----- Original Message -----
From: "Dunn Matthew Dr.
> Thanks, Rowley. A good paper. However, has anyone taken this to its
logical
> conclusion and actually discharged these patients? Don't want to be the
> first myself.
Matt, we've been discharging patients with transitory LOC or amnesia for
years, way before the use of CT became widespread. Check out the group of
neurosurgeons recommendations from 1984 (BMJ; Harrogate; don't have the
precise reference to hand but could hunt it out).
> Does the paper go further and explain how someone who is orientated in
time,
> place and person, spontaneously opening their eyes and obeying commands
can
> rank as intoxicated. I suppose you can do it if pretty drowsy, but it
seems
> to be stretching the definition of 'intoxicated' a bit.
Intoxication often has little effect on cognition and GCS. Early signs tend
to cause alteration of the patient's affect and co-ordination only.
> Related questions:
> 1. Anyone read the RCR 'Appropriate use of a department...' guidance that
> says scan every patient with a skull fracture?
> 2. Anyone doing it? Our radiologists don't seem keen, but it would be a
help
> if I could come back and give a list of other departments doing it.
> 3. Anyone then discharging the patients?
We're now scanning most "skull fractures" Matt, although we're less
aggressive with children. We're not scanning these patients in order to
discharge them though, as they have a 12 to 24 hour risk of deterioration,
we're scanning them as there's a high yield of intracranial pathology. I'm
not convinced though that a CT is needed in the "well patient" with skull
fracture. They're unlikely to have significant pathology and even more
unlikely to need neurosurgical intervention if they're clinically well to
begin with. Most patients with fracture though tend to deserve their scan
for other reasons i.e. lowered GCS, so overall we don't see well patients
with GCS 15 presenting with a skull fracture very often.
Adrian Fogarty
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