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Make the Diagnosis: Severe Intracranial Injury Caused by Minor Head Trauma

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Prior Probability of Severe Intracranial Injury Caused by Minor Head Trauma

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Across all studies that included a total of 23 079 patients after minor head trauma, the incidence of severe intracranial injury was 7.1% (95% CI, 6.8%-7.4%).

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Population in Whom Severe Intracranial Injury Should Be Considered

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Intracranial injury is always evaluated with computed tomography (CT) in patients who have severe head trauma, as determined by a Glasgow Coma Scale (GCS) score of 8 or less, or moderate head trauma as determined by a GCS score of 9-12 (Table 100-1). However, some patients appear well (ie, they have a GCS score of ≥ 13) after minor injury and have minimal or no alterations in their mental status. Despite the fact that most patients with minor head trauma will not have experienced severe intracranial injury, a CT scan will identify them, so many patients and their physicians request CT when patients arrive in emergency departments after the traumatic event.

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Table Graphic Jump Location
Table 100-1.Glasgow Coma Scale
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Assessing the Likelihood of Severe Intracranial Injury

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Risk stratification begins with the GCS. A GCS score of 13, which is generally associated with minor head trauma, is associated with increased likelihood of severe intracranial injury (LR, 4.9; 95% CI, 2.8-8.5). In patients with a GCS score of 14 to 15 on initial examination, the GCS should be repeated, because patients with a GCS score of less than 15 two hours after the initial score are more likely (LR, 3.5; 95% CI, 1.6-7.6) to have a severe intracranial injury than those with a normal result on all components of the GCS (GCS = 15). The mechanism of injury is important. For example, pedestrians struck by automobiles are at higher risk for severe injury vs those who have experienced other injuries (Table 100-2). Patients older than 60 years are also more likely to have a severe intracranial injury than younger patients. The most useful symptom for identifying an increased likelihood of severe intracranial injury is the presence of vomiting, especially repetitive vomiting of ≥ 2 episodes (LR, 3.6; 95% CI, 3.1-4.1), or posttraumatic seizures (LR, 2.5; 95% CI, 1.3-4.3). Signs of skull fractures on physical examination are also associated with a higher likelihood of severe intracranial injury ...

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