Archives of Academic Emergency Medicine. 2020; 8(1): e86 OR I G I N A L RE S E A RC H ACEP’s Recommendations for Brain Computed Tomogra- phy Scan in Adult Minor Head Trauma Patients; a Diagnos- tic Accuracy Study Mohammad Mohammaddoust1, Niaz-Mohammad Jafari Chokan2, Seyedeh Maryam Moshirian Farahi3, Ayoub Tavakolian4, Mahdi Foroughian2∗ 1. Department of Emergency Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. 2. Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. 3. Department of Psychology, Salman Institute of Higher Education, Mashhad, Iran. 4. Department of Emergency Medicine, Faculty of Medicine, Sabzevar University of Medical Sciences, Sabzevar, Iran. Received: August 2020; Accepted: September 2020; Published online: 29 October 2020 Abstract: Introduction: Some clinical decision rules have been developed to identify minor head trauma (MHT) patients in need of brain computed tomography (CT) scan for detection of possible traumatic brain injuries (TBIs). This study aimed to evaluate the performance of American College of Emergency Physicians (ACEP) recommenda- tions in this regard. Methods: This study is a cross-sectional study of MHT (GCS: 13-15) cases who referred to emergency department of a level one trauma center, Mashhad, Iran, from October 2017 to March 2018. The screening performance characteristics of ACEP recommendations for performing brain CT scan in these pa- tients were calculated. Results: 500 patients with a mean age of 37.97 ± 15.96 years were evaluated. Based on level one recommendations, 73 (14.6 %) patients had to be assessed by brain CT scan. 67 (91.8%) were assessed and 6 (8.2%) were not assessed based on decision of their in-charge physician. According to level two recom- mendations, 125 (25.0%) patients did not need brain CT scan, 85 (68%) of whom had been assessed (all normal). Performing brain CT scan according to the level one recommendation of ACEP’s clinical policy showed 29.6% sensitivity (95% CI: 13.75 to 50.18) and 86.3% specificity (95% CI: 82.68 to 89.14). The overall ACEP’s clinical pol- icy for neuroimaging of adults with MTBI showed sensitivity and specificity of 92.59% (95% CI: 75.71 to 99.09) and 26.4% (95% CI: 22.51 to 30.65), respectively. Conclusion: ACEP’s clinical policy has a high-level sensitivity for using brain CT scan in detection of probable TBI in patients with MHT. Keywords: Craniocerebral Trauma; Brain; Tomography, X-Ray Computed; Health Planning Guidelines Cite this article as: Mohammaddoust M, Jafari Chokan N M, Moshirian Farahi S M, Tavakolian A, Foroughian M. ACEP’s Recommendations for Brain Computed Tomography Scan in Adult Minor Head Trauma Patients; a Diagnostic Accuracy Study. Arch Acad Emerg Med. 2020; 8(1): e86. 1. Introduction Minor Head Trauma (MHT) is blunt trauma to the head in patients with GCS scores between 13 to 15 secondary to the trauma (1). Traumatic brain injury (TBI) indicates an injury to the brain itself and more than 75% of treated TBI cases are mild (2). Mild TBI is a common neurological disorder and only 0.4% to 1% of these injuries require neurosurgical inter- ∗Corresponding Author: Mahdi Foroughian; Department of Emergency Medicine, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran. Tel: 05138525312; Email: foroughianmh@mums.ac.ir vention (3). The most important issue in patients with minor head trauma is to identify patients with probable intracra- nial injuries who require hospitalization and proper man- agement. Brain CT scan is the standard imaging modality for detecting intracranial injury of trauma patients in emer- gency department (ED). Most of these patients (80-90%) do not need to be admitted, and almost all of them are dis- charged with appropriate instructions. The common use of brain CT scans is associated with exposure to ionizing radi- ation and high healthcare costs, considering the large num- ber of people affected (4). Therefore, some clinical decision- making rules have been developed to find MHT patients who are susceptible to intracranial lesions on CT scans in This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Mohammaddoust et al. 2 ED. Some of the important clinical decision rules are the Canadian CT Head Rule (CCHR), the New Orleans Criteria (NOC), the National Emergency X-Radiography Utilization Study II (NEXUS II) criteria, and American College of Emer- gency Physicians (ACEP) Clinical Policy (5, 6). In many stud- ies, the efficacy of these guidelines, such as CCHR, NOC, and NEXUS II, has been evaluated (7-9). However, the best guide- line to be used in routine practice may be highly dependent on the ED’s policies and situation and level of infrastructures availability (7-12). According to one study, which was done in Taiwan, the sensitivity and specificity of ACEP guideline were 75.97% and 34.68%, respectively. The study concluded that, al- though ACEP guideline reduced unnecessary brain CT scans, it wasn’t an appropriate guideline for use in Taiwan (13). Based on the above-mentioned points, this study aimed to evaluate the accuracy of ACEP’s recommendation in identi- fying MHT patients in need of brain CT scan and ruling out of susceptible intracranial injuries. 2. Methods 2.1. Study design and setting This prospective cross-sectional study was conducted on adult MHT patients (GCS score of 13 to 15 one day after trauma) who referred to the ED of a hospital affiliated to Mashhad University of Medical Sciences (level one trauma center), Mashhad, Iran, from 2017 to March 2018. The screening performance characteristics of ACEP recommen- dations for performing brain CT scan in these patients were calculated. This study has been approved by the Ethics Com- mittee of Mashhad University of Medical Sciences under the Ethics code of IR.MUMS.fm.REC.1396.70. 2.2. Participants This study has evaluated patients with minor head trauma (GCS≥13), 18 years old or older who referred to the trauma center. Patients aged less than 18 years and those with an ob- vious penetrating skull injury, unstable vital signs associated with major trauma, and pregnancy were excluded. 2.3. Study Protocol The ACEP recommendations were taught to emergency res- idents responsible for data gathering. Brain CT scans were performed based on the opinion of emergency physicians. Patients who were discharged without a brain CT scan were followed in 2 weeks and were asked to come back to the ED immediately if they encountered any unusual symp- toms (as previously announced). Therefore, patients who were asymptomatic after 2 weeks were considered as brain damage-free cases. Table 1: Baseline characteristics of study population Characteristics Number (%) Gender Male 335 (67.0) Female 165 (33.0) Age (year) ≤ 60 449 (89.8) > 60 51 (10.2) Trauma mechanism Falling down 30 (6.0) Motor vehicle collision 174 (34.8) Passenger-related accident 60 (12.0) Hitting injury (assault) 172 (34.4) Other 64 (12.8) Signs and symptoms Post-traumatic amnesia 54 (10.8) Vomiting 37 (7.4) Short memory loss 22 (4.4) Coagulopathy 3 (0.6) Decreased level of consciousness 31 (6.2) Moderate headache 88 (17.6) Severe headache 123 (24.6) Intoxication 16 (3.2) Trauma above the clavicle 115 (23.0) 2.4. Data gathering After history taking and performing physical examination, demographic characteristics and clinical symptoms and signs of the patients were recorded on a checklist that had been designed based on ACEP recommendations (1). 2.5. Statistical Analysis The data were entered into SPSS 22 (SPSS Inc., Chicago, Illi- nois, USA). To assess the accuracy of ACEP recommenda- tions, sensitivity, specificity, positive and negative predictive values, and positive and negative likelihood ratios as well as area under the receiver operating characteristic (ROC) curve were calculated and reported with 95% confidence interval (CI). The findings were presented as mean ± standard devia- tion or frequency (%). 3. Results 3.1. Baseline characteristics of studied cases 500 patients with a mean age of 37.97 ± 15.96 (18 – 90) years were evaluated (67% male). Table 1 shows the baseline char- acteristics of studied case. The most frequent trauma mech- anisms were motor vehicle collision (34.8%) and direct hit- ting on the head (34.4%), respectively. Brain CT scan was done for 404 (80.0%) cases based on the in-charge physi- cians’ decision. The frequency of ACEP-recommended vari- ables for doing brain CT scan have been shown in table 2. The most frequent symptoms that indicated performance of This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 3 Archives of Academic Emergency Medicine. 2020; 8(1): e86 Table 2: Frequency of level one and two ACEP-recommended vari- ables in the study population Variables Number (%) Level one Post-traumatic amnesia 54 (10.8) Vomiting 37 (7.4) Short memory loss 22 (4.4) Coagulopathy 3 (0.6) Headache 211 (42.2) Age> 60 year 51 (10.2) Intoxication 16 (3.2) Trauma above the clavicle 115 (23.0) Post-traumatic seizure 0 (0.0) Focal neurological deficit 0 (0.0) Level two Focal neurological deficit 0 (0.0) Vomiting 37 (7.4) Severe headache 123 (24.6) Age ≥ 65 year 40 (0.8) Basilar skull fracture 0 (0.0) GCS < 15 31 (6.2) Coagulopathy 3 (0.6) Dangerous mechanism of injury 195 (39.0) brain CT scan based on level one and two recommendations, were headache (42.2%) and dangerous mechanism of trauma (39%), respectively. 3.2. Brain CT scan; Indications and Findings Level one recommendation Based on level one recommendations, 427 (85.4%) patients did not need brain CT scan, 337 (78.9%) of which were as- sessed by CT scan, based on the decision of their in-charge physician (318 (94.4%) normal, 2 (0.59%) intracranial hemor- rhage, 1 (0.29%) epidural hematoma, 4 (1.18%) subarachnoid hemorrhage, and 12 (3.56%) skull fracture). Based on this level of recommendation, 73 (14.6 %) pa- tients should have been assessed by brain CT scan [6 (8.2%) were not assessed based on decision of their in-charge physician (1(1.5%) intracranial hemorrhage, 1 (1.5%) epidu- ral hematoma, 1(1.5%) subarachnoid hemorrhage, 1 (1.5%), intra-ventricular hemorrhage and 2 (6%) skull fracture]. Level two recommendation Based on level two recommendations, 125 (25.0%) patients did not need brain CT scan, 85 (68%) of which had been as- sessed (all normal). Also based on this level of recommen- dations, 375 (75.0%) patients should have been assessed by CT scan, 319 (85%) of which had been assessed (292 (91.5%) normal, 3(0.94%) intracranial hemorrhage, 2 (0.65%) epidu- ral hematoma, 5 (1.6%) subarachnoid hemorrhage, 1 (0.31%) intra-ventricular hemorrhage, and 16 (5%) skull fracture). Screening performance characteristics of ACEP recom- mendations Doing brain CT scan according to level one recommenda- tions of ACEP’s clinical policy showed 29.6% sensitivity (95% CI: 13.75 to 50.18) and 86.3% specificity (95% CI: 82.68 to 89.14). Overall, ACEP’s clinical policy for neuroimaging of adults with MTBI showed sensitivity and specificity of 92.6% (95% CI: 75.71 to 99.09) and 26.4% (95% CI: 22.51 to 30.65), respectively (table 3). 4. Discussion This study, found that the ACEP criteria for conducting brain CT scan in traumatic brain injury is highly sensitive (92.59%) for finding pathologies in patients with minor head trauma. The ACEP criteria identify patients who need to undergo a brain CT scan in two levels (14). Based on the criteria, pa- tients who have symptoms or signs according to the first level of recommendation should be assessed via CT scan (14). This study shows that conducting a brain CT scan only based on the first level of recommendation has low sensitivity (29.6%) but relatively high specificity (86.3%). The high specificity of the first level of this criteria shows that the recommen- dation of ACEP criteria for conducting brain CT scan for all patients corresponding to the first level of ACEP criteria is completely reasonable (14), while low sensitivity of the first level of recommendation shows that conducting brain CT scan only based on the first level of recommendation leads to missing many patients with TBI (15). The second level of ACEP criteria states that CT scan should be performed only for some of the patients corresponding to this level (16). The results of our study confirm the recommendation of the ACEP criteria. When patients corresponding to the second level of recommendations underwent a CT, the sensitivity of this study extremely increased, while it’s specificity extremely decreased, which means that the number of patients under- going CT scan with no indication and normal CT results in- creased. Therefore, based on these criteria it’s better to ob- serve patients corresponding to the second level of ACEP cri- teria and not conduct a brain CT scan once they arrived at the emergency department. This observation will indicate which patients need to undergo brain CT scan (17). The sensitivity of our study was higher than the study per- formed in Taiwan, while the specificity of our study was lower (13). The review of literature shows that similar studies, which investigate the effectiveness of the ACEP criteria, are rare. While several studies have investigated other guidelines such as CCHR, NOC, and NEXUS II. In these studies, the sen- sitivities of CCHR and NOC were (100, and 95 %) and (100- 99%), respectively; also, the specificities of CCHR and NOC were (47-70%) and (3-31%), respectively (1, 7, 13, 18-20). An- other study, which has been done on the NEXUS II criteria, has reported the sensitivity and specificity of this guideline as (100%) and (33%), respectively (21). Ro and et al. compared This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem M. Mohammaddoust et al. 4 Table 3: Screening performance characteristics of ACEP-recommended criteria (level one, two, and overall) for performing brain computed tomography scan in patients with minor head trauma Characters Level one Level two One + two (0verall) Value 95% CI Value 95% CI Value 95% CI Sensitivity 29.61 13.75 - 50.18 89.49 66.86 -98.70 92.59 75.71- 99.09 Specificity 86.28 82.68- 89.14 26.33 21.95- 31.95 26.41 22.51- 30.65 PPV 11.00 6.76 - 20.24 6.80 5.81- 7.94 7.80 7.06 - 8.80 NPV 94.00 92.88 - 95.55 97.70 91.88- 99.38 97.00 91.70 - 99.39 PLR 2.12 1.15 - 3.99 1.22 1.03 -1.44 1.30 1.12 - 1.42 NLR 0.81 0.64 - 1.05 0.39 0.10 - 1.48 0.32 0.07 - 1.07 Accuracy 80.59 76.50 - 84.43 30.21 25.41- 35.48 27.21 22.94 - 31.85 CI: Confidence interval; PPV: Positive predictive value; NPV: Negative predictive value; PLR: Positive likelihood ratio; NLR: Negative Likelihood Ratio. the predictive performance of CCHR, NOC, and NEXUS II, for detecting clinically important TBI. The mentioned study showed that their sensitivity and specificity for clinically im- portant brain injury were as follows: CCHR, (79.2%, 95%) and (41.3%, 95%); NOC, (91.9%, 95%) and (22.4%, 95%); and NEXUS-II, (88.7%, 95%) and (46.5%, 95%), respectively (12). In the present study, the sensitivity found for ACEP was sim- ilar to those found for other guidelines in previous studies, and it was shown that it can detect almost all pathological cases of mild TBI; whereas the specificity of ACEP is lower than CCHR and NEXUS II and higher than NOC. As a result, compared to other guidelines, CCHR could best decrease ex- cessive use of CT. Though ACEP guidelines increased using CT scan, if physicians pay further attention to choose pa- tients in the second level of the recommendation of ACEP to do a CT scan it will be a useful guideline. 5. Limitation This study only assessed the ACEP guideline and did not as- sess other guidelines to compare them. The study was done in a single trauma center. Some patients cooperated poorly and were, therefore, excluded from this study. 6. Conclusion The findings revealed that ACEP’s recommendation for per- forming brain CT scan in MHT patients has 92% sensitivity and 26% specificity. It could be a useful guideline to decrease the number of unnecessary CT scans, reduce radiation, and avoid extra costs for the patient and the healthcare system. 7. Declarations 7.1. Acknowledgements We would like to thank the Clinical Research Development Unit of Peymanieh Educational and Research and Therapeu- tic Center of Jahrom University of Medical Sciences for revis- ing the manuscript. 7.2. Author contribution MM, NMJC, and MF designed the study. NMJC, SMMF, and AT contributed in data collection and data analysis. Draft manuscript was written by MF and MM. all authors have con- firmed the final manuscript version. 7.3. Funding/Support This study was supported by Mashhad University of Medical Sciences. 7.4. Conflict of interest All authors declare any conflict of interest. References 1. Essam A. Elgamal, Sherif M. El-Watidy, Zain A. Jamjoom, Ali Abdel-Raouf, Hamdy Hassan, Hassan Alwaraqi, Sabry Al-Malah, Elgamal, E.A., El-Watidy, S.M., Jamjoom, Z.A. et al. Evaluation of the Canadian CT Head Rule for Mi- nor Head Trauma in a Tertiary Referral Institution. Eur J Trauma (2006) 32: 527. doi:10.1007/s00068-006-5156-8. 2. Emergency Medicine News. Continuing Medical Educa- tion in EMN, Emergency Medicine News: January 2004 - Volume 26 - Issue 13 - p 5. 3. Cassidy JD, Carroll L, Peloso P, Borg J, Von Holst H, Holm L, Kraus J, Coronado V. Incidence, risk factors and pre- vention of mild traumatic brain injury: results of the WHO Collaborating Centre Task Force on Mild Traumatic Brain Injury. Journal of rehabilitation medicine. 2004 Feb 1;36(0):28-60. 4. Mower WR, Hoffman JR, Herbert M, et al. Developing a clinical decision instrument to rule out intracranial injuries in patients with minor head trauma: Method- ology of the NEXUS II investigation. Ann Emerg Med 2002;40:505–14. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem 5 Archives of Academic Emergency Medicine. 2020; 8(1): e86 5. Mower WR, Hoffman JR, Herbert M, Wolfson AB, Pollack CV Jr, Zucker MI. Developing a decision instrument to guide computed tomographic imaging of blunt head in- jury patients. J Trauma. 2005; 59:954–9. 6. Anish TS, Sreelakshmi PR, Medhavan S, Babu S, Sugathan S. Efficacy of Canadian computed tomography head rule in predicting the need for a computed–axial tomography scans among patients with suspected head injuries. In- ternational journal of critical illness and injury science. 2012 Sep;2(3):163. 7. Mata-Mbemba D, Mugikura S, Nakagawa A, Murata T, Kato Y, Tatewaki Y, Takase K, Kushimoto S, Tominaga T, Takahashi S. Canadian CT head rule and New Orleans Criteria in mild traumatic brain injury: comparison at a tertiary referral hospital in Japan. SpringerPlus. 2016 Dec;5(1):176. 8. 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– 8.Stiell IG, Clement CM, Rowe BH, et al. Comparison of the Canadian CT head rule and the New Orleans Cri- teria in patients with minor head injury. JAMA. 2005; 294:1511–8. 9. Stein SC, Fabbri A, Servadei F, Glick HA. A critical com- parison of clinical decision instruments for computed to- mographic scanning in mild closed traumatic brain in- jury in adolescents and adults. Ann Emerg Med. 2009; 53:180–8. 10. Smits M, Dippel DW, de Haan GG, et al. External valida- tion of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head in- jury. JAMA. 2005; 294:1519–25. 11. Rosengren D, Rothwell S, Brown AF, Chu K. The appli- cation of North American CT scan criteria to an Aus- tralian population with minor head injury. Emerg Med Australas. 2004; 16:195–200. 12. Ro YS, Shin SD, Holmes JF, Song KJ, Park JO, Cho JS, Lee SC, Kim SC, Hong KJ, Park CB, Cha WC. Comparison of clinical performance of cranial computed tomography rules in patients with minor head injury: a multicenter prospective study. Academic Emergency Medicine. 2011 Jun;18(6):597-604. 13. Abdalla RO, Qureshi MM, Saidi H, Abdallah A Aga Khan . Introduction of the Canadian CT Head Rule Reduces CT Scan Use in Minor Head Injury. The ANNALS of AFRICAN SURGERY. January 2015 Volume 12 Issue 1 19(115-133). 14. Jagoda AS, Bazarian JJ, Bruns Jr JJ, Cantrill SV, Gean AD, Howard PK, Ghajar J, Riggio S, Wright DW, Wears RL, Bak- shy A. Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Journal of Emergency Nursing. 2009 Mar 1;35(2):e5-40. 15. Maguen S, Lau KM, Madden E, Seal K. Factors associated with completing comprehensive traumatic brain injury evaluation. Military medicine. 2012 Jul 1;177(7):797-803. 16. Hsiao KY, Li WC, Chang CH, Lin MH, Yang JT, Wang PC, Chen KH. An evaluation of the ACEP guideline for mild head injuries in Taiwan. Hong Kong Journal of Emer- gency Medicine. 2017 Mar;24(2):73-8. 17. Jagoda AS. Mild traumatic brain injury: key decisions in acute management. Psychiatric Clinics. 2010 Dec 1;33(4):797-806. 18. Cemil Kaval, GokhanAksel, Omer Salt, M Serkan Yilmaz, Ali Demir, GulsümKavalci, BetulAkbugaOzel, Ertugru- lAltinbilek, Tamer Durdu, CihatYel, PolatDurukan , Ba- hattinIsik - Comparison of the Canadian CT head rule and the new orleans criteria in patients with minor head injury - World Journal of Emergency Surgery 2014 9:31, DOI: 10.1186/1749-7922-9-31. 19. Linda P, Ian GS, Catherine MC, Artur P, Andrew W, Sameer D, et al. Performance of the Canadian CT Head Rule and the New Orleans Criteria for Predicting Any Trau- matic Intracranial Injury on Computed Tomography in a United States Level I Trauma Center. Academic Emer- gency Medicine 2012; 19:2–10. 20. Schachar JL, Zampolin RL, Miller TS, Farinhas JM, Free- man K, Taragin BH. External validation of the New Or- leans Criteria (NOC), the Canadian CT Head Rule (CCHR) and the National Emergency X-Radiography Utilization Study II (NEXUS II) for CT scanning in pediatric patients with minor head injury in a non-trauma center. Pediatric radiology. 2011 Aug 1;41(8):971. 21. Mower WR, Gupta M, Rodriguez R, Hendey GW. Valida- tion of the NEXUS II Pediatric Head Computed Tomog- raphy Decision Instrument. The Journal of Emergency Medicine. 2017 Sep 30;53(3):441. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: http://journals.sbmu.ac.ir/aaem Introduction Methods Results Discussion Limitation Conclusion Declarations References