Matt,
We are following the RCR guidelines. We do CT scan all our confirmed skull
fractures (vault and base. Most of the patients that we discharge
immediately with normal CTs are those presenting late (>24 hrs) with
persistent neurological symptoms who are GCS 15 and not intoxicated etc. We
will discharge patients with normal CTs within 24 hours of admission
provided they have been fully assessed and fulfil our discharge criteria
(GCS 15, responsible supervising adult at home etc. All such patients are
provided with written advice on what circumstances patients should return to
the department for reassessment.
Of the patients who re-present with positive findings on CT have usually had
a skull fracture that was not identified at the initial presentation. We
have a low threshold to perform SXR in head injury patients who we plan to
discharge from the ED if the mechanism or clinical signs give rise to
suspicion of an underlying vault fracture (boggy scalp haematoma etc.
Currently we admit all our skull fractures at least overnight irrespective
of CT findings unless they present late.
John Black
Oxford
-----Original Message-----
From: Dunn Matthew Dr. (RJC) ACCIDENT & EMERGENCY - SwarkHosp-TR
[mailto:[log in to unmask]]
Sent: 17 September 2002 09:05
To: [log in to unmask]
Subject: Re: radiologists compromise timely emergency care
> CONCLUSION: CT is a useful test in patients with minimal head
> injury because it may lead to a change in therapy in a small but
> significant number of patients. Subsequent hospital observation adds
> nothing to the CT results and is not necessary in patients
> with isolated
> minimal head injury.
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.
> All patients had Glasgow Coma
> Scale scores of 15 on arrival and had a history of either loss of
> consciousness or amnesia to the event. Two hundred forty-seven patients
> (21.1%) were intoxicated with drugs or alcohol on admission
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.
> The radiation dose is phenomenal. I'm not sure of the
> millisiverts but
> equivalent to 350 chest x-rays I beleive for a brain scan.
>
> We also have the habitual self induced head injurer who
> frequently gets
> p*****'ed and bangs his head.
>
> CT scanning is not the panacea that we are led to beleive.
Good point, Danny. Met an American a few years back- a young woman of child
bearing age who'd had 3 CT scans in the last 4 years (sports injury
related). Makes you think.
Good topic for debate and evidence hunting though- CT scanning (and indeed
MRI scanning) has made little change to standard management of head
injuries. Maybe it should.
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?
Matt Dunn
Warwick
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