今日の臨床サポート

軽症頭部外傷

著者: 山中俊祐 福井大学医学部附属病院 救急部

監修: 林寛之 福井大学医学部附属病院

著者校正/監修レビュー済:2020/01/17
参考ガイドライン:
  1. 日本脳神経外科学会:頭部外傷治療・管理のガイドライン(第4版)2019
患者向け説明資料

概要・推奨   

  1. 頭部外傷患者には経時的なGCSの評価が必要である(推奨度1)。
  1. 頭部外傷後のけいれん発作は長期的予後を予測しないが、早期に2次的脳傷害を起こす可能性がある。適応によっては、早期(受傷1週間以内)の抗けいれん薬予防的投与を検討する(推奨度2)。
  1. 頭部外傷は救急外来を訪れる疾患としてコモンである。そのなかでも、GCS14~15の軽症頭部外傷が約8割を占める(推奨度1)。
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  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
山中俊祐 : 研究費・助成金など(福井県「新型コロナウイルス感染症研究推進事業」,福田記念医療技術振興財団)[2021年]
監修:林寛之 : 講演料(メディカ出版),原稿料(羊土社)[2021年]

改訂のポイント:
  1. 小児の軽症頭部外傷のCT撮影基準(CHALICE、CATCH2)について加筆した。
  1. 頭部外傷治療・管理のガイドラインに基づいて、定義、治療指針について加筆した。
  1. 新規抗凝固薬(NOAC:Non-vitamin K antagonist oral anticoagulant)について加筆した。

病態・疫学・診察

疫学情報・病態・注意事項  
  1. 本稿で論ずる軽症頭部外傷の対象患者は、以下のすべてを満たすものである[1]
  1. 非穿通性頭部外傷
  1. 救急外来受診が外傷後24時間以内
  1. 救急外来受診時のGCS 14~15(JATEC 2016年改訂版ではこの条件のみ)
  1. 年齢16歳以上
  1. 多発外傷ではなく、頭部のみの外傷
  1. なお頭部外傷治療・管理のガイドライン(第4版)では受診時のGCSスコア13~15またはJapan coma scale 0~3を軽症頭部外傷としている[2]
  1. 米国では、頭部外傷により救急外来を受診する患者は年間100万人以上に及ぶ。その80%は「軽症」であるとされ、その原因は転倒と交通外傷である[3][4]
  1. 成人の頭部外傷の患者層では、15~24歳の男性および65歳以上の女性が多い[5]
  1. 救急外来を受診するGCS 15の頭部外傷患者のうち、多ければ15%が頭部CTに急性の所見があり、さらにその1%以下が脳神経外科的介入を要する[1]
  1. 後遺症の定義にもよるが、軽症頭部外傷患者の5~15%は受傷1年後に何らかの機能障害を持つ[6]
  1. 臨床家にとってのチャレンジは、軽症頭部外傷患者のなかから、急性頭蓋内傷害(頭蓋骨骨折、クモ膜下出血、硬膜外出血、硬膜下出血、脳内出血、脳挫傷)を同定するとともに、安全に帰宅できる患者も同定することである。
 
  1. 頭部外傷患者には経時的なGCSの評価が必要である(推奨度1)。
  1. 1974年にTeasdaleらによって開発されたGlasgow Coma Scale (GCS)は、本来、昏睡患者の神経学的所見を経時的に評価するためのツールであり、軽症や中等症の頭部外傷の評価に使用されるものではない。
  1. さらに1回だけのGCSの評価は、頭部外傷後の脳実質損傷の評価には不十分であることがわかっている。
  1. 一方で、GCSが高いまま推移する場合やGCSが改善する場合には、その予後が良好であることも示唆されている。
  1. 頭部外傷患者には経時的なGCSの評価が必要である。
 
  1. 頭部外傷は救急外来を訪れる疾患としてコモンである。そのなかでも、GCS14~15の軽症頭部外傷が約8割を占める(推奨度1)。
  1. 全米の救急外来を受診する頭部外傷患者は、年間110万人と推定されている[3]。その多くは15~24歳の若年であるが、同様のピークが5歳以下の小児と85歳以上の高齢者にも存在する[4]。頭部外傷はGCSを利用して分類されることが多く、以下のように分類される。
  1. 重症:GCS 8以下
  1. 中等症:GCS 9~13
  1. 軽症:GCS 14~15
  1. それぞれの頻度は10%、10%、80%と推定されている。
問診・診察のポイント  
  1. 常にABCの評価から評価を開始する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Andy S Jagoda, Jeffrey J Bazarian, John J Bruns, Stephen V Cantrill, Alisa D Gean, Patricia Kunz Howard, Jamshid Ghajar, Silvana Riggio, David W Wright, Robert L Wears, Aric Bakshy, Paula Burgess, Marlena M Wald, Rhonda R Whitson, American College of Emergency Physicians, Centers for Disease Control and Prevention
雑誌名: Ann Emerg Med. 2008 Dec;52(6):714-48. doi: 10.1016/j.annemergmed.2008.08.021.
Abstract/Text This clinical policy provides evidence-based recommendations on select issues in the management of adult patients with mild traumatic brain injury (TBI) in the acute setting. It is the result of joint efforts between the American College of Emergency Physicians and the Centers for Disease Control and Prevention and was developed by a multidisciplinary panel. The critical questions addressed in this clinical policy are: (1) Which patients with mild TBI should have a noncontrast head computed tomography (CT) scan in the emergency department (ED)? (2) Is there a role for head magnetic resonance imaging over noncontrast CT in the ED evaluation of a patient with acute mild TBI? (3) In patients with mild TBI, are brain specific serum biomarkers predictive of an acute traumatic intracranial injury? (4) Can a patient with an isolated mild TBI and a normal neurologic evaluation result be safely discharged from the ED if a noncontrast head CT scan shows no evidence of intracranial injury? Inclusion criteria for application of this clinical policy's recommendations are nonpenetrating trauma to the head, presentation to the ED within 24 hours of injury, a Glasgow Coma Scale score of 14 or 15 on initial evaluation in the ED, and aged 16 years or greater. The primary outcome measure for questions 1, 2, and 3 is the presence of an acute intracranial injury on noncontrast head CT scan; the primary outcome measure for question 4 is the occurrence of neurologic deterioration.

PMID 19027497  Ann Emerg Med. 2008 Dec;52(6):714-48. doi: 10.1016/j.an・・・
著者: T E Jager, H B Weiss, J H Coben, P E Pepe
雑誌名: Acad Emerg Med. 2000 Feb;7(2):134-40.
Abstract/Text OBJECTIVE: To describe the incidence and patient characteristics of traumatic brain injuries (TBIs) treated in U.S. emergency departments (EDs).
METHODS: A secondary analysis was performed on data from the National Hospital Ambulatory Medical Care Survey administered from 1992 to 1994. An ED visit was determined to represent a case of TBI if the case record contained ICD-9-CM codes of 800.0-801.9, 803.0-804.9, or 850.0-854.1.
RESULTS: The average annual estimate of new TBI treated in U.S. EDs was 1,144,807, equaling 444 per 100,000 persons (95% CI = 390 to 498), which represents approximately 3,136 new cases of TBI per day and accounts for 1.3% of all ED visits. Males were 1.6 times as likely as females to suffer TBI until the age of 65 years, when the female rate exceeded the male. The rate for blacks was 35% higher than that for whites. The highest overall incidence rate of TBI occurred in the less-than-5-year age group (1,091 per 100,000), closely followed by the more-than-85-year age group (1,026 per 100,000). Falls represented the most common mechanism of TBI injury, followed by motor vehicle-related trauma.
CONCLUSIONS: This study underscores the ongoing need for effective surveillance of all types of TBI and evaluation of prevention strategies targeting high-risk individuals. It serves as a clinically grounded and ED-based corroboration of prior survey research, providing a basis for comparison of incidence rates over time and a tool with which to measure the efficacy of future interventions.

PMID 10691071  Acad Emerg Med. 2000 Feb;7(2):134-40.
著者: Wesley Rutland-Brown, Jean A Langlois, Karen E Thomas, Yongli Lily Xi
雑誌名: J Head Trauma Rehabil. 2006 Nov-Dec;21(6):544-8.
Abstract/Text Traumatic brain injury (TBI) is an important public health problem in the United States. In 2003, there were an estimated 1,565,000 TBIs in the United States: 1,224,000 emergency department visits, 290,000 hospitalizations, and 51,000 deaths. Findings were similar to those from previous years in which rates of TBI were highest for young children (aged 0-4) and men, and the leading causes of TBI were falls and motor vehicle traffic.

PMID 17122685  J Head Trauma Rehabil. 2006 Nov-Dec;21(6):544-8.
著者: James F Holmes, Gregory W Hendey, Jennifer A Oman, Valerie C Norton, Gerald Lazarenko, Steven E Ross, Jerome R Hoffman, William R Mower, NEXUS group
雑誌名: Am J Emerg Med. 2006 Mar;24(2):167-73. doi: 10.1016/j.ajem.2005.08.009.
Abstract/Text STUDY OBJECTIVE: We sought to describe the epidemiology of emergency department (ED) patients with blunt head injury undergoing cranial computed tomography (CT) scanning for the evaluation of possible traumatic brain injury (TBI).
METHODS: Prospective, multicenter, observational study of ED patients undergoing cranial CT after blunt head injury. Patient's date of birth, sex, and race/ethnicity were documented before CT scanning. Individual patients were considered to have "significant" TBI if the official radiographic interpretation at the end of all imaging studies associated with the trauma was consistent with any of a set of predefined diagnoses. The relative prevalence of TBI among various prespecified groups from those undergoing cranial CT scanning was also calculated.
RESULTS: Of 13728 patients who were enrolled, 8988 (65%) were men and 1193 (8.7%) had a significant acute TBI. Demographic findings associated with increased risk of TBI, among patients selected for scanning, included the following: age below 10 years (relative risk [RR] = 1.44, 95% confidence interval [CI], 1.19-1.77); age above 65 years (RR = 1.59; 95% CI, 1.40-1.80), and male sex (RR = 1.27; 95% CI, 1.30-1.43).
CONCLUSION: Among patients selected for cranial CT scanning after blunt head injury, men, patients younger than 10 years, and those older than 65 years have an increased likelihood of significant TBI.

PMID 16490645  Am J Emerg Med. 2006 Mar;24(2):167-73. doi: 10.1016/j.a・・・
著者: R W Rimel, B Giordani, J T Barth, T J Boll, J A Jane
雑誌名: Neurosurgery. 1981 Sep;9(3):221-8.
Abstract/Text
PMID 7301062  Neurosurgery. 1981 Sep;9(3):221-8.
著者: I G Stiell, G A Wells, K Vandemheen, C Clement, H Lesiuk, A Laupacis, R D McKnight, R Verbeek, R Brison, D Cass, M E Eisenhauer, G Greenberg, J Worthington
雑誌名: Lancet. 2001 May 5;357(9266):1391-6.
Abstract/Text BACKGROUND: There is much controversy about the use of computed tomography (CT) for patients with minor head injury. We aimed to develop a highly sensitive clinical decision rule for use of CT in patients with minor head injuries.
METHODS: We carried out this prospective cohort study in the emergency departments of ten large Canadian hospitals and included consecutive adults who presented with a Glasgow Coma Scale (GCS) score of 13-15 after head injury. We did standardised clinical assessments before the CT scan. The main outcome measures were need for neurological intervention and clinically important brain injury on CT.
FINDINGS: The 3121 patients had the following characteristics: mean age 38.7 years); GCS scores of 13 (3.5%), 14 (16.7%), 15 (79.8%); 8% had clinically important brain injury; and 1% required neurological intervention. We derived a CT head rule which consists of five high-risk factors (failure to reach GCS of 15 within 2 h, suspected open skull fracture, any sign of basal skull fracture, vomiting >2 episodes, or age >65 years) and two additional medium-risk factors (amnesia before impact >30 min and dangerous mechanism of injury). The high-risk factors were 100% sensitive (95% CI 92-100%) for predicting need for neurological intervention, and would require only 32% of patients to undergo CT. The medium-risk factors were 98.4% sensitive (95% CI 96-99%) and 49.6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT.
INTERPRETATION: We have developed the Canadian CT Head Rule, a highly sensitive decision rule for use of CT. This rule has the potential to significantly standardise and improve the emergency management of patients with minor head injury.

PMID 11356436  Lancet. 2001 May 5;357(9266):1391-6.
著者: M J Haydel, C A Preston, T J Mills, S Luber, E Blaudeau, P M DeBlieux
雑誌名: N Engl J Med. 2000 Jul 13;343(2):100-5. doi: 10.1056/NEJM200007133430204.
Abstract/Text BACKGROUND: Computed tomography (CT) is widely used as a screening test in patients with minor head injury, although the results are often normal. We performed a study to develop and validate a set of clinical criteria that could be used to identify patients with minor head injury who do not need to undergo CT.
METHODS: In the first phase of the study, we recorded clinical findings in 520 consecutive patients with minor head injury who had a normal score on the Glasgow Coma Scale and normal findings on a brief neurologic examination; the patients then underwent CT. Using recursive partitioning, we derived a set of criteria to identify all patients who had abnormalities on CT scanning. In the second phase, the sensitivity and specificity of the criteria for predicting a positive scan were evaluated in a group of 909 patients.
RESULTS: Of the 520 patients in the first phase, 36 (6.9 percent) had positive scans. All patients with positive CT scans had one or more of seven findings: headache, vomiting, an age over 60 years, drug or alcohol intoxication, deficits in short-term memory, physical evidence of trauma above the clavicles, and seizure. Among the 909 patients in the second phase, 57 (6.3 percent) had positive scans. In this group of patients, the sensitivity of the seven findings combined was 100 percent (95 percent confidence interval, 95 to 100 percent). All patients with positive CT scans had at least one of the findings.
CONCLUSIONS: For the evaluation of patients with minor head injury, the use of CT can be safely limited to those who have certain clinical findings.

PMID 10891517  N Engl J Med. 2000 Jul 13;343(2):100-5. doi: 10.1056/NE・・・
著者: Ian G Stiell, Catherine M Clement, Brian H Rowe, Michael J Schull, Robert Brison, Daniel Cass, Mary A Eisenhauer, R Douglas McKnight, Glen Bandiera, Brian Holroyd, Jacques S Lee, Jonathan Dreyer, James R Worthington, Mark Reardon, Gary Greenberg, Howard Lesiuk, Iain MacPhail, George A Wells
雑誌名: JAMA. 2005 Sep 28;294(12):1511-8. doi: 10.1001/jama.294.12.1511.
Abstract/Text CONTEXT: Current use of cranial computed tomography (CT) for minor head injury is increasing rapidly, highly variable, and inefficient. The Canadian CT Head Rule (CCHR) and New Orleans Criteria (NOC) are previously developed clinical decision rules to guide CT use for patients with minor head injury and with Glasgow Coma Scale (GCS) scores of 13 to 15 for the CCHR and a score of 15 for the NOC. However, uncertainty about the clinical performance of these rules exists.
OBJECTIVE: To compare the clinical performance of these 2 decision rules for detecting the need for neurosurgical intervention and clinically important brain injury.
DESIGN, SETTING, AND PATIENTS: In a prospective cohort study (June 2000-December 2002) that included 9 emergency departments in large Canadian community and university hospitals, the CCHR was evaluated in a convenience sample of 2707 adults who presented to the emergency department with blunt head trauma resulting in witnessed loss of consciousness, disorientation, or definite amnesia and a GCS score of 13 to 15. The CCHR and NOC were compared in a subgroup of 1822 adults with minor head injury and GCS score of 15.
MAIN OUTCOME MEASURES: Neurosurgical intervention and clinically important brain injury evaluated by CT and a structured follow-up telephone interview.
RESULTS: Among 1822 patients with GCS score of 15, 8 (0.4%) required neurosurgical intervention and 97 (5.3%) had clinically important brain injury. The NOC and the CCHR both had 100% sensitivity but the CCHR was more specific (76.3% vs 12.1%, P<.001) for predicting need for neurosurgical intervention. For clinically important brain injury, the CCHR and the NOC had similar sensitivity (100% vs 100%; 95% confidence interval [CI], 96%-100%) but the CCHR was more specific (50.6% vs 12.7%, P<.001), and would result in lower CT rates (52.1% vs 88.0%, P<.001). The kappa values for physician interpretation of the rules, CCHR vs NOC, were 0.85 vs 0.47. Physicians misinterpreted the rules as not requiring imaging for 4.0% of patients according to CCHR and 5.5% according to NOC (P = .04). Among all 2707 patients with a GCS score of 13 to 15, the CCHR had sensitivities of 100% (95% CI, 91%-100%) for 41 patients requiring neurosurgical intervention and 100% (95% CI, 98%-100%) for 231 patients with clinically important brain injury.
CONCLUSION: For patients with minor head injury and GCS score of 15, the CCHR and the NOC have equivalent high sensitivities for need for neurosurgical intervention and clinically important brain injury, but the CCHR has higher specificity for important clinical outcomes than does the NOC, and its use may result in reduced imaging rates.

PMID 16189364  JAMA. 2005 Sep 28;294(12):1511-8. doi: 10.1001/jama.294・・・
著者: Marion Smits, Diederik W J Dippel, Gijs G de Haan, Heleen M Dekker, Pieter E Vos, Digna R Kool, Paul J Nederkoorn, Paul A M Hofman, Albert Twijnstra, Hervé L J Tanghe, M G Myriam Hunink
雑誌名: JAMA. 2005 Sep 28;294(12):1519-25. doi: 10.1001/jama.294.12.1519.
Abstract/Text CONTEXT: Two decision rules for indications of computed tomography (CT) in patients with minor head injury, the Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC), suggest that CT scanning may be restricted to patients with certain risk factors, which would lead to important reductions in the use of CT scans.
OBJECTIVE: To validate and compare these 2 published decision rules in Dutch patients with head injuries.
DESIGN, SETTING, AND PATIENTS: A prospective multicenter study conducted between February 11, 2002, and August 31, 2004, in 4 university hospitals in the Netherlands of 3181 consecutive adult patients with minor head injury who presented with a Glasgow Coma Scale (GCS) score of 13 to 14 or with a GCS score of 15 and at least 1 risk factor.
MAIN OUTCOME MEASURES: Primary outcome was any neurocranial traumatic finding on CT scan. Secondary outcomes were neurosurgical intervention and clinically important CT findings. Sensitivity and specificity were estimated for each outcome for the CCHR and the NOC, using both rules as originally derived and also as adapted to apply to an expanded patient population.
RESULTS: Of 3181 patients with a GCS score of 13 to 15, neurosurgical intervention was performed in 17 patients (0.5%); neurocranial traumatic CT findings were present in 312 patients (9.8%). Sensitivity for neurosurgical intervention was 100% for both the CCHR and the NOC. The NOC had a higher sensitivity for neurocranial traumatic findings and for clinically important findings (97.7%-99.4%) than did the CCHR (83.4%-87.2%). Specificities were very low for the NOC (3.0%-5.6%) and higher for the CCHR (37.2%-39.7%). The estimated potential reduction in CT scans for patients with minor head injury would be 3.0% for the adapted NOC and 37.3% for the adapted CCHR.
CONCLUSIONS: For patients with minor head injury and a GCS score of 13 to 15, the CCHR has a lower sensitivity than the NOC for neurocranial traumatic or clinically important CT findings, but would identify all cases requiring neurosurgical intervention, and has greater potential for reducing the use of CT scans.

PMID 16189365  JAMA. 2005 Sep 28;294(12):1519-25. doi: 10.1001/jama.29・・・
著者: Sue E Harnan, Alastair Pickering, Abdullah Pandor, Steve W Goodacre
雑誌名: J Trauma. 2011 Jul;71(1):245-51. doi: 10.1097/TA.0b013e31820d090f.
Abstract/Text BACKGROUND: There are many clinical decision rules for adults with minor head injury, but it is unclear how they compare in terms of diagnostic accuracy. This study aimed to systematically identify clinical decision rules for adults with minor head injury and compare the estimated diagnostic accuracies for any intracranial injury and injury requiring neurosurgical intervention.
METHODS: Several electronic bibliographic databases covering biomedical, scientific, and gray literature were searched from inception to March 2010. At least two independent reviewers determined the eligibility of cohort studies that described a clinical decision rule to identify adults with minor head injury (Glasgow Coma Scale score, 13-15) at risk of intracranial injury or injury requiring neurosurgical intervention.
RESULTS: Twenty-two relevant studies were identified. Differences existed in patient selection, outcome definition, and reference standards used. Nine rules stratified patients into high- and moderate-risk categories (to identify neurosurgical or nonsurgical intracranial lesions). The Canadian Computed Tomography Head Rule (CCHR) high-risk criteria have sensitivity of 99% to 100% with specificity of 48% to 77% for injury requiring neurosurgical intervention. Other rules such as New Orleans criteria, National Emergency X-Radiography Utilization Study II, Neurotraumatology Committee of the World Federation of Neurosurgical Societies, Scandinavian, and Scottish Intercollegiate Guidelines Network produce similar sensitivities for injury requiring neurosurgical intervention but with lower and more variable specificity values.
DISCUSSION: The most widely researched decision rule is the CCHR, which has consistently shown high sensitivity for identifying injury requiring neurosurgical intervention with an acceptable specificity to allow considered use of cranial computed tomography. No other decision rule has been as widely validated or demonstrated as acceptable results, but its exclusion criteria make it difficult to apply universally.

PMID 21818031  J Trauma. 2011 Jul;71(1):245-51. doi: 10.1097/TA.0b013e・・・
著者: Nathan Kuppermann, James F Holmes, Peter S Dayan, John D Hoyle, Shireen M Atabaki, Richard Holubkov, Frances M Nadel, David Monroe, Rachel M Stanley, Dominic A Borgialli, Mohamed K Badawy, Jeff E Schunk, Kimberly S Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A Lillis, Michael G Tunik, Elizabeth S Jacobs, James M Callahan, Marc H Gorelick, Todd F Glass, Lois K Lee, Michael C Bachman, Arthur Cooper, Elizabeth C Powell, Michael J Gerardi, Kraig A Melville, J Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J Michael Dean, Sandra L Wootton-Gorges, Pediatric Emergency Care Applied Research Network (PECARN)
雑誌名: Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0. Epub 2009 Sep 14.
Abstract/Text BACKGROUND: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.
METHODS: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights).
FINDINGS: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.
INTERPRETATION: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.
FUNDING: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

PMID 19758692  Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S014・・・
著者: Jean-Luc af Geijerstam, Sven Oredsson, Mona Britton, OCTOPUS Study Investigators
雑誌名: BMJ. 2006 Sep 2;333(7566):465. doi: 10.1136/bmj.38918.669317.4F. Epub 2006 Aug 8.
Abstract/Text OBJECTIVE: To compare immediate computed tomography during triage for admission with observation in hospital in patients with mild head injury.
DESIGN: Multicentre, pragmatic, non-inferiority randomised trial.
SETTING: 39 acute hospitals in Sweden.
PARTICIPANTS: 2602 patients (aged > or = 6) with mild head injury.
INTERVENTIONS: Immediate computed tomography or admission for observation.
MAIN OUTCOME MEASURE: Dichotomised extended Glasgow outcome scale (1-7 v 8). The non-inferiority margin was 5 percentage points.
RESULTS: At three months, 275 patients (21.4%) in the computed tomography group had not recovered completely compared with 300 (24.2%) admitted for observation. The difference was - 2.8 percentage points, non-significantly in favour of computed tomography (95% confidence interval - 6.1% to 0.6%). The worst outcomes (mortality and more severe loss of function) were similar between the groups. In the patients admitted for observation, there was a considerable delay in time to treatment in those who required surgery. None of the patients with normal findings on immediate computed tomography had complications later. Patients' satisfaction with the two strategies was similar.
CONCLUSIONS: The use of computed tomography in the management of patients with mild head injury is feasible and leads to similar clinical outcomes compared with observation in hospital.
TRIAL REGISTRATION: ISRCTN81464462.

PMID 16895944  BMJ. 2006 Sep 2;333(7566):465. doi: 10.1136/bmj.38918.6・・・
著者: Alfred A Mina, John F Knipfer, David Y Park, Holly A Bair, Greg A Howells, Phillip J Bendick
雑誌名: J Trauma. 2002 Oct;53(4):668-72. doi: 10.1097/01.TA.0000025291.29067.E9.
Abstract/Text BACKGROUND: We have evaluated our recent experience as a Level I trauma center to test the hypothesis that preinjury anticoagulation adversely affects the morbidity and mortality of trauma patients with an intracranial injury.
METHODS: Records of 380 patients admitted to the trauma service from January 1997 to December 1998 who at the time of admission were taking warfarin, low-molecular-weight heparin, aspirin, nonsteroidal anti-inflammatory drugs, clopidogrel, dipyridamole, pentoxifylline, or naproxen were reviewed. Thirty-seven patients with intracranial injuries were identified and compared with a matched (age, gender, mechanism, and severity of injury) control group of 37 patients with similar head injury but not taking any anticoagulant randomly selected from the trauma registry for that same time period.
RESULTS: The control and anticoagulated groups were comparable in terms of age, 75 +/- 8 versus 74 +/- 11 years (p = 0.655); gender, 22 men/15 women versus 21 men/16 women; mechanism of injury, 30 falls/7 motor vehicle crashes versus 30 falls/7 motor vehicle crashes; and length of hospital stay, 11 +/- 14 versus 10 +/- 11 days (p = 0.853). In the anticoagulated group, the mean Injury Severity Score was 17.0 +/- 7.8 and the mean Glasgow Coma Scale score was 11.8 +/- 4.0; these were not significantly different from the control group, which had a mean Injury Severity Score of 19.8 +/- 8.1 (p = 0.143) and a Glasgow Coma Scale score of 12.5 +/- 2.6 (p = 0.378). There were 14 deaths (38%) in the anticoagulation group, versus 3 deaths in the control group (8%) (p = 0.006). In the anticoagulation group, 4 of 12 patients (33%) taking warfarin died, whereas 9 of 19 patients (47%) taking aspirin died (p = 0.285). All deaths were secondary to head injuries; all deaths in the control group and all but one in the anticoagulated group were the result of a fall; 6 of 10 anticoagulated patients who fell on stairs died, and 5 of these were taking aspirin only.
CONCLUSION: These data indicate that the trauma patient with preinjury anticoagulation such as warfarin or even aspirin who has an intracranial injury has a four- to fivefold higher risk of death than the nonanticoagulated patient. The efficacy of reversing the anticoagulant effect at the time of hospital admission remains to be evaluated.

PMID 12394864  J Trauma. 2002 Oct;53(4):668-72. doi: 10.1097/01.TA.000・・・
著者: Sergey Spektor, Samuel Agus, Vladimir Merkin, Shlomo Constantini
雑誌名: J Neurosurg. 2003 Oct;99(4):661-5. doi: 10.3171/jns.2003.99.4.0661.
Abstract/Text OBJECT: The goal of this paper was to investigate a possible relationship between the consumption of low-dose aspirin (LDA) and traumatic intracranial hemorrhage in an attempt to determine whether older patients receiving prophylactic LDA require special treatment following an incidence of mild-to-moderate head trauma.
METHODS: Two hundred thirty-one patients older than 60 years of age, who arrived at the emergency department with a mild or moderate head injury (Glasgow Coma Scale [GCS] Scores 13-15 and 9-12, respectively), were included in the study. One hundred ten patients were receiving prophylactic LDA (100 mg/day) and these formed the aspirin-treated group. One hundred twenty-one patients were receiving no aspirin, and these formed the control group. There was no statistically significant difference between the two groups with respect to age, sex, mechanism of trauma, or GCS score on arrival at the emergency department. Most of the patients sustained the head injury from falls (88.2% of patients in the aspirin-treated group and 85.1% of patients in the control group), and had external signs of head trauma such as bruising or scalp laceration (80.9% of patients in the aspirin-treated group and 86.8% of patients in the control group). All patients underwent similar neurological examinations and computerized tomography (CT) scanning of the head. The CT scans revealed evidence of traumatic intracranial hemorrhage in 27 (24.5%) patients in the aspirin-treated group and in 31 patients (25.6%) in the control group. Surgical intervention was required for five patients in each group (4.5% of patients in the aspirin-treated group and 4.1% of patients in the control group). A surprising number of the patients who arrived with GCS Score 15 were found to have traumatic intracranial hemorrhage, as revealed by CT scanning (11.5% of patients in the aspirin-treated group and 16.5% of patients in the control group). Surgery, however, was not necessary for any of these patients.
CONCLUSIONS: There was no statistically significant difference in the frequency or types of traumatic intracranial hemorrhage between patients who had received aspirin prophylaxis and those who had not. The authors conclude that LDA does not increase surgically relevant parenchymal or meningeal bleeding following moderate and minor head injury in patients older than 60 years of age.

PMID 14567600  J Neurosurg. 2003 Oct;99(4):661-5. doi: 10.3171/jns.200・・・
著者: Chad W Washington, Douglas J E Schuerer, Robert L Grubb
雑誌名: J Trauma. 2011 Aug;71(2):358-63. doi: 10.1097/TA.0b013e318220ad7e.
Abstract/Text INTRODUCTION: To determine whether there is a benefit to platelet transfusion in mild traumatic brain injury (MTBI) patients with intracranial hemorrhage (ICH), taking antiplatelet therapy before hospitalization.
MATERIALS AND METHODS: The study design retrospectively reviewed patients admitted to a Level I trauma center during a 2-year period with an isolated MTBI (Glasgow Coma Scale score ≥13, ICH seen on a head computed tomographic scan (head computed tomography [HCT]), and taking an antiplatelet agent before hospitalization. HCT's were categorized based on the Marshall Classification, Rotterdam Score, and ICH volume. Hospital records were reviewed noting neurologic, cardiac, respiratory events, and discharge Glasgow Outcome Scale.
RESULTS: There were 1,101 patients with TBI hospitalized during the 2-year study period. Three hundred twenty-one of these patients had an MTBI with ICH at the time of admission, and from this group, 113 were taking an antiplatelet agent. Only 4 (1.2%) of the 321 patients suffered a neurologic decline. All were gradual in nature, and none required emergent intervention. An analysis of the 113 patients taking antiplatelet agents, comparing patients who were not given a platelet transfusion with those who received a platelet transfusion, found no significant difference in the rate of HCT progression, neurologic decline, or Glasgow Outcome Scale at hospital discharge between the two groups. There was a trend, which was not significant, toward more medical declines in patients who received a platelet transfusion. A further review, analyzing all 321 patients with ICH showed receiving a transfusion of any type (i.e., platelets, fresh frozen plasma, or blood) was a strong predictor of medical decline (p < 0.0001). The odds ratio of having a medical decline after transfusion was 5.8 (95% confidence interval, 1.2-28.2).
CONCLUSIONS: Platelet transfusion did not improve short-term outcomes after MTBI. Further randomized controlled trials need to be done to truly assess if there is no benefit in platelet transfusion in patients taking antiplatelet agents suffering an MTBI. Because the overall outcome in MTBI patients is favorable, platelet transfusion in these patients may not be indicated.

PMID 21825939  J Trauma. 2011 Aug;71(2):358-63. doi: 10.1097/TA.0b013e・・・
著者: Stephan A Mayer, Nikolai C Brun, Kamilla Begtrup, Joseph Broderick, Stephen Davis, Michael N Diringer, Brett E Skolnick, Thorsten Steiner, Recombinant Activated Factor VII Intracerebral Hemorrhage Trial Investigators
雑誌名: N Engl J Med. 2005 Feb 24;352(8):777-85. doi: 10.1056/NEJMoa042991.
Abstract/Text BACKGROUND: Intracerebral hemorrhage is the least treatable form of stroke and is associated with high mortality. Among patients who undergo computed tomography (CT) within three hours after the onset of intracerebral hemorrhage, one third have an increase in the volume of the hematoma related to subsequent bleeding. We sought to determine whether recombinant activated factor VII (rFVIIa) can reduce hematoma growth after intracerebral hemorrhage.
METHODS: We randomly assigned 399 patients with intracerebral hemorrhage diagnosed by CT within three hours after onset to receive placebo (96 patients) or 40 microg of rFVIIa per kilogram of body weight (108 patients), 80 microg per kilogram (92 patients), or 160 microg per kilogram (103 patients) within one hour after the baseline scan. The primary outcome measure was the percent change in the volume of the intracerebral hemorrhage at 24 hours. Clinical outcomes were assessed at 90 days.
RESULTS: Hematoma volume increased more in the placebo group than in the rFVIIa groups. The mean increase was 29 percent in the placebo group, as compared with 16 percent, 14 percent, and 11 percent in the groups given 40 microg, 80 microg, and 160 microg of rFVIIa per kilogram, respectively (P=0.01 for the comparison of the three rFVIIa groups with the placebo group). Growth in the volume of intracerebral hemorrhage was reduced by 3.3 ml, 4.5 ml, and 5.8 ml in the three treatment groups, as compared with that in the placebo group (P=0.01). Sixty-nine percent of placebo-treated patients died or were severely disabled (as defined by a modified Rankin Scale score of 4 to 6), as compared with 55 percent, 49 percent, and 54 percent of the patients who were given 40, 80, and 160 microg of rFVIIa, respectively (P=0.004 for the comparison of the three rFVIIa groups with the placebo group). Mortality at 90 days was 29 percent for patients who received placebo, as compared with 18 percent in the three rFVIIa groups combined (P=0.02). Serious thromboembolic adverse events, mainly myocardial or cerebral infarction, occurred in 7 percent of rFVIIa-treated patients, as compared with 2 percent of those given placebo (P=0.12).
CONCLUSIONS: Treatment with rFVIIa within four hours after the onset of intracerebral hemorrhage limits the growth of the hematoma, reduces mortality, and improves functional outcomes at 90 days, despite a small increase in the frequency of thromboembolic adverse events.

Copyright 2005 Massachusetts Medical Society.
PMID 15728810  N Engl J Med. 2005 Feb 24;352(8):777-85. doi: 10.1056/N・・・
著者: Marcel Levi, Jerrold H Levy, Henning Friis Andersen, David Truloff
雑誌名: N Engl J Med. 2010 Nov 4;363(19):1791-800. doi: 10.1056/NEJMoa1006221.
Abstract/Text BACKGROUND: The use of recombinant activated factor VII (rFVIIa) on an off-label basis to treat life-threatening bleeding has been associated with a perceived increased risk of thromboembolic complications. However, data from placebo-controlled trials are needed to properly assess the thromboembolic risk. To address this issue, we evaluated the rate of thromboembolic events in all published randomized, placebo-controlled trials of rFVIIa used on an off-label basis.
METHODS: We analyzed data from 35 randomized clinical trials (26 studies involving patients and 9 studies involving healthy volunteers) to determine the frequency of thromboembolic events. The data were pooled with the use of random-effects models to calculate the odds ratios and 95% confidence intervals.
RESULTS: Among 4468 subjects (4119 patients and 349 healthy volunteers), 401 [corrected] had thromboembolic events (9.0%). [corrected] Rates of arterial thromboembolic events among all 4468 subjects were higher among those who received rFVIIa than among those who received placebo (5.5% vs. 3.2%, P=0.003). Rates of venous thromboembolic events were similar among subjects who received rFVIIa and those who received placebo (5.3% vs. 5.7%). Among subjects who received rFVIIa, 2.9% had coronary arterial thromboembolic events, as compared with 1.1% of those who received placebo (P=0.002). Rates of arterial thromboembolic events were higher among subjects who received rFVIIa than among subjects who received placebo, particularly among those who were 65 years of age or older (9.0% vs. 3.8%, P=0.003); the rates were especially high among subjects 75 years of age or older (10.8% vs. 4.1%, P=0.02).
CONCLUSIONS: In a large and comprehensive cohort of persons in placebo-controlled trials of rFVIIa, treatment with high doses of rFVIIa on an off-label basis significantly increased the risk of arterial but not venous thromboembolic events, especially among the elderly. (Funded by Novo Nordisk.).

PMID 21047223  N Engl J Med. 2010 Nov 4;363(19):1791-800. doi: 10.1056・・・
著者: D A Pierce, D L Preston
雑誌名: Radiat Res. 2000 Aug;154(2):178-86.
Abstract/Text To clarify the information in the Radiation Effects Research Foundation data regarding cancer risks of low radiation doses, we focus on survivors with doses less than 0.5 Sv. For reasons indicated, we also restrict attention mainly to survivors within 3, 000 m of the hypocenter of the bombs. Analysis is of solid cancer incidence from 1958-1994, involving 7,000 cancer cases among 50,000 survivors in that dose and distance range. The results provide useful risk estimates for doses as low as 0.05-0.1 Sv, which are not overestimated by linear risk estimates computed from the wider dose ranges 0-2 Sv or 0-4 Sv. There is a statistically significant risk in the range 0-0.1 Sv, and an upper confidence limit on any possible threshold is computed as 0.06 Sv. It is indicated that modification of the neutron dose estimates currently under consideration would not markedly change the conclusions.

PMID 10931690  Radiat Res. 2000 Aug;154(2):178-86.
著者: D Brenner, C Elliston, E Hall, W Berdon
雑誌名: AJR Am J Roentgenol. 2001 Feb;176(2):289-96. doi: 10.2214/ajr.176.2.1760289.
Abstract/Text OBJECTIVE: In light of the rapidly increasing frequency of pediatric CT examinations, the purpose of our study was to assess the lifetime cancer mortality risks attributable to radiation from pediatric CT.
MATERIALS AND METHODS: Organ doses as a function of age-at-diagnosis were estimated for common CT examinations, and estimated attributable lifetime cancer mortality risks (per unit dose) for different organ sites were applied. Standard models that assume a linear extrapolation of risks from intermediate to low doses were applied. On the basis of current standard practice, the same exposures (milliampere-seconds) were assumed, independent of age.
RESULTS: The larger doses and increased lifetime radiation risks in children produce a sharp increase, relative to adults, in estimated risk from CT. Estimated lifetime cancer mortality risks attributable to the radiation exposure from a CT in a 1-year-old are 0.18% (abdominal) and 0.07% (head)-an order of magnitude higher than for adults-although those figures still represent a small increase in cancer mortality over the natrual background rate. In the United States, of approximately 600,000 abdominal and head CT examinations annually performed in children under the age of 15 years, a rough estimate is that 500 of these individuals might ultimately die from cancer attributable to the CT radiation.
CONCLUSION: The best available risk estimates suggest that pediatric CT will result in significantly increased lifetime radiation risk over adult CT, both because of the increased dose per milliampere-second, and the increased lifetime risk per unit dose. Lower milliampere-second settings can be used for children without significant loss of information. Although the risk-benefit balance is still strongly tilted toward benefit, because the frequency of pediatric CT examinations is rapidly increasing, estimates that quantitative lifetime radiation risks for children undergoing CT are not negligible may stimulate more active reduction of CT exposure settings in pediatric patients.

PMID 11159059  AJR Am J Roentgenol. 2001 Feb;176(2):289-96. doi: 10.22・・・
著者: R L Mittl, R I Grossman, J F Hiehle, R W Hurst, D R Kauder, T A Gennarelli, G W Alburger
雑誌名: AJNR Am J Neuroradiol. 1994 Sep;15(8):1583-9.
Abstract/Text PURPOSE: To assess the prevalence of MR evidence for diffuse axonal injury at 1.5 T in patients with normal head CT findings after mild head injury.
METHODS: Twenty consecutive patients with mild head injury (Glasgow Coma Scale, 13 to 15; no subsequent deterioration, loss of consciousness < 20 minutes) and normal head CT findings were examined with MR at 1.5 T. Pulse sequences included a conventional T2-weighted spin-echo sequence (2500-3000/30,80/1[repetition time/echo time/excitations]) and a T2*-weighted gradient-echo sequence (750/40/2, 10 degrees flip angle). Each sequence was read independently by two blinded readers.
RESULTS: The readers agreed that abnormalities compatible with diffuse axonal injury were present in the white matter of 6 (30%) of 20 patients (95% confidence interval, 12% to 54%). Both readers agreed that foci of high signal intensity were present on the T2-weighted spin-echo sequence in 3 (15%) of the 20 cases (95% confidence interval, 3% to 38%) and that foci of hypointensity compatible with hemorrhagic shear injury were present on the T2*-weighted sequence in 4 (20%) of the 20 patients (95% confidence interval, 6% to 44%). Both types of abnormality were noted by the readers in one patient.
CONCLUSIONS: MR shows evidence of diffuse axonal injury in some patients with normal head CT findings after mild head injury. These lesions may represent the pathologic substrate underlying the postconcussion syndrome that occurs in many patients with moderate to severe head injury.

PMID 7985582  AJNR Am J Neuroradiol. 1994 Sep;15(8):1583-9.
著者: Clare Atzema, William R Mower, Jerome R Hoffman, James F Holmes, Anthony J Killian, Jennifer A Oman, Andrew H Shen, Stephen D Greenwood, National Emergency X-Radiography Utilization Study (NEXUS) II Group
雑誌名: Ann Emerg Med. 2004 Jul;44(1):47-56. doi: 10.1016/S0196064404001969.
Abstract/Text STUDY OBJECTIVE: Many injuries detected by computed tomographic (CT) imaging of blunt head trauma patients are considered "therapeutically inconsequential." We estimate the prevalence of these findings and determine how frequently affected patients had "important neurosurgical outcomes," defined as either a directed intervention or a poor Glasgow Outcome Scale score.
METHODS: We prospectively enrolled all blunt head trauma patients undergoing emergency head CT imaging at 18 centers participating in the National Emergency X-radiography Utilization Study II (NEXUS). From these cases, we identified all patients whose official CT reading met predefined criteria for "therapeutically inconsequential" injuries. We obtained detailed follow-up information on all such patients at 6 sites, including the need for neurosurgical intervention and Glasgow Outcome Scale scores. Among patients having "important neurosurgical outcomes," we assessed the frequency of 2 potential clinical identifiers: altered mental status and coagulopathy.
RESULTS: "Therapeutically inconsequential" head CT findings were present in 155 of 8,374 subjects (1.85%; 95% confidence interval 1.57% to 2.16%). Sites participating in the follow-up study enrolled 81 of these patients, of whom 10 (12%) had "important neurosurgical outcomes." Follow-up information was available for 9 patients, all of whom had abnormal mental status at CT scanning. Coagulopathy was also present in 5 of 7 patients for whom coagulation status was known.
CONCLUSION: "Therapeutically inconsequential" findings are identified in less than 2% of blunt head trauma patients who undergo CT scanning. A small proportion of these patients have an "important neurosurgical outcome," but it appears that such patients may be identified clinically by the presence of abnormal mental status or coagulopathy.

PMID 15226708  Ann Emerg Med. 2004 Jul;44(1):47-56. doi: 10.1016/S0196・・・
著者: S C Stein, S E Ross
雑誌名: Neurosurgery. 1990 Apr;26(4):638-40.
Abstract/Text The determination that a particular head injury is "mild" or "low-risk" is usually made on clinical grounds. Observation at home or in the hospital has been the usual treatment for such patients. A recent report of excessive mortality among these patients with low-risk head injuries in some hospital settings suggests the need for improvement in diagnostic criteria. Our study included 658 patients admitted to Cooper Hospital for a mild head injury, who had a Glasgow Coma Scale score of 13 to 15 on admission, and who experienced a brief loss of consciousness or amnesia after the injury. Their records and cranial computed tomographic (CT) scans on admission were reviewed to determine their subsequent course. In 18% of patients abnormalities were seen on the initial CT scan and 5% required surgery. Among the 62 patients with a Glasgow Coma Scale score of 13, 40% had abnormalities on the CT scan and 10% required surgery. None of the 542 patients with normal CT scans on admission showed subsequent deterioration and none needed surgery. These figures suggest that history and physical examination alone are not adequate to assess head injury or severity of risk and that the addition of a CT scan greatly improves patient assessment. Abnormalities on CT scans are so common in patients with a Glasgow Coma Scale score of 13 that head injuries in these patients should be classified as "moderate" rather than "mild" in severity and risk. Patients with normal CT scans should be considered for observation at home, allowing hospital personnel to devote full attention to the more seriously injured patients.

PMID 2330085  Neurosurgery. 1990 Apr;26(4):638-40.
著者: Casula Claudia, Ranalli Claudia, Ognibene Agostino, Magazzini Simone, Grifoni Stefano
雑誌名: J Trauma. 2011 Apr;70(4):906-9. doi: 10.1097/TA.0b013e3182031ab7.
Abstract/Text BACKGROUND: Head injury represents one of the most important and frequent traumatic pathology in the emergency department. Among the different risk factors, preinjury use of warfarin has received considerable attention in trauma literature. The aim of this study was to identify further risk indicators of intracranial hemorrhage (ICH) to improve risk stratification of warfarinized patients with minor head injuries.
METHODS: Medical records of 1,554 adult patients with minor head injuries evaluated by the Emergency Department of Azienda Ospedaliera, Universitaria Careggi from January 2007 to February 2008 were analyzed retrospectively. All the patients included in the study were subjected to blood tests. The international normalized ratio (INR) measured on admission was correlated with the results of head computed tomography scan.
RESULTS: Of the 1,410 patients included in the study, 75 (5.2%) were warfarin anticoagulated at the time of trauma. The INR measured on admission was 2.37 ± 1.04 (mean ± standard deviation), and this value was significantly associated with occurrence of ICH after head trauma (r = 0.37; p < 0.005). For 12 (of 75) patients of this group, the findings of the computed tomography scans were positive. The receiver operating characteristic curve show that the most effective INR cutoff value was 2.43, with a sensitivity of 92%, a specificity of 66%, and positive and negative predictive values of 33% and 97%, respectively.
CONCLUSIONS: This study highlights the strong relationship between INR values and the probability of ICH, as shown in previous studies. The high negative predictive value of the identified cutoff, if confirmed, could be used to exclude ICH.

PMID 21610395  J Trauma. 2011 Apr;70(4):906-9. doi: 10.1097/TA.0b013e3・・・
著者: Kenneth Frumkin
雑誌名: Ann Emerg Med. 2013 Dec;62(6):616-626.e8. doi: 10.1016/j.annemergmed.2013.05.026. Epub 2013 Jul 3.
Abstract/Text Life-threatening warfarin-associated hemorrhage is common, with a high mortality. In the United States, the most commonly used therapies--fresh frozen plasma and vitamin K--are slow and unpredictable and can result in volume overload. Outside of the United States, prothrombin complex concentrates are often used instead; these pooled plasma products reverse warfarin anticoagulation in minutes rather than hours. This article reviews the literature relating to warfarin reversal with fresh frozen plasma, prothrombin complex concentrates, and recombinant factor VIIa and provides elements for a management protocol based on this literature.

Copyright © 2013 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
PMID 23829955  Ann Emerg Med. 2013 Dec;62(6):616-626.e8. doi: 10.1016/・・・
著者: Crispijn L van den Brand, Tanya Tolido, Anna H Rambach, Myriam G M Hunink, Peter Patka, Korné Jellema
雑誌名: J Neurotrauma. 2017 Jan 1;34(1):1-7. doi: 10.1089/neu.2015.4393. Epub 2016 May 9.
Abstract/Text The objective of this systematic review and meta-analysis is to evaluate whether the pre-injury use of antiplatelet therapy (APT) is associated with increased risk of traumatic intracranial hemorrhage (tICH) on CT scan. PubMed, Medline, Embase, Cochrane Central, reference lists, and national guidelines on traumatic brain injury were used as data sources. Eligible studies were cohort studies and case-control studies that assessed the relationship between APT and tICH. Studies without control group were not included. The primary outcome of interest was tICH on CT. Two reviewers independently selected studies, assessed methodological quality, and extracted outcome data. This search resulted in 10 eligible studies with 20,247 patients with head injury that were included in the meta-analysis. The use of APT in patients with head injury was associated with significant increased risk of tICH compared with control (odds ratio [OR] 1.87, 95% confidence interval [CI]1.27-2.74). There was significant heterogeneity in the studies (I2 84%), although almost all showed an association between APT use and tICH. This association could not be established for patients receiving aspirin monotherapy. When considering only patients with mild traumatic brain injury (mTBI), the OR is 2.72 (95% CI 1.92-3.85). The results were robust to sensitivity analysis on study quality. In summary, APT in patients with head injury is associated with increased risk of tICH; this association is most relevant in patients with mTBI. Whether this association is the result of a causal relationship and whether this relationship also exists for patients receiving aspirin monotherapy cannot be established with the current review and meta-analysis.

PMID 26979949  J Neurotrauma. 2017 Jan 1;34(1):1-7. doi: 10.1089/neu.2・・・
著者: A Karni, R Holtzman, T Bass, G Zorman, L Carter, L Rodriguez, V J Bennett-Shipman, L Lottenberg
雑誌名: Am Surg. 2001 Nov;67(11):1098-100.
Abstract/Text Warfarin is the most common oral anticoagulant used for chronic anticoagulation therapy. Even without any antecedent trauma overanticoagulation can result in intracranial hemorrhage. The triad of anticoagulation with warfarin, age greater than 65 years, and traumatic head injury frequently produces a lethal brain hemorrhage. A retrospective review of more than 2000 patients admitted to the Trauma Service between September 1998 and May 2000 produced 278 patients with head injury and CT-documented intracranial hemorrhage. Of these patients 21 were admitted with an elevated prothrombin time (PT) due to anticoagulation with warfarin. Eighteen patients (86%) were above the age of 70. The most common indications for anticoagulation were atrial fibrillation (71%), deep venous thrombosis (19%), aortic valve replacement (9%), and ischemic cerebral infarcts (9%). Fourteen injuries were the result of a fall, one resulted from a gunshot wound, and one resulted from an assault. The remaining five patients were excluded as their history, workup, and evaluation by neurosurgery suggested a spontaneous bleed leading to fall rather than a fall causing a traumatic bleed. The average Glasgow Coma Score on admission was 11. The average PT and International Normalized Ratio (INR) on admission were 19.2 and 2.99 respectively. Eight of the 16 patients analyzed died. The risk of intracranial hemorrhage with relatively minor head injury is increased dramatically in the anticoagulated patient. A mortality rate of 50 per cent far exceeds the mortality rate in patients with similar head injuries who are not anticoagulated. In addition the risk/benefit equation of anticoagulation for the elderly is more complex and differs from that for younger patients. Perhaps more frequent and judicious monitoring of prothrombin time levels with lower therapeutic ranges (INR 1.5-2) is necessary.

PMID 11730229  Am Surg. 2001 Nov;67(11):1098-100.
著者: Jan Franko, Karen J Kish, Brendan G O'Connell, Sujata Subramanian, James V Yuschak
雑誌名: J Trauma. 2006 Jul;61(1):107-10. doi: 10.1097/01.ta.0000224220.89528.fc.
Abstract/Text BACKGROUND: A large population of patients on oral anticoagulants is exposed to the risk of traumatic brain injury (TBI). Effects of age and anticoagulation on TBI outcomes need to be assessed separately.
METHODS: Retrospective analysis of consecutive series of TBI patients (age 18 years and older) in a suburban teaching hospital.
RESULTS: A total of 1,493 adult blunt head trauma patients between January 2001 and May 2005 were analyzed. Of these, 159 patients were warfarin-anticoagulated at the time of trauma. The mortality in anticoagulated patients was statistically significantly higher than in the control group (38/159, 23.9% vs. 66/1,334, 4.9%; p < 0.001; odds ratio 6.0). Mortality of patients over 70 years of age was significantly higher than in the younger population (p < 0.001). Both mortality and the occurrence of intracranial hemorrhage (ICH) after head trauma were significantly increased with higher INR (Cochran's linear trend p < 0.001), especially with INR over 4.0 (mortality 50%, risk of ICH 75%). Preinjury warfarin anticoagulation and age were found to be predictive of survival in a binary logistic regression model (92.5% correct prediction, p = 0.027). Addition of Injury Severity Score and initial Glasgow Coma Score to this model only modestly improved its predictive performance (95.4% correct prediction, p < 0.001).
CONCLUSIONS: Both age and warfarin anticoagulation are independent predictors of mortality after blunt TBI. Warfarin anticoagulation carries a six-fold increase in TBI mortality. Age over 70 years and excessive anticoagulation are associated with higher mortality, as well.

PMID 16832256  J Trauma. 2006 Jul;61(1):107-10. doi: 10.1097/01.ta.000・・・
著者: David B Cohen, Charles Rinker, Jack E Wilberger
雑誌名: J Trauma. 2006 Mar;60(3):553-7. doi: 10.1097/01.ta.0000196542.54344.05.
Abstract/Text BACKGROUND: Coumadin is widely used in the elderly population. Despite its widespread use, little is known about its effect on the outcome of elderly traumatic brain-injured patients. This study was undertaken to describe the outcomes of such a cohort.
METHODS: Clinical material was identified from a Level I trauma center prospective head injury database, and a database obtained from the American College of Surgeons Committee on Trauma Verification and Review Committee from 1999 to 2002. Both databases contain many relevant variables, including age, sex, Glasgow Coma Scale (GCS) score, mechanism of injury, Injury Severity Score, International Normalized Ratio (INR), computed tomography (CT) findings, operative procedure, time to operating room, complications, length of stay, and outcome at hospital discharge.
RESULTS: For patients with GCS scores less than 8, average INR was 6.0, with almost 50% having an initial value greater than 5.0. Overall mortality was 91.5%. For the 77 patients with GCS scores of 13 to 15, average INR was 4.4. Overall mortality for this group was 80.6%. A subset of patients deteriorated to a GCS score of less than 10 just hours after injury, despite most having normal initial CT scans. Mortality in this group was 84%.
CONCLUSIONS: All patients on warfarin should have an INR performed, and a CT scan should be done in most anticoagulated patients. All supratherapeutically anticoagulated patients, as well as any anticoagulated patient with a traumatic CT abnormality, should be admitted for neurologic observation and consideration given to short term reversal of anticoagulation. Routine repeat CT scanning at 12 to 18 hours or when even subtle signs of neurologic worsening occur is a strong recommendation. A multi-institutional, prospective trial using these guidelines would be a first step toward demonstrating improved outcomes in the anticoagulated patient population after head trauma.

PMID 16531853  J Trauma. 2006 Mar;60(3):553-7. doi: 10.1097/01.ta.0000・・・
著者: James M Feeney, Elizabeth Santone, Monica DiFiori, Lilla Kis, Vijay Jayaraman, Stephanie C Montgomery
雑誌名: J Trauma Acute Care Surg. 2016 Nov;81(5):843-848. doi: 10.1097/TA.0000000000001245.
Abstract/Text BACKGROUND: Falls represent the leading cause of traumatic brain injury in adults older than 65, with nearly one third experiencing a fall each year. Evidence suggests that up to 0.5% of anticoagulated patients suffer from intracranial hemorrhage (ICH) annually. Direct oral anticoagulants (DOACs) have become an increasingly popular alternative to warfarin for anticoagulation; however, there is a dearth of research regarding the safety of DOACs, in particular on the outcome of traumatic ICH while taking DOACs.
METHODS: We queried our Trauma Quality Improvement Project registry for patients who presented with traumatic intracranial hemorrhage during anticoagulant use. Patients were grouped into those prescribed warfarin and patients prescribed DOAC medications. The groups were compared with respect to age, gender, Glasgow Coma Score (GCS) on arrival, Abbreviated Injury Scale (AIS) (head), Injury Severity Score (ISS), mortality, need for operative intervention, hospital and ICU lengths of stay, proportion of patients transfused (and their transfusion requirements), and rates of discharge to skilled nursing facility. Poisson regression was conducted to determine the relationship between mortality and treatment group while controlling for covariates (comorbidities, ISS).
RESULTS: There were no differences between DOAC and warfarin groups in terms of age, gender, median ISS, median AIS head, or median admission GCS. Mechanisms of injury, median hospital and ICU lengths of stay, ICU free days, and transfusion requirements were also not significantly different.DOAC use was associated with significantly lower mortality (4.9% vs. 20.8%; p < 0.008) and a lower rate of operative intervention (8.2% vs. 26.7%; p = 0.023) when compared with warfarin. Excluding patients who died, the observed rate of discharge to skilled nursing facility was lower in the DOAC group (28.8% compared with 39.7%; p = 0.03). Multivariate Poisson regression analysis demonstrated that warfarin use was associated with an increased mortality when controlling for injury severity, and comorbidities.
CONCLUSIONS: We report improved mortality and reduced rates of operative intervention in patients with traumatic ICH associated with DOACs compared with a similar group taking warfarin. We also noted an association with decreased rate of discharge to SNF in patients taking DOACs compared with warfarin.
LEVEL OF EVIDENCE: Therapeutic study, level IV.

PMID 27602897  J Trauma Acute Care Surg. 2016 Nov;81(5):843-848. doi: ・・・
著者: Marion Wiegele, Herbert Schöchl, Alexander Haushofer, Martin Ortler, Johannes Leitgeb, Oskar Kwasny, Ronny Beer, Cihan Ay, Eva Schaden
雑誌名: Crit Care. 2019 Feb 22;23(1):62. doi: 10.1186/s13054-019-2352-6. Epub 2019 Feb 22.
Abstract/Text There is a high degree of uncertainty regarding optimum care of patients with potential or known intake of oral anticoagulants and traumatic brain injury (TBI). Anticoagulation therapy aggravates the risk of intracerebral hemorrhage but, on the other hand, patients take anticoagulants because of an underlying prothrombotic risk, and this could be increased following trauma. Treatment decisions must be taken with due consideration of both these risks. An interdisciplinary group of Austrian experts was convened to develop recommendations for best clinical practice. The aim was to provide pragmatic, clear, and easy-to-follow clinical guidance for coagulation management in adult patients with TBI and potential or known intake of platelet inhibitors, vitamin K antagonists, or non-vitamin K antagonist oral anticoagulants. Diagnosis, coagulation testing, and reversal of anticoagulation were considered as key steps upon presentation. Post-trauma management (prophylaxis for thromboembolism and resumption of long-term anticoagulation therapy) was also explored. The lack of robust evidence on which to base treatment recommendations highlights the need for randomized controlled trials in this setting.

PMID 30795779  Crit Care. 2019 Feb 22;23(1):62. doi: 10.1186/s13054-01・・・
著者: Javier Ibañez, Fuat Arikan, Salvador Pedraza, Esther Sánchez, Maria A Poca, David Rodriguez, Enrique Rubio
雑誌名: J Neurosurg. 2004 May;100(5):825-34. doi: 10.3171/jns.2004.100.5.0825.
Abstract/Text OBJECT: The aims of this study were to analyze the relevance of risk factors in mild head injury (MHI) by studying the possibility of establishing prediction models based on these factors and to evaluate the reliability of the clinical guidelines proposed for the management of MHI.
METHODS: A series of 1101 patients with MHI were prospectively enrolled in this study. In all cases clinical data were collected and a computerized tomography (CT) scan was obtained. The relationship between clinical findings and the presence of intracranial lesions was studied to establish prediction models based on logistic regression and recursive partitioning analysis. Recently proposed guidelines and recommendations for the treatment of MHI were selected, calculating their diagnostic efficiency when applying each of them to our series. The incidence of acute intracranial lesions was 7.5% (83 patients). A Glasgow Coma Scale score of 14, loss of consciousness, vomiting, headache, signs of basilar skull fracture, neurological deficit, coagulopathies, hydrocephalus treated with shunt insertion, associated extracranial lesions, and patient age greater than 65 years were identified as independent risk factors. Prediction models built on clinical variables were able to indicate patients with clinically important lesions, but failed to achieve 100% sensitivity in the detection of all patients with CT scans positive for intracranial lesions within reasonable specificity limits.
CONCLUSIONS: Clinical variables are insufficient to predict all cases of intracranial lesions following MHI, although they can be used to detect patients with relevant injuries. Avoiding systematic CT scan indication implies a rate of misdiagnosis that should be known and assumed when planning treatment in these patients by using guidelines based on clinical parameters.

PMID 15137601  J Neurosurg. 2004 May;100(5):825-34. doi: 10.3171/jns.2・・・
著者: J Dunning, J Patrick Daly, J-P Lomas, F Lecky, J Batchelor, K Mackway-Jones, Children's head injury algorithm for the prediction of important clinical events study group
雑誌名: Arch Dis Child. 2006 Nov;91(11):885-91. doi: 10.1136/adc.2005.083980.
Abstract/Text BACKGROUND: A quarter of all patients presenting to emergency departments are children. Although there are several large, well-conducted studies on adults enabling accurate selection of patients with head injury at high risk for computed tomography scanning, no such study has derived a rule for children.
AIM: To conduct a prospective multicentre diagnostic cohort study to provide a rule for selection of high-risk children with head injury for computed tomography scanning.
DESIGN: All children presenting to the emergency departments of 10 hospitals in the northwest of England with any severity of head injury were recruited. A tailor-made proforma was used to collect data on around 40 clinical variables for each child. These variables were defined from a literature review, and a pilot study was conducted before the children's head injury algorithm for the prediction of important clinical events (CHALICE) study. All children who had a clinically significant head injury (death, need for neurosurgical intervention or abnormality on a computed tomography scan) were identified. Recursive partitioning was used to create a highly sensitive rule for the prediction of significant intracranial pathology.
RESULTS: 22,772 children were recruited over 2 1/2 years. 65% of these were boys and 56% were <5 years old. 281 children showed an abnormality on the computed tomography scan, 137 had a neurosurgical operation and 15 died. The CHALICE rule was derived with a sensitivity of 98% (95% confidence interval (CI) 96% to 100%) and a specificity of 87% (95% CI 86% to 87%) for the prediction of clinically significant head injury, and requires a computed tomography scan rate of 14%.
CONCLUSION: A highly sensitive clinical decision rule is derived for the identification of children who should undergo computed tomography scanning after head injury. This rule has the potential to improve and standardise the care of children presenting with head injuries. Validation of this rule in new cohorts of patients should now be undertaken.

PMID 17056862  Arch Dis Child. 2006 Nov;91(11):885-91. doi: 10.1136/ad・・・
著者: Martin H Osmond, Terry P Klassen, George A Wells, Jennifer Davidson, Rhonda Correll, Kathy Boutis, Gary Joubert, Serge Gouin, Simi Khangura, Troy Turner, Francois Belanger, Norm Silver, Brett Taylor, Janet Curran, Ian G Stiell, Pediatric Emergency Research Canada (PERC) Head Injury Study Group
雑誌名: CMAJ. 2018 Jul 9;190(27):E816-E822. doi: 10.1503/cmaj.170406.
Abstract/Text BACKGROUND: There is uncertainty about which children with minor head injury need to undergo computed tomography (CT). We sought to prospectively validate the accuracy and potential for refinement of a previously derived decision rule, Canadian Assessment of Tomography for Childhood Head injury (CATCH), to guide CT use in children with minor head injury.
METHODS: This multicentre cohort study in 9 Canadian pediatric emergency departments prospectively enrolled children with blunt head trauma presenting with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. Phys icians completed standardized assessment forms before CT, including clinical predictors of the rule. The primary outcome was neurosurgical intervention and the secondary outcome was brain injury on CT. We calculated test characteristics of the rule and used recursive partitioning to further refine the rule.
RESULTS: Of 4060 enrolled patients, 23 (0.6%) underwent neurosurgical intervention, and 197 (4.9%) had brain injury on CT. The original 7-item rule (CATCH) had sensitivities of 91.3% (95% confidence interval [CI] 72.0%-98.9%) for neurosurgical intervention and 97.5% (95% CI 94.2%-99.2%) for predicting brain injury. Adding "≥ 4 episodes of vomiting" resulted in a refined 8-item rule (CATCH2) with 100% (95% CI 85.2%-100%) sensitivity for neurosurgical intervention and 99.5% (95% CI 97.2%-100%) sensitivity for brain injury.
INTERPRETATION: Among children presenting to the emergency department with minor head injury, the CATCH2 rule was highly sensitive for identifying those children requiring neurosurgical intervention and those with any brain injury on CT. The CATCH2 rule should be further validated in an implementation study designed to assess its clinical impact.

© 2018 Joule Inc. or its licensors.
PMID 29986857  CMAJ. 2018 Jul 9;190(27):E816-E822. doi: 10.1503/cmaj.1・・・
著者: Pierre Frémont, Lindsay Bradley, Charles H Tator, Jill Skinner, Lisa K Fischer, Canadian Concussion Collaborative
雑誌名: Br J Sports Med. 2015 Jan;49(2):88-9. doi: 10.1136/bjsports-2014-093961. Epub 2014 Jul 12.
Abstract/Text The Canadian Concussion Collaborative (CCC) is composed of health-related organisations concerned with the recognition, treatment and management of concussion. Its mission is to create synergy between organisations concerned with concussion to improve education and implementation of best practices for the prevention and management of concussions. Each of the organisations that constitute the CCC has endorsed two recommendations that address the need for relevant authorities to develop policies about concussion management in sports. The recommendations were developed to support advocacy for regulations, policies or legislation to improve concussion prevention and management at all levels of sport.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.
PMID 25016603  Br J Sports Med. 2015 Jan;49(2):88-9. doi: 10.1136/bjsp・・・
著者: G Teasdale, B Jennett
雑誌名: Lancet. 1974 Jul 13;2(7872):81-4.
Abstract/Text
PMID 4136544  Lancet. 1974 Jul 13;2(7872):81-4.
著者: S R Shackford, S L Wald, S E Ross, T H Cogbill, D B Hoyt, J A Morris, P A Mucha, H L Pachter, H J Sugerman, K O'Malley
雑誌名: J Trauma. 1992 Sep;33(3):385-94. doi: 10.1097/00005373-199209000-00009.
Abstract/Text The evaluation and management of patients with minor head injury (MHI: history of loss of consciousness or posttraumatic amnesia and a GCS score greater than 12) remain controversial. Recommendations vary from routine admission without computed tomographic (CT) scanning to mandatory CT scanning and admission to CT scanning without admission for selected patients. Previous reports examining this issue have included patients with associated non-CNS injuries who confound the interpretation of the data and affect outcome. We hypothesized that patients with MHI and no other reason for admission with normal neurologic examinations and normal CT scans would have a negligible risk of neurologic deterioration requiring surgical intervention. To validate this hypothesis we studied 2766 patients with an isolated MHI admitted to seven trauma centers between January 1, 1988, and December 31, 1991. There were 1898 male patients and 868 female patients; injury was blunt in 99%. A neurologic examination and a CT scan were performed on 2166 patients; 933 patients had normal neurologic examinations and normal CT scans and none required craniotomy; 1170 patients had normal CT scans and none required craniotomy; 2112 patients had normal neurologic examinations and 59 required craniotomy. The sensitivity of the CT scan was 100%, with positive predictive value of 10%, negative predictive value of 100%, and specificity of 51%. The use of CT alone as a diagnostic modality would have saved 3924 hospital days, including 814 ICU days, and $1,509,012 in hospital charges. Based on these data, we believe that CT scanning is essential in the management of patients with MHI and that if the neurologic examination is normal and the scan is negative patients can be safely discharged from the emergency room.

PMID 1404507  J Trauma. 1992 Sep;33(3):385-94. doi: 10.1097/00005373-・・・
著者:
雑誌名: Br J Sports Med. 2017 Jun;51(11):851-858. doi: 10.1136/bjsports-2017-097506SCAT5. Epub 2017 Apr 26.
Abstract/Text
PMID 28446451  Br J Sports Med. 2017 Jun;51(11):851-858. doi: 10.1136/・・・

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