 |
 |
The SIGN guidelines have just been reviewed by the Royal College of Paediatrics and CHild Health from the perspective of paediatric head injuries- these can be looked at by going to www.rcpch.ac.uk - then to library then to the clinical effectiveness section. There is also some mention of these on the trauma care uk site. Regards Ian -----Original Message----- From: Adrian Fogarty To: [log in to unmask] Sent: 17/11/2001 03:29 Subject: Re: Head injuries Original Message from Paul Bailey, 27th September 2001 > The real issue with skull films in my opinion is that they do not answer the question that you need to ask..... which is: does this patient have a clinically significant intracerebral injury that requires neurosurgery? Sure, a skull fracture might alter the probabilities, but you probably go from rare to slightly less rare.... Skull XRays are a relic of the pre CT era for the vast majority of patients.... The evidence is that in patients with rigidly defined minor head injury, and GCS of 15..... approx 5-7% will have any form of CT abnormality, and somewhere around 0.5%-1.0% will have an intracerebral abnormality requiring neurosurgery. Armed with this knowledge that a large number of normal scans will be required to detect those with significant intracerebral pathology..... it is up to the clinician to decide which test is appropriate. In my humble opinion, radiology and radiologists have no place in deciding what investigation is appropriate in this setting. We are the clinicians, experienced in the assessment of these patients.....In addition, the value of a normal scan is that neurological observation is not required, the patient can go home safely, and it's one less patient in the department to worry about.....I would think that the only use for skull films in an institution where CT head is readily available is in the infant paediatric population..... but that is an entirely different argument. ---------------------- Just thought it was timely to raise this subject again. Saw a five month old baby tonight, fell off bed onto stone floor. No LOC and well since. However Mum worried as large parietal swelling rapidly developed. My exam revealed very well baby and large parietal scalp haematoma. So I did a skull film which showed a long parietal skull fracture. Admitted child under paeds and discussed with our neurosurgeons. They felt a CT was not indicated, partly as child very well and partly as a CT would probably require a GA or sedation. In other words the CT might well lead to more problems than it would solve, so simple observation was the lesser of two evils. Another factor must be the radiation involved in head CT, which would be considerable for an infant. Although it's difficult to be precise about this, it cannot be discounted as a factor. Do I presume this is what Paul Bailey meant by the use of skull films in the paediatric population? Basically I felt the skull film was an ideal investigation to stratify risk and direct management in this case. I can't CT all well-babies who have temporoparietal swellings, but neither should I admit them all for neuro-obs. A plain skull film neatly discriminates in this situation. Adrian Fogarty