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Scandinavian guidelines for initial management
of minimal, mild and moderate head injuries in
adults: an evidence and consensus-based update
Undén et al.
Undén et al. BMC Medicine 2013, 11:50
http://www.biomedcentral.com/1741-7015/11/50 (25 February 2013)
GUID ELI NE Open Access
Scandinavian guidelines for initial management
of minimal, mild and moderate head injuries in
adults: an evidence and consensus-based update
Johan Undén
1*
, Tor Ingebrigtsen
2
and Bertil Romner
3
, for the Scandinavian Neurotrauma Committee (SNC)
See related commentary article here http://www.biomedcentral.com/1 741-7015/11/51
Abstract
Background: The management of minimal, mild and moderate head injuries is still controversial. In 2000, the
Scandinavian Neurotrauma Committee (SNC) presented evidence-based guide lines for initial management of these
injuries. Since then, considerable new evidence has emerged.
Methods: General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II
framework and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Systematic evidence-based review according to Preferred Reporting Items for Systematic Reviews and Meta-
Analyses (PRISMA) methodology, based upon relevant clinical questions with respect to patient-important
outcomes, including Quality Assessment of Diagnostic Accuracy Studies (QUADAS) and Centre of Eviden ce Based
Medicine (CEBM) quality ratings. Based upon the results, GRADE recommendations, guidelines and discharge
instructions were drafted. A modified Delphi approach was used for consensus and relevant clinical stakeholders
were consulted.
Conclusions: We present the updated SNC guidelines for initial management of minimal, mild and moderate head
injury in adults including criteria for computed tomography (CT) scan selection, admission and discharge with
suggestions for monitoring routines and discharge advice for patients. The guidelines ar e design ed to primarily
detect neurosurgical interve ntion with traumatic CT findings as a seconda ry goal. For elements lacking good
evidence, such as in-hospital monitoring, routines were largely based on consensu s. We suggest external validation
of the guidelines before widespread clinical use is recomme nded.
Keywords: computed tomography, GRADE, guidelines, head/brain injury/trauma, management, prediction rule,
routines, S100/S100B/S100BB
Background
Traumatic brain injury (TBI) is one of the most common
reasons f or emergency department (ED) care [1]. Cases
of TBI account for over 1 million visits per year in both
the USA and the UK [2,3] and are responsible for two-
thirds of all trauma deaths [4]. Only a small proportion
of these are classed as severe head injury [1], with a Glas-
gow Coma Scale (GCS) score of 3 to 8. The majority of
patients are instead classed as minimal, mild and
moderat e head injuries [5] and ar e generally conscious in
the ED with varying degrees of neurological symptoms. A
minority of these patients will have intracranial pathology
on computed tomography (CT) scanning and an even
smaller proportion will need neurosurgical intervention
[6,7]. In particular, the inte rmediate risk group of mild
head injury (MHI) has been notoriously difficult to man-
age as these patients have a very low, but not negligi ble,
risk of needing neurosurgical intervention [7,8].
Over the past decade, initial management strategies have
become focused on selective CT use based upon presence
or absence of specific aspects of patient history and/or
clinical examination [6,9-11], in order to effectively use
* Correspondence: dr.johan.unden@gmail.com
1
Department of Intensive Care and Perioperative Medicine, Institute for
Clinical Sciences, Södra Förstadsgatan 101, 20502 Malmö, Sweden
Full list of author information is available at the end of the article
Undén et al. BMC Medicine 2013, 11:50
http://www.biomedcentral.com/1741-7015/11/50
© 2013 Undén et al; licensee BioMed Central Ltd. This is an Open Access articl e distribut ed under the terms of the Creat ive Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
health care resources. This selective management has
received more attention following reports of increased
cancer risks from CT scans, estimated at 1 in 5,000 to
10,000 for a single head CT scan in young adults [12].
Following a normal CT scan after mild head injury,
consensus is generally to discharge patients from the hos-
pital [13,14], although subgroups of patients may still be
at risk of developing delaye d intracranial complication s
of varying significance [15,16].
In 2000, the Scandinavian Neurotrauma Committee
(SNC) presented evidence-based guidelines for the initial
management of minimal, mild a nd moderate head inju-
ries [5]. Alt hough external and independent validation
has shown the guidelines to function favorably [17,18], it
is likely that new evidence exists which needs to be con-
sidered. The SNC has therefore mandated an update of
the guidelines. The aim of the present report is to present
these updated guidelines for adults, including the metho-
dology and considerations behind the workflow.
Methods
The overall policy was to follow the Appraisal of G uide-
lines for Research and Evaluation ( AGREE) II guideline
development framework [19], complemented by the
Grading of Recommendations Assessment, Development
and Evaluation (GRADE) system [20]. Consensus was that
these two aids would result in a transparent and systematic
methodology and the best possible workflow from available
evidence to guideline construction and implementation.
The overall workflow process is shown in Figure 1.
Task force, working group and stakeholders
The SNC consists of neurosurgeons and anesthesiologists
from Scandin avia with expertise in neurotrauma. A task
force was init iated within the SNC, consi sting of three
authors wit h experience within the field (JU, TI, BR), to
propose evidence-based recommendations and a draft for
the updated guidelines. For the consensus stage of devel-
opment, a working group was formed consisting of SNC
members. Important stak eholde rs from gener al surgery,
emergency medicine and orthopedics were also involved
in this process. These specialties initially manage the vast
majority of head injury pati ents in Scandina via. We also
considered including members of the public in the pro-
cess but unanimously decided against this as we did not
believe it would facilitate optimal guideline development
in the present scenario.
Scope, purpose and target population
The objective of the guidelines c reated in the present
work would be to assist ED physicians with initial (the
first 24 h) management of all adult patients with minimal,
mild and moderate head injury, specifically to decide
which patients are to receive CT scanning, admission or
discharge (or combinations of these) from the ED. Head
injury severity was predefined according to the Head
Injury Severity Score (HISS [21]) where minimal repre-
sents patients with a GCS score of 15 and no risk factor s,
mild is a GCS score of 14 or 15 with risk factors (such as
amnesia or loss of consciousness (LOC)) and moderate is
a GCS score of 9 to 13.
The rationale was primarily to identify all patients
needing neurosurgical intervention, i ncluding medica l
intervention for high intracranial pressure (assigned a
critical level with regard to patient-important outcomes).
The secondary goals (assigned important, but n ot c riti-
cal, wit h regar d to patient-import ant out comes) were
identification of non-neurosurgical intracran ial trau-
matic co mplications and also strong consider ation of
resource use with minimizati on of unnecessary (normal)
CT scans and/or admission.
The task force decided a priori to make an attempt to
keep the guidelines applicable to the complete patient
spectrum within EDs, that is, to ensure that a ll adult
patients with minimal, mild and moderate head injury
can be managed according to the guidelines.
Certain assumptions were also made a priori concern-
ing aspects of management that were deemed unneces-
sary for critical review. The task force all agreed that
magnetic resonance imaging (MRI) would not be con-
sidered in these guidelines conc erning initial manage-
ment and that in-hospital observation, instead of CT,
would be r egarded only as a secondary management
option. The use of plain skull films was addressed and
rejected in the previous g uidelines. A dditionally, we
chose not to consider later aspects of management, such
as detection and treatment of post-concussion syndrome
(PCS) and chronic subdural hematomas. We also agreed
that all pathological findings on head CT should lead
to hospital admission. Finally, we would not address
the surgical or medical management of intracranial
complications.
The task force was unclear concerning the selection of
patients for CT scanning or discharge, following minimal,
mild and moderate head injuries. We were also unclear
concerning which patients, irrespective of initial CT scan
results, should have hospital admission for clinical obser-
vation, a repeat CT scan, or both. Theref ore, consensus
was achieved to addr ess two important clinical questions
that would require systematic review of eviden ce and
would form the basis of the updated guidelines, shown
below.
Clinical question 1: ‘Which adult patients with mini-
mal, mild and moderate head injury need a head CT
and which patients may be directly discharged?’.
Clinical question 2: ‘Which adult patients with mini-
mal, mild and moderate head injury need in-hospital
observation and/or a repeat head CT?’.
Undén et al. BMC Medicine 2013, 11:50
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Search strategy
In order to address the clinical questions we performed
two separate systematic reviews of the literature, in
accordance to the Preferred Reporting Items for Systema-
tic Reviews and Meta-Analyses (PRISMA) statement [22].
Both utilized broad searches of t he MEDLINE and
EMBASE databases, from 1985 until January 2010 and
then complemented to July 2012, using prespecified
Medical Subject Headings (MeS H) terms and key words
depicted by the task force. MeSH terms were pretested
for vali dity through identification of several key articles.
It was deemed unlikely that studies prior to 1985 would
be useful considering the wide-scale introduction of CT
scanning around this period. We did not ap ply any other
limitations to the search.
For the first clinical question, the MeSH terms and key-
words were; ((head trauma) OR (brain injury) OR (head
injury) OR (traumatic head injury) OR (traumatic brain
injury)) AND (minimal OR mild OR minor OR moder-
ate) AND (management OR predictors OR predictor).
For the second clinical question we used; ((head trauma)
OR (brain injury) OR (head injury) OR (traumatic head
injury) OR (traumatic brain injury)) AND (minimal OR
mild OR minor OR moderate) AND (hospitalization OR
hospitalisation OR observation OR admission OR dis-
charge OR delayed OR ((normal OR negative OR repeat
Literature search
Final Guideline
Literature Selection
Evidence Grading
Evaluation of Clinical
Predictors
Evidence Summary and Draft
Recommendation
Recommendation and
Guideline development
Step in work process
Method Description/Result
PRISMA In text
In text Figures 2 and 3
CEBM Additional files 2 and 4: Tables S2 and S4
QUADAS Additional files 3 and 5: Tables S3 and S5
In text Additional file 1: Table S1
GRADE Table 1
Deplhi process Tables 2, ͵ and Ͷ
In text Additional files 6-7: Figures S1-2
Figure 1 Flow diagram showing the overall work process.
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OR multiple OR serial OR follow-up) AND (CT OR CCT
OR computed tomography)).
Additional papers were identified by hand-searching
bibliographies of retrieved studies.
Selection criteria and study eligibility
Titles were examined by one author (JU) and borderline
titl es were included. Titles that were obviously not rele-
vant were excluded. A bstracts were e xamined indepe n-
dently by two authors (JU, BR) and the third (TI) was
consulted when discrepancies arose. Selected full papers
were independently reviewed by all authors (JU, TI, BR)
and discrepancies were resolved through discussion.
Review art icles, letters, expert opi nion and editorials
coul d be retrieved for exa mination of bibliographies but
were excluded from the analysis. Papers reporting only
children (<18 years) were excluded in both searches. In
cases where essential data was missing or unclear, we
made an attempt to contact corresponding authors for
clarification. Studies including patients with all severit ies
of head injury were only inc luded if at least 50% of
patients were within the GCS 9 to 15 range.
For the first c linical ques tion, we included studies
reporting patients with admission/initial GCS scores ≥9
and that included one or more predictive risk factors for
the reference standards of CT findings, intracranial
injury (ICI) and/or neurosurgical intervention. We
decided apriorito only include stu dies where informa-
tion concerning true positives (TP), false posit ives (FP),
true negatives (TN) and false negatives (FN) could be
extracted. This information would be necessary to fully
appreciate the possible clinical effect and role of a risk
factor, allowing consideration of other effects than the
positive predictive power. Studies reporting less than 50
patients were excluded. Definitions for risk factors were
defined a priori.
For the second clinical question, we included studies
reporting patients with admission/initial GCS scores ≥9
with an initial CT scan (norma l or abnormal) a nd con-
tained info rmation regarding clinical characteristics that
were associated with a positive or worsening repeat CT
scan, ICI and/or neurosurgical intervention within 1
week following trauma.
CT findings were defined as any traumatic finding on
head CT. ICI was defined as any intracranial ( isolated
non-depressed cranial f ract ures not included ) traumatic
finding on CT. Also, s ince not all patients can be sub-
jected to CT, absence of ICI was defined as relevant and
robust clinical follow-up suggestive of normal neurologi-
cal functioning ( with the exception of classical PCS
symptoms). The decision to consider any CT findings
and ICI as separate reference standards was due to the
difference in cl inical importance of these measures. This
approach should also stratify reference standards in a
more homogenous selection compared to a combined
definition. Finally, neurosurgical intervention was
defined as any neurosurgical procedure for a cranial or
intracranial injury with in the f irst week following
trauma. Medical treatment for elevated intracranial pres-
sure, within the first week f ollowing trauma, was also
included in this group since some patients with diffuse
brain injury cannot be managed surgically.
Data extraction and quality assessment
Data was extracted by one author (JU) and checked by
another (BR). Data was entered into a predefined protocol
and then inputted into Excel (Microsoft; Redmond, WA,
USA). Evidentiary tables were constructed to summaries
the studies. We decided to address the quality of papers in
different phases, due to the nature of the studies and the
phase of assessment. Firstly, all retrieved studies w ere
independent ly graded by all authors in the task force (JU,
TI, BR) according to the Centre of Evidence Based Medi-
cine (CEBM) diagnosis criteria [23]. Discrepancies in grad-
ing were resolved through discussion. Quality ratings
ranged from 1 (strongest evidence, for instance reports of
clinical decision rules and high quality validation studies)
to 5 (weakest evidence, oftenexpertopinion).Studies
receiving CEBM scores of 5 were excluded.
Studies were then graded according to the Quality
Assessment of Diagnostic Accuracy Studies (QUADAS)
tool [24], which was modified for the purpose of the
review. This tool considers 14 criteria relevant to diagnos-
tic studies accounting for bias (items 3 to 7, 10 to 12),
variability (items 1 and 2) and reporting (items 8 and 9).
Items 4 (regarding the time period between index and
reference test) and 7 (regarding the inde pend ency of the
reference test) wer e omitted with regard to the selection
criteria and the previously applied CEBM criteria. Addi-
tionally, item 3 (regarding the ability of the reference test
to correctly classify the target condition) was applied to
CT findings, ICI and neurosurgery separately.
Data analysis
Although extracted data regarding the first clinical ques-
tion, predictors of CT f indings, ICI and neurosurgery,
could theoretically be summarized in a meta-analysis, the
task force decided apriorinot to perform such an analysis
for the purpose of development of the guidelines, indepen-
dent of heterogeneity between studies. We felt combining
the d ata in this way could mislead the working group in
the consensus process and opted to instead present
uncombined data for studies including their quality assess-
ment. We therefo re calculated individual positive likeli-
hood ratios (PLR) and negative likelihood ratios (NLR) for
each risk factor with respect to the corresponding refer-
ence test (CT, ICI or neurosurgery) and the prevalence
of both the reference test and the risk factor in the
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population. We felt that these indices would represent the
most relevant clinical applications for the working group
when considering the recommendations. For the second
clinical question, we presented only descriptive analysis.
Evidence summary and recommendations draft
Recommendations were formed by the task force (JU, TI,
BR)basedupontheevidenceinaccordancewiththe
GRADE system [ 20,25]. This system is increasingly been
used in the development of recommend ations and allows
consideration of aspects other than level of evidence in
determining the strength of a recommendation [25].
Clinical predictors were chosen based upon the summar-
ized evidence (see Additional fi le 1, Table S1). Focus was
put on the more severe outcome variables (need for neu-
rosurgery being of critical importance), but ICI and any
CT findings were also c onsidered, especially in cases
where the evidence concerning neurosurgery was poor
and/or inconsistent. We also considered the prevalence
of the risk factors in the studied cohorts. Risk factors
relatively co mmon in a population would lead to many
CT scans and these risk factors would therefore need to
show high predictive abilities to be included.
The summarized quality of evidence, from studies
forming the basis of a recomm endation, was graded from
high quality to very low quality, see Table 1. Evidence
was initially considered high quality when derived from
cohort studies reporting patients with diagnostic uncer-
tainty and appropriate reference standards, as described
earlier. Evidence could be downgraded due to risk of bias
(selection (population indirectness), verification, observer
and reporting), outcome indirectness (balance between
the presumed influence on patient outcome of the test
result (combination of risk factors) in relation to the
complications and resource use of the test), inconsistency
(large differences in prevalence of reference tests, preva-
lence of risk f actors, PLR or NLR) or differing general
results between studies), impreciseness (studies with
small number of patients and few positive CT, ICI or
neurosurgery events) and suspicion of publication bias
(small number of studies, industry funding).
Recommendations, relating to the clinical questions,
were classed as strong (we recommend...), weak (w e
suggest...) or uncertain (we cannot recommend...) (see
Table 1). For this process, careful consideration was again
made to risk/benefit aspects of patient-important outcomes
(need for neurosurgery was classed as the most important)
in relation to test results, including assumptions for pretest
probabilities (different magnitudes of risk for a positive
reference result of CT, ICI or neurosurgery) for different
patients, quality of evidence, uncertainty of the preferences
and values for outcomes and the use of health care
resources. Therefore, it is theoretically possible to achieve a
strong recommendation despite low quality evidence or vice
versa.
Recommendations and guideline development
Based upon the recommendations, a draft for the updated
guidelines was constructed by the task force. Following
this, a modified Delphi process w as used [26], involving
the working grou p previously described, consisting o f at
least two rounds of consensus. The aprioricriteria to
determine acceptance, rejection or lack of consensus are
shown in Table 2. In the first round, the recommenda-
tions, including data from included studies with CEBM,
QUADAS and GRADE evaluations together with a guide-
line draft were sent via email to the working group.
Ratings, including feedback, were anonym ously collected.
The task force adjusted the recommendations and draft
based upon the se responses. Then, in conjunction with a
2-day SNC meeting in September 2012 outside Copenha-
gen, Denmark, results were discussed and suggestions for
improvements made. Following this, the second round of
Delh i was completed via email. Additional rounds would
be undertaken if necessary. The task force and working
group were urged to consider the GRADE aspects pre-
viously mentioned, espe cially health risk/benefit aspects
including resource use, as well as side effects and risks
(misclassification of patients), at all stages of development.
The final guidel ines w ere evaluated, independently of
the task force an d working group, in the ED of Skane
University Hospital, Malmo, Sweden, to judge clarity o f
presentation and ease of use. Simultaneously, the guide-
lines were evaluated by importa nt stakeholders from
specialties directly involved in the everyday management
of these patients. Feedback was documented and appro-
priate changes were made, if necessary, but only to con-
sensus aspects. Finally, the working group reapproved
the guidelines after presentation of changes and feed-
back from the evaluation.
Implementation, monitoring and future updates
Guidelines will only be successful if they are used correctly
and on a wide scale. Previous experience with the 2000
Scandinavian guidel ines has shown poor compliance and
varying degrees of implementation success [27,28]. Imple-
mentation and monitoring strategies were discussed within
the working group in order to facilitate long-term successful
use of the guidelines in Scandinavia. Focus was put on over-
coming barriers to application and effectively using available
resources. The working group also outlined a procedure
and approximate time period for updating the guidelines.
Results
The search and selection process is shown in Figures 2
and 3 for the two clinical questions.
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For the first clinical question, we found 72 studies that
adhered to our inclusion criteria (see Additional File 2,
Table S2 for evidentiary information). These studies
included 226,606 individual patients. The level of evidence
according to CEBM was variable and overall judged to be
moderate (see Additional file 2, Table S2). Quality assess-
ment with the QUADAS tool (see Additional file 3, Table
S3)showedsubstantialbiasinthe studies, particularly
concerning the rep resentativeness of the studied popula-
tion (selection bias, criteria 1), blinding of the index test
(criteria 8) and withdrawals (criteria 12). Studies scored
better regarding the reporting of selection criteria (criteria
2) and most had acceptable reference standards (criteria
3), although they were often described poorly.
Clinical predictors, with according source study, PLR,
NLR, reference test prevalence and risk factor preva-
lence are shown in Additional file 1, Table S1.
With regard to the second clinical question, w e f ound
21 stud ies a dhering t o o ur inclusion criteria (see Addi-
tional file 4, Table S 4 for evidentiary information and
relevant results). The CEBM rating was generally low,
with several studies reporting non-independent reference
standards (see Addit ional file 4, Table S 4). QUADAS
assessment showed selection bias in most studies (criteria
1). Other consistent weaknesses of the studies were a lack
of reference test description and blinding (see Additional
file 5, Table S5 for details).
Recommendations
Based upon the evidence, drafts for recommendations,
guidelines and written discharge advice were constructed
by the task force. These, with according presentation of
the evidence (Additional files 1, 2, 3, 4, 5, Tables S1-S5),
were reviewed by the working group using the predefined
Delphi process. Foll owing round 1 (see Table 3), discus-
sion in the working group concerned points 4 and 7. Since
point 7 regarded the overall guidelines, minor adjustments
were also made to other points. Only consensus points
were changed (the risk factors shunt-treated hydrocepha-
lus and the combination of age >65 and antiplatelet medi-
cation were added, discharge advice was simplified,
monitoring routines were ad justed and the graphical lay-
out of the guidelines was improved).
Following round 2 (see Table 4), consensus was achieved
in favor o f all recommendations, the guidelines and the
discharge instructions. One recommendation, concerning
Table 1 Grading of Recommendations Assessment, Development and Evaluation (GRADE) system [24] for rating
quality of evidence and strength of recommendation
Factor Description
Evidence:
High quality Considerable confidence of the estimate of effect. Further research is very unlikely to change our confidence in the
estimated effect.
Moderate quality Confidence that the estimate is close to the truth. Further research is likely to have an important impact on our
confidence in the estimate effect and may change the estimate.
Low quality Limited confidence in the effect. Further research is likely to have an important impact on our confidence in the
estimate effect and is likely to change the estimate.
Very low quality Little confidence in the effect estimate. Any change of effect is uncertain.
Recommendation:
Strong: ‘We recommend...’ A strong recommendation indicates that most well informed people will make the same choice
Weak: ‘We suggest...’ A weak recommendation indicates that the majority of well informed people will make the same choice but a
substantial minority will not
Uncertain: ‘We cannot
recommend...’
No specific recommendation for or against
Factors influencing the strength of the recommendation include evidence quality, risk/benefit aspects of presumed patient-important outcomes, costs and
uncertainty concerning values and preferences.
Table 2 A priori established seven-point response scale and criteria to determine acceptance, rejection or lack of
consensus for recommendations and guidelines for the working group using a modified Delphi process [25]
Level of agreement
Strongly
disagree
Disagree Moderately
disagree
Neither agree or disagree Moderately
agree
Agree Strongly
agree
Score 1 2 3 4 5 6 7
Criteria 75% of respondents score ≤3 on the 7-point scale All other situations 75% of respondents score 5≥ on the 7-
point scale
Result Consensus against No consensus Consensus in favor
Action Reject recommendation Indicates no consensus has been
reached
Accept recommendation
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clinical question 1, was removed due to the working group
finding the information irrelevant, despite consensus. This
rec ommendation was an unce rtain recommendation (we
cannot recommend...) for risk factors not included in the
other recommendations (such as headache, intoxication,
nausea and amnesia). The working group felt this recom-
mendation was unnecessary and confusing, shifting focus
from the important recommendations below.
The final recomm endations, based purely on evidence,
are presented below.
Clinical question 1: ‘Which adult patients with minimal,
mild and moderate head injury need a head CT and
which patients may be directly discharged?’
(1) We recommend that adult patients after mild and
moderate head injury with GCS ≤14, loss of consciousness,
repeated (≥2) vomiting, anticoagulant therapy or coagula-
tion disorders, clinical signs of depressed or basal skull
fracture, post-traumatic seizures or focal neurological defi-
cits should have a CT scan (moderate quality, strong
recommendation).
Excluded by title
n=3295
Abstracts
n=401
Titles initially screened
n=3696
Full-text papers
n=201
Additional papers from
reference lists of retrieved
papers
n=27
Excluded by abstract
n=200
Papers included in review
n=72
Excluded by full-text n=156
• Not relevant n=79
• No data n=24
• Reporting only
children n=43
• <50 patients n=6
• Duplicate data n=4
Full-text papers
n=228
Figure 2 Adapted Preferred Reporting It ems for Systematic Reviews and Meta-Analyses (PRISMA) diagram showing the review
process with reference to the clinical question: ‘Which adult patients with minimal, mild and moderate head injury need a head CT
and which patients may be directly discharged?’.
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The evidence was initially of high quality but was down-
graded due to limitations in study design (mostly selection
bias), indirectness (outcomes were rarely reported) and
impreciseness (different magnitudes of predictive power of
risk factors between studies). However, the strength of the
recommendation was view as strong by the working
group, considering the seriousness of the complication
and h ealth/economic impact of missing a patient with a
neurosurgical lesion. The working group also discussed
older age (≥60 years and ≥65 years) as well as antiplatelet
medication as risk factors of importance, partly due to the
presence of these criteria in other guidelines and decision
rules. However, the predictive ability was only moderate
and these individual risk factors would lead to an unaccep-
table CT increase and so consensus was not to include
these in our recommendation.
(2) We recommend that adult patients after mild head
injury with GCS 14 and no risk factors (anticoagulant
therapy or coagulation disorders, post-traumatic seizures,
clinical signs of depressed or basal skull fracture, focal
Excluded by title
n=2795
Abstracts
n=131
Titles initially screened
n=2926
Full-text papers
n=33
Additional papers from
reference lists of retrieved
papers
n=12
Excluded by abstract
n=98
Papers included in review
n=21
Excluded by full-text n=24
• Not relevant n=20
• No data n=2
• Reporting only
children n=2
Full-text papers
n=45
Figure 3 Adapted Preferred Reporting It ems for Systematic Reviews and Meta-Analyses (PRISMA) diagram showing the review
process with reference to the clinical question: ‘Which adult patients with minimal, mild and moderate head injury need in-hospital
observation and/or a repeat head CT?’.
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neurological d eficits), or GCS 15 with loss of conscious-
ness or rep eated (≥2) vomiting and no other risk factors,
be sampled for analysis of S100B if less than 6 h have
elapsed following trauma. If S100B is less than 0.10 μg/l,
the patient may be discharged without a CT (moderate
quality, strong recommendation).
The evidence was initially of high quality but was
downgraded due to study design (m ostly selection bias)
and indirectness (outcomes were rarely reported). How-
ever, studies consistently show that low S100B levels
can be used to s elect patie nts who do not need a CT
scan and, hence, may save valuable resources. Of the
few miss ed patients in the literature, almost all are non-
neurosurgical lesions. Some studies include risk factors
such as GCS 13, anticoagulation and focal neurological
deficits in the inclusion criteria. The working group,
however, found these risk factors to be too predi ctive of
intracranial injury.
This recommendation may seem conflicting with
recommendation 1, above. However, S100B is recom-
mended as an option for reducing unnecessary CT
scans in a subgroup of Mild head injury patients with
low risk for intracranial complication and/or neurosurgi-
cal intervention.
(3) We recommend that adult patients after minimal
and mild head injury with GCS 15 and without risk fac-
tors (loss of consciousness, repeated (≥2) vomiting,
anticoagulation therapy or coagulation disorders, post-
traumatic seizures, clinical signs of d epressed or basal
skull f racture, focal neurological deficits) can be dis-
charged from the hospital without a CT scan (moderate
quality, strong recommendation).
The evidence was initially of high quality but was
downgraded due to limitations in study design (mostly
selection bias), indirectness (outcomes were rarely
reported) and impreciseness (different magnitudes of
predictive power of risk factors between studies). The
working group felt, however, that the large proportion
of patients with head injury would fall into th is category
and that a CT policy in all these p atients would not be
health/economically viable considering the very low risk
of intracranial injury, and even lower risk of neurosur-
gery, in this patient group. As previously discussed,
older age and antiplatelet medication was again consid-
ered but rejected by the working group.
Clinical question 2: ‘Which adult patients with minimal,
mild and moderate head injury need in-hospital
observation and/or a repeat head CT?’
(1) We suggest that all adult patients after head injury
with GCS ≤1 3, clinical signs of depresse d or basa l skull
fracture, anticoagulation therapy or coagulation disorder,
post-traumatic seizure or focal neurological deficit
should have a CT scan and be admitted to hospital for
observation, irrespective of CT findings (low quality,
weak recommendation).
The evidence was sparse and also of low quality due to
study limitations (selection bias) and inconsistency in
findings. The working group felt that it would not be
good clinical prac tice to discharge patients with any of
these risk factors, despite the low quality of evidence.
(2) We recommend that repeat CT scans should be per-
formed in patients with neurological and/or GCS (≥2
points) deterioration (low quality, strong recommendation).
The evidence was of moderate quality and was down-
graded due to serious limitations in study design and
some inconsistency. Most of the evidenc e indicates that
routine repeat CT of these patients with or without CT
findings is unnecessary in the absence of clinical deteriora-
tion, specifically dete rioration of GCS >2 points and/or
Table 3 Results of the modified Delphi process, round 1
Delphi point Working group member Result Cf/nC/Ca
12345678910
1 6666266577 90% Cf
2 666- 366647 78% Cf
3 7676366717 80% Cf
4 5446266662 60% nC
5 6 5 6 6 7 6 6 7 6 6 100% Cf
6 6674766677 90% Cf
7 6656266- 43 67% nC
8 55666667- 3 89% Cf
9 5 - 5 6 6 6 6 6 - 5 100% Cf
Delphi points 1 to 3 refer to recommendations 1 to 3 concerning clinical
question 1, point 4 refers to a recommendation that was dropped due to
irrelevance (see main text), points 5 and 6 refer to recommendations 1 and 2
concerning clinical question 2, point 7 refers to the guideline draft including
the help sheet, point 8 refers to the written discharge advice and point 9 to
the in-hospital monitoring routines.
Ca = consensus against; Cf = consensus in favor; nC = no consensus.
Table 4 Results of the modified Delphi process, round 2
Delphi point Working group member Result Cf/nC/Ca
12345678910
1 76367767 88% Cf
2 - 6466667 86% Cf
3 76366677 88% Cf
4 76666376 88% Cf
5 7 6 7 6 7 - 6 7 100% Cf
6 7 7 7 6 7 - - 7 100% Cf
7 7 6 7 6 6 7 5 7 100% Cf
8 7 6 4 - - - 6 7 80% Cf
9 7 6 6 5 7 - 6 7 100% Cf
Two members did not reply. Delphi points 1 to 3 refer to recommendations 1
to 3 concerning clinical question 1, point 4 refers to a recommendation that
was finally dr opped due to irrelevance (see main text), points 5 and 6 refer to
recommendations 1 and 2 concerning clinical question 2, point 7 refers to the
guideline draft including the help sheet, point 8 refers to the written
discharge advice and point 9 to the in-hospital monitoring routines.
Ca = consensus against; Cf = consensus in favor; nC = no consensus.
Undén et al. BMC Medicine 2013, 11:50
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neurological status. A strong recommendation was chosen
in spite of weak evidence due to the seriousn ess of the
condition. Clinical aspects such as anticoagulation and
persistent neurological findings were discussed but the
working group could not reach consensus on a recom-
mendation for follow-up scans in these patients.
Guidelines
Based upon the recommendations, guidelines were con-
structed. The addition of shunt-treated hydrocephalus
was bas ed upon consensus in the working g roup with
little evidence to support this. T he working group dis-
cussed risk factors relating to trauma mechanism and
multitrauma injuries but found these difficult to recom-
mend, mainly due to practical i ssues with clinical appli-
cation. We considered serious extracranial injuries
(defined as Abbreviated Injury Score (AI S) >3 to any
organ system, for instan ce large (for example, femur)
fractures or serious thoracic or abdominal injuries) as a
risk factor due to the probability of a higher magnit ude
of trauma, need for extracranial CT and the poorer
prognosis of brain injury in these patients. However, we
finally decided to omit this as a risk factor primari ly due
to the difficulty of classifying this risk factor in a busy
clinical scenario. Additionally, predictive abilit y was gen-
erally only moderate for these risk factors. Also, loss of
consciousness was expanded to suspected/confirmed
loss of consciousness, as it is often d ifficult to confirm
this finding in the clinical setting. Patients who could
not clearly deny any loss of consciousness should be
classed as suspected. Finally, the working group could
not recommend older age or antiplatelet medication as
individual risk factors due to the unacceptable CT
increase such a recommendation would cause, in combi-
nation wit h only moderate predictive abilities. However,
consensus was reached to combine these into one risk
factor, namely age ≥65 years and antiplatelet medication.
Written instructions for patients being discharged wer e
adapted from the 2000 guidelines with consideration of
the National Institute of Clinical Excellence (NICE)
instructions [29] and a proposal for evidence-based
instructions from Fung et al. [30], (see Additional file 6,
Figure S1). With the Scandinavian setting in mind, the
discharge sheet was heavily simplified for clarity. Obser-
vation and monitoring routines for admitted patients
were based on consensus in the working group. We dis-
cussed the intensity of monitoring routines in relation to
the severity o f t he complications and burden on hospital
wards and finally decided that these should be relatively
frequent shortly after trauma (the first 4 h) with de-esca-
lation over time. Reasonably, most admitted patients will
arrive to a ward after at least 4 h and h ence already have
passed the 15-minute interval period. Also, these moni-
toring routines will only be used in small minority of
patients as mode rate and high-risk patients are relatively
uncommon and other patients should preferentially have
a CT.
Feedback from ED evaluation and from stakeholders
resulted in mi nor changes to wording and general
appearance of the guidelines. All stakeholders and the
working group approved the final version, see Additional
file 7, Figure S2.
Implementation, monitoring and future updates
The working group decided on implementat ion by S NC
members in their respective countries. This would be
performed through a combination of written and oral
presentations in national medical journals and national
meetings, respectively. We discussed barriers to imple-
mentation and decided that the most important of these
was probably the absence of sufficient education co n-
cerning head injury management in Scandinavia. We
would attempt to further facilitate implementation by
printing flyers and placards with the guidelines and to
send these to Scandinavian hospitals. We would also
initiate national training initiatives within the respective
Scandinavian countries.
With respect to monitoring aspects, the working group
decided to plan a questionnaire to Scandinavian physi-
cians treating head injury to determine the present use of
guidelines, similar to previous efforts [31]. At 1 year fol-
lowing implementation, a follow-up questionnaire will be
sent out to establish changes in management routines.
We will also initiate studies examining compliance wit h
the guidelines, as previously established in Norway
[27,28], and at tempt to improve insufficient use of the
guidelines depending on these results. Finally, we will
initiate a prospective validation study, also comparing the
performance of our guidelines with other guidelines,
decision rules and, importantly, unstructured physician
judgment [32].
The working group decided that an update of the
guidelines would be necessary in 2015. This would
include evidence updates concerning the clinical ques-
tions addressed in the present update and would further
examine the observation and monitoring routines for
admitted patients.
Discussion
Since 2000, considerable evidence has emerged conce rn-
ing the initial management, particularly risk factors for
CT selection, of minimal, mild and moderate head injury.
The work presented here is, in contrast to our previous
guidelines, confined to adults but a similar effort regard-
ing management of children is underway. Although these
guidelines can theoretically be used in any settin g, they
were designed with the Scandinavian emergency care set-
ting in mind. They are also designed to primarily iden tify
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patients needing neurosurgical or medical intervention,
with traumatic CT findings being the secondary identifi-
cation goal.
In summary, the evidence was of reasonable quality
referring to the predictive ability of risk factors for compli-
cations following head injury in these patients. Unsurpris-
ingly, many of the risk factors included here are also
found in other guidelines and decision rules [6,9-11,29,33].
However, several differences can be noted. We found that
the predictive power of amnesia was too low to be
included. This risk fac tor was present in the SNC guide-
lines from 2000, mostly due to the difficultly in ruling out
loss of consciousness in some patients. For this reason, we
include suspected loss of consciousness as a risk factor.
Risk factors such as intoxication, trauma above the cla-
vicles, nausea, vertigo and headache were not included
due to poor predictive ability combined with a high pre-
valence of these factors in the head injury population.
The working group found injury mechanisms compli-
cated to use p ractically in initial management and
decided not to include these as risk factors.
Older age, most often defined as ≥60 or ≥65 years, is
often included in other guidelines. The predictive ability of
this risk factor was only moderate and there was consider-
able uncertainty in the group with regard to patient
important outcomes and resource use. The number of
people in older age groups in industrialized coun tries is
increasing [34] and the increased CT rate that would be
associated with this risk factor was deemed unacceptable.
Also, the risk factor is common in the head injury cohorts,
with between 10% and 45% of patients being over 65 years
of age in reported cohorts of mild [10,35-38] and moder-
ate [39] TBI. Fabbri et al. recently presented results con-
sidering the combination of older age and antiplatelet
agents [40]. Despite the lack of good evidence for this
combination, consensus wa s reached to include age ≥65
years in combination with any antiplatelet agent as a risk
factor. It is reasonable t o expect that the combination
would be more predictive of complications after h ead
injury and result in a smaller CT rate increase when com-
pared to the risk factors used individually. Additionally, it
has been suggested that antiplatelet medication may be at
least partly responsible for the higher risks for intracranial
complications seen after head injury in older patients [40].
Shunt-treated hydrocephalus was added purely based
on consensus, with evidence derived from exp ert opinion
in the group. We acknowledge the poor evidence-based
background to this decision but this patient group is
uncommon and will not lead to a noticeable increase in
CT scanning.
Evidence concerning repeat CT was reasonable but lack-
ing concerning both written discharge advice and observa-
tion routines. These aspects were therefore based heavily
upon consensus with special weight put o n adaptation to
the Scandinavian health care system. Since in-hospital
observation consumes valuable resources, there is a need
for stronger evidence examining the need and magnitude
of these routines.
For the first time, a brain biomarker has been intro-
duced into clinical practice guidelines. Using a low cut-
off of 0.10 μg/l, the biomarker has shown considerable
ability to predict the absence of CT pathology and neuro-
surgical intervention [36,41,42] . Th is negative prediction
is welcomed since all other risk factors are of positive
predictive nature. S100B allows for a safe reduction in
CT scans in a subpopulation of patients with mild head
injury. In order to maintain the theoretical safety and
cost-saving ability, the biomarker should pri marily not
exhibit fal se negative results . Al so, the biomarker should
only be taken in patients that would usually rece ive a CT
scan and the fraction of negative S100B results (below
cut-off) should be as large as possible. S100B is clinically
unspecific [43,44] and has a short half-life [45]. There-
fore, patients with extracranial injuries and those seeking
care more than 6 h after trauma are not good candidates
for S100B sampling due to a risk of false positives and
negatives, respectively. Some patients have risk f actors
with higher predictive abilities and also factors that
would usually warrant admission irrespective of CT find-
ings. This group is therefore also not suit able for S100B
sampling. Despite the rel atively good evidence for S100B
in this setting, biomarkers have historically had different
effects in actual management and the clinical impact and
health economic implications may alter future recom-
mendations. Based upon the current evidence and clinical
setting, however, this biomarker should safely reduce
resource use if used correctly since low levels are very
uncommon in patients needing neurosurgical interven-
tion in this setting.
There are limitations to the process outli ned in this
paper. Although the recommendations are based upon
evidence, there were elemen ts of consensus input to the
final guidelines. This is inevitable when dealing with
these injuries and we attempted to minimize the negative
effects of this through our stringent and extensive metho-
dology using the best available tools. Particularly, the
GRADE system [20] allows consideration of other impor-
tant aspects other than the level of evidence in recom-
mendations. The derivation and validation of predictive
risk factors as performed by other authors [6,10,18]
would hardly be feasible in Scandinavia and would only
account for one aspect of the management guidelines.
Our methodology was judged as the most feasible consid-
ering the target population. However, external clinical
validation of our guidelines is welcomed and would natu-
rally support successful implementation.
Finally, these guidelines are, by definition, guidelines
andshouldbeutilizedaccordingly.Theyareprimarily
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designed as evidence and consensus-based guidance for
physicians who are not experts in the field. Physicians
whohaveconsiderableexperiencewiththesepatients
should naturally be allowed to defer from the guidelines
according to clinical judgment.
Conclusions
We present guidelines for initial management of adults
with minimal, mild and moderate head injury based upon
a thorough evidence and consensus-based methodology.
The guidelines are primarily designed to detect complica-
tions after head injury needing either neurosurgical or
medical intervention. They can be applied to all adult
patients and include aspects such as CT and admission
selection, repeat CT selection, monitoring routines and
discharge aspects. However, we suggest external valida-
tion before they are widely implemented. Furthermore,
areas with poor evidence, such as clinical monitoring
routines for patients following head injury, should be
addressed in future studies.
Additional material
Additional file 1: Table S1. Predictive risk factors with according studies
derived from the clinical question: ‘Which adult patients with minimal,
mild and moderate head injury need a head CT and which patients may
be directly discharged?’ showing corresponding positive likelihood ratio
(PLR), negative likelihood ratio (NLR), prevalence for the reference test
(CT findings (CT)), intracranial injury (ICI) and neurosurgery (NS)) and the
risk factor prevalence. CT = computed tomography.
Additional file 2: Table S2. Evidentiary table of studies with reference
to the clinical question: ‘Which adult patients with minimal, mild and
moderate head injury need a head CT and which patients may be
directly discharged?’. CT = computed tomography.
Additional file 3: Table S3. Modified Quality Assessment of Diagnostic
Accuracy Studies (QUADAS) grading of studies referring to the clinical
question: ‘Which adult patients with minimal, mild and moderate head
injury need a head CT and which patients may be directly discharged?’.
CT = computed tomography.
Additional file 4: Table S4. Evidentiary table of studies with reference
to the clinical question: ‘Which adult patients with minimal, mild and
moderate head injury need in-hospital observation and/or a repeat head
CT?’. CT = computed tomography.
Additional file 5: Table S5. Modified Quality Assessment of Diagnostic
Accuracy Studies (QUADAS) grading of studies referring to the clinical
question: ‘Which adult patients with minimal, mild and moderate head
injury need in-hospital observation and/or a repeat head CT?’.CT=
computed tomography.
Additional file 6: Figure S1. Discharge advice for adults following
minimal, mild and moderate head injury.
Additional file 7: Figure S2. Final management guidelines for adults
following minimal, mild and moderate head injury (including help sheet).
Authors’ contributions
This work was initiated and designed by JU with input from the SNC
committee. JU, TI and BR all participated in the review process and
recommendation/guideline draft, see text for details. For the Delphi process,
the entire SNC working group (see below), including JU, TI and BR, was
involved. Clinical stakeholders were involved in later processes of guideline
approval, see main text. All main authors approved the final manuscript.
Competing interests
JU and BR are organizers of the international BMBD conference (http://www.
bmbd.org) concerning neurological biomarkers in brain injury. Some SNC
meetings have been sponsored by Roche Diagnostics Scandinavia AB. These
sponsors have had no involvement or influence on any aspects of the SNC
work. JU and BR have been invited to speak at educational meetings
arranged by Roche Diag nostics Scandinavia AB but Roche have always
remained strictly independent from the scientific program and content and
these took place before the present work was initiated. JU, TI and BR have
in previous research received compensation for travel expenses and lab
analysis from Roche AB, Diasorin AB and Sangtec Medical AB. None of these
had any involvement or influence on any scientific aspects.
Acknowledgements
SNC working group: Carsten Kock-Jensen (SNC president), Hammel,
Denmark; Johan Undén, Malmo, Sweden; Bertil Romner, Copenhagen,
Denmark; Tor Ingebrigtsen, Tromso, Norway; Terje Sundstrom, Bergen,
Norway; Jacob Springborg, Copenhagen, Denmark; Knut Wester, Bergen,
Norway; Per Olof Grände, Lund, Sweden; Vagn Eskesen, Copenhagen,
Denmark; Snorre Sollid, Tromso, Norway; Niels Juul, Aarhus, Denmark; Bo-
Michael Bellander, Stockholm, Sweden; Bent Dahl, Aarhus, Denmark; Christina
Rosenlund, Aarhus, Denmark; Peter Reinstrup, Lund, Sweden.
Additional clinical stakeholders: Per Wihlborg, Malmo, Sweden; Louis Riddez,
Stockholm, Sweden; Steen Mejdahl, Copenhagen, Denmark; Jesper Erdal,
Copenhagen, Denmark; Ole Molgaard, Aarhus, Denmark; Knut Melhuus, Oslo,
Norway; Martine Enger, Oslo, Norway; Kenneth Thors, Stavanger, Norway.
This work was funded by the non-commercial Swedish state sources of:
Region Skåne, Södra Sjukvårdsregionen and Vetenskapsrådet Hallands
Sjukhus, all in Sweden. None of the funding bodies had any involvement or
influence on any aspects of the work.
Author details
1
Department of Intensive Care and Perioperative Medicine, Institute for
Clinical Sciences, Södra Förstadsgatan 101, 20502 Malmö, Sweden.
2
Department of Neurosurgery, Institute for Clinical Medicine, Sykehusveien
38, 9038 Tromsö, Norway.
3
Department of Neurosurgery, Institute for Clinical
Medicine, Blegdamsvej 9, 2100 Copenhagen, Denmark.
Received: 18 October 2012 Accepted: 25 February 2013
Published: 25 February 2013
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Pre-publication history
The pre-publication history for this paper can be accessed here:
http://www.biomedcentral.com/1741-7015/11/50/prepub
doi:10.1186/1741-7015-11-50
Cite this article as: Undén et al.: Scandinavian guidelines for initial
management of minimal, mild and moderate head injuries in adults: an
evidence and consensus-based update. BMC Medicine 2013 11:50.
Undén et al. BMC Medicine 2013, 11:50
http://www.biomedcentral.com/1741-7015/11/50
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