New Orleans/Charity Head Trauma/Injury Rule

Introduction
Head trauma complaints in the outpatient setting (emergency department, urgent care and primary care) are common. However, the majority of patients have minor head trauma that will not require specialized treatment or neurosurgical intervention. Yet, rates of CT imaging of the head have more than doubled starting in the early 1990s. The New Orleans/Charity (NOC) head trauma rule is a well-validated clinical decision aid that assists clinicians in determining which minor head injury patients need head CT imaging. Thus, safely ruling out the presence of intracranial injuries that would require neurosurgical intervention. In several prospective trials, the NOC was 100% sensitive for intracranial injuries that required neurosurgical intervention. 

Providers often consider applying the Canadian CT Head Rule (CCHR) for head trauma in addition to the NOC. Both the CCHR and the NOC have demonstrated 100% sensitivity for ruling out intracranial injuries that would require neurosurgical intervention. One trial found the NOC more sensitive for detecting clinically significant intracranial injuries (99.4% versus 87.3%) but a decreased specificity (5.6% versus 39.7%) compared to the CCHR. The NOC is less complex than the CCHR but much less specific than the CCHR in all settings. The decrease in specificity can be attributed to the NOC's broad questions, such as "Any trauma above the clavicles."

The New Orleans/Charity (NOC) head trauma rule is a well-validated clinical decision aid that assists clinicians in determining which minor head injury patients need head CT imaging. Thus, safely ruling out the presence of intracranial injuries that would require neurosurgical intervention. Consider the PECARN Pediatric Head Injury/Trauma Algorithm for patients < 19 years old.

Recommendations and Criteria

Management Considerations

 For those with suspected or radiologically-confirmed traumatic brain injury (TBI):

• First assess ABC's and consider neurosurgical/ICU consultation 

• Consult institutional protocols on, for example: 

  • Fluid management

  • Seizure prophylaxis

  • Hypertonic saline or mannitol

  • Admission or disposition

If CT is negative and patient is referred for outpatient follow-up, consider the following recommendations:

• Provide reassurance, education and strict return precautions. 

  • CDC patient handout: Mild Traumatic Brain Injury and Concussion 

• Discuss post-concussive symptoms and clinical course. 

  • Headache

  • Balance problems or dizziness

  • Sound and light sensitivity

  • Feeling agitated or irritable

  • Confusion, concentration or memory problems

• Discuss brain bleed symptoms. Go to the ED if you experience any of these symptoms:

  • Drowsiness or inability to wake up

  • Worsening headache

  • Slurred speech, weakness, numbness, or decreased coordination

  • Repeated vomiting or seizures

  • Unusual behavior

• Follow-up with primary care, sports medicine or neurologist as indicated.

Provider Resources

• Concussion awareness, diagnosis and treatment (AAFP)

• Providers often consider applying the Canadian CT Head Rule (CCHR) for head trauma in addition to the New Orleans/Charity Rule (NOC). Both the CCHR and the NOC have demonstrated 100% sensitivity for ruling out intracranial injuries that would require neurosurgical intervention.

Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PM. Indications for computed tomography in patients with minor head injury. N Engl J Med. 2000 Jul 13;343(2):100-5. doi: 10.1056/NEJM200007133430204. PMID: 10891517.