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Utility of Repeat Head Computed Tomography for Intracranial Hemorrhage After Trauma and Importance of Direct Patient Care

Zimmermann, Mary Ellen BSN; Brown, Zachary DO; Matemavi, Praise DO; Melnic, Gloria MSN; Sample, Jason MD

doi: 10.1097/JTN.0000000000000232
RESEARCH
Open

At many institutions, it is common practice for trauma patients with traumatic intracranial hemorrhage (ICH) to receive routine repeat head computed tomographic (CT) scans after the initial CT scan, regardless of symptoms, to evaluate progression of the injury. The purpose of this study was to assess quantifiable risk factors (age, anticoagulation, gender) that could place patients at greater risk for progression of injury, thus requiring surgical intervention (craniotomy, craniectomy) for which serial CT scanning would be useful. From January 2014 to June 2015, a total of 211 patients presented with traumatic ICH and 198 were eligible for inclusion. Twenty-six patients required operative intervention for ICH. One of 26 patients went to the operating room as a result of repeat head CT scans without associated mental status change, change in neurological examination, or associated symptoms such as nausea or vomiting. Significant changes in patient management due to routine repeat CT scans were not observed. There were no statistically significant risk factors identified to place patients at higher risk for progression of disease. The data from this analysis emphasized the importance of nursing care in identifying and relaying changes in patient condition to the trauma team.

NewYork-Presbyterian/Queens, Flushing, New York.

Correspondence: Mary Ellen Zimmermann, BSN, NewYork-Presbyterian/Queens, 56-45 Main St, Flushing, NY 11355 (Maz9026@nyp.org).

The authors declare no conflicts of interest.

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

At many institutions, it is common practice for trauma patients with traumatic intracranial hemorrhage (ICH) to receive routine repeat head computed tomographic (CT) scans after the initial CT scan, regardless of symptoms, to assess progression of the injury (Brown, 2004). Recent studies have shown there is limited value in repeated head CT scans in patients with traumatic ICH and stable neurological examination. Joseph et al. (2014) showed repeat head CT scans are not warranted in patients with stable neurological examination. A limitation of this study by Brown (2004) is the exclusion of patients on anticoagulation medication.

An additional study performed by Docimo, Demin, and Vinces (2014) showed the risk of delayed head bleed in those taking anticoagulation but failed to show whether repeat head CT scans were warranted. Rubino et al. (2014) studied the use of outpatient repeat head CT scans in asymptomatic patients after nonoperative cerebral contusion and traumatic subarachnoid hemorrhage and demonstrated repeat scans were unlikely to demonstrate significant new pathology and repeat imaging should be reserved for patients with significant symptoms or focal neurological findings. Similarly, Probst et al. (2009) found that a vast majority of significant findings on CT scans will present with neurological change. On the contrary, Kreitzer et al. (2014) concluded that discharge from the emergency department after traumatic brain injury with a period of observation and stable repeat head CT scans were both safe and cost-effective.

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PURPOSE

The purpose of this study was to determine whether repeat head CT scans were warranted in traumatic ICH patients without additional findings on physical examination such as neurological changes, altered mental status, or nausea and vomiting. Additional aims were to identify patients in the high-risk groups who were more likely to receive operative intervention and may benefit from routine repeat head CT scans. The subsets identified were age, gender, and use of anticoagulation or antiplatelet therapy.

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METHODS

The NewYork-Presbyterian/Queens trauma registry was utilized for a retrospective medical record review of adult trauma patients over an 18-month period from January 2014 to June 2015 for patients admitted to the hospital with the diagnosis of ICH, including subdural, epidural, subarachnoid, and intraparenchymal, with a traumatic cause regardless of mechanism of injury. NewYork-Presbyterian/Queens Institutional Review Board approval was obtained for this study.

Patients suffering hemorrhagic stroke were excluded from the study. Patients whose family members decided to withdraw or withhold care prior to operative intervention were also excluded from the study. Age criteria included adult trauma patients defined as those 15 years and older. Patients were then subdivided to investigate whether age, gender, or history of anticoagulation medication predisposed patients to progressing to require operative intervention. Fisher's exact test was performed to observe statistical significance.

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RESULTS

From January 2014 to June 2015, a total of 1,827 patients were admitted with a traumatic injury. Of those, 211 (12%) patients were admitted with a diagnosis of ICH. Thirteen of the 211 patients died on arrival, or families decided not to pursue an operation and were excluded from the study. Of the 198 eligible patients, 28 required operative intervention for ICH. All of the patients (N = 172) were admitted with ICH who did not go to the operating room for surgical intervention; of which, all patients received repeat head CT scans (Table 1).

TABLE 1

TABLE 1

Twenty-six patients underwent an operation; of which, 14 patients went to the operating room on the basis of initial CT and physical examination findings. Twelve of the 26 patients who received operative intervention went to the operating room on the basis of changes in physical examination. Eleven of the 12 patients had changes in mental status or neurological examination and one of the 12 patients had nausea and vomiting. One of the 26 patients who received operative intervention went as a result of repeat head CT scans without associated physical examination changes (Table 2).

TABLE 2

TABLE 2

Thirty-six of the 198 patients admitted with traumatic ICH were on anticoagulation therapy; of which, six went to the operating room, whereas 30 did not require an operation, with no significant difference between the two groups (p = .58). Seven of the 26 patients who received operative intervention were 65 years or older, whereas 59 patients were 65 years or older who did not undergo an operation, with no significant difference between the two groups (p = .51). In addition, 17 patients who went to the operating room were men, with nine women undergoing an operation, with again no significance between the two groups (p = .52) (Table 3).

TABLE 3

TABLE 3

Of the 26 patients in whom an operation was necessitated, 25 had valid nursing neurological assessments documented. Of the 12 who received operative intervention after changes in neurological examination, 12 had valid nursing neurological assessments documented. This study brings awareness to the importance of nursing assessment, specifically pertaining to changes in neurological status. According to Pangilinan, Kelly, and Hornyak (2012), initial and repeat neurological assessments are essential for early detection of neurological changes, which can often be subtle (Table 4).

TABLE 4

TABLE 4

Iavagnilo (2011) points out that a failure to timely diagnose can result in the escalation of a condition for which the treatment options are no longer viable. To combat this and other preventable complications in patients with ICH, the American College of Surgeons (2015) Trauma Quality Improvement Program offers a set of best practice guidelines for the management of traumatic brain injury. An alteration in mental status, deviation from the baseline Glasgow Coma Scale score, and pupillary response, as well as a change in vital signs such as blood pressure, pulse, and temperature, should prompt the attention of the nurse. A patient's neurological deterioration must then be communicated with the appropriate parties. In our study, the nurses communicated with the surgical residents, prompting their direct attention. Actions in the form of repeat head CT scans and further operation interventions were taken, all stemming from the nurse's excellent neurologic examination.

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LIMITATIONS

The main limitation of this study was not subdividing the classification of traumatic ICH into subdural, epidural, subarachnoid, and intraparenchymal hemorrhages, as well as mechanism of injury, as there were not enough patients in the study to produce significant power.

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CONCLUSIONS

It has been demonstrated in previous studies that there is little use of routine repeat head CT scans in patients with traumatic ICH, as the repeat scans will not change management. Of patients who need operative management, the majority have associated physical examination changes, which prompt intervention. Similar results were found at our institution, with one patient having a CT scan that prompted surgical intervention without associated physical examination changes.

In addition, there were no patient characteristics such as age, gender, or use of anticoagulation that placed patients at higher risk for surgical intervention with statistical significance. Therefore, none of these characteristics are reliable for patients who should receive routine repeat head CT scans after traumatic ICH. The only consistent finding in this study and others was patients who had associated mental status or physical examination changes should prompt repeat imaging and possible operative intervention, emphasizing the importance of nursing care in identifying and relaying changes in a patient's condition to the surgical team.

Findings suggest the importance of adequate nursing care in identifying and relaying changes in a patient's condition. Communication between the nurse(s) and the surgical team is crucial to the effectiveness of this process.

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KEY POINTS

  • Routine use of repeat head CT scans did not change the management of patients with traumatic ICH.
  • Use of anticoagulation, age, and gender did not predict progression of traumatic ICH to require operative intervention.
  • Vigilance of nursing staff to report changes in the patient's condition can help identify patients requiring neurosurgical intervention.
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REFERENCES

American College of Surgeons. (2015). ACS TQIP best practices in the management of traumatic brain injury. Retrieved from https://www.facs.org/∼/media/files/quality%20programs/trauma/tqip/traumatic%20brain%20injury%20guidelines.ashx
    Brown C. V., Weng J., Oh D., Salim A., Kasotakis G., Demetriades D., Rhee P. (2004). Does routine serial computed tomography of the head influence management of traumatic brain injury? A prospective evaluation. Journal of Trauma and Acute Care Surgery, 57(5), 939–943.
    Docimo S., Demin A., Vinces F. (2014). Patients with blunt head trauma on anticoagulation and antiplatelet medications: Can they be safely discharged after a normal initial cranial computed tomography scan? The American Surgeon, 80(6), 610–613.
    Iavagnilo C. L. (2011). Traumatic brain injury: Improving the patient's outcome demands timely and accurate diagnosis. Journal of Legal Nurse Consulting, 22(3), 3–9.
    Joseph B., Aziz H., Pandit V., Kulvatunyou N., Hashmi A., Tang A., Friese R. S. (2014). A three-year prospective study of repeat head computed tomography in patients with traumatic brain injury. Journal of the American College of Surgeons, 219(1), 45–51.
    Kreitzer N., Lyons M. S., Hart K., Lindsell C. J., Chung S., Yick A., Bonomo J. (2014). Repeat neuroimaging of mild traumatic brain-injured patients with acute traumatic intracranial hemorrhage: Clinical outcomes and radiographic features. Academic Emergency Medicine, 21(10), 1083–1091.
    Pangilinan P. H., Kelly B. M., Hornyak J. E. (2012). Classification and complications of traumatic brain injury. Medscape. Retrieved from http://emedicine.medscape.com/article/326643-overview
    Probst M. A., Baraff L. J., Hoffman J. R., Wolfson A. B., Ourian A. J., Mower W. R. (2009). Can patients with brain herniation on cranial computed tomography have a normal neurologic exam? Academic Emergency Medicine, 16(2), 145–150.
    Rubino S., Zaman R. A., Sturge C. R., Fried J. G., Desai A., Simmons N. E., Lollis S. S. (2014). Outpatient follow-up of nonoperative cerebral contusion and traumatic subarachnoid hemorrhage: Does repeat head CT alter clinical decision-making? Journal of Neurosurgery, 121(4), 944–949.
    Keywords:

    Computed tomography; Neurological examination; Traumatic brain injury

    Copyright © 2016 by the Society of Trauma Nurses.