In the last few days Twitter has been buzzing (does twitter buzz? Or does it chirp? Tweet?) with EM practitioners getting to grips with the latest iteration of the NICE Head Injury Clinical Guideline, updated this month to CG176. The BMJ has produced a nice summary but sadly it’s behind a paywall – so here’s my FOAM version.
Updated? But I’ve Just Learned It All For FCEM..!
For ED clinicians in the UK, the guidelines define our management of patients with “any trauma to the head other than superficial injuries to the face”; there are departmental pathways and protocols based on this document across the UK.
The previous incarnation of the guideline (CG56) was updated in 2007, prior to the publication of major bodies of research into trauma management (including CRASH 2 and a whole host of studies from the TARN network) and into the decisions we make when we see patients with head injuries who take anticoagulants and antiplatelet agents – like this study we looked at in the St Emlyn’s Journal Club in Virchester (and this review of the clinical challenges of anticoagulated patients by Rick).
We’ve also seen, in Virchester at least, the development of a major trauma network whereby patients are triaged in the pre-hospital setting and transported not to the nearest ED but to the ED best suited to their constellation of injuries and clinical need (or, at least, that’s the idea). I have certainly seen far fewer traumatic brain injuries in the last two years and while I’d like to believe it’s because our local population have suddenly realised they can have a good night out while intoxicating themselves to a responsible degree, other attendances suggest that just isn’t the whole story.
So, here are the headlines of the new NICE Head Injury Guidelines and what they mean for our ED practice. I would strongly suggest you take the time to read the guidelines themselves too. But if you have some upcoming exams this might serve as a revision note
Patients being transported by ambulance should be transported to a hospital which has resources to resuscitate them and to manage patients with multiple injuries. This is recommended relative to the patient’s age (children to a trauma receiving PED, adults to a trauma unit or major trauma centre) and is probably (hopefully) standard care through major trauma pathways across the UK.
NICE recommends that a clinician with training in safeguarding should be involved in the initial assessment of patients with head injuries and that safeguarding concerns should be acted upon in accordance with local safeguarding procedures. This is an important reminder that many head injuries are non-accidental – especially in paediatric patients (10% of kids presenting as major trauma were NAI in this Australian study) – and that we have a duty of ongoing care towards vulnerable patients (which may include the elderly, victims of domestic violence irrespective of gender or sexuality, the homeless and those with drug and alcohol addiction).
Criteria for Performing a CT Scan
The most notable addition in this section is that, irrespective of the reason for the scan, NICE recommends that a provisional written radiology report should be made available within one hour of the scan.
Firstly, the criteria for an “immediate” (<1 hour) and “delayed” (within 8 hours) scan look similar:
The indications for “immediate” scan in paediatric patients have changed (which is great news, since the guidelines now reflect the approach suggested by Gareth in his great post about paediatric head injury management). There are two lists; stand alone indications for CT scan and signs which, when found in combination (and in the absence of the “immediate” indicators) should also prompt imaging:
Children who only have one of the findings in the second list should be observed for a minimum of four hours (I’m not entirely sure whether this is an evidence-based timeframe) and CT performed if GCS is persistently <15, there is further vomiting or the child is abnormally drowsy. NICE advises clinical discretion for decisions about ongoing observation or disposal if none of these features develops within the 4 hour observation time.
Patients on Warfarin
For adults and children on warfarin presenting with head injury in the absence of other indications for a CT scan should have a CT brain within 8 hours. This has caused some consternation in twitter conversations but actually I don’t think this is very different from how I practice at present. I would have to have a really good reason not to request a CT head on a warfarinised patient with a head injury, however minor. Happy to hear your thoughts on this though!
To find specific mention of the management of patients on other anticoagulant/antiplatelet agents, you need to delve a bit deeper into the full guideline. Pages 109-114 outline the evidence base for decisions made by NICE regarding indications for scan in anticoagulated patients. The separation of warfarin from other anticoagulant agents is further justified on pages 119-122 along with a research recommendation, since it is difficult to extrapolate from existing studies whether patients on other anticoagulant/antiplatelet agents would have had CT scans under the prior guideline (and therefore where there would be clinical benefit from recommending an alternative approach). The Guideline Development Group adds:
…limited evidence has been identified for patients using other antiplatelet or anticoagulant drugs within studies deriving or validating clinical decision rules for determining which patients need CT head scans. There is a particular paucity of evidence in determining whether they are at increased risk of intracranial haemorrhage.
A study with appropriate economic evaluation is needed to quantify the risk of taking these drugs over and above the risk factors included in an existing clinical decision rule.
For now, then, the management of patients on these agents is incorporated in the “history of loss of consciousness or amnesia” section of the guideline (it looks like “history of bleeding/clotting disorder” includes treatment with aspirin, clopidogrel etc.) and outside of these circumstances whether or not the patient should be scanned remains a matter of clinical discretion.
Cervical Spine Imaging
The indications for CT scanning of the cervical spine look a little different too, now including “softer” indications such as “definitive diagnosis of cervical spine injury is urgently needed.”
It’s worth noting the advice on C-spine clearance too. In patients without indication for CT cervical spine but for whom it is not considered “safe” to assess range of movement (or who are unable to laterally rotate at least 45 degrees to both sides), traditional 3-view plain radiographs are recommended and these should be reviewed by a clinician trained in their interpretation within one hour.
Safe assessment of movement is determined by the absence of high risk features (i.e. an indication for CT scan) and the presence of low risk features in an algorithm reminiscent of the Canadian C-Spine rule:
Patients discharged from ED or observation ward after head injury should be given advice in verbal and written format, shared also with their families and carers. NICE has produced suggested content for printed discharge advice leaflets which now includes details of support organisation Headway, presumably reflecting increased research into and recognition of the post-concussion syndrome after mild traumatic brain injury; most departments have these and their provision should be documented in the notes (my advice!).
So there you have it: check out the full NICE Guidance here. For my practice, the changes seem sensible and reflect what we have been doing (or trying to do); hopefully those conversations with Radiology will continue to get easier. If not, try giving the Radiologists cake. It works for me.