Clement Catherine M, Stiell Ian G, Schull Michael J, Rowe Brian H, Brison Robert, Lee Jacques S, Perry Jeffrey J, Wells George A
Clinical Epidemiology Program, University of Ottawa, Ottawa, Ontario, Canada.
Ann Emerg Med. 2006 Sep;48(3):245-51. doi: 10.1016/j.annemergmed.2006.04.008. Epub 2006 Jun 12.
Emergency physicians are concerned about minor head injury patients who present with a Glasgow Coma Scale (GCS) score of 15 yet require neurosurgical intervention. Our objectives are to determine the accuracy of the Canadian CT Head Rule (CCHR) in this important subset, the prevalence of patients requiring urgent intervention, and their clinical course and possible warning signs.
We conducted a secondary data analysis of the CCHR study cohorts from 10 hospital emergency departments (EDs). We included head trauma patients with witnessed loss of consciousness, disorientation, or definite amnesia and who presented with an initial GCS score of 15. Records were reviewed and specific variables added to the database. The primary outcome was need for urgent neurosurgical intervention.
Among the 4,551 study patients, only 26 (0.6%; 95% confidence interval [CI] 0 to 1.0%) required neurosurgical intervention, and the CCHR identified all 26 cases with 100% sensitivity. Eleven patients required "urgent" craniotomy within 7 days, and of those, 2 patients deteriorated precipitously. These 11 (0.2%; 95% CI 0.1% to 0.3%) cases had additional signs: GCS score decrease within 6 hours (82%), GCS score decrease within 3 hours (73%), confusion (64%), any vomiting (36%), focal temporal blow (36%), restlessness (36%), and severe headache (45%).
For patients with minor head injury and GCS score of 15, urgent neurosurgical intervention and precipitous deterioration are rare. The CCHR accurately identified all patients requiring neurosurgical intervention. Warning signs that may portend need for urgent intervention include any vomiting, restlessness, any GCS score decrease, severe headache, confusion, and focal temporal blow.
急诊医生关注格拉斯哥昏迷量表（GCS）评分为15分但仍需要神经外科干预的轻度头部受伤患者。我们的目标是确定加拿大头部CT规则（CCHR）在这一重要亚组中的准确性、需要紧急干预的患者的患病率、他们的临床病程以及可能的警示信号。
我们对来自10家医院急诊科（ED）的CCHR研究队列进行了二次数据分析。我们纳入了有目击意识丧失、定向障碍或明确失忆且初始GCS评分为15分的头部创伤患者。对记录进行了审查，并将特定变量添加到数据库中。主要结局是是否需要紧急神经外科干预。
在4551名研究患者中，只有26名（0.6%；95%置信区间[CI]为0至1.0%）需要神经外科干预，CCHR以100%的灵敏度识别出了所有26例病例。11名患者在7天内需要“紧急”开颅手术，其中2名患者病情急剧恶化。这11例（0.2%；95%CI为0.1%至0.3%）病例有其他体征：6小时内GCS评分下降（82%）、3小时内GCS评分下降（73%）、意识模糊（64%）、任何呕吐（36%）、颞部局部打击伤（36%）、烦躁不安（36%）和严重头痛（45%）。
对于轻度头部受伤且GCS评分为15分的患者，紧急神经外科干预和病情急剧恶化很少见。CCHR准确识别出了所有需要神经外科干预的患者。可能预示需要紧急干预的警示信号包括任何呕吐、烦躁不安、任何GCS评分下降、严重头痛、意识模糊和颞部局部打击伤。
