive of a fracture to the base of the skull such as hemotympanum, CSF draining from the ears and nose, bruising underneath the eye or behind the ear. So, all of these findings are suggestive that a patient had a skull fracture and suggest that the patient experienced some high-energy trauma that was enough to fracture their skull. And as you can imagine, some of that energy likely was transmitted through to the brain. And so it intuitively makes sense that if you have a patient who appears to have a skull fracture on exam that they're going to be at very high risk of having intracranial injury and, therefore, should undergo neuroimaging.
>> In the Rational Clinical Examination article, studies were polled that assessed outcomes for patients who have Glasgow coma scores ranging between 13 and 15. The authors then looked for articles that had the relevant outcomes. >> So severe intracranial injury is defined as an intracranial injury that would require further intervention and that intervention could be needing to see a neurosurgeon, needing to be admitted to the hospital for observation, or as extreme as requiring neurosurgical intervention, whether that be a craniotomy, intracranial pressure monitoring, or mechanical ventilation.
>> The most important findings were that if you take all patients who present with a history of minor head trauma, meaning they don't have any physical evidence of a severe head injury, and have a Glasgow coma score ranging from 13 to 15, about 7% of these patients will have a severe enough injury to require some form of an intervention. For those patients with minor head trauma, only about 0.9% will go on to die or need neurosurgical intervention. When a patient has minor head trauma, there are a few features which are highly predictive of the need for an intervention.
These include a physical examination finding suggestive of a skull fracture, having a Glasgow coma score of 13, having a history of two or more vomiting episodes, having the Glasgow coma score decline over time, and if the injury is related to being a pedestrian who's struck by a motor vehicle. Two clinical prediction rules perform very well for predicting the absence of a significant injury in minor head trauma patients. These were the Canadian CT Head Rule and the New Orleans Criteria.
>> So, the Canadian CT Head Rule essentially says that if a patient is less than 65, did not experience a dangerous mechanism, which is being a pedestrian struck by a vehicle, being ejected from a motor vehicle, or falling more than three feet or five stairs, if they didn't vomit more than one time, if they're not amnestic to the event for more than 30 minutes, and if they did not have a depressed GCS score at two hours or suspicion of a skull fracture, then they are at very low risk of having an intracranial injury.
Similarly, the New Orleans Criteria says that if you're less than 60 years of age, you were not intoxicated, you don't have a headache, you have not vomited at all, and not experienced a seizure, you're not amnestic to the event, and you don't have any evidence of trauma above the clavicle, then you are also at extremely low risk of having intracranial injury. And so both of those rules, if you have none of those features, had very low negative likelihood ratios that put the chance of having a head injury at 0.3% if you had none of the features of the Canadian CT Head Rule and 0.6% if you had none of the features of the New Orleans Criteria.
>> These rules can be very helpful but, unfortunately, they're not used all that much in the US. A recent survey showed that only about a third of US-based ED physicians even knew the Canadian Rule exists. For patients with minor head trauma, the rules are really good at predicting who does not have a clinically significant injury; however, there's a tendency to rely on CT scanning to identify major injuries but even this may be misleading. >> Probably the best example of this are people that have concussions. We're finding out a lot about people who have sports concussions, where the CT scan can be perfectly normal yet probably 10% of those people will go on to have persistent symptoms after concussion in terms of memory problems, fatigue, headache, as well as depression and anxiety following concussion.
The CT scan, unfortunately, though, is very poor in identifying those individuals who are going to have those sort of more persistent problems that are not related necessarily to injuries requiring neurosurgical intervention but injuries that are nevertheless still there and result in long-term problems. >> This is Dr. Frederick Rivara, Professor of Pediatrics at the University of Washington and Editor Chief of JAMA Pediatrics. Dr. Rivara wrote an editorial in JAMA to accompany the head trauma Rational Clinical Examination article. >> It's incorrect to get a CT scan so that you can reassure a parent or their family that this individual is normal.
The CT scan may not show any abnormalities there but that does not mean the person does not have a traumatic brain injury. [ Music ] >> Irrespective of whether you get a CT scan or not, when the patient leaves your clinic or the emergency department, it's really important to tell them what to look for in case their condition should worsen. >> The main thing is you want to make sure that there is someone there who can watch them closely so that if they were to deteriorate, they're able to return or have somebody bring them back to the emergency department.
But the specific things that I'll tell any patient who's going home, whether they've been imaged or not, is that if they start to get a new headache that becomes severe or if their existing headache starts to worsen substantially, if they start to vomit multiple times, if their mental status to the person who is watching them seems to be declining, or if they have a seizure that they should immediately return to the emergency department. >> You know this old idea that wake up the patient every hour, shine a light in their eyes and make sure the pupils are reactive and they can still talk with you, well, there's no evidence that that kind of a neuro check done by a family member is really going to be very effective.
I think that it is sort of-- the chances of having some acute deterioration I think are extremely small. And, you know, it's typical things of not acting normally, having vomiting, repeated vomiting, I think is the sign that we oftentimes see is these individuals that have episodes of vomiting at home but I think it's important to remember that even in those few individuals, and there really are very few, that come back to the emergency department and may have a CT scan, which they had not had the first visit, the CT scan may show some minor contusion but the chances of that resulting in a neurosurgical intervention are really, really low.
>> Head trauma in children is really common and always a matter of great anxiety for their parents. Dr. Rivara tells us what he says to parents of children who've suffered minor head trauma. >> Well, I think it's important to first of all understand their concerns. I think it's important to do a thorough exam and to be able to reassure yourself that this child is normal. I think it's a matter of knowing the literature, having your experience, and knowing what the risk of a serious intracranial injury to this child is, and to reassure the parent that you feel like the risks of doing a CT scan really outweigh the potential benefits here and that you want to be in touch with the family.
You're not dismissing their concerns, that you want to hear from them the next day to make sure the child is okay, and that you're happy to see the child again if they're at all concerned about how the child is doing. >> Surveys have shown that most clinicians get CT scans to minimize their risk of liability. To better understand how to address that liability, I spoke to Michelle Mello, Professor of Law at the Stanford University School of Law. Dr. Mello is also a professor of research and health policy at Stanford. Dr. Mello, not all patients with minor head trauma benefit from a head CT.
Some decision rules are very helpful in predicting which patients will not benefit from a CT. But many clinicians believe that CT scans are necessary in all minor trauma patients to avoid liability. What advice do you have for the clinician who would like to avoid getting CT scans in situations like this and minimize their risk for liability? >> Of course, the clinician always should and can decide according to his best clinical judgment. When he goes to court, he will be evaluated by reference to what his colleagues in the similar specialty would have done under similar circumstances.
That's generally speaking the national standard of care with some accommodation for differences in resources. For example, if you're in an area where there literally is no CT scanner, you won't be held accountable for not ordering a scan. Having said that, the difficult bind that some physicians are in when it comes to procedures like this that are widely in use in circumstances where they needn't be from a clinical perspective is that the legal standard tends to be based in custom what other people are doing even when emergent guidelines come out saying we should reel this in, there should be less of this.
So there is some element of medical legal risk associated with being in the vanguard of movement, as we have here, like choosing wisely to try to reel things back in. >> So how that does clinician determine what the national standard of care is? >> Well, it's assumed that one is aware of the standard just by ident of being a physician, being around other physicians, being trained by other physicians, and keeping up with medical journals and new developments in the field. All of that is part of reasonable care in being a physician.
Guidelines and decision rules, like the ones discussed in the article, are certainly relevant evidence of what others are doing but they'll be used at trial by an expert who will testify not just to what they say but also to what others do. So it's no use having a guideline that nobody follows. That's not going to be very helpful in court. On the other hand, a physician who for example is in a practice that has decided to follow the Canadian rule, everybody doesn't, that's also the standard in the profession generally, should feel quite comfortable heading into a malpractice suit that an expert called by his attorney will testify to the fact that this is not only a good rule but a rule that is perceived as good by others in the profession.
>> So imagine you're practicing in a group practice, like in a big HMO, you have five surgeons who all might do something the same way and that same way may be different from five surgeons in some other part of the country and there's no really firm nationally agreed upon standard of care for that particular procedure. When you're defining the standard of care, is it good enough to rely on the fact that you work with these five other people and you talk to one another all the time and you all do things the same way? >> Well, it depends on the circumstances.
The law does appreciate and accommodate situations in which there is not a consensus in the field about how to handle this situation. There's a doctrine called The Respectable Minority Rule that takes account of situations where most physicians [inaudible] in one way but there is a respectable minority, both respectable in size and in reputation, that does things another way. Having said that, if the decision of this HMO for example was, you know, we're going to make this decision solely based on cost.
It has nothing to do with the quality of care. We know nobody else does it this way but this is what makes financial sense for us. That's probably not going to qualify as a respectable minority. >> What do you recommend clinicians tell patients in terms of the various treatment options, and how much information should they give the patient? >> Empirically, I don't know how much data they do give the patient. I think my view as a patient as well as a lawyer is that patients need to understand also when there is a dissensus in the field about what to do in a particular situation.
It's reassuring as a patient to think that everybody knows exactly what to do and everyone is in agreement. Of course, medicine doesn't really work that way. So particularly in situations where you have respectable guidelines pushing medicine in a direction other than where it is now or as is the case in other types of screening situations like breast cancer, conflicting guidelines, patients need to know that reputable experts disagree about what to do in particular circumstances or they disagree with what the patient might come in presuming is the best course of action which is always more care, more screening.
I think it's particularly salient to point out to patients that CT scanning involves a risk of cancer later in life that is not negligible and that is weighing in the physician's mind, that is a worry in the physician's mind when in weighing risks and benefits. Most patients won't understand statistical information at the level that the article about CT scanning discusses the statistics like 0.31%, won't resonate, won't have meaning for most patients but they will understand that there is a vanishingly small chance of missing something without the scan but a much greater risk of having harm as well as increased cost if you do order the scan.
>> One thing I was told throughout my career is that it's really important to document in the medical record what you are thinking when you did something or when you talk to a patient, you document what you told them. How much information should a clinician put in the medical record? >> Well, legally, the documentation can be helpful in establishing reasonableness. That's the standard ultimately to which all physicians are held. Plaintiff attorneys may try to portray a decision as careless or driven by something more nefarious like cost considerations, but a physician who has written in the notes, for example, patient meets no criteria of the Canadian Rule or the New Orleans Rule, CT scanning not indicated for that reason is going, that's going to be a helpful note to have in there come trial time.
In terms of documenting what was conveyed to the patient, that really would only come in legally if the patient's claim was for a breach of informed consent, where she is saying, you know, I would've gone to another physician to get this scan had I known what I know now. And so in this particular circumstance, it may be less important. More generally, of course, if we're talking about consenting a patient in for a procedure or something, then it tends to be more important to write down that the risks and benefits of the procedure were discussed and the patient, you know, had questions about this that were answered.
>> Let's return to our two patients. What happened to them? The woman who hit her head on the pavement didn't lose consciousness. She even heard the noise when her head hit the cement; however, there were concerns that she had intracranial injury. She vomited a couple times and that's always concerning. She did have a CT scan which showed a subdural hematoma. She was admitted to the hospital and observed for 24 hours. Her symptoms improved.
She was discharged and never had any further problems. Our basketball player didn't have any criteria for serious intracranial injury based on the Canadian CT Rule. He did have loss of consciousness and a headache but he didn't undergo a CT scan. The decision not to pursue a CT scan was based on the clinical evaluation of this patient and the negative Canadian Head CT Rule. He was discharged from the emergency room and given instructions to return to the emergency department if there was severe or worsening headache, multiple episodes of vomiting, seizures, or worsening of his mental status.
He was seen by his physician a week after the episode, was symptom free, and had no further problems. The bottom line is that patients who suffered minor head injury who don't have much in terms of functional impairment have very little risk of ever needing an intervention. There are some patients with minor head injury who have various clinical features or things in their history such as being a pedestrian hit by a motor vehicle or having evidence of a skull fracture, those patients are at risk for needing an intervention and should undergo CT scanning.
Lastly, the Canadian CT Rule and New Orleans Criteria are really good at identifying patients who have a very low risk for ever needing an intervention. If you go about doing a careful assessment of the patient, and appropriately document what you did and what you were thinking when you made your decisions, there's very little likelihood that a malpractice action brought against you is going to succeed. Dr. Easter is an experienced emergency department clinician who did a lot of thinking about this problem when he wrote the Rational Clinical Examination article on head trauma.
And this is what he learned from reviewing all the evidence reported in the article. >> I think that you have to be sure that you are applying the rules in the fashion that they were intended. And so there are certain populations that have not been studied extensively with the rules. For example, patients who are anti-coagulated or patients who are intoxicated or the elderly. They were incorporated in some of these studies but they're not large studies looking at how the rules perform in those specific cohorts and so you have to be cautious applying these rules to those particular patient populations.
[Background Music] >> Once again, this is Ed Livingston, Deputy Editor of Clinical Reviews and Education. Thank you for listening to this JAMAevidence podcast. We have a wide array of topics covered in podcasts on the JAMAevidence website at JAMAevidence.com. [ Music ]
Segment:0 .
>> Clinicians are asked to evaluate minor head trauma all the time. And when they do it, they usually get a CT scan to make sure there's nothing seriously wrong. But CT scans aren't risk free and scanning everybody with minor head trauma when very few patients have a clinically important injury is not a good strategy. So let me ask you, what would you do for these patients? >> So I was walking down Michigan Avenue. It was really cold outside and there was a lot of ice on the sidewalk. I don't know how I did it but I slipped and fell right on my head.
[Background Music] >> I was at the gym and I was playing basketball. I was playing with this larger guy and he shoved me pretty hard and I hit the ground. I fell pretty hard and the first thing that hit was my head. >> So I remember that the whole thing, especially the sound my head made when it hit the sidewalk. It sounded like someone had slapped a watermelon.
>> It was the weirdest thing. I passed out for just a couple seconds but I got back up and got right back in the game. >> So, I didn't pass out or anything but I threw up all over the sidewalk right there and it was really embarrassing. A couple people came and helped me up and someone called a cab. They took me to the hospital and when I got there, I threw up again. >> So I think four hours later, I started feeling this really bad headache on the left side of my head where I hit the ground and I actually was feeling a pretty large bump underneath my scalp.
>> I didn't realize it at the time but I had a cut on my forehead about an inch long. >> When you have patients like this in front of you, you have to decide a few things. Does the patient have minor and not major head trauma? If they've got minor trauma, do they need a head CT or do they not need a head CT? When they leave the emergency room, what do you tell them they should be looking for in case you've missed something? Finally, what's the medical malpractice liability associated with not getting a CT scan?
How do you protect yourself against losing a malpractice case should you evaluate a patient with minor head trauma and choose not to get a CT scan? These are the questions that we're going to address in this podcast. Hello. This is Ed Livingston, Deputy Editor of Clinical Reviews and Education for JAMA. In today's JAMAevidence podcast, we cover the topic of neuroimaging for head trauma. This is based on a Rational Clinical Examination article published in the December 22, 2015 issue of JAMA. [ Music ] Minor head trauma is distinct from moderate or major head trauma.
Each of these gets treated differently. Moderate and major head trauma clearly need neuroimaging and some form of an intervention. That's not the case for minor head trauma. The author of The Rational Clinical Examination article on head trauma, Dr. Joshua Easter, Assistant Professor of Emergency Medicine at the University of Virginia, explains. >> Severe head injuries happen when a patient experiences trauma to their head and after the initial blow has a persistent alteration in their level of alertness associated with a Glasgow coma scale score of less than nine.
These patients are at high risk of having intracranial injuries. And there is little question after they're stabilized initially that they need emergent neuroimaging. The next category in this spectrum would be moderate head injury. Like severe head injury, these patients also have persistent alterations in their level of alertness that would be clear on a physician's exam after an initial blow to their head. They have Glasgow coma scale scores between nine and 12 and they're also at relatively high risk of having intracranial injuries and need emergent neuroimaging.
In contrast, minor or sometimes called mild head injury represents a patient who has a blow to their head and after that blow has a minimal alteration in their level of alertness. They have a Glasgow coma scale score of between 13 to 15 and concussion would be a subset of this category as well. >> The Glasgow coma scale is meant to classify the level of consciousness of patients with head trauma. It goes from zero to 15 and it's based on three major clinical features Eye opening, motor response, and verbal response.
If you open your eyes spontaneously, you get a Glasgow coma score of four and if they don't open at all, it's a one. If you're completely oriented, you get a Glasgow coma of five. And if you can't generate any verbal response at all, it's a one. If you can obey all commands, you get a six. If you can't obey any commands, you get a one. Parenthetically, this command scale is what I use to evaluate clinical interns. Minor head trauma includes patients who have a Glasgow coma score of 13, 14, or 15.
A Glasgow coma score of 15 pretty much means that you've got some head trauma, nothing else is wrong with you and you're pretty much normal. [Background Music] One of the vexing problems in managing patients with minor head trauma is deciding if they need a CT scan or not. CT scans are easy to get. Every emergency room has got one but not all of the two and a half million patients who suffer from head trauma needs a CT scan. The question is, how do you decide who doesn't need one.
[ Music ] This question was addressed in the head trauma Rational Clinical Examination article. We decided that minor head trauma involves having a head injury associated with a patient who pretty much looks normal, and has a Glasgow coma score between 13 and 15. One aspect of this assessment is examination of the head. Again, Dr. Easter. >> There are multiple different things which could indicate that a patient has a skull fracture.
The simplest would be that they have a large laceration to their scalp and you're able to look in and see the skull and you see a break in the integrity of the skull through the open wound. Other potential signs that you could see a skull fracture would be being able to palpate it with your fingers. So you're running your hand along the edge of the skull and you feel a divot or a break again in the integrity of the skull, which is suggestive that there could be a fracture at that location.
And then there are other signs which could be suggestive of a fracture to the base of the skull such as hemotympanum, CSF draining from the ears and nose, bruising underneath the eye or behind the ear. So, all of these findings are suggestive that a patient had a skull fracture and suggest that the patient experienced some high-energy trauma that was enough to fracture their skull. And as you can imagine, some of that energy likely was transmitted through to the brain. And so it intuitively makes sense that if you have a patient who appears to have a skull fracture on exam that they're going to be at very high risk of having intracranial injury and, therefore, should undergo neuroimaging.
>> In the Rational Clinical Examination article, studies were polled that assessed outcomes for patients who have Glasgow coma scores ranging between 13 and 15. The authors then looked for articles that had the relevant outcomes. >> So severe intracranial injury is defined as an intracranial injury that would require further intervention and that intervention could be needing to see a neurosurgeon, needing to be admitted to the hospital for observation, or as extreme as requiring neurosurgical intervention, whether that be a craniotomy, intracranial pressure monitoring, or mechanical ventilation.
>> The most important findings were that if you take all patients who present with a history of minor head trauma, meaning they don't have any physical evidence of a severe head injury, and have a Glasgow coma score ranging from 13 to 15, about 7% of these patients will have a severe enough injury to require some form of an intervention. For those patients with minor head trauma, only about 0.9% will go on to die or need neurosurgical intervention. When a patient has minor head trauma, there are a few features which are highly predictive of the need for an intervention.
These include a physical examination finding suggestive of a skull fracture, having a Glasgow coma score of 13, having a history of two or more vomiting episodes, having the Glasgow coma score decline over time, and if the injury is related to being a pedestrian who's struck by a motor vehicle. Two clinical prediction rules perform very well for predicting the absence of a significant injury in minor head trauma patients. These were the Canadian CT Head Rule and the New Orleans Criteria.
>> So, the Canadian CT Head Rule essentially says that if a patient is less than 65, did not experience a dangerous mechanism, which is being a pedestrian struck by a vehicle, being ejected from a motor vehicle, or falling more than three feet or five stairs, if they didn't vomit more than one time, if they're not amnestic to the event for more than 30 minutes, and if they did not have a depressed GCS score at two hours or suspicion of a skull fracture, then they are at very low risk of having an intracranial injury.
Similarly, the New Orleans Criteria says that if you're less than 60 years of age, you were not intoxicated, you don't have a headache, you have not vomited at all, and not experienced a seizure, you're not amnestic to the event, and you don't have any evidence of trauma above the clavicle, then you are also at extremely low risk of having intracranial injury. And so both of those rules, if you have none of those features, had very low negative likelihood ratios that put the chance of having a head injury at 0.3% if you had none of the features of the Canadian CT Head Rule and 0.6% if you had none of the features of the New Orleans Criteria.
>> These rules can be very helpful but, unfortunately, they're not used all that much in the US. A recent survey showed that only about a third of US-based ED physicians even knew the Canadian Rule exists. For patients with minor head trauma, the rules are really good at predicting who does not have a clinically significant injury; however, there's a tendency to rely on CT scanning to identify major injuries but even this may be misleading. >> Probably the best example of this are people that have concussions. We're finding out a lot about people who have sports concussions, where the CT scan can be perfectly normal yet probably 10% of those people will go on to have persistent symptoms after concussion in terms of memory problems, fatigue, headache, as well as depression and anxiety following concussion.
The CT scan, unfortunately, though, is very poor in identifying those individuals who are going to have those sort of more persistent problems that are not related necessarily to injuries requiring neurosurgical intervention but injuries that are nevertheless still there and result in long-term problems. >> This is Dr. Frederick Rivara, Professor of Pediatrics at the University of Washington and Editor Chief of JAMA Pediatrics. Dr. Rivara wrote an editorial in JAMA to accompany the head trauma Rational Clinical Examination article. >> It's incorrect to get a CT scan so that you can reassure a parent or their family that this individual is normal.
The CT scan may not show any abnormalities there but that does not mean the person does not have a traumatic brain injury. [ Music ] >> Irrespective of whether you get a CT scan or not, when the patient leaves your clinic or the emergency department, it's really important to tell them what to look for in case their condition should worsen. >> The main thing is you want to make sure that there is someone there who can watch them closely so that if they were to deteriorate, they're able to return or have somebody bring them back to the emergency department.
But the specific things that I'll tell any patient who's going home, whether they've been imaged or not, is that if they start to get a new headache that becomes severe or if their existing headache starts to worsen substantially, if they start to vomit multiple times, if their mental status to the person who is watching them seems to be declining, or if they have a seizure that they should immediately return to the emergency department. >> You know this old idea that wake up the patient every hour, shine a light in their eyes and make sure the pupils are reactive and they can still talk with you, well, there's no evidence that that kind of a neuro check done by a family member is really going to be very effective.
I think that it is sort of-- the chances of having some acute deterioration I think are extremely small. And, you know, it's typical things of not acting normally, having vomiting, repeated vomiting, I think is the sign that we oftentimes see is these individuals that have episodes of vomiting at home but I think it's important to remember that even in those few individuals, and there really are very few, that come back to the emergency department and may have a CT scan, which they had not had the first visit, the CT scan may show some minor contusion but the chances of that resulting in a neurosurgical intervention are really, really low.
>> Head trauma in children is really common and always a matter of great anxiety for their parents. Dr. Rivara tells us what he says to parents of children who've suffered minor head trauma. >> Well, I think it's important to first of all understand their concerns. I think it's important to do a thorough exam and to be able to reassure yourself that this child is normal. I think it's a matter of knowing the literature, having your experience, and knowing what the risk of a serious intracranial injury to this child is, and to reassure the parent that you feel like the risks of doing a CT scan really outweigh the potential benefits here and that you want to be in touch with the family.
You're not dismissing their concerns, that you want to hear from them the next day to make sure the child is okay, and that you're happy to see the child again if they're at all concerned about how the child is doing. >> Surveys have shown that most clinicians get CT scans to minimize their risk of liability. To better understand how to address that liability, I spoke to Michelle Mello, Professor of Law at the Stanford University School of Law. Dr. Mello is also a professor of research and health policy at Stanford. Dr. Mello, not all patients with minor head trauma benefit from a head CT.
Some decision rules are very helpful in predicting which patients will not benefit from a CT. But many clinicians believe that CT scans are necessary in all minor trauma patients to avoid liability. What advice do you have for the clinician who would like to avoid getting CT scans in situations like this and minimize their risk for liability? >> Of course, the clinician always should and can decide according to his best clinical judgment. When he goes to court, he will be evaluated by reference to what his colleagues in the similar specialty would have done under similar circumstances.
That's generally speaking the national standard of care with some accommodation for differences in resources. For example, if you're in an area where there literally is no CT scanner, you won't be held accountable for not ordering a scan. Having said that, the difficult bind that some physicians are in when it comes to procedures like this that are widely in use in circumstances where they needn't be from a clinical perspective is that the legal standard tends to be based in custom what other people are doing even when emergent guidelines come out saying we should reel this in, there should be less of this.
So there is some element of medical legal risk associated with being in the vanguard of movement, as we have here, like choosing wisely to try to reel things back in. >> So how that does clinician determine what the national standard of care is? >> Well, it's assumed that one is aware of the standard just by ident of being a physician, being around other physicians, being trained by other physicians, and keeping up with medical journals and new developments in the field. All of that is part of reasonable care in being a physician.
Guidelines and decision rules, like the ones discussed in the article, are certainly relevant evidence of what others are doing but they'll be used at trial by an expert who will testify not just to what they say but also to what others do. So it's no use having a guideline that nobody follows. That's not going to be very helpful in court. On the other hand, a physician who for example is in a practice that has decided to follow the Canadian rule, everybody doesn't, that's also the standard in the profession generally, should feel quite comfortable heading into a malpractice suit that an expert called by his attorney will testify to the fact that this is not only a good rule but a rule that is perceived as good by others in the profession.
>> So imagine you're practicing in a group practice, like in a big HMO, you have five surgeons who all might do something the same way and that same way may be different from five surgeons in some other part of the country and there's no really firm nationally agreed upon standard of care for that particular procedure. When you're defining the standard of care, is it good enough to rely on the fact that you work with these five other people and you talk to one another all the time and you all do things the same way? >> Well, it depends on the circumstances.
The law does appreciate and accommodate situations in which there is not a consensus in the field about how to handle this situation. There's a doctrine called The Respectable Minority Rule that takes account of situations where most physicians [inaudible] in one way but there is a respectable minority, both respectable in size and in reputation, that does things another way. Having said that, if the decision of this HMO for example was, you know, we're going to make this decision solely based on cost.
It has nothing to do with the quality of care. We know nobody else does it this way but this is what makes financial sense for us. That's probably not going to qualify as a respectable minority. >> What do you recommend clinicians tell patients in terms of the various treatment options, and how much information should they give the patient? >> Empirically, I don't know how much data they do give the patient. I think my view as a patient as well as a lawyer is that patients need to understand also when there is a dissensus in the field about what to do in a particular situation.
It's reassuring as a patient to think that everybody knows exactly what to do and everyone is in agreement. Of course, medicine doesn't really work that way. So particularly in situations where you have respectable guidelines pushing medicine in a direction other than where it is now or as is the case in other types of screening situations like breast cancer, conflicting guidelines, patients need to know that reputable experts disagree about what to do in particular circumstances or they disagree with what the patient might come in presuming is the best course of action which is always more care, more screening.
I think it's particularly salient to point out to patients that CT scanning involves a risk of cancer later in life that is not negligible and that is weighing in the physician's mind, that is a worry in the physician's mind when in weighing risks and benefits. Most patients won't understand statistical information at the level that the article about CT scanning discusses the statistics like 0.31%, won't resonate, won't have meaning for most patients but they will understand that there is a vanishingly small chance of missing something without the scan but a much greater risk of having harm as well as increased cost if you do order the scan.
>> One thing I was told throughout my career is that it's really important to document in the medical record what you are thinking when you did something or when you talk to a patient, you document what you told them. How much information should a clinician put in the medical record? >> Well, legally, the documentation can be helpful in establishing reasonableness. That's the standard ultimately to which all physicians are held. Plaintiff attorneys may try to portray a decision as careless or driven by something more nefarious like cost considerations, but a physician who has written in the notes, for example, patient meets no criteria of the Canadian Rule or the New Orleans Rule, CT scanning not indicated for that reason is going, that's going to be a helpful note to have in there come trial time.
In terms of documenting what was conveyed to the patient, that really would only come in legally if the patient's claim was for a breach of informed consent, where she is saying, you know, I would've gone to another physician to get this scan had I known what I know now. And so in this particular circumstance, it may be less important. More generally, of course, if we're talking about consenting a patient in for a procedure or something, then it tends to be more important to write down that the risks and benefits of the procedure were discussed and the patient, you know, had questions about this that were answered.
>> Let's return to our two patients. What happened to them? The woman who hit her head on the pavement didn't lose consciousness. She even heard the noise when her head hit the cement; however, there were concerns that she had intracranial injury. She vomited a couple times and that's always concerning. She did have a CT scan which showed a subdural hematoma. She was admitted to the hospital and observed for 24 hours. Her symptoms improved.
She was discharged and never had any further problems. Our basketball player didn't have any criteria for serious intracranial injury based on the Canadian CT Rule. He did have loss of consciousness and a headache but he didn't undergo a CT scan. The decision not to pursue a CT scan was based on the clinical evaluation of this patient and the negative Canadian Head CT Rule. He was discharged from the emergency room and given instructions to return to the emergency department if there was severe or worsening headache, multiple episodes of vomiting, seizures, or worsening of his mental status.
He was seen by his physician a week after the episode, was symptom free, and had no further problems. The bottom line is that patients who suffered minor head injury who don't have much in terms of functional impairment have very little risk of ever needing an intervention. There are some patients with minor head injury who have various clinical features or things in their history such as being a pedestrian hit by a motor vehicle or having evidence of a skull fracture, those patients are at risk for needing an intervention and should undergo CT scanning.
Lastly, the Canadian CT Rule and New Orleans Criteria are really good at identifying patients who have a very low risk for ever needing an intervention. If you go about doing a careful assessment of the patient, and appropriately document what you did and what you were thinking when you made your decisions, there's very little likelihood that a malpractice action brought against you is going to succeed. Dr. Easter is an experienced emergency department clinician who did a lot of thinking about this problem when he wrote the Rational Clinical Examination article on head trauma.
And this is what he learned from reviewing all the evidence reported in the article. >> I think that you have to be sure that you are applying the rules in the fashion that they were intended. And so there are certain populations that have not been studied extensively with the rules. For example, patients who are anti-coagulated or patients who are intoxicated or the elderly. They were incorporated in some of these studies but they're not large studies looking at how the rules perform in those specific cohorts and so you have to be cautious applying these rules to those particular patient populations.
[Background Music] >> Once again, this is Ed Livingston, Deputy Editor of Clinical Reviews and Education. Thank you for listening to this JAMAevidence podcast. We have a wide array of topics covered in podcasts on the JAMAevidence website at JAMAevidence.com. [ Music ]
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