Traumatic Intracranial Injury in Intoxicated Patients With Minor Head Trauma

Objectives Studies focusing on minor head injury in intoxicated patients report disparate prevalences of intracranial injury. It is unclear if the typical factors associated with intracranial injury in published clinical decision rules for computerized tomography (CT) acquisition are helpful in differentiating patients with and without intracranial injuries, as intoxication may obscure particular features of intracranial injury such as headache and mimic other signs of head injury such as altered mental status. This study aimed to estimate the prevalence of intracranial injury following minor head injury (Glasgow Coma Scale [GCS] score ≥14) in intoxicated patients and to assess the performance of established clinical decision rules in this population. Methods This was a prospective cohort study of consecutive intoxicated adults presenting to the emergency department (ED) following minor head injury. Historical and physical examination features included those from the Canadian CT Head Rule, National Emergency X-Radiography Utilization Study (NEXUS), and New Orleans Criteria. All patients underwent head CT. Results A total of 283 patients were enrolled, with a median age of 40 years (interquartile range [IQR] = 28 to 48 years) and median alcohol concentration of 195 mmol/L (IQR = 154 to 256 mmol/L). A total of 238 of 283 (84%) were male, and 225 (80%) had GCS scores of 15. Clinically important injuries (injuries requiring admission to the hospital or neurosurgical follow-up) were identified in 23 patients (8%; 95% confidence interval [CI] = 5% to 12%); one required neurosurgical intervention (0.4%, 95% CI = 0% to 2%). Loss of consciousness and headache were associated with clinically important intracranial injury on CT. The Canadian CT Head Rule had a sensitivity of 70% (95% CI = 47% to 87%) and NEXUS criteria had a sensitivity of 83% (95% CI = 61% to 95%) for clinically important injury in intoxicated patients. Conclusions In this study, the prevalence of clinically important injury in intoxicated patients with minor head injury was significant. While the presence of the common features associated with intracranial injury in nonintoxicated patients should raise clinical suspicion for intracranial injury in intoxicated patients, the Canadian CT Head Rule and NEXUS criteria do not have adequate sensitivity to be applied in intoxicated patients with minor head injury. Resumen Lesion Intracraneal Traumatica en los Pacientes Intoxicados con Traumatismo Craneoencefalico Leve Objetivos Los estudios centrados en traumatismos craneoencefalicos leves en pacientes intoxicados documentan prevalencias discrepantes de lesion intracraneal. No esta claro si los factores tipicamente asociados con lesion intracraneal en las reglas de decision clinica publicadas para la realizacion de una tomografia computarizada (TC) son de ayuda para diferenciar a los pacientes con y sin lesiones intracraneales, ya que la intoxicacion puede enmascarar hallazgos particulares de la lesion intracraneal, como la cefalea, y minimizar otros signos del traumatismo craneoencefalico como la alteracion del nivel de conciencia. Este estudio tiene el objetivo de estimar la prevalencia de lesion intracraneal tras un traumatismo craneoencefalico leve (puntuacion de la Escala del Coma de Glasgow ≥14) en pacientes intoxicados y valorar el rendimiento de las reglas de decision clinica establecidas en esta poblacion. Metodologia Estudio de cohorte prospectivo consecutivo de los adultos intoxicados que acudieron al servicio de urgencias tras un traumatismo craneoencefalico leve. Se incluyeron aquellos hallazgos de la historia clinica y la exploracion fisica de la Canadian CT Head Rule, el National Emergency X-Radiography Utilization Study (NEXUS) y los New Orleans Criteria. A todos los pacientes se les realizo una TC craneal. Resultados Se incluyeron 283 pacientes, con una mediana de 40 anos (RIC 28 a 48 anos) y una mediana de concentracion de alcoholemia de 195 mmol/L (RIC 154 a 256 mmol/L). Doscientos treinta y ocho de los 283 (84%) fueron hombres, y 225 (80%) tuvieron una puntuacion en la escala de Glasgow de 15. Se identificaron lesiones clinicamente importantes (ej: lesiones que requirieron ingreso en el hospital o seguimiento neuroquirurgico) en 23 pacientes (8%; IC 95% = 5% a 12%) y uno requirio intervencion neuroquirurgica (0,4%, IC95% = 0% a 2%). La perdida de conciencia y la cefalea se asociaron con lesion intracraneal clinicamente importante en la TC. La Canadian CT Head Rule tuvo una sensibilidad del 70% (IC 95% = 47% a 87%) y los NEXUS criteria tuvieron una sensibilidad del 83% (IC 95% = 61% a 95%) para la lesion intracraneal clinicamente importante en los pacientes intoxicados. Conclusiones En este estudio, la prevalencia de la lesion clinicamente importante en pacientes intoxicados con traumatismo craneoencefalico leve fue significativa. Mientras la presencia de hallazgos comunes asociados con la lesion intracraneal en pacientes no intoxicados podria incrementar la sospecha clinica para la lesion intracraneal en pacientes intoxicados, la Canadian CT Head Rule y los NEXUS criteria no tienen una adecuada sensibilidad para ser aplicados en pacientes intoxicados con un traumatismo craneoencefalico leve.