Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries

The Scandinavian Neurotrauma Committee (SNC) published practical, evidence based guidelines for children with Glasgow Coma Scale (GCS) scores of 9-15.

The Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults (Scandinavian guidelines) are the first to incorporate serum measurement of the S100 astroglial calcium-binding protein B (S100B) to emergency department (ED) triage of patients with head injury (HI).

1).


A prospective validation study was conducted in the ED of the Tampere University Hospital, Finland, between November 2015 to November 2016. All consecutive adult patients with HI presenting to the ED within 24 hours from injury were eligible for inclusion. Venous blood for S100B sampling was drawn from all patients and the result was available at the ED. Head CTs were performed according to the on-call physician’s evaluation. Only the samples collected within 6 hours after injury were used. A one-week follow-up was conducted to identify possible HI-related complications. A total of 295 patients (median age=67.0 years, range=18-100; women=48.8%) were enrolled. Of those, 196 (66.4%) were scanned. Acute traumatic lesions were detected on 31 (15.8%) of the scans. Two of the CT-positive patients were scanned without a guidelines-based indication. These lesions did not require any specific treatment or repeated imaging. The guidelines-based sensitivity was 0.94 (95% CI=0.77-0.99) and specificity 0.19 (95% CI=0.13-0.26) for predicting traumatic intracranial CT abnormalities. The positive and negative predictive value for positive head CT was 0.18 (95% CI=0.12-0.25) and 0.94 (95% CI=0.78-0.99), respectively. In the mild-low risk group, no false negative S100B values were recorded. Thirteen patients (4.4%) were re-admitted to the ED and 2 patients (0.7%) died one week after the primary HI. The deaths were unrelated to the injury. None of these adverse events were directly caused by a primarily undiagnosed intracranial injury. The Scandinavian guidelines incorporated with S100B are a valid means of screening clinically significant acute traumatic lesions following HI and have the potential to reduce unnecessary CT scanning 2).


In a large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, they compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13-15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT.

The SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1-100.0; 32/32), 97.8% (94.5-99.4; 179/183) and 95% (95% CI 91.6-97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs.

The SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI 3).

References

1)

Ingebrigtsen T, Romner B, Kock-Jensen C. Scandinavian guidelines for initial management of minimal, mild, and moderate head injuries. The Scandinavian Neurotrauma Committee. J Trauma. 2000 Apr;48(4):760-6. PubMed PMID: 10780615.
2)

Minkkinen M, Iverson GL, Kotilainen AK, Pauniaho SL, Mattila V, Lehtimäki T, Berghem K, Posti JP, Luoto TM. Prospective Validation of the Scandinavian Guidelines for Initial Management of Minimal, Mild, and Moderate Head Injuries in Adults. J Neurotrauma. 2019 May 21. doi: 10.1089/neu.2018.6351. [Epub ahead of print] PubMed PMID: 31111795.
3)

Undén J, Dalziel SR, Borland ML, Phillips N, Kochar A, Lyttle MD, Bressan S, Cheek JA, Neutze J, Donath S, Hearps S, Oakley E, Dalton S, Gilhotra Y, Babl FE; Paediatric Research in Emergency Departments International Collaborative (PREDICT). External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC Med. 2018 Oct 12;16(1):176. doi: 10.1186/s12916-018-1166-8. PubMed PMID: 30309392; PubMed Central PMCID: PMC6182797.

Book: Nerves and Nerve Injuries

Nerves and Nerve Injuries: Vol 1: History, Embryology, Anatomy, Imaging, and Diagnostics

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Nerves and Nerve Injuries: Vol 2: Pain, Treatment, Injury, Disease and Future Directions

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Nerves and Nerve Injuries is the first comprehensive work devoted to the nerves of the body. An indispensable work for anyone studying the nerves or treating patients with nerve injuries, these books will become the ‘go to’ resource in the field. The nerves are treated in a systematic manner, discussing details such as their anatomy (both macro- and microscopic), physiology, examination (physical and imaging), pathology, and clinical and surgical interventions. The authors contributing their expertise are international experts on the subject. The books cover topics from detailed nerve anatomy and embryology to cutting-edge knowledge related to treatment, disease and mathematical modeling of the nerves.
Nerves and Nerve Injuries Volume 1 focuses on the history of nerves, embryology, anatomy, imaging, and diagnostics. This volume provides a greatly detailed overview of the anatomy of the peripheral and cranial nerves as well as comprehensive details of imaging modalities and diagnostic tests.

  • Detailed anatomy of the peripheral and cranial nerves including their history and ultrastructure
  • Comprehensive details of the imaging modalities and diagnostic tests used for viewing and investigating the nerves
  • Authored by leaders in the field around the globe – the broadest, most expert coverage available.

Nerves and Nerve Injuries Volume 2 focuses on pain, treatment, injury, disease and future directions in the field. This volume also addresses new information regarding neural interfaces, stem cells, medical and surgical treatments, and medical legal issues following nerve injury.

  • Most up-to-date comprehensive overview available on nerves and nerve injuries
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Product Details

  • Published on: 2015-05-07
  • Original language: English
  • Dimensions: 11.00″ h x 8.75″ w x 2.00″ l, 5.47 pounds
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Editorial Reviews

From the Back Cover
This long overdue update of Sydney Sunderland’s classic Nerves and Nerve Injuries is a must-have for clinicians and researchers dealing with the PNS and neuropathy. The third has been created as an edited work emphasizing the importance of considering the anatomical, physiological, pathological, and clinical aspects of the nervous system in concert for a better understanding of nerve injuries and their treatment. Constituting an organized review of our current understanding of peripheral nerve injury and repair, this edition also makes more readily available analyses of the various morphological and topographical aspects of the PNS.
Major sections of the work will address: anatomical and physiological features of peripheral nerve fibers and nerve trunks; degeneration, regeneration a classification of nerve injury; clinico-pathological considerations; bones, joints, muscles, and motor function; peripheral sensory mechanisms; peripheral sympathetic mechanisms; diagnosis and treatment; and individual nerves.
About the Author
Dr. Tubbs is lead researcher in Pediatric Neurosurgery. He is Editor-in-Chief of the journal Clinical Anatomy, is author/editor of multiple books, and is a new editor for the 41st edition of Gray’s Anatomy.
Dr. Rizk is a neurosurgeon at the Penn State Hershey Medical Center with a clinical specialty in pediatric peripheral nerve surgery. He has multiple publications on the PNS and is active in basic science research regarding peripheral nerve regeneration.
Physician and anatomist for the Department of Ophthalmology at the Indiana University School of Medicine who has written extensively in the field of anatomy and on the peripheral nerves.
Chair and Professor in the Department of Anatomical Sciences at St. George’s University who has written extensively in the field of anatomy and on the peripheral nerves.
Dr. Robert Spinner is a neurosurgeon in Rochester, Minnesota. He is affiliated with multiple hospitals in the area, including Mayo Clinic and Mayo Clinic – Saint Marys Hospital. He received his medical degree from Mayo Medical School and has been in practice for 25 years. He is one of 17 doctors at Mayo Clinic and one of 13 at Mayo Clinic – Saint Marys Hospital who specialize in Neurological Surgery.
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