Yes, alcohol is a problem, but NICE makes some (unwritten) allowances. The
2-hour rule is one such allowance, but this only applies to GCS 13 or 14
patients, Andy, and NICE actually suggest immediate scan of GCS<13 patients.
GCS 13 allows for patients who are somnolent (eyes closed) with mild
disorientation, which you can read as compatible with intoxication if you
wish. This 2-hour window for the "lighter" patient is therefore one way of
allowing for alcohol intoxication to resolve, although I hasten to add that
NICE is not explicit about their reasoning for this delay. Once you get to
GCS 12, however, particularly a consistent 12, then it's less easily
explained by alcohol alone. Alcohol can, of course, be distinguished by
large fluctuations of GCS (sometimes from 3 to 15 and back again) and by
predominant cerebellar signs (ataxia, dysarthria and nystagmus) but a
consistent GCS of 12 or lower is more suggestive of other pathology. I think
it was a Perth EP on this list who spoke of their 4-hour rule, which amounts
to the same sort of thing really. Finally, I am not so concerned about
radiation risk in these patients, Marcello, but GAs are certainly risky in
the intoxicated patient. Like I said earlier, whatever way you go you're
going to have to absorb some risk with such patients.
Adrian Fogarty
----- Original Message -----
From: "Andy Webster" <[log in to unmask]>
To: <[log in to unmask]>
Sent: Sunday, November 16, 2003 1:06 PM
Subject: Re: nice head injury
> The Nice head injury guidelines are very clear on this aspect intracranial
> injury until proven otherwise. Ie. Scan if GCS<13 at 2 hours. Even when
> alcohol is likely cause.
> Andy Webster
>
> -----Original Message-----
> From: Accident and Emergency Academic List
> [mailto:[log in to unmask]] On Behalf Of
> [log in to unmask]
> Sent: 16 November 2003 12:43
> To: [log in to unmask]
> Subject: nice head injury
>
> Apologies if this has been already said or discussed previously, I must
> have missed it.
> The real problem is the intoxicated patient(or supposedly so). I have the
> feeling that there is a tendency to dismiss these patients as "just drunk"
> with a risk to miss important injuries. Perhaps these are the patients
> where there is a really fine balance between risk of radiation and risk of
> missing an intracranial bleed.
> In fact, I feel that theye are the patients where clear and neat
guidelines
> would be most useful even though probably fairly difficult to produce.
>
> M. Della Corte
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