Department of Emergency Medicine, UC Davis School of Medicine, Sacramento, CA, USA.
Acad Emerg Med. 2013 Feb;20(2):140-5. doi: 10.1111/acem.12074.
OBJECTIVES: Appropriate use of cranial computed tomography (CT) scanning in patients with mild blunt head trauma and preinjury anticoagulant or antiplatelet use is unknown. The objectives of this study were: 1) to identify risk factors for immediate traumatic intracranial hemorrhage (tICH) in patients with mild head trauma and preinjury warfarin or clopidogrel use and 2) to derive a clinical prediction rule to identify patients at low risk for immediate tICH. METHODS: This was a prospective, observational study at two trauma centers and four community hospitals that enrolled adult emergency department (ED) patients with mild blunt head trauma (initial ED Glasgow Coma Scale [GCS] score 13 to 15) and preinjury warfarin or clopidogrel use. The primary outcome measure was immediate tICH, defined as the presence of ICH or contusion on the initial cranial CT. Risk for immediate tICH was analyzed in 11 independent predictor variables. Clinical prediction rules were derived with both binary recursive partitioning and multivariable logistic regression. RESULTS: A total of 982 patients with a mean (± standard deviation [SD]) age of 75.4 (±12.6) years were included in the analysis. Sixty patients (6.1%; 95% confidence interval [CI] = 4.7% to 7.8%) had immediate tICH. History of vomiting (relative risk [RR] = 3.53; 95% CI = 1.80 to 6.94), abnormal mental status (RR = 2.85; 95% CI = 1.65 to 4.92), clopidogrel use (RR = 2.52; 95% CI = 1.55 to 4.10), and headache (RR = 1.81; 95% CI = 1.11 to 2.96) were associated with an increased risk for immediate tICH. Both binary recursive partitioning and multivariable logistic regression were unable to derive a clinical prediction model that identified a subset of patients at low risk for immediate tICH. CONCLUSIONS: While several risk factors for immediate tICH were identified, the authors were unable to identify a subset of patients with mild head trauma and preinjury warfarin or clopidogrel use who are at low risk for immediate tICH. Thus, the recommendation is for urgent and liberal cranial CT imaging in this patient population, even in the absence of clinical findings.
目的：在患有轻度钝性头部创伤且有预先抗凝或抗血小板治疗的患者中，头颅 CT 扫描的合理应用尚不清楚。本研究的目的是：1）确定有预先使用华法林或氯吡格雷的轻度头部创伤患者发生即刻外伤性颅内出血（tICH）的危险因素；2）制定一种临床预测规则，以确定低危即刻 tICH 患者。
方法：这是在两个创伤中心和四个社区医院进行的前瞻性、观察性研究，纳入了伴有轻度钝性头部创伤（初始急诊格拉斯哥昏迷量表[GCS]评分 13-15 分）且有预先使用华法林或氯吡格雷的成年急诊患者。主要结局指标为即刻 tICH，定义为初始头颅 CT 上存在颅内出血或挫伤。对 11 个独立预测变量进行即刻 tICH 的风险分析。使用二元递归分区和多变量逻辑回归来制定临床预测规则。
结果：共纳入 982 例平均（±标准差[SD]）年龄 75.4（±12.6）岁的患者。60 例（6.1%；95%置信区间[CI]为 4.7%至 7.8%）患者发生即刻 tICH。呕吐史（相对风险[RR] = 3.53；95%CI = 1.80 至 6.94）、意识状态异常（RR = 2.85；95%CI = 1.65 至 4.92）、氯吡格雷使用（RR = 2.52；95%CI = 1.55 至 4.10）和头痛（RR = 1.81；95%CI = 1.11 至 2.96）与即刻 tICH 风险增加相关。二元递归分区和多变量逻辑回归均无法确定一种能够识别出低危即刻 tICH 患者亚组的临床预测模型。
结论：尽管确定了一些即刻 tICH 的危险因素，但作者未能确定轻度头部创伤且预先使用华法林或氯吡格雷的患者中有哪些亚组患者为即刻 tICH 的低危人群。因此，建议在这类患者人群中紧急且广泛地进行头颅 CT 成像，即使没有临床发现。
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