Scandinavian guidelines for initial management of minimal, mild and moderate head injuries in adults: an evidence and consensus-based update

Abstract

Background: The management of minimal, mild and moderate head injuries is still controversial. In 2000, the Scandinavian Neurotrauma Committee (SNC) presented evidence-based guidelines 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 Evidence 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 are designed to primarily detect neurosurgical intervention with traumatic CT findings as a secondary goal. For elements lacking good evidence, such as in-hospital monitoring, routines were largely based on consensus. We suggest external validation of the guidelines before widespread clinical use is recommended.

Figure 1

Flow diagram showing the overall work process.

Figure 2

Adapted Preferred Reporting Items 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?'.

Figure 3

Adapted Preferred Reporting Items 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?'.