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    New Orleans/Charity Head Trauma/Injury Rule

    Criteria for which patients are unlikely to require imaging after head trauma.
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    INSTRUCTIONS

    Use ONLY in head injury patients who are neurologically normal (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.
    About the Creator
    Dr. Micelle J. Haydel
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    Next Steps
    Evidence
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    Advice

    • Consider CT Head pending outcome of the rule.
    • Consider Neurosurgery Consult as per rule guidelines.

    Management

    In patients with signs of intracranial hemorrhage, contusion, skull fracture, or other abnormalities diagnosed on brain imaging:

    • Always assess ABCs first.
    • Neurosurgery consultation.
    • Consider hypertonic saline or mannitol after consultation with neurosurgery.
    • Admit to neurosurgical ICU for monitoring and further care.

    Critical Actions

    • Providers in more conservative settings could consider applying both rules and choosing to image if either rule suggests that a patient is not completely low risk according to their respective criteria.
    • If a trauma patient, with a head injury and loss of consciousness, presenting with a GCS 15 is positive for any of the NOC (age >60, headache, vomiting, alcohol or drug intoxication, persistent anterograde amnesia, visible trauma above the clavicle or seizures) then they require a CT scan of the head to evaluate for intracranial injury.
    • If the patient does not have any of the NOC then they can be discharged without undergoing a CT of the head and without the need for any further clinical observation.

    Formula

    Series of Yes/No Questions, as above.

    Evidence Appraisal

    • The NOC were derived from analysis of 520 patients, >3 years of age, who presented with minor head trauma within in 24 hours of their injury.
    • The NOC were then validated among 909 patients presenting to a single US level 1 trauma center. The rule was found to be 100% sensitive for all intracranial injuries and had a specificity of 25%.
    • 6.5% of patients had intracranial injuries on CT (93/1429) and of those, 0.4% (6/1429) required neurosurgical intervention.
    • Subsequent studies have found the NOC to have a sensitivity of 86-100% for intracranial injuries.There is conflicting evidence as to whether the NOC performs better than the CCHR for detecting all clinically significant intracranial injuries, with two validation trials finding that both had 100% sensitivity for these injuries, another trial2 finding that the NOC was more sensitive (99.4 vs. 87.2%) and one additional trial finding that the CCHR was more sensitive for detecting clinically significant intracranial injuries (95 vs. 86%).
    • Regardless, in all settings the NOC has been shown to be less specific than the CCHR (50.6% vs 12.7%1, 39.7% vs. 5.6%2, 36.3% vs. 10.2%3 and 65% vs. 28%4).
    • Another issue is the interrater reliability of applying the NOC vs. the CCHR. The kappa values for physician interpretation of the rules, CCHR vs NOC, were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging for 4.0% of patients according to CCHR and 5.5% according to NOC (P = .04)1.
    • The New Orleans Criteria have been validated in several settings and to 100% sensitivity for detecting injuries that will require neurosurgery.
      • There is an outlier study based on patients evaluated in a center in Tunisia that found the NOC to only be 82% sensitive (25/1017 patients with GCS 15 who were NOC negative, or 2.5%) for injuries that required neurosurgical intervention.
      • There has been at least one trial that found the NOC was more sensitive than the CCHR (99.4% vs 87.3%). Though this comes at the price of markedly decreased specificity (5.6% vs. 39.7%).
      • In United States, Canada and the Netherlands, both the NOC and the CCHR have demonstrated 100% sensitivity for ruling out intracranial injuries that would require neurosurgical intervention.

    Literature

    Other References

    Research PaperSmits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool DR, Nederkoorn PJ, Hofman PA, Twijnstra A, Tanghe HL, Hunink MG. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA. 2005 Sep 28;294(12):1519-25.Research PaperPapa L, Stiell IG, Clement CM, Pawlowicz A, Wolfram A, Braga C, Draviam S, Wells GA. Performance of the Canadian CT Head Rule and the New Orleans Criteria for predicting any traumatic intracranial injury on computed tomography in a United States Level I trauma center. Acad Emerg Med. 2012 Jan;19(1):2-10. doi: 10.1111/j.1553-2712.2011.01247.x.Research PaperBouida W, Marghli S, Souissi S, Ksibi H, Methammem M, Haguiga H, Khedher S, Boubaker H, Beltaief K, Grissa MH, Trimech MN, Kerkeni W, Chebili N, Halila I, Rejeb I, Boukef R, Rekik N, Bouhaja B, Letaief M, Nouira S. Prediction value of the Canadian CT head rule and the New Orleans criteria for positive head CT scan and acute neurosurgical procedures in minor head trauma: a multicenter external validation study. Ann Emerg Med. 2013 May;61(5):521-7. doi: 10.1016/j.annemergmed.2012.07.016. Epub 2012 Aug 22.
    Dr. Micelle J. Haydel

    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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