New Orleans/Charity Head Trauma/Injury Rule
Criteria for which patients are unlikely to require imaging after head trauma.
INSTRUCTIONS
Use ONLY in patients with head injury and loss of consciousness (LOC) who are neurologically normal (i.e., GCS 15 and normal brief neurological exam).
When to Use
Pearls/Pitfalls
Why Use
Patients with head injury and loss of consciousness (LOC) who are neurologically normal (i.e., GCS 15 and normal brief neurological exam).
The New Orleans Criteria (NOC) were developed to help physicians determine which patients need CT head imaging.
- The NOC has been demonstrated in several prospective trials to have a sensitivity of 100% for intracranial injuries that require neurosurgical intervention.
Points to keep in mind:
- The NOC authors' goal was to find a rule that was 100% sensitive for all intracranial injuries, not just those that would require neurosurgical intervention. In the original validation study and two other trials, the NOC was found to be 99.4-100% sensitive for these injuries.
- One recent trial among trauma patients in Tunisia found that the NOC was only 82-86% sensitive for injuries requiring neurosurgery and for all clinically important brain injuries, suggesting that the NOC might not be translatable to all clinical settings.
- While the NOC is less complex than the CCHR, and both rules have excellent sensitivity, the NOC is much less specific than the CCHR in all settings given the NOC’s very broad questions, especially “Any trauma above the clavicles.”
- There are more than 8 million patients who present annually to US Emergency Departments for evaluation of head trauma. The vast majority of these patients have minor head trauma that will not require specialized treatment or neurosurgical treatment. At the same time, rates of CT imaging of the head have risen dramatically in the US, more than doubling from the early 1990s through the 2000s.
- Using the NOC as a clinical decision aid would allow physicians to safely forgo head CT in 12-25% of patients presenting to the emergency department with minor head trauma.
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Next Steps
Evidence
Creator Insights
From the Creator
- Why did you develop the New Orleans/Charity Head Injury/Trauma Rule? Was there a clinical experience that inspired you to create this tool for clinicians?
- As a resident at the University of Pittsburgh, I was convinced that CT was overused in patients with minor head injury (MHI). When I became faculty at Charity Hospital in New Orleans, I was much wiser and less cavalier, noting that occasionally some patients with MHI really did have badness on CT. But not very many, and usually it was quite unexpected. As a county hospital, we had little funds available for research, but I plied the residents with candy and ended up enrolling over 1,000 patients.
- What pearls, pitfalls and/or tips do you have for users of the New Orleans/Charity Head Injury/Trauma Rule? Are there cases in which it has been applied, interpreted, or used inappropriately?
- Users should be aware that the original data set only included patients with either loss of consciousness or post-traumatic amnesia, although subsequent studies have shown that the 'rule' is equally sensitive in patients without loss of consciousness. The mnemonic HEAD CT'S can be used to remember the seven criteria: headache, emesis, age over 60, drug or alcohol intoxication, convulsion, trauma visible above the clavicles, and short-term memory deficits. Several definitions are important when using this rule. Trauma visible above the clavicles implies any bruises, contusions or lacerations. Short-term memory deficits are defined as loss of anterograde amnesia, not the expected retrograde amnesia.
- What recommendations do you have for health care providers once they have applied the New Orleans/Charity Head Injury/Trauma Rule? Are there any adjustments or updates you would make to the score given recent changes in medicine like imaging or the research we now have on concussion?
- Clinical decision rules do not replace clinical judgment.
About the Creator
Micelle J. Haydel, MD, is the residency director of emergency medicine and associate professor of clinical medicine at Louisiana State University Health Sciences Center. She began her career in medicine as a nurse, completing her training at LSU School of Nursing and then later attended Tulane School of Medicine for her medical degree. Dr. Haydel currently researches head and facial injury/trauma.
To view Dr. Micelle J. Haydel's publications, visit PubMed
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