Canadian CT head rule

Canadian CT Head Rule (CCHR) is a clinical decision rule that helps physicians determine whether patients with minor head injuries require computed tomography (CT) scanning to diagnose intracranial injuries. The rule aims to safely reduce the number of unnecessary CT scans, thereby minimizing radiation exposure to patients and optimizing the use of medical resources.

Background

Head injuries are common in emergency departments worldwide, with a significant number being classified as minor. Despite their classification, there is a risk of intracranial injuries that could be life-threatening if not identified and treated promptly. However, the indiscriminate use of CT scans has raised concerns due to the associated costs, potential for increased emergency department wait times, and the long-term risk of radiation-induced cancer. The Canadian CT Head Rule was developed to address these concerns by providing clear guidelines for the use of CT scans in patients with minor head injuries.

Development

The Canadian CT Head Rule was developed by a team of researchers led by Dr. Ian Stiell in the early 2000s. The study involved adult patients presenting with minor head injuries at multiple emergency departments across Canada. The rule was derived and validated through prospective studies, demonstrating high sensitivity and specificity for identifying patients at risk of clinically significant brain injuries.

Criteria

The Canadian CT Head Rule applies to patients with minor head injuries, characterized by a Glasgow Coma Scale (GCS) score of 13 to 15 after a witnessed loss of consciousness, amnesia, or disorientation. The rule identifies high-risk factors that necessitate a CT scan, including:

• Signs of a basal skull fracture
• Two or more episodes of vomiting
• Age 65 years or older
• Amnesia before impact of 30 minutes or more
• Dangerous mechanism of injury (e.g., pedestrian struck by vehicle, occupant ejected from motor vehicle, fall from elevation of 3 feet or more)

If none of these high-risk factors are present, the rule then considers medium-risk factors that suggest the need for observation rather than immediate CT scanning:

• Retrograde amnesia of 30 minutes or less
• Dangerous mechanism of injury (as defined above)
• Evidence of external head injury (other than basal skull fracture)

Application

The Canadian CT Head Rule has been widely adopted in emergency departments in Canada and internationally. Its implementation has been shown to reduce the number of CT scans performed on patients with minor head injuries without missing clinically significant injuries. This has implications for patient safety, healthcare costs, and emergency department efficiency.

Limitations

While the Canadian CT Head Rule is a valuable tool, it is not applicable to all patient populations. It does not apply to patients under the age of 16, those with a GCS score below 13, patients with a seizure following the injury, or those with a known history of coagulopathy or taking anticoagulant medication. Clinical judgment should always be used in conjunction with the rule.

Conclusion

The Canadian CT Head Rule is an evidence-based guideline that assists physicians in making informed decisions about the use of CT scanning in patients with minor head injuries. By identifying patients at low risk of intracranial injuries, the rule helps to avoid unnecessary CT scans, thereby reducing radiation exposure and healthcare costs, while ensuring that patients with potentially serious injuries receive the appropriate diagnostic imaging.