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Partners Healthcare: Clinical Pathway for Imaging in Mild Traumatic Brain Injury

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Partners Healthcare: Clinical Pathway for Imaging in Mild Traumatic Brain Injury Partners Healthcare: Clinical Pathway for Imaging in Mild Traumatic Brain Injury Please answer the following 3 questions, selecting all of the responses that apply: QUESTION 1: Does the patient have mild traumatic brain injury (MTBI)? Injury to the head, resulting from blunt trauma or acceleration or deceleration forces, AND, ONE OR MORE OF THE FOLLOWING conditions attributable to the head injury: Transient confusion, disorientation, or impaired consciousness Dysfunction of memory (amnesia) around the time of injury Observed signs of other neurologic or neuropsychological dysfunction Loss of consciousness lasting 30 minutes or less QUESTION 2: Is the patient eligible for the clinical pathway? Exclusion Criteria: The patient must have NONE of the following: Penetrating head trauma GCS score < 15 on initial evaluation Age < 16 years Presenting to ED more than 24‐hours after injury Severe Multisystem Trauma, defined as: Hemodynamic instability (HR > 120, SBP <90) Major trauma with suspected or proven life‐threatening injuries QUESTION 3: Did the patient have loss of consciousness (LOC) or post‐traumatic amnesia? YES NO Head CT is unlikely to be helpful UNLESS the Head CT is unlikely to be helpful UNLESS the patient has one or more of the following: patient has one or more of the following: Focal neurologic deficit Focal neurologic deficit Coagulopathy Coagulopathy Vomiting Vomiting GCS score < 15 GCS score < 15 Age > 60 years Age 65 years Headache Severe headache Physical evidence of trauma above the clavicles Physical signs of basilar skull fracture Deficits in short‐term memory Dangerous mechanism of injury (persistent anterograde amnesia) MVC with ejection Pedestrian struck Fall from height of >3feet or 5 steps Post‐traumatic seizure Drug or alcohol intoxication 1 Partners Healthcare: Clinical Pathway for Imaging in Mild Traumatic Brain Injury 2 Partners Healthcare: Clinical Pathway for Imaging in Mild Traumatic Brain Injury Frequently Asked Questions (FAQ): What is the purpose of this clinical pathway? The purpose of this pathway is to improve the appropriateness of imaging for patients with mild traumatic brain injury (MTBI). It designates minimum criteria that should be met prior to ordering a CT scan for patients with MTBI in order to standardize care and reduce unnecessary testing. Am I obligated to get a head CT if my patient meets any of the above criteria? No. You can use another validated clinical decision rule (e.g., the Canadian CT Head Rule) or your clinical judgment in conjunction with a discussion of risks and benefits with the patient to designate patients with MTBI at low risk for intracranial injury and thus not requiring neuroimaging. This goal of this pathway is to designate minimum criteria that should be met prior to performing a CT scan for patients with MTBI, not to ensure that all patients meeting the criteria listed in this pathway receive head CT. What is this pathway based on? This clinical pathway is based on the ACEP Clinical Policy: Neuroimaging and Decisionmaking in Adult Mild Traumatic Brain Injury in the Acute Setting (2008), which was based on a review of current best evidence. It is in compliance with the National Quality Forum‐endorsed quality measure for neuroimaging of patients with mild traumatic brain injury. What is a mild traumatic brain injury? MTBI refers to injury to the head, resulting from blunt trauma or acceleration or deceleration forces, with one or more of the following conditions attributable to the head injury during the surveillance period: . Any period of observed or self‐reported transient confusion, disorientation, or impaired consciousness . Any period of observed or self‐reported dysfunction of memory (amnesia) around the time of injury . Observed signs of other neurologic or neuropsychological dysfunction . Any period of observed or self‐reported loss of consciousness lasting 30 minutes or less. What is post‐traumatic amnesia? Post‐traumatic amnesia is a state of confusion that occurs immediately following a traumatic brain injury in which the patient is disoriented and unable to remember the traumatic event or the events occurring shortly before or after the injury. There are two types of post‐traumatic amnesia: retrograde amnesia (loss of memories that were formed shortly before the injury) and anterograde amnesia (problems with creating new memories after the injury has taken place). What are physical signs of a basal skull fracture? Signs include periorbital ecchymoses (“raccoon eyes”), mastoid bruising (Battle’s sign), cerebrospinal fluid otorrhea/rhinorrhea, or hemotympanum. What constitutes a “coagulopathy?” A coagulopathy consists of a known bleeding disorder (e.g., hemophilia), use of either oral (e.g., warfarin, dabigatran) or parenteral anticoagulants (e.g., unfractionated or low molecular weight heparin). For the purposes of this clinical pathway, use of aspirin, clopidogrel or other antiplatelet agents either alone or in combination is not considered a coagulopathy. 3.
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