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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 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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    Result:

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    Next Steps
    Evidence
    Creator Insights

    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.
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    About the Creator
    Dr. Micelle J. Haydel
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