Adrian,
This is exactly the situation that I was referring to.  The risk / benefit
of CT in the paediatric population is surely different to adults.  In
particular, CT in the paed minor head injury will often require the use of
sedation / general anaesthesia, which is, of itself, inherently risky.
This is a vastly different situation than what we routinely see in adult
MHI.

 agree with you that SXR is a useful investigation in this patient group
in terms of risk stratification.

Regards to the list

Paul Bailey
Emergency Physician
Perth Western Australia

> 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