As I have previously pointed out, the evidence is good that a CT has
100% sensitivity and specificity in trauma, and there is no need to
admit a patient with a normal CT.
-----Original Message-----
From: Accident and Emergency Academic List
[mailto:[log in to unmask]] On Behalf Of Black, John
Sent: 24 September 2002 16:18
To: [log in to unmask]
Subject: Re: radiologists compromise timely emergency care
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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