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Head injuries in the rural setting : what is the role of the Canadian CT head guidelines Von der Porten, Fern


The Canadian CT head rule is a valuable tool in the clinical assessment of head injuries. It risk stratifies head injured patients, identifying the ones that will require neurological intervention and the ones having clinically important brain injuries (sensitivities 100% and 98.6%, respectively). This standardized approach to head injuries may challenge the rural practitioner without access to CT scan. The Whistler Health Care Center (WHCC) is a Diagnostic and Treatment Centre seeing approximately 23,000 patients annually, many of them trauma patients with a high acuity level. There is no CT scanner on site. This provides a unique setting to study head injuries: a large number of head-injured patients with limited diagnostic tools, like many other rural facilities in Canada. It was hypothesized that following the Canadian CT Head Guidelines at the Whistler Health Care Center would have increased the number of scans performed. This study is a retrospective chart review of all patients triaged with head injury, or trauma, to the WHCC in 2004. Canadian CT head guidelines were applied to all charts, and were risk stratified according to the guidelines. 516 charts were reviewed, 305 of which were excluded (5 GCS<13, 1 pregnant, 5 seizures prior to assessment, 56 no amnesia, LOC or disorientation, 38 follow-ups, 174 age < 16 yrs, 22 not seen by MD , 1 acute neurological deficit, 1 unstable vitals, 1 depressed skull fracture, 1 anticoagulant use), and 211 were included. Of the 211 included charts, 51 had CT indicated, and only 4 of these were transferred to a health care facility with CT scan available. A further 9 patients, without meeting the CT criteria were also transferred. The WHCC has a high number of head injuries annually. When the Canadian CT head guidelines are applied, a greater number of scans are indicated. Some scans, however, in the minor risk group, could have been avoided. When the CT head guidelines are applied to the rural setting without diagnostic CT, patients with high-risk criteria should all be transferred. A prospective study in a similar setting is recommended to determine the management of moderate risk patients.

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