Wednesday, October 24, 2012

More Probably Unnecessary Head CTs/Admissions

I work at one of only two trauma centers in a city of four million potential patients, and I have firsthand experience with this issue.  The issue is to determine the best management strategy for patients with mild traumatic brain injury and bleeding.  We already know what to do with major bleeding – but patients with minor bleeding are a little more of a dilemma.  They almost universally do well, but we observe them and repeat tests on nearly all of them.

This is a retrospective review of 36 months of trauma admissions to a level one trauma center in New Jersey, trying to describe the natural progression of mild traumatic intracranial bleeding.  Historically, 1/3rd of these patients have bleeding that progresses, but only 1-3% will require neurosurgical intervention.  This review found 341 patients with mild injuries and bleeding, and noted that 69% of these patients had no interval change in head CT results when repeated at 24 hours.  Of the remaining patients, either no CT was performed (25 patients) because the injury was too insignificant or there was interval progression – including 11 patients who received neurosurgical intervention.  But, the point of the article is generally supposed to be shown in Figure 2 – estimating the number of ongoing hemorrhages at each time point in the first 24 hours.  Essentially, >80% of the bleeding ceases to expand within the first few hours from injury.

This is a useful jumping off point to perform the sort of work that isn't featured in this article – characterizing the characteristics of patients and bleeding that progresses.  If patients with bleeding unlikely to progress can be safely discharged rather than being observed for interval CT, this is a useful reduction in ED length of stay, observation admissions, or CT use.

"The temporal course of intracranial haemorrhage progression: How long is observation necessary?"
www.ncbi.nlm.nih.gov/pubmed/22658418

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