TRAUMA/ORIGINAL RESEARCH

Application of the Canadian Computed

Tomography Head Rule to Patients With Minimal
Head Injury
Kevin Davey, MD*; Turandot Saul, MD, RDMS; Geoffrey Russel, BS; Jonathan Wassermann, MD; Joshua Quaas, MD
*Corresponding Author. E-mail: kdavey0210@gmail.com.

Study objective: Two clinical decision rules, the Canadian CT Head Rule and the New Orleans Criteria, set the standard
to guide clinicians in determining which patients with minor head trauma need computed tomography (CT) imaging.
Both rules were derived with patients with minor head injury who had had a loss of consciousness or witnessed
disorientation. No evidence exists for evaluating patients and need for CT imaging with minimal head injury; that is,
patients who had a head injury but no loss of consciousness or disorientation and therefore would have been excluded
from the Canadian CT Head Rule and New Orleans Criteria trials. We evaluate the Canadian CT Head Rule in patients
with head injury without loss of consciousness or witnessed disorientation (minimal head injury).

Methods: We studied a prospective convenience sample of patients with minimal head injury who received head CTs as
part of their evaluations in the emergency department (ED). Participants were enrolled after head CT was ordered, but
before the physician received the imaging results. Physicians were surveyed on their clinical reasoning for ordering
imaging in this low-risk cohort of patients. Physicians surveyed consisted of ED attending physicians and senior-level
emergency medicine residents. Final patient disposition was recorded when it became available. Patients with positive
CT findings had their medical records reviewed for specific disposition, admission length of stay, ICU stay, and any
operative or procedural interventions.

Results: Two hundred forty patients with minimal head injury were enrolled. Five patients (2.1%) had head CTs that
were positive for intracranial hemorrhage. All instances of intracranial hemorrhage occurred in patients who were at
high or moderate risk by the Canadian CT Head Rule (2 high risk [age], 3 moderate risk [mechanism]). No patient with
intracranial hemorrhage went to the ICU or underwent any intervention; the average hospital length of stay was 1.25
days. The Canadian CT Head Rule was 100% sensitive (95% confidence interval 40% to 100%) and 29% specific (95%
confidence interval 23% to 35%) for the presence of intracranial hemorrhage. Physicians listed their own reassurance
(24.6%), patient reassurance (24.2%), patient expectation (14.6%), and reduction of legal liability (11.7%) as the
rationale for ordering head CT in patients with minimal head injury. Shared decisionmaking was used in 51% of cases.

Conclusion: Risk of intracranial hemorrhage in patients with minimal head injury was very low, and even in patients
found to have an intracranial hemorrhage, none had any serious adverse outcome (eg, death, intubation, prolonged
hospitalization, surgical procedure). The Canadian CT Head Rule was 100% sensitive in this small cohort of patients
with minimal head injury. Among our study cohort, which specifically included only patients who had CT scanning,
applying the Canadian CT Head Rule may have reduced the need for CT, potentially saving costs and resources.
However, because many patients with minimal head injury who present to the ED may not have CTs, it is unclear what
effect the broad application of this rule would have on overall CT use. Providers’ rationale for obtaining CT was
multifactorial. These represent barriers that may need to be overcome before physicians are comfortable changing CT
ordering patterns in this group of head injury patients. [Ann Emerg Med. 2018;-:1-9.]

Please see page XX for the Editor’s Capsule Summary of this article.

0196-0644/$-see front matter

Copyright © 2018 by the American College of Emergency Physicians.
https://doi.org/10.1016/j.annemergmed.2018.03.034

SEE EDITORIAL, P. --- . reliable test to determine the presence of bleeding or

INTRODUCTION
The use of computed tomography (CT) for traumatic
head injury has been well established, and its use is
now routine in emergency medicine. CT is a fast and
other significant injuries with high sensitivity. In head
trauma, the negative predictive value of a normal head
CT result approaches 100% and has essentially
eliminated the need for hospital admission or
observation after head injury in the neurologically intact

Volume -, no. - : - 2018 Annals of Emergency Medicine 1

Canadian Computed Tomography Head Rule and Patients With Minimal Head Injury
Editor’s Capsule Summary
What is already known on this topic
Clinical decision rules for mild traumatic brain injury
have included only patients with either loss of
consciousness or transient disorientation.
What question this study addressed
In patients with injury too mild to be included in
previous validation cohorts, how well does the
Canadian CT Head Rule perform in adult patients
with minimal head injury?
What this study adds to our knowledge
The Canadian CT Head Rule identified all 5 cases of
traumatic intracranial hemorrhage from a cohort of
240 patients with minimal head injury.
How this is relevant to clinical practice
The Canadian CT Head Rule appears to identify
patients with minimal head injury and clinically
relevant intracranial injuries despite their being a
different population from validation studies.
Research we would like to see
Prospective data from a larger cohort of patients with
minimal head injury who are receiving oral
anticoagulants would better define the safety of this
approach.
patient.1,2 A head CT for minor head injury is therefore a
simple and reliable test for excluding injury that expedites
patient care in the emergency department (ED) for a safe
discharge home.
As CT imaging has become faster and less expensive,
its increased use has been well documented both
nationally3,4 and at the specific institution where this
study was conducted.5,6 In the 1980s, there were no
published guidelines for the use of CT in head injury,
and expert recommendations at that time advised CT
evaluation only for patients with a Glasgow Coma Scale
(GCS) score of 8 or less.7
Two high-quality clinical decision rules emerged during
this time. The first was the New Orleans Criteria,8 which
evaluated the practice of ordering head CT scans for all
patients with minor head injury and loss of consciousness
and developed a rule that has been externally validated with
100% sensitivity.9 Criticism of the rule is that it is overly
inclusive because one of the inclusion criteria was any
visible sign of external head injury (eg, a simple forehead
2 Annals of Emergency Medicine
Davey et al
abrasion). The Canadian CT Head Rule,10 which also
studied minor head injury, with an inclusion criterion of
witnessed disorientation or loss of consciousness, was
published thereafter and reported 100% sensitivity for
clinically important injury and a much higher specificity
(50.6% versus 12.7% for clinically important brain injury),
using different inclusion parameters. The significantly
higher specificity reduced CT use; however, this rule was
criticized because it was not designed to detect
nonoperative intracranial bleeding with 100% specificity,
something that many physicians would be uncomfortable
with for both medical and legal reasons. The clinical use of
both rules has led to some reductions in CT imaging of
patients with minor head injury with loss of consciousness,
although the reduction has been less than expected, and
overall use continues to increase.3
The number of people who seek emergency treatment
for traumatic brain injury is increasing. From 2006 to 2010,
the number of ED visits for traumatic brain injury, as
defined by the Centers for Disease Control and Prevention
(CDC), increased by more than 30%, 8-fold faster than the
rate of increase of ED visits overall.11 According to CDC
data, there are 1.7 million ED visits for traumatic brain
injury each year, and 1.2 to 1.3 million are for mild
traumatic brain injury.12,13 Eighty percent of patients who
go to the ED for head injuries—95% of which are classified
as mild—undergo CT scans of the brain, and 91% of the
results are negative.14 As more patients presenting to the ED
with minor head injury undergo head CT, costs associated
with their care are likely to increase. If consistent application
of evidence-based clinical decision rules could reduce the
percentage of these patients who undergo head CTs by
33%, as found by previous research, this could result in a
substantial reduction in costs associated with ED visits for
traumatic brain injury.15
The definition of what constitutes minor head injury is
highly subjective. Throughout the literature, the terms
“mild” head injury, “minor” head injury, “minimal” head
injury, “low-risk” traumatic brain injury, and various other
terms have been used interchangeably. The lack of defined
consensus on nomenclature has added to the confusion in
this area of study. For the purposes of this study, we use the
term “minor head injury” to refer to patients with blunt
head trauma, a GCS score of 14 or 15, and any one of the
following: a period of observed or self-reported
disorientation or confusion after the trauma, a period of
observed or self-reported amnesia at approximately the time
of the injury, observed signs of neurologic or neuropsychic
dysfunction, or any observed or self-reported loss of
consciousness lasting less than 30 minutes. These criteria
are consistent with those laid out by the CDC.16 We define
Volume -, no. - : - 2018
Davey et al Canadian Computed Tomography Head Rule and Patients With Minimal Head Injury
minimal head injury as the subset of patients with minor
head injury and without witnessed disorientation or loss of
consciousness.
Patients with minimal head injury were not included in
these previous clinical decision rules. Because this subgroup
was always considered to be very low risk, there are no
significant data to guide providers about when to use CT
imaging in this patient group. These patients would
presumably have a very low incidence of injury, possibly
low enough that the group as a whole (or a subgroup)
would not require or would only rarely require diagnostic
imaging. This study aims to validate the Canadian CT
Head Rule in this cohort of patients with minimal head
injury, and examine physician motivations in regard to
diagnostic imaging decisions. This could lead to the
identification of a clinical decision rule for a group of very-
low-risk patients who could avoid the radiation exposure
and costs of an unnecessary CT scan.
MATERIALS AND METHODS
This was a prospective convenience sample of patients
with minor head injury and minimal head injury and their
ED providers. This study was reviewed and approved by
the institutional review board. It was performed at 2 large,
urban, academic EDs that include one Level I trauma
center and one Level II trauma center with a combined
190,000 visits per year. Inclusion criteria included patients
who presented for minor head injury or minimal head
injury and for whom the clinician ordered a head CT, and
aged 18 years or older. Exclusion criteria included English
not listed as the primary spoken language, clinical
intoxication, previous recent (<30 day) intracranial injury
(based on triage history and notes or noncontrast head CT
found in the electronic medical record), GCS score less
than 15, neurologic deficits, loss of consciousness,
witnessed disorientation, or any patient who was
considered a “trauma code” by our institutional guidelines.
At our institution, trauma code patients are evaluated in the
resuscitation room by the entire trauma team. Decisions
about whether to image these patients are made in tandem
with the entire surgical team. Because our goal was to study
patients for whom the decision to image was made solely by
the emergency physician, we excluded trauma code and
trauma alert patients from our study. Trauma code criteria
included GCS score less than 13, open skull fracture,
gunshot wound, and fall from greater than 20 feet or 3
times height; trauma alert criteria included pedestrian or
cyclist struck at greater than 5 miles/hour, cyclist separated
from vehicle or traveling greater than 20 miles/hour,
unrestrained passenger in a rollover, ejection from vehicles,
death of occupant of same passenger compartment, motor
Volume -, no. - : - 2018
vehicle collision with intrusion greater than 12 inches, 2 or
more fractures and torso trauma, 2 or more long bone
fractures, pelvic fracture, and penetrating injury above the
knee or elbow. The decision to activate a trauma code or
trauma alert was made by the triage nurse. Occasionally a
patient who met trauma code criteria may have eluded the
triage nurse. If patients later met trauma code activation
after they were enrolled, they could have been included in
the study because their primary evaluation was conducted
by the emergency physician and not the trauma team.
Once triaged, patients were assigned in a rotating fashion to
one of the 2 or 3 teams in the ED. Patients were evaluated
and treated by their assigned physician according to
individual physician practices. Physicians took standard
practice guidelines into account during their
decisionmaking; however, no particular guidelines were
reviewed with them before this study, nor were they
encouraged to use one set of guidelines preferentially over
another. All supervising physicians were board certified in
emergency medicine. In the department, we use research
assistants trained to evaluate patients for research studies
from 8 AM to midnight 7 days per week. During these
hours, a research assistant identified potential patients for
enrollment by monitoring the tracking board in the
electronic medical record. The study was conducted during
a 24-month period, from May 9, 2014, to May 9, 2016.
Once a patient was identified (minor head injury or
minimal head injury; noncontrast head CT ordered), he or
she was screened by a research assistant for exclusion
criteria present in the chart. Charts were reviewed by
pretrained research assistants in real time. The research
assistants determined language and previous head injury by
using the electronic medical record. They spoke to the
treating physician about the clinical exclusion criteria. If it
was determined that a patient met exclusion criteria, or the
treating physician could not verify confidently that the
patient met inclusion criteria, the subject was not enrolled
in the study. The research assistants enrolled patients after
the physician ordered the noncontrast head CT, but before
he or she reviewed the scan or received the results from the
Department of Radiology. After an explanation of the
study, patients signed the informed consent. The treating
physicians were given a survey about concerning features of
the history and physical examination and which factors
contributed to the decision to obtain a noncontrast head
CT (Figure 1). Treating physicians surveyed consisted of
faculty and senior residents (postgraduate year 3) practicing
under attending physician supervision. There were no
management changes or any interventions performed
according to survey participation or responses. The decision
to obtain noncontrast head CT imaging was made before
Annals of Emergency Medicine 3
Canadian Computed Tomography Head Rule and Patients With Minimal Head Injury Davey et al

Head CT Study Form Page 1 (RA and MD) Form #_____

AA to fill out grey area

1) Name: ____________________ 2) MR#____________________ 3) Date___________ 4) Sex: M0 / F1
5) Prescribed Meds (supposed to be taking regularly):
___Aspirin1 ___Aggrenox3 ___Ticlodipine (Ticlid)5 ___Effient (prasugrel)7
2 4 6
___Warfarin (Coumadin) ___Clopidogrel (Plavix) ___Pradaxa (Dabigatran) ___None of the above0
____________________________________________________________________________________________________________

6) The patient had: No LOC0 / No LOC but witnessed disorientation1 / Positive LOC2

7) Does the patient have any high risk features of head injury? (Check all that apply)
___GCS < 15 at 2h post-injury 0/1 ___ Suspected open or depressed skull fracture 0/1 ___Sign of basilar skull fx 0/1
___ Vomiting > 2 0/1 ___Age > 65 0/1 ___Pre-injury amnesia >30min 0/1 ___Dangerous Mechanism0/1

8) Mechanism (Check all that apply)

___Fall from Standing Height0/1 ___pedestrian struck0/1
0/1 0/1
___Fall from larger height ___MVC
0/1
___assaulted with blunt object ___recreational sports
___Walked / ran into stationary object0/1
___Other0/1__________________________(specify)
0/1

9) Approximately how many hours ago did the injury occur? _______________ (best estimate)

10) Why are you ordering the Head CT: (check all that apply)
___Has high risk criterion above 0/1 ___To minimize legal liability0/1
0/1
___ Patient expectation/satisfaction ___To avoid observation (speedier discharge) 0/1
___Patient reassurance 0/1

___ My own reassurance0/1 ___ PMD wants this test0/1

___ I’m concerned for an injury that requires an intervention0/1 ___ To identify fractures (nasal/orbital/sinus/skull) 0/1

___I’m concerned about any injury (including those NOT requiring an intervention) 0/1

11) What is your best estimate that this patient has traumatic bleeding that will be seen on the CT today? ________ %

12) What is your best estimate that this patient has a brain injury requiring an intervention*? ________ %
*(interventions = intubation, admission for >48 hrs, any neurosurgical procedure)

13) If there were limited legal liability AND you were asked by society to conserve resources would you order the study?
No0 / Yes1

14) Did concern for radiation exposure weigh into your decision? No0 / Yes1

15) Did cost to the patient weigh into the decision? No0 / Yes1

16) Did you use shared decision-making today in the decision to order a CT? No0 / Yes1

Head CT Study Form (Page 2) RA Form #_____

Results
AA to fill out grey area
1) Head CT results: ___ Negative0
___ Positive for traumatic hemorrhage1 Positives:(SAH1 / subdural2 / epidural3 / parenchymal4)
___ Positive for cerebral contusion2
___ Positive for fracture3 Positives: (nasal1 / orbital2 / skull3)

2) Patient was: ____ Discharged0 _____ Admitted1 to floor1 / ICU2 / OR3

Figure 1. Survey.

4 Annals of Emergency Medicine Volume -, no. - : - 2018

Davey et al Canadian Computed Tomography Head Rule and Patients With Minimal Head Injury

the patient was approached or enrolled in the research 390 non-tra uma a le rt pa tie nts
study. Patients who refused participation were not included unde rgoing he ad CT we re e nrolle d

in the study.
For the purposes of our study, a positive noncontrast
head CT result was defined as any CT read by attending 62/390 (15.9%) e xclude d
due to duplica tion (1) or
radiologists as positive for intracranial hemorrhage. da ta ba se e ntry e rror (61)*.
Patients with positive noncontrast head CT results were
retrospectively subjected to the Canadian CT Head Rule to 76/390 (19.5%) we re
determine whether they would have required a noncontrast e xclude d due to los s of
cons cious ne s s
head CT by this rule if it did not include the requirement
for loss of consciousness or witnessed disorientation. These
patients also had their medical records reviewed for 12/390 (3.1%) we re e xclude d
due to pos t-injury witne s s e d
disposition, hospital length of stay, and any operative or dis orie nta tion without los s of
cons cious ne s s
procedural interventions. Abstractors were trained research
associates who were not blinded to the study hypothesis.
Data analysis consisted of basic descriptive statistics and
comparisons of matched-question answers using raw 240/328 (73.2%) us able
da ta ba se e ntrie s me t the 5/240 (2.8%) hea d
numbers, the reporting of raw differences, and differences de finition of minima l he a d injury CTs pos itive for ICH
a nd we re furthe r a na lyze d
in raw proportions in the case of binary outcomes.
Sensitivity and specificity measures and their respective Figure 2. Patient enrollment. ICH, Intracranial hemorrhage.
95% confidence intervals (CIs) were computed through
comparison of case-by-case Canadian CT Head Rule–based
risk assessment, and final head CT reading was taken as the Although only 5 patients had a noncontrast head CT
reference standard. Patient-physician communication and showing intracranial hemorrhage, 14 other patients had
physician rationale were recorded through study form positive noncontrast head CT findings. An injury summary
responses. for all subjects can be found in Table 4.
Of the 240 patients with minimal head injury, the
RESULTS majority (207/240; 86.3%) were discharged home from
the ED. Thirty-three (13.8%) were admitted (Table 5). Of
Three hundred ninety patients with minor head injury
the 5 patients with intracranial hemorrhage observed on
were enrolled during the study period. Sixty-two were
noncontrast head CT, 4 were admitted to the medicine unit
excluded for incomplete or duplicate data. Of the 328
for observation, serial neurologic examinations, and repeated
remaining patients, 240 met the study criteria for minimal
noncontrast head CT, after which they were discharged.
head injury and were further analyzed. A flow diagram of
One patient was observed in the ED, a noncontrast head CT
patient enrollment can be found in Figure 2. Baseline
was repeated after 6 hours, and the patient was discharged
characteristics of these patients can be found in Table 1.
from the ED. No patients with an intracranial hemorrhage
Sixty-five of 240 patients (27.1%) were receiving one or
or facial fracture went to the ICU or had any surgical
more forms of anticoagulation or antiplatelet agents, 145
intervention performed during their admission. The average
(60.4%) were not receiving anticoagulation or antiplatelet
hospital length of stay was 1.25 days.
agents, and 30 (12.5%) did not have these data recorded.
Physicians’ reasons for ordering head CTs for patients
Of these patients with minimal head injury, 171 met
with minimal head injury varied. The most common
high- or moderate-risk criteria by the Canadian CT Head
answers given were physician reassurance (24.6%), patient
Rule. Details on these patients can be found in Table 2.
reassurance (24.2%), patient expectations (14.6%), and
Five patients (2.1%) had an intracranial hemorrhage.
reduction of legal liability (11.7%). Shared decisionmaking
Specific details about these patients can be found in
was stated to be used in 51% of cases by providers.
Table 3. All 5 patients with intracranial hemorrhage would
have been considered moderate or high risk by the
Canadian CT Head Rule (2 high risk [age], 3 moderate risk LIMITATIONS
[mechanism]). The sensitivity and specificity of the There were incomplete data for 30 patients in regard to
Canadian CT Head Rule from our data were 100% (95% their anticoagulation or antiplatelet use. These data were
CI 48% to 100%) and 29% (95% CI 23% to 35%), available for the 5 patients who did have intracranial
respectively. hemorrhage. Thus, the incomplete data on the other

Volume -, no. - : - 2018 Annals of Emergency Medicine 5

Canadian Computed Tomography Head Rule and Patients With Minimal Head Injury Davey et al

Table 1. Baseline characteristic of patients with and without excluded. The rationale for excluding these patients was
confirmed intracranial injury. that, in regard to trauma alerts, decisions about imaging
Any studies are made in conjunction with the entire trauma
ICH ICH Positive
team. This does not translate to the typical patient with
Total Present Absent Findings
Characteristics (%) (%) (%) (%) minimal head injury. If patients who met trauma alert
n 240 5 (2.1) 235 (97.9) 18 (10.1)
criteria, but no other exclusion criteria, eluded the triage
M 86 (38.6) 3 83 7 nurse, we considered it reasonable to include them in our
F 154 (61.4) 2 152 11 results because they were evaluated as having minimal head
Antithrombotic injury and were not evaluated by the trauma team on their
medications
Aspirin 50 (21) 0 50 (21) 3 (16.7) initial presentation. It is possible that additional
Warfarin 16 (6.7) 0 16 (9) 0 information was obtained after the initial triage with a
Aggrenox 0 0 0 0 different interpretation of their presenting history that
Clopidogrel 5 (2.9) 0 5 (3) 0
Ticlopidine (Ticlid) 0 0 0 0
prompted further evaluation. None of the 5 patients with
Pradaxa 2 (1.2) 0 2 (1.2) 0 positive intracranial hemorrhage on noncontrast head CT
(dabigatran) met trauma alert criteria. The trauma alert criteria used
Effient (prasugrel) 0 0 0 0
None of the above 145 (60.4) 5 (100) 140 (58.3) 11 (61.1)
were specific to our institution and thus limit the
Unreported 30 (12.5) 0 30 (12.5) 4 (22) generalizability of the study. Furthermore, excluding
Mechanism of injury trauma alert patients from our study may have introduced a
Fall from standing 161 (66.3) 3 (50) 158 (66.7) 16 (64) selection bias because many of these patients may otherwise
Fall from greater 17 (7) 2 (33.3) 15 (6.3) 2 (8)
than standing have met our inclusion criteria.
Assault by blunt 11 (4.5) 0 11 (4.6) 0 There was no interrater reliability assessment performed
object between radiologists who read the noncontrast head CT
Pedestrian struck 5 (2.1) 0 5 (2.1) 1 (4)
Motor Vehicle 7 (2.9) 0 7 (3) 0
scans.
Collision Abstractors who reviewed the charts of patients with
Recreational 4 (1.6) 0 4 (1.6) 1 (4) positive findings were not blinded to the study hypothesis.
sports
Walked/ran into 11 (4.5) 1 (16.7) 10 (4.2) 1 (4)
There were no interrater reliability assessments conducted
stationary object between abstractors. Given that the data points were simple
Other 27 (11) 0 27 (11.4) 4 (16) and few (admission location [floor, ICU], length of stay,
M, Male patient; F, female patient. intervention), we thought this was an unnecessary measure.
The survey was not pilot tested before the beginning of
the study.
patients would not change our finding that the use of The timing of the injury was not specified in relation to
anticoagulation or antiplatelet agents was not associated a given patient’s presentation. It may be that patients who
with an increased risk of intracranial hemorrhage in our presented immediately after an injury were treated
sample. This study’s small sample size relative to an differently than those with delayed presentations.
infrequent clinically significant event precludes premature No follow-up was conducted for any patient, and it is
conclusions, and larger studies are needed to confirm these unknown whether some of these individuals, particularly
results. Furthermore, because this study included only those receiving anticoagulants, developed delayed bleed
patients with minimal head injury for whom the clinician events.
ordered a head CT, no conclusions about the larger This study was conducted as a convenience sample and
population of patients with minimal head injury can be lacks the protections against bias and sampling error that
made. may be found in a randomized controlled trial. Our
It is possible that some patients who were included in inability to enroll patients who presented overnight limited
our study met trauma alert criteria and should have been the number of providers who participated in our study and

Table 2. Canadian CT Head Rule–positive patients.

GCS Open or Depressed Signs of Basilar Vomiting >2 >65 Retrograde Dangerous
Total Score <15 Skull Fracture Skull Fracture Episodes Years Amnesia Mechanism
171 0 0 3 4 137 1 35
Patients with 2 or more features: 9.

6 Annals of Emergency Medicine Volume -, no. - : - 2018

Davey et al Canadian Computed Tomography Head Rule and Patients With Minimal Head Injury

Table 3. Specific data for 5 patients with positive intracranial hemorrhage results.
Sex ICH Anticoagulants CCHR Risk Factors CCHR Advice Disposition
M Subdural None Dangerous mechanism: fall from height CT required Admit: floor
M Subdural None >65 y CT required Admit: floor
F Subdural None >65 y CT required Admit: floor
M Subarachnoid None Dangerous mechanism: fall from height CT required Discharged
M Subdural None Dangerous mechanism: fall from height CT required Admit: floor
CCHR, Canadian CT Head Rule.

may have given disproportionate representation to daytime head CT, it is not clear whether applying this strategy
providers who work during the hours when the hospital is would increase or decrease imaging if it were applied to the
maximally staffed. Furthermore, any difference in patient broader population of minimal head injury. These results
population and presenting complaint that occurred during suggest that even without the use of a decision tool, the risk
overnight shifts would not have been captured by this for serious outcome in minimal head injury among patients
study. who receive a head CT is very low. Patients who do not
This study was specifically focused on the presence or meet the inclusion criteria of the Canadian CT Head Rule
absence of surgically important intracranial pathology and in minimal head injury likely do not require any imaging,
does not denote the lack of concussion, does not clear a and it is an effective tool in evaluating the need for
patient to return to activity (sport or other), and does not noncontrast head CT in patients with minimal head injury.
provide insight into the risk of postconcussive syndrome or Given the increasing rate of CT use nationally, this
other issues related to traumatic head injury. represents an opportunity to provide more effective
resource use and to spare patients the unnecessary radiation
exposure and cost of a noncontrast head CT.
DISCUSSION
None of the 171 patients identified as being at moderate
The results of this study demonstrate that the risk of or high risk by the Canadian CT Head Rule received any
intracranial hemorrhage in patients with minimal head neurosurgical procedure. The 95% CI of this proportion
injury for whom a head CT was ordered is very low. When (0%) ranges from 0% to 3.6%. As such, the argument can
applied, the Canadian CT Head Rule was 100% sensitive be made that none of these patients required a noncontrast
in detecting intracranial hemorrhage in this patient head CT and that applying the Canadian CT Head Rule to
population. Furthermore, if the Canadian CT Head Rule the minimal-risk population could decrease the diagnostic
had been used in this patient population at our institution, yield and increase unnecessary testing. There are data from
with our unique cultural practices, CT usage could have previous studies that demonstrate that a subset of patients
been cut by 29% (69/240) without a single missed event. with minimal head injury may be at risk for clinically
In the small number of patients who did have an significant intracranial hemorrhage.17-19 As a result of these
intracranial hemorrhage on noncontrast head CT, none studies, in 2008 the American College of Emergency
had serious adverse outcomes, including ICU admission or Physicians (ACEP) reversed a previous policy statement on
need for surgical intervention. Because this study included neuroimaging decisionmaking in adults with head
only patients for whom the clinician elected to perform a trauma,20 deciding to promote the judicious use of head
CT in patients with minimal head injury.21 Although
Table 4. Injury summary for all subjects (n¼240). future studies may demonstrate that even patients with
Head CT Result n % minimal head injury who meet the Canadian CT Head
Negative 221 92.1
Subarachnoid hemorrhage 1 0.4 Table 5. Patient disposition.
Subdural hematoma 4 1.6
Patient ICH ICH Any Positive
Epidural hematoma 0 0
Disposition Total (%) Present (%) Absent (%) Findings (%)
Parenchyma hemorrhage 0 0
Cerebral contusion 0 0 Home 207 (86.3) 1 (20) 206 (85.8) 10 (35.7)
Any fracture 15 6.3 Admission 33 (13.8) 4 (80) 29 (12.3) 9 (32.1)
Nasal fracture 11 4.6 Floor 33 (13.0) 4 (80) 29 (12.3) 9 (32.1)
Orbital fracture 1 0.4 ICU 0 0 0 0
Skull fracture 3 1.3 OR 0 0 0 0

Volume -, no. - : - 2018 Annals of Emergency Medicine 7

Canadian Computed Tomography Head Rule and Patients With Minimal Head Injury
Rule do not require noncontrast head CT, we believe that
because of the limited size and scope of our study, it would
be premature to draw larger conclusions about all patients
with minimal head injury until larger studies can be
conducted.
ACEPs most recent 2008 guidelines advise obtaining a
noncontrast head CT for any patient with head trauma
even in the absence of loss of consciousness or witnessed
disorientation “if there is a focal neurologic deficit,
vomiting, severe headache, age 65 years or greater, physical
signs of a basilar skull fracture, GCS score less than 15,
coagulopathy, or a dangerous mechanism of injury.”21
Careful examination of these recommendations shows that
with the addition of severe headache, the criteria are the
same as those used in the Canadian CT Head Rule despite
that the rule was never validated in this patient population.
These findings highlight the need for a defined clinical
decision rule that includes patients with minimal head
injury.
Previous attempts to derive new clinical decision rules to
include patients with minimal head injury have failed
because of low sensitivity, a cumbersome number of clinical
inclusion criteria, or lack of external validation.17,19,22 As
such, it seems reasonable that currently, providers may
choose to manage these patients by applying guidelines
such as the Canadian CT Head Rule or the New Orleans
Criteria to this low-risk cohort. Although both rules have
been proven effective in identifying patients with
intracranial injury, we thought that the Canadian CT Head
Rule—with its greater specificity and consistency with
current ACEP guidelines—would be a more ideal tool if it
could be adapted to patients with minimal head injury and
thus made it the focus of this study. Our results suggest
that in this small cohort of patients, the Canadian CT
Head Rule may be an effective tool in screening the need
for noncontrast head CT in patients with minimal head
injury.
None of the 53 patients receiving some form of
anticoagulation or antiplatelet agent had noncontrast head
CT positive for intracranial hemorrhage. These patients were
excluded from the initial Canadian CT Head Rule
validation, so further study is needed to directly evaluate
anticoagulation and antiplatelet agents as risk factors for
intracranial hemorrhage in patients with minor and minimal
head injury. Although our results are encouraging, this study
was not designed to assess the use of the Canadian CT Head
Rule in patients receiving anticoagulation therapy who may
be at increased risk for delayed bleeding after initial discharge
from the ED, and conclusions cannot be drawn about this
patient population from our findings. Future studies may
focus on better delineating the risk factors for intracranial
8 Annals of Emergency Medicine
Davey et al
injury in these patients to promote the judicious use of
noncontrast head CT and rapid discharge from the ED.
Physician rationale for ordering a noncontrast head CT
varied. The most common reasons given by physicians
included patient reassurance, physician reassurance, and
concern for an injury that might require an intervention.
This is to be expected because a physician’s clinical
impression always takes precedence over any clinical decision
rule used in management decisions. Clinical decision rules
should be used as a guide, whereas individual providers’
clinical judgment should prevail in individual circumstances.
This may include diagnostic imaging to search for other
injuries such as facial fractures, as clinically indicated. A
significant percentage of physicians also listed the desire to
avoid legal liability and to avoid a prolonged observation
period as reasons for ordering a noncontrast head CT.
Multiple studies have shown that concerns about legal
liability can result in changes in physician ordering
practices.23,24 This additional testing is not without
associated costs. Some estimates suggest that in the United
States, up to $210 billion per year in medical costs can be
attributed to unnecessary laboratory and imaging tests
ordered because of fear of legal repercussions.25 This increase
in use highlights the need for clear decisionmaking rules to
guide physicians, support their documentation, and avoid
excessive and unnecessary diagnostic imaging. The results of
this study support using a previously validated decision rule
to avoid unnecessary imaging in this very-low-risk cohort of
patients. Because the use of CT imaging varies by provider
and institution, larger studies will be needed to determine the
effect that applying the Canadian CT Head Rule to patients
with minimal head injury may have on overall CT use.
Our study suggests that the Canadian CT Head Rule is
an effective screening tool for patients with minimal head
injury. As rates of CT use continue to increase,
investigating which of these patients do not require a
noncontrast head CT represents an opportunity to
significantly decrease overuse of resources. In our study,
when clinicians decided to obtain a noncontrast head CT
despite relatively minimal head injury, the Canadian CT
Head Rule seemed an effective tool in identifying patients
with intracranial bleeding that did not need intervention.
Further research is needed to understand what effect the
broad application of this strategy would have on CT use.
Supervising editor: William J. Meurer, MD, MS
Author affiliations: From the Department of Emergency Medicine,
George Washington University, Washington, DC (Davey); and the
Department of Emergency Medicine, Mount Sinai St. Luke’s
Hospital, Mount Sinai Roosevelt Hospital, New York, NY (Saul,
Russel, Wassermann, Quaas).
Volume -, no. - : - 2018
Davey et al Canadian Computed Tomography Head Rule and Patients With Minimal Head Injury
Author contributions: KD, JW, and JQ conceived the study and
designed the trial. GR and JQ supervised the conduct of the trial
and data collection, undertook recruitment of participating centers
and patients, and managed the data, including quality control. GR
provided statistical advice on study design and analyzed the data.
KD drafted the article, and all authors contributed substantially to
its revision. KD takes responsibility for the paper as a whole.
All authors attest to meeting the four ICMJE.org authorship criteria:
(1) Substantial contributions to the conception or design of the
work; or the acquisition, analysis, or interpretation of data for the
work; AND (2) Drafting the work or revising it critically for important
intellectual content; AND (3) Final approval of the version to be
published; AND (4) Agreement to be accountable for all aspects of
the work in ensuring that questions related to the accuracy or
integrity of any part of the work are appropriately investigated and
resolved.
Funding and support: By Annals policy, all authors are required to
disclose any and all commercial, financial, and other relationships
in any way related to the subject of this article as per ICMJE conflict
of interest guidelines (see www.icmje.org). The authors have stated
that no such relationships exist.
Publication dates: Received for publication August 2, 2017.
Revisions received December 18, 2017; January 20, 2018, and
March 9, 2018. Accepted for publication March 23, 2018.
Presented at the American College of Emergency Physicians
Academic Assembly, Boston, MA, October 2015.
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