Utilidad de las reglas de decisión clínica para evaluar Traumatismos Craneo-Encefálicos menores


Cual regla de decisión clínica (la Canadian CT Head Rule -CCHR – o los “Criterios de New Orleans” – CNO – son los más útiles en la evaluación de adultos con injuria cefálica menor?

Tanto los CNO como los CCHR son igualmente precisos para identificar pacientes con importante injuria cerebral que requieren intervención neuroquirúrgica y/o seguimiento cercano del paciente. Sin embargo, pacientes que presentan injurias de caracter punzante y un score en la escala de Coma de Glasgow de 15 , quienes tienen alguna injuria intracraneal son más precisamente identificados usando el CNO. El CCHR tiene una significativia especificidad para importantes resultados clinicos y un gran potencial pra reducir la necesidad de solicitud de TAC. Preocupaciones acerca de problemas legales, segun este articulo, determina en qué específica situación se puede aplicar cada una de éstas reglas, que se corresponden con especificas situaciones clinicas. Un estudio en el cual los pacientes fueron adecuadamente evaluados en forma aletorizada para cada regla de predicción y la medición a largo plazo de la morbilidad y mortalidad es necesario para definir en forma completa esta pregunta de gran importancia clinica. (NdE =1b)

Reference:

Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA 2005;294:1511-18.
Study Design:

Decision rule (validation)
Funding: Government
Setting: Emergency department

Resúmen: (en particular luego de leer el articulo y hacer la primer parte de la traducción creo que si tiene a mano un buen libro de Garcia Márquez, no lo desaproveche).

Two clinical rules — the CCHR and the New Orleans Criteria — are currently used to identify adults with blunt head injury at increased risk and in need of cranial CT. To compare accuracy of the 2 rules the investigators consecutively enrolled 1822 eligible and consenting adults with blunt head trauma and a Glasgow Coma Scale score of 15 (normal). Emergency medicine attendings and residents trained to use both tools assessed all patients. Another emergency physician randomly assessed some patients to judge interobserver agreement. Eighty percent of the patients underwent emergency CT and the remaining patients were clinically followed up for 14 days. An independent committee reviewed all outcomes and made the final determination of all diagnoses. Individuals blinded to clinical data interpreted all CT scans. Of the 1822 patients with blunt head injury, 8 (0.4%) required neurosurgical intervention and 97 (5.3%) had “clinically important” brain injury. “Clinically important” brain injury was defined as any acute finding revealed on CT that would, in an independent formal survey of 129 academic neurosurgeons and emergency physicians, require hospitalization and neurosurgical follow-up. Both the NOC and CCHR had 100% sensitivity for predicting the need for neurosurgical intervention and clinically important brain injury (no cases were missed by either rule). The CCHR had a significantly higher specificity (patients without either outcome are more accurately identified) for both events (76.3% vs 12.1% and 50.6% vs 12.7%, respectively). CT rates would be significantly lower with the use of the CCHR than with NOC (52.1% vs 88%). Physician agreement for interpretation of the rules is significantly higher for the CCHR, meaning the CCHR is easier to interpret.

A second study in the same journal (Smits M, Dippel DW, de Haan GG, et al. JAMA 2005;294:1519-25) found that the CCHR has a lower sensitivity than the NOC for identifying all cases of neurocranial trauma, but supported that fact that the CCHR identified all cases requiring neurosurgical intervention. In addition, the CCHR had a greater potential for reducing the need for CT.

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