Validation of the Scandinavian guidelines for initial management of minimal, mild and moderate traumatic brain injury in adults
Background Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5–7 % who may be harboring potentially life-threatening intracranial hemorrhage (IH) using CT scanning. Guidelines intending to reduce unnecessary head CT scans using available clinic...
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| Published in | BMC medicine Vol. 13; no. 1; p. 292 |
|---|---|
| Main Authors | , , , , |
| Format | Journal Article |
| Language | English |
| Published |
London
BioMed Central
09.12.2015
BioMed Central Ltd |
| Subjects | |
| Online Access | Get full text |
| ISSN | 1741-7015 1741-7015 |
| DOI | 10.1186/s12916-015-0533-y |
Cover
| Abstract | Background
Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5–7 % who may be harboring potentially life-threatening intracranial hemorrhage (IH) using CT scanning. Guidelines intending to reduce unnecessary head CT scans using available clinical variables to detect those at high IH risk have shown varying results. Recently, the Scandinavian Neurotrauma Committee (SNC) derived a new set of high-IH risk variables for adults with TBI using an evidence-based literature review. Unlike previous guidelines, the SNC guideline incorporates serum values of the brain protein S100B with clinical variables.
Methods
We performed a nested cohort study of adults with mild TBI presenting to six emergency departments in New York and Pennsylvania within 6 h of injury. Patients were managed according to existing guidelines for CT selection. All patients underwent head CT scanning and serum S100B measurement, as well as prospective collection of clinical variables, as a requirement of the parent study. Using the SNC guidelines, S100B values and clinical variables were applied to these subjects, classifying each into one of five pre-defined severity categories, as well as predicting the need for head CT scanning to identify IH. This classification was then compared to actual head CT results to determine guideline sensitivity and specificity.
Results
In total, 662 adults (mean age 42 years, range 18–96; 258 females, 549 Caucasians) were available for analysis; 36 (5 %) had IH on head CT scan. The SNC guidelines had a sensitivity of 97 % (95 % CI, 84–100 %) and a specificity of 34 % (95 % CI, 30–37 %) for the detection of IH on head CT. Application of the SNC guidelines would have resulted in a CT reduction of 32 % (211/662 patients). One patient with low-risk mild TBI and a S100B level under 0.10 μg/L had a traumatic CT abnormality and would have been discharged with strict adherence to the guidelines. However, this patient did not need any intervention for the injury and had a good outcome.
Conclusion
Using the SNC guideline could save approximately one third of CT scans in a pre-selected cohort of mild TBI patients with little or no impact on patient outcome. |
|---|---|
| AbstractList | Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5-7 % who may be harboring potentially life-threatening intracranial hemorrhage (IH) using CT scanning. Guidelines intending to reduce unnecessary head CT scans using available clinical variables to detect those at high IH risk have shown varying results. Recently, the Scandinavian Neurotrauma Committee (SNC) derived a new set of high-IH risk variables for adults with TBI using an evidence-based literature review. Unlike previous guidelines, the SNC guideline incorporates serum values of the brain protein S100B with clinical variables.
We performed a nested cohort study of adults with mild TBI presenting to six emergency departments in New York and Pennsylvania within 6 h of injury. Patients were managed according to existing guidelines for CT selection. All patients underwent head CT scanning and serum S100B measurement, as well as prospective collection of clinical variables, as a requirement of the parent study. Using the SNC guidelines, S100B values and clinical variables were applied to these subjects, classifying each into one of five pre-defined severity categories, as well as predicting the need for head CT scanning to identify IH. This classification was then compared to actual head CT results to determine guideline sensitivity and specificity.
In total, 662 adults (mean age 42 years, range 18-96; 258 females, 549 Caucasians) were available for analysis; 36 (5%) had IH on head CT scan. The SNC guidelines had a sensitivity of 97% (95% CI, 84-100%) and a specificity of 34% (95% CI, 30-37%) for the detection of IH on head CT. Application of the SNC guidelines would have resulted in a CT reduction of 32% (211/662 patients). One patient with low-risk mild TBI and a S100B level under 0.10 μg/L had a traumatic CT abnormality and would have been discharged with strict adherence to the guidelines. However, this patient did not need any intervention for the injury and had a good outcome.
Using the SNC guideline could save approximately one third of CT scans in a pre-selected cohort of mild TBI patients with little or no impact on patient outcome. Background Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5-7 % who may be harboring potentially life-threatening intracranial hemorrhage (IH) using CT scanning. Guidelines intending to reduce unnecessary head CT scans using available clinical variables to detect those at high IH risk have shown varying results. Recently, the Scandinavian Neurotrauma Committee (SNC) derived a new set of high-IH risk variables for adults with TBI using an evidence-based literature review. Unlike previous guidelines, the SNC guideline incorporates serum values of the brain protein S100B with clinical variables. Methods We performed a nested cohort study of adults with mild TBI presenting to six emergency departments in New York and Pennsylvania within 6 h of injury. Patients were managed according to existing guidelines for CT selection. All patients underwent head CT scanning and serum S100B measurement, as well as prospective collection of clinical variables, as a requirement of the parent study. Using the SNC guidelines, S100B values and clinical variables were applied to these subjects, classifying each into one of five pre-defined severity categories, as well as predicting the need for head CT scanning to identify IH. This classification was then compared to actual head CT results to determine guideline sensitivity and specificity. Results In total, 662 adults (mean age 42 years, range 18-96; 258 females, 549 Caucasians) were available for analysis; 36 (5 %) had IH on head CT scan. The SNC guidelines had a sensitivity of 97 % (95 % CI, 84-100 %) and a specificity of 34 % (95 % CI, 30-37 %) for the detection of IH on head CT. Application of the SNC guidelines would have resulted in a CT reduction of 32 % (211/662 patients). One patient with low-risk mild TBI and a S100B level under 0.10 [mu]g/L had a traumatic CT abnormality and would have been discharged with strict adherence to the guidelines. However, this patient did not need any intervention for the injury and had a good outcome. Conclusion Using the SNC guideline could save approximately one third of CT scans in a pre-selected cohort of mild TBI patients with little or no impact on patient outcome. Keywords: Biomarkers, Brain injury, Computed tomography, Decision rule, Guidelines, Head injury, Management, Mild traumatic brain injury, S100B/S100/S100BB, Traumatic brain injury Background Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5-7 % who may be harboring potentially life-threatening intracranial hemorrhage (IH) using CT scanning. Guidelines intending to reduce unnecessary head CT scans using available clinical variables to detect those at high IH risk have shown varying results. Recently, the Scandinavian Neurotrauma Committee (SNC) derived a new set of high-IH risk variables for adults with TBI using an evidence-based literature review. Unlike previous guidelines, the SNC guideline incorporates serum values of the brain protein S100B with clinical variables. Methods We performed a nested cohort study of adults with mild TBI presenting to six emergency departments in New York and Pennsylvania within 6 h of injury. Patients were managed according to existing guidelines for CT selection. All patients underwent head CT scanning and serum S100B measurement, as well as prospective collection of clinical variables, as a requirement of the parent study. Using the SNC guidelines, S100B values and clinical variables were applied to these subjects, classifying each into one of five pre-defined severity categories, as well as predicting the need for head CT scanning to identify IH. This classification was then compared to actual head CT results to determine guideline sensitivity and specificity. Results In total, 662 adults (mean age 42 years, range 18-96; 258 females, 549 Caucasians) were available for analysis; 36 (5 %) had IH on head CT scan. The SNC guidelines had a sensitivity of 97 % (95 % CI, 84-100 %) and a specificity of 34 % (95 % CI, 30-37 %) for the detection of IH on head CT. Application of the SNC guidelines would have resulted in a CT reduction of 32 % (211/662 patients). One patient with low-risk mild TBI and a S100B level under 0.10 μg/L had a traumatic CT abnormality and would have been discharged with strict adherence to the guidelines. However, this patient did not need any intervention for the injury and had a good outcome. Conclusion Using the SNC guideline could save approximately one third of CT scans in a pre-selected cohort of mild TBI patients with little or no impact on patient outcome. Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5-7 % who may be harboring potentially life-threatening intracranial hemorrhage (IH) using CT scanning. Guidelines intending to reduce unnecessary head CT scans using available clinical variables to detect those at high IH risk have shown varying results. Recently, the Scandinavian Neurotrauma Committee (SNC) derived a new set of high-IH risk variables for adults with TBI using an evidence-based literature review. Unlike previous guidelines, the SNC guideline incorporates serum values of the brain protein S100B with clinical variables. Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5-7 % who may be harboring potentially life-threatening intracranial hemorrhage (IH) using CT scanning. Guidelines intending to reduce unnecessary head CT scans using available clinical variables to detect those at high IH risk have shown varying results. Recently, the Scandinavian Neurotrauma Committee (SNC) derived a new set of high-IH risk variables for adults with TBI using an evidence-based literature review. Unlike previous guidelines, the SNC guideline incorporates serum values of the brain protein S100B with clinical variables. We performed a nested cohort study of adults with mild TBI presenting to six emergency departments in New York and Pennsylvania within 6 h of injury. Patients were managed according to existing guidelines for CT selection. All patients underwent head CT scanning and serum S100B measurement, as well as prospective collection of clinical variables, as a requirement of the parent study. Using the SNC guidelines, S100B values and clinical variables were applied to these subjects, classifying each into one of five pre-defined severity categories, as well as predicting the need for head CT scanning to identify IH. This classification was then compared to actual head CT results to determine guideline sensitivity and specificity. In total, 662 adults (mean age 42 years, range 18-96; 258 females, 549 Caucasians) were available for analysis; 36 (5 %) had IH on head CT scan. The SNC guidelines had a sensitivity of 97 % (95 % CI, 84-100 %) and a specificity of 34 % (95 % CI, 30-37 %) for the detection of IH on head CT. Application of the SNC guidelines would have resulted in a CT reduction of 32 % (211/662 patients). One patient with low-risk mild TBI and a S100B level under 0.10 [mu]g/L had a traumatic CT abnormality and would have been discharged with strict adherence to the guidelines. However, this patient did not need any intervention for the injury and had a good outcome. Using the SNC guideline could save approximately one third of CT scans in a pre-selected cohort of mild TBI patients with little or no impact on patient outcome. BACKGROUNDAcute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5-7 % who may be harboring potentially life-threatening intracranial hemorrhage (IH) using CT scanning. Guidelines intending to reduce unnecessary head CT scans using available clinical variables to detect those at high IH risk have shown varying results. Recently, the Scandinavian Neurotrauma Committee (SNC) derived a new set of high-IH risk variables for adults with TBI using an evidence-based literature review. Unlike previous guidelines, the SNC guideline incorporates serum values of the brain protein S100B with clinical variables.METHODSWe performed a nested cohort study of adults with mild TBI presenting to six emergency departments in New York and Pennsylvania within 6 h of injury. Patients were managed according to existing guidelines for CT selection. All patients underwent head CT scanning and serum S100B measurement, as well as prospective collection of clinical variables, as a requirement of the parent study. Using the SNC guidelines, S100B values and clinical variables were applied to these subjects, classifying each into one of five pre-defined severity categories, as well as predicting the need for head CT scanning to identify IH. This classification was then compared to actual head CT results to determine guideline sensitivity and specificity.RESULTSIn total, 662 adults (mean age 42 years, range 18-96; 258 females, 549 Caucasians) were available for analysis; 36 (5%) had IH on head CT scan. The SNC guidelines had a sensitivity of 97% (95% CI, 84-100%) and a specificity of 34% (95% CI, 30-37%) for the detection of IH on head CT. Application of the SNC guidelines would have resulted in a CT reduction of 32% (211/662 patients). One patient with low-risk mild TBI and a S100B level under 0.10 μg/L had a traumatic CT abnormality and would have been discharged with strict adherence to the guidelines. However, this patient did not need any intervention for the injury and had a good outcome.CONCLUSIONUsing the SNC guideline could save approximately one third of CT scans in a pre-selected cohort of mild TBI patients with little or no impact on patient outcome. Background Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5–7 % who may be harboring potentially life-threatening intracranial hemorrhage (IH) using CT scanning. Guidelines intending to reduce unnecessary head CT scans using available clinical variables to detect those at high IH risk have shown varying results. Recently, the Scandinavian Neurotrauma Committee (SNC) derived a new set of high-IH risk variables for adults with TBI using an evidence-based literature review. Unlike previous guidelines, the SNC guideline incorporates serum values of the brain protein S100B with clinical variables. Methods We performed a nested cohort study of adults with mild TBI presenting to six emergency departments in New York and Pennsylvania within 6 h of injury. Patients were managed according to existing guidelines for CT selection. All patients underwent head CT scanning and serum S100B measurement, as well as prospective collection of clinical variables, as a requirement of the parent study. Using the SNC guidelines, S100B values and clinical variables were applied to these subjects, classifying each into one of five pre-defined severity categories, as well as predicting the need for head CT scanning to identify IH. This classification was then compared to actual head CT results to determine guideline sensitivity and specificity. Results In total, 662 adults (mean age 42 years, range 18–96; 258 females, 549 Caucasians) were available for analysis; 36 (5 %) had IH on head CT scan. The SNC guidelines had a sensitivity of 97 % (95 % CI, 84–100 %) and a specificity of 34 % (95 % CI, 30–37 %) for the detection of IH on head CT. Application of the SNC guidelines would have resulted in a CT reduction of 32 % (211/662 patients). One patient with low-risk mild TBI and a S100B level under 0.10 μg/L had a traumatic CT abnormality and would have been discharged with strict adherence to the guidelines. However, this patient did not need any intervention for the injury and had a good outcome. Conclusion Using the SNC guideline could save approximately one third of CT scans in a pre-selected cohort of mild TBI patients with little or no impact on patient outcome. |
| ArticleNumber | 292 |
| Audience | Academic |
| Author | Calcagnile, Olga Undén, Linda Undén, Johan Reinstrup, Peter Bazarian, Jeff |
| Author_xml | – sequence: 1 givenname: Linda surname: Undén fullname: Undén, Linda organization: Lund University – sequence: 2 givenname: Olga surname: Calcagnile fullname: Calcagnile, Olga organization: Department of Pediatric Medicine, Hallands Hospital – sequence: 3 givenname: Johan surname: Undén fullname: Undén, Johan email: dr.johan.unden@gmail.com organization: Department of Intensive Care and Perioperative Medicine, Lund University – sequence: 4 givenname: Peter surname: Reinstrup fullname: Reinstrup, Peter organization: Department of Neuroanesthesia, Skane University Hospital and Lund University – sequence: 5 givenname: Jeff surname: Bazarian fullname: Bazarian, Jeff organization: Department of Emergency Medicine, University of Rochester School of Medicine |
| BackLink | https://www.ncbi.nlm.nih.gov/pubmed/26645914$$D View this record in MEDLINE/PubMed |
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| Keywords | Mild traumatic brain injury Traumatic brain injury Computed tomography Head injury Biomarkers Management S100B/S100/S100BB Brain injury Decision rule Guidelines |
| Language | English |
| License | Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. |
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Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5–7 % who may be harboring potentially... Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5-7 % who may be harboring potentially... Background Acute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5-7 % who may be harboring potentially... BACKGROUNDAcute management of traumatic brain injury (TBI), in particular mild TBI, focuses on the detection of the 5-7 % who may be harboring potentially... |
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| SubjectTerms | Adolescent Adult Adults Aged Aged, 80 and over Analysis Anestesi och intensivvård Anesthesiology and Intensive Care Biomarkers Biomedicine Brain Brain Injuries - diagnosis Case-Control Studies Clinical Medicine Cohort analysis Cohort Studies Consciousness CT imaging Disease Management Emergency medical care Female Hematoma Hospitals Humans Injuries Klinisk medicin Male Medical and Health Sciences Medical imaging Medicin och hälsovetenskap Medicine Medicine & Public Health Middle Aged Prospective Studies Proteins Research Article S100 Calcium Binding Protein beta Subunit - metabolism Scandinavian and Nordic Countries Traumatic brain injury Variables Young Adult |
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| Title | Validation of the Scandinavian guidelines for initial management of minimal, mild and moderate traumatic brain injury in adults |
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