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Klinisk Biokemi i Norden · 2 2015
New Scandinavian guidelines for initial manage-
ment of minimal, mild and moderate head injuries
in adults – implications for clinical laboratories
Knut Wester
1
, Kristin Lilleholt
2
, Linda Hilsted
3
, Anders Larsson
4
, Johan Undén
5
1
Department of Clinical Medicine, University of Bergen and Department of Neurosurgery,
Haukeland University Hospital Bergen, Norway.
2
Department of Medical Biochemistry,
Sørlandet Hospital Kristiansand, Kristiansand, Norway.
3
Department of Clinical Biochemistry,
Rigshospitalet, Copenhagen, Denmark.
4
Department of Medical Sciences, Clinical Chemistry,
Uppsala University Hospital, Sweden.
5
Department of Intensive Care and Perioperative
Medicine, Institute for Clinical Sciences, Malmö, Sweden.
On behalf of the Scandinavian Neurotrauma Committee (SNC)
E-mail:
Introduction
In 2000, the Scandinavian Neurotrauma Committee
(SNC) presented evidence-based guidelines for the
initial management of minimal, mild and moderate
head injuries, which constitute the great majority of
such head traumas (1). These guidelines have since
represented the standard for managing patients with
such head traumas in the Nordic countries.
Only a small fraction of head trauma patients
will turn out to have intracranial pathology and an
even smaller proportion will need neurosurgical
intervention. The aim of such guidelines is therefore
to identify patients at risk of developing dangerous
intracranial conditions, e.g. haematomas or brain
contusion. For this purpose, the SNC 2000 guidelines
recommended routine use of CT scanning for patients
with mild and moderate head injuries.
This routine has however been questioned follo-
wing recent reports of increased cancer risks from
CT scans, estimated at 1 in 5,000 - 10,000 for a single
head CT scan in young adults (2). As young adults and
children constitute a large proportion of head injury
patients, SNC have now revised their guidelines with
the aim of reducing the routine use of CT scanning
and thereby hopefully the related cancer risk (3).
National versions of the guidelines have also been
published in the Danish, Norwegian, and Swedish
medical journals (4-6).
In the new guidelines the biomarker S100B may
be used to identify patients with a very low risk of
intracranial complication, hence not needing a rou-
tine CT scan. S100B is a calcium binding protein
that is released from astrocytes into the blood and
cerebrospinal fluid (CSF) after a trauma to the cen-
tral nervous system (CNS). Studies on this biomarker
have consistently demonstrated a very high sensitivity
to complications after mild head trauma. As these
complications are relatively rare, this results in a
near 100% negative predictive value (7). S100B can
be analysed at most Scandinavian laboratories using
pre-existing apparatus and the analysis time is less
than 30 minutes.
As the revised guidelines will involve the coope-
ration of clinical laboratories, the aim of the present
article is therefore to inform the Nordic clinical
laboratories about the guidelines, with emphasis on
practical matters, limitations, and pitfalls.
Methods
The new guidelines were developed by a working
team from the Scandinavian Neurotrauma Com-
mittee after an extensive process, for details see (3).
As mentioned above, the guidelines aim to detect
patients with serious intracranial complications while
minimizing unnecessary CT scans of head injury
patients. The evidence for using serum levels of the
