I received the following letter today:
< Dear Dr Fogarty
My Name is Joel Dunning and I worked as one of the two full time systematic
reviewers on the NICE guidelines for 6 months during their development.
With regard to whether the NICE guidelines recommendation that anyone who
has GCS<13 at any stage is the same as stating 'anyone who has lost
consciousness should have a CT':
Andrew Hobart got this exactly correct. GCS<13 refers only to the patient's
GCS once it has been assessed by a medically qualified person.
The reason for the GCS<13 at any stage recommendation is that we took the
view that the Canadian Head CT rule was by far the best clinical decision
rule and that we should follow their guidance in full. This left the issue
of what do you recommend for patients who were excluded from their study.
Most reasons for exclusion were because Ian Stiell felt that it was clear
that these patients should definitely have a CT scan and therefore
there would be no point studying them.
Thus we went through each exclusion criteria and considered them
individually. Any patient on admission or at any time after that who had a
GCS<13 was excluded and I am sure that everyone would agree that if there
is no other reason for a low GCS, that this person should certainly have a
scan.
The GCS score is to my understanding not a score that you can
retrospectively assign to a person who is giving a history of loss of
consciousness, and therefore the most you can record in the notes about
this patient is a hitory of LOC or amnesia if it was not witnessed.
It would be entirely inappropriate for a Coroner or any other person to
attempt to assign a GCS score retrospectively in this way as this is a
completely invalid use of the Glasgow Coma Score. The Glasgow Coma Score is
for use by medically trained personel ON EXAMINATION and not on the history.
You may be in a different situation if a Paramedic assesses the GCS as
below 13 , in which case this would qualify for GCS <13 , And this may make
for an interesting discussion but I do not think that there is really any
issue about trying to retrospectively assign a GCS from the witnesses to an
incident or from the patient themselves.
I hope this clarifies the situation, and when we come to revising the
guidelines in 2005 I will propose to the Guideline Development committee
that we explicitly state that the GCS score can only be assigned to a
patient after examination by a medically trained person and cannot be
assigned retrospectively from the history.
Yours sincerely
Joel Dunning >
So essentially, this fits with my own interpretation, and with Andrew's
i.e. loss of consciousness per se is not in itself sufficient indication
for a scan, particularly if you follow the algorithm and establish that 1)
the patient is not over 65 years old, 2) the patient has no coagulopathy,
3) there wasn't a dangerous mechanism of injury and 4) any retrograde
amnesia was no longer than 30 minutes.
I hope this is helpful,
Adrian Fogarty
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