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Sun Aug 24 14:17:35 BST 2003

Caesar,

Thanks for your comments.

I flagged up this issue because of all the previous posts (except for Dr
Morrow's yesterday) could give the impression that CT head should be the
only imaging modality of choice for significant head trauma - which I
continue to challenge in the specific subset described, irrespective or not
of whether there are the resources for CT locally. I will review our data as
you rightly recommend.

I assume from your comments that you institution has stopped undertaking
plain films with the advent of CT - ours has not - yet!

Apologies re any confusion with the crow bar case which was not the
mechanism of my original post (mechanism was unknown as is too often the
case). I would advocate proceeding directly to CT with any case in which I
had good clinical reason (high index of suspicion) to suspect a depressed
(or linear)skull fracture. This may be overlooked by the less experienced,
especially if there is an incomplete history, has not been any clouding of
consciousness , and a lack of impressive local signs in the scalp.

John Black
Oxford, UK   

-----Original Message-----
From: caesar ursic [mailto:cmursic at yahoo.com] 
Sent: 23 August 2003 16:11
To: Trauma & Critical Care mailing list
Subject: RE: x-ray work up for blunt head injury - selective use of SXRs a s
potential pre-discharge filter from the ED

--- "Black, John" <John.Black at orh.nhs.uk> wrote:
> Thanks for your comments.
> 
> Caesar, we have not formally studied the positive
> and negative predictive
> values of SXRs at our institution and we should do
> so. Have you? 

No, of course we haven't studied our numbers - for the
simple reason that we don't use plain skull films.

> The vast majority are negative (as you would expect)
> although last night in
> our department a depressed skull fracture (crow bar
> assault) was diagnosed
> by a junior clinician using plain skull films......

The patient you describe had clinical signs and
symptoms associated with a small but real incidence of
brain injury: repetitive questioning, no recall of
events, headache, AND an obvious mechanism (crowbar to
the head).  He merited a CT scan.

> Are you advocating that plain skull x-rays be banned
> in the Emergency
> Department that may not have the resources to CT
> scan every GCS 15 head
> injured patient with a significant scalp haematoma
> (irrespective of the CT
> radiation concerns) that cannot be adequately
> clinically assessed?

Of course not, John, but haven't you now changed your
tune just a little bit?  Initially you advocated plain
skull films as a screening method, period.  Now you
want them only when CT is unavailable.  That's a
different case alltogether, isn't it?  I may be
misinterpreting your post, but if my hospital's CT
scanner is broken or constantly unavailable, then I
guess I'd shrug my shoulders and resign myself to
using outdated diagnostic approaches because - well,
that's the best that I can do.  I fully realize that
not all institutions have the benefit of a constantly
available scanner.  Luckily, I work in one that does. 
I applaud those who must by necessity rely on their
clinical skills yet get results as good or better than
mine.  Really!

C.M. Ursic, M.D.
Dept. of Surgery
UCSF-East Bay
Oakland, California

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x-ray work up for blunt head injury - selective use of SXRs a s potential pre-discharge filter from the ED