Guidelines on indications for imaging in patients with suspected mild head injury

There are various guidelines, clinical policies and clinical decision rules available regarding imaging in patients with mild, minimal or minor head injury to identify suspected traumatic brain injury (TBI). To some extent the published recommendations are quite comprehensive but difficult to review and to interpret. In this study we analyzed the different recommendations with regards to methods, contents and implementation in adult patients presenting to the emergency department with suspected mild head injury. We conducted a systematic review of the literature in Pubmed about indications for imaging with computed tomography in adult patients with mild head injury (Glasgow Coma Scale 13-15 points) and suspected TBI published between January 2000 and February 2011. All retrieved references were checked manually for additional relevant articles. We applied the DELBI (German guidelines assessment instrument) tool based on the Appraisal of Guidelines Research & Evaluation (AGREE) instrument to assess the methodological quality of guidelines and clinical policies. To evaluate the quality of contents we compared the published recommendations particularly regarding patient inclusion criteria, indications for imaging and feasibility in daily clinical practice. Of the 142 publications identified, 3 clinical decision rules, 1 clinical policy and 3 guidelines on the diagnostic approach for patients with suspected mild TBI met the inclusion criteria. Methodological quality revealed overall DELBI standardized domain scores with a maximum variation between 0.01-1.0. Contents quality showed substantial differences in recommendations predominantly regarding the criteria loss of consciousness, amnesia, coagulation disorder and anticoagulation. Over all scientifically based guidelines, clinical policies and clinical decision rules on the subject of indications for imaging in adults with mild head injury were limited. There were considerable discrepancies in the quality of methods and contents between published recommendations. Local facility conditions and requirements should also be considered besides criteria of quality when implementation in daily practice is intended.