CORRESPONDENCE
Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma To the Editor: We thank Dr. Easter and colleagues for addressing a very important aspect of minor head injury management, i.e., dealing with the intoxicated patient.1 The authors’ findings regarding the Canadian Computed Tomography Head Rule (CCHR) are quite at odds with our findings in two very large prospective and multicenter cohort studies (n = 3,121 and n = 2,707), which found the CCHR to be 100% sensitive for need for neurosurgical intervention and for clinically important brain injury.2,3 These two studies combined had 777 of 5,828 (13.3%) patients judged to have drug/alcohol intoxication, a sample size two and a half times that of the current study. In neither study did we find an association between intoxication and the presence of clinically important injury. Several issues should be considered in assessing the current study: 1. A low sample size with very small number of important outcomes. 2. The number of clinically unimportant injuries was not clarified; the CCHR was not designed to identify patients who generally do not require treatment or follow-up. 3. No explicit assessment of the complete CCHR (only its components), and no training on its use. We can assume that these physicians had little familiarity with the CCHR.4,5 4. Specificity was not reported in this study, but the New Orleans Criteria were previously found to be 12.7% versus 50.6% for CCHR.3 While intoxication is a very common component of minor head injury, careful application of the CCHR to such patients will ensure that no important injuries are
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12306
missed and that clinicians can be efficient and pragmatic in their use of imaging. Clinical assessment is alive and well in the ED! doi: 10.1111/acem.12306
Ian G. Stiell, MD, MSc, FRCPC ([email protected]) Jeffrey J. Perry, MD, MSc, CCFP-EM Department of Emergency Medicine University of Ottawa Ottawa Hospital Research Institute Ottawa, Ontario, Canada Supervising Editor: Jeffrey Kline, MD.
References 1. 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. 2. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391–6. 3. Stiell IG, Clement C, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA 2005;294:1151–8. 4. Stiell IG, Greenberg GH, McKnight RD, Wells GA. The “real” Ottawa ankle rules. Ann Emerg Med 1996;27:103–4. 5. Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33:437–47.
ISSN 1069-6563 PII ISSN 1069-6563583
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Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma To the Editor: We thank Dr. Easter and colleagues for addressing a very important aspect of minor head injury management, i.e., dealing with the intoxicated patient.1 The authors’ findings regarding the Canadian Computed Tomography Head Rule (CCHR) are quite at odds with our findings in two very large prospective and multicenter cohort studies (n = 3,121 and n = 2,707), which found the CCHR to be 100% sensitive for need for neurosurgical intervention and for clinically important brain injury.2,3 These two studies combined had 777 of 5,828 (13.3%) patients judged to have drug/alcohol intoxication, a sample size two and a half times that of the current study. In neither study did we find an association between intoxication and the presence of clinically important injury. Several issues should be considered in assessing the current study: 1. A low sample size with very small number of important outcomes. 2. The number of clinically unimportant injuries was not clarified; the CCHR was not designed to identify patients who generally do not require treatment or follow-up. 3. No explicit assessment of the complete CCHR (only its components), and no training on its use. We can assume that these physicians had little familiarity with the CCHR.4,5 4. Specificity was not reported in this study, but the New Orleans Criteria were previously found to be 12.7% versus 50.6% for CCHR.3 While intoxication is a very common component of minor head injury, careful application of the CCHR to such patients will ensure that no important injuries are
© 2014 by the Society for Academic Emergency Medicine doi: 10.1111/acem.12306
missed and that clinicians can be efficient and pragmatic in their use of imaging. Clinical assessment is alive and well in the ED! doi: 10.1111/acem.12306
Ian G. Stiell, MD, MSc, FRCPC ([email protected]) Jeffrey J. Perry, MD, MSc, CCFP-EM Department of Emergency Medicine University of Ottawa Ottawa Hospital Research Institute Ottawa, Ontario, Canada Supervising Editor: Jeffrey Kline, MD.
References 1. 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. 2. Stiell IG, Wells GA, Vandemheen K, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet 2001;357:1391–6. 3. Stiell IG, Clement C, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA 2005;294:1151–8. 4. Stiell IG, Greenberg GH, McKnight RD, Wells GA. The “real” Ottawa ankle rules. Ann Emerg Med 1996;27:103–4. 5. Stiell IG, Wells GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33:437–47.
ISSN 1069-6563 PII ISSN 1069-6563583
221 221
