CORRESPONDENCE
Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma To the Editor: Despite the regularity with which intoxicated patients present to the emergency department (ED) with head injury, we have limited evidence on which to base our clinical practice. Further, the large variation in the frequency with which intoxicated individuals receive neuroimaging indicates considerable differences in our approaches.1–3 Our ability to use existing guidelines to aid in decisions about whether or not to image these patients is hindered by limitations in the quality of the history and physical examination due to intoxication. The authors of “Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma”4 showed that many significant intracranial injuries would be missed by translating exiting clinical guidelines to intoxicated patients, a finding that highlights the need to further research this understudied, commonly encountered, patient population and clinical scenario. In the absence of an accepted standard practice or evidence-based clinical decision tools for intoxicated patients with possible head injury, it is important to evaluate current practices and to assess the risks, benefits, costs, and effectiveness of varying approaches. At our institution, Bellevue Hospital in New York City, we see multiple intoxicated patients with potential head injuries on every shift. In part to manage our resources efficiently, we have adopted a culture of serial examinations in lieu of early imaging. In the setting of limited resources, having a low threshold to perform computed tomography (CT) scans may delay needed imaging studies for other patients and add to health care costs. Although the radiation exposure associated with a single head CT scan is relatively low, cumulative exposure from repeated CT scans for patients who are frequently brought to the ED for intoxication is of potential significance.2,3,5 On the other hand, the practice of serial examinations has its own less tangible costs. It requires vigilance to ensure that patients are not simply left unattended, may prolong length of stay, and may place patients at risk of delayed diagnosis. Further, the risk of brain injury in this population, or at least the subset that are frequent ED users, is considerable and must be taken into account when adopting a “watchful waiting” approach. In a retrospective series of 51 alcohol-dependent patients having more than nine annual ED visits
220
ISSN 1069-6563 PII ISSN 1069-6563583
each for 2 consecutive years, almost half had evidence of prior focal brain injury, and a quarter had acute intracranial injuries in the 3 years they were followed.3 The lack of consistency in our approach to this common problem, the risk for consequential occult injury, and the inadequate sensitivity of established clinical decision rules demands further attention. Additional study is needed to determine the prevalence and indicators of serious injury in this population and to compare the clinical and cost-effectiveness of differing approaches. Please also note the flaw in units of measure for ethanol; mmol/L should be mg/dL. doi: 10.1111/acem.12307
Ryan P. McCormack, MD ([email protected]) New York University School of Medicine Department of Emergency Medicine New York, NY Supervising Editor: Jeffrey Kline, MD.
References 1. Godbout BJ, Lee J, Newman DH, Bodie EE, Shah K. Yield of head CT in the alcohol-intoxicated patient in the emergency department. Emerg Radiol 2011;18: 381–4. 2. Grover CA, Close RJ, Villarreal K, Goldman LM. Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography. West J Emerg Med 2010;11:336– 43. 3. Hamilton BH, McCormack RT, Sheth A, McCormack RP. Imaging of frequent emergency department users with alcohol use disorders. J Emerg Med. e-pub ahead of publication 10 January 2014. 4. Easter JS, Haukoos JS, Claud J, et al. Traumatic intracranial injury in intoxicated patients with minor head trauma. Acad Emerg Med 2013;20:753–60. 5. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012;380:499–505.
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12307
Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma To the Editor: Despite the regularity with which intoxicated patients present to the emergency department (ED) with head injury, we have limited evidence on which to base our clinical practice. Further, the large variation in the frequency with which intoxicated individuals receive neuroimaging indicates considerable differences in our approaches.1–3 Our ability to use existing guidelines to aid in decisions about whether or not to image these patients is hindered by limitations in the quality of the history and physical examination due to intoxication. The authors of “Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma”4 showed that many significant intracranial injuries would be missed by translating exiting clinical guidelines to intoxicated patients, a finding that highlights the need to further research this understudied, commonly encountered, patient population and clinical scenario. In the absence of an accepted standard practice or evidence-based clinical decision tools for intoxicated patients with possible head injury, it is important to evaluate current practices and to assess the risks, benefits, costs, and effectiveness of varying approaches. At our institution, Bellevue Hospital in New York City, we see multiple intoxicated patients with potential head injuries on every shift. In part to manage our resources efficiently, we have adopted a culture of serial examinations in lieu of early imaging. In the setting of limited resources, having a low threshold to perform computed tomography (CT) scans may delay needed imaging studies for other patients and add to health care costs. Although the radiation exposure associated with a single head CT scan is relatively low, cumulative exposure from repeated CT scans for patients who are frequently brought to the ED for intoxication is of potential significance.2,3,5 On the other hand, the practice of serial examinations has its own less tangible costs. It requires vigilance to ensure that patients are not simply left unattended, may prolong length of stay, and may place patients at risk of delayed diagnosis. Further, the risk of brain injury in this population, or at least the subset that are frequent ED users, is considerable and must be taken into account when adopting a “watchful waiting” approach. In a retrospective series of 51 alcohol-dependent patients having more than nine annual ED visits
220
ISSN 1069-6563 PII ISSN 1069-6563583
each for 2 consecutive years, almost half had evidence of prior focal brain injury, and a quarter had acute intracranial injuries in the 3 years they were followed.3 The lack of consistency in our approach to this common problem, the risk for consequential occult injury, and the inadequate sensitivity of established clinical decision rules demands further attention. Additional study is needed to determine the prevalence and indicators of serious injury in this population and to compare the clinical and cost-effectiveness of differing approaches. Please also note the flaw in units of measure for ethanol; mmol/L should be mg/dL. doi: 10.1111/acem.12307
Ryan P. McCormack, MD ([email protected]) New York University School of Medicine Department of Emergency Medicine New York, NY Supervising Editor: Jeffrey Kline, MD.
References 1. Godbout BJ, Lee J, Newman DH, Bodie EE, Shah K. Yield of head CT in the alcohol-intoxicated patient in the emergency department. Emerg Radiol 2011;18: 381–4. 2. Grover CA, Close RJ, Villarreal K, Goldman LM. Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography. West J Emerg Med 2010;11:336– 43. 3. Hamilton BH, McCormack RT, Sheth A, McCormack RP. Imaging of frequent emergency department users with alcohol use disorders. J Emerg Med. e-pub ahead of publication 10 January 2014. 4. Easter JS, Haukoos JS, Claud J, et al. Traumatic intracranial injury in intoxicated patients with minor head trauma. Acad Emerg Med 2013;20:753–60. 5. Pearce MS, Salotti JA, Little MP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. Lancet 2012;380:499–505.
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12307
