Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury

David H. Livingston, Robert F. Lavery, Marian R. Passannante, Joan H. Skurnick, Stephen Baker, Timothy C. Fabian, Donald E. Fry, Mark A. Malangoni

Research output: Contribution to journalArticle

104 Citations (Scopus)

Abstract

Objective: To determine the negative predictive value of cranial computed tomography (CT) scanning in a prospective series of patients and whether hospital admission for observation is mandatory after a negative diagnostic evaluation after minimal head injury (MHI). Summary Background Data: Hospital admission for observation is a current standard of practice for patients who have sustained MHI, despite having undergone diagnostic studies that exclude the presence of an intracranial injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that admission will allow prompt diagnosis of Occult injuries, and medicolegal considerations about the risk of early discharge. Methods: In a prospective, multiinstitutional study during a 22-month period at four level I trauma centers, all patients with MHI were evaluated using the following protocol: a standardized physical and neurologic examination in the emergency department, cranial CT scanning, and then admission for observation. MHI was defined as either a documented loss of consciousness or evidence of posttraumatic amnesia and an emergency department Glasgow Coma Scale score of 14 or 15. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, need for craniotomy, and death. Results: Two thousand one hundred fifty-two consecutive patients fulfilled the study protocol. The CT was interpreted as negative for intracranial injury in 1,788, positive in 217, and equivocal in 119. Five patients with CT scans initially interpreted as negative required intervention. There was one craniotomy in a patient whose CT scan was initially interpreted as negative. This patient had facial fractures that required surgical intervention and elevation of depressed intracranial fracture fragments. The negative predictive power of a cranial CT scan based on the preliminary reading of the CT scan and defined by the subsequent need for neurosurgical intervention in the population fully satisfying the protocol was 99.70%. Conclusions: Patients with a cranial CT scan, obtained on a helical CT scanner, that shows no intracerebral injury and who do not have other body system injuries or a persistence of any neurologic finding can be safely discharged from the emergency department without a period of either inpatient or outpatient observation. Implementation of this practice could result in a potential decrease of more than 500,000 hospital admissions annually.

Original languageEnglish (US)
Pages (from-to)126-132
Number of pages7
JournalAnnals of Surgery
Volume232
Issue number1
DOIs
StatePublished - Jul 2000

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Patient Discharge
Craniocerebral Trauma
Hospital Emergency Service
Tomography
Observation
Wounds and Injuries
Craniotomy
Glasgow Coma Scale
Amnesia
Unconsciousness
Spiral Computed Tomography
Trauma Centers
Neurologic Examination
Neurologic Manifestations
Routine Diagnostic Tests
Physical Examination
Reading
Inpatients
Outpatients
Prospective Studies

All Science Journal Classification (ASJC) codes

  • Surgery

Cite this

Livingston, D. H., Lavery, R. F., Passannante, M. R., Skurnick, J. H., Baker, S., Fabian, T. C., ... Malangoni, M. A. (2000). Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury. Annals of Surgery, 232(1), 126-132. https://doi.org/10.1097/00000658-200007000-00018

Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury. / Livingston, David H.; Lavery, Robert F.; Passannante, Marian R.; Skurnick, Joan H.; Baker, Stephen; Fabian, Timothy C.; Fry, Donald E.; Malangoni, Mark A.

In: Annals of Surgery, Vol. 232, No. 1, 07.2000, p. 126-132.

Research output: Contribution to journalArticle

Livingston, DH, Lavery, RF, Passannante, MR, Skurnick, JH, Baker, S, Fabian, TC, Fry, DE & Malangoni, MA 2000, 'Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury', Annals of Surgery, vol. 232, no. 1, pp. 126-132. https://doi.org/10.1097/00000658-200007000-00018
Livingston, David H. ; Lavery, Robert F. ; Passannante, Marian R. ; Skurnick, Joan H. ; Baker, Stephen ; Fabian, Timothy C. ; Fry, Donald E. ; Malangoni, Mark A. / Emergency department discharge of patients with a negative cranial computed tomography scan after minimal head injury. In: Annals of Surgery. 2000 ; Vol. 232, No. 1. pp. 126-132.
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abstract = "Objective: To determine the negative predictive value of cranial computed tomography (CT) scanning in a prospective series of patients and whether hospital admission for observation is mandatory after a negative diagnostic evaluation after minimal head injury (MHI). Summary Background Data: Hospital admission for observation is a current standard of practice for patients who have sustained MHI, despite having undergone diagnostic studies that exclude the presence of an intracranial injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that admission will allow prompt diagnosis of Occult injuries, and medicolegal considerations about the risk of early discharge. Methods: In a prospective, multiinstitutional study during a 22-month period at four level I trauma centers, all patients with MHI were evaluated using the following protocol: a standardized physical and neurologic examination in the emergency department, cranial CT scanning, and then admission for observation. MHI was defined as either a documented loss of consciousness or evidence of posttraumatic amnesia and an emergency department Glasgow Coma Scale score of 14 or 15. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, need for craniotomy, and death. Results: Two thousand one hundred fifty-two consecutive patients fulfilled the study protocol. The CT was interpreted as negative for intracranial injury in 1,788, positive in 217, and equivocal in 119. Five patients with CT scans initially interpreted as negative required intervention. There was one craniotomy in a patient whose CT scan was initially interpreted as negative. This patient had facial fractures that required surgical intervention and elevation of depressed intracranial fracture fragments. The negative predictive power of a cranial CT scan based on the preliminary reading of the CT scan and defined by the subsequent need for neurosurgical intervention in the population fully satisfying the protocol was 99.70{\%}. Conclusions: Patients with a cranial CT scan, obtained on a helical CT scanner, that shows no intracerebral injury and who do not have other body system injuries or a persistence of any neurologic finding can be safely discharged from the emergency department without a period of either inpatient or outpatient observation. Implementation of this practice could result in a potential decrease of more than 500,000 hospital admissions annually.",
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AU - Fabian, Timothy C.

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