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Coagulopathy and NICE recommendations for patients with mild head injury

Management of patients with mild head injury (MHI) is open to debate.1 In the last few years, there has been a trend towards earlier diagnosis, implying an extensive use of computed tomography (CT), rather than admission and observation. The National Institute for Clinical Excellence (NICE) has recently proposed new evidence based recommendations on all steps of the management of patients with MHI.2 In the diagnostic algorithm, coagulopathy (history of bleeding, clotting disorder, or current treatment with warfarin) is not considered a predictor variable necessitating early CT in subjects without loss of consciousness (LOC) or amnesia since injury. This statement conflicts with previous guidelines, where history of coagulopathy, independently of symptoms, indicated CT.3

Since 1999, all cases with MHI attending the Emergency Department of our district hospital have been treated and registered in a comprehensive database according to predefined procedures.3 Our criteria for CT and/or hospital admission are wider than the NICE criteria; in particular, there is routine detailing of NICE variables, but in addition, all subjects with coagulopathy have an early CT, independently of symptoms and signs after injury. This provides the opportunity to determine the risk related to coagulopathy and the accuracy of the NICE recommendations.

We analysed the data of 7955 consecutive …