List Archives

Mon Nov 17 13:13:11 GMT 2008

The clinical utility of computed tomographic scanning and
neurologic examination in the management of patients with minor head
injuries.
  Shackford SR, Wald SL, Ross SE, Cogbill TH, Hoyt DB, Morris JA, Mucha PA, Pachter HL, Sugerman HJ, O'Malley K, et al.
  Department of Surgery, Medical Center Hospital of Vermont, Burlington 05401.
  The
evaluation and management of patients with minor head injury (MHI:
history of loss of consciousness or posttraumatic amnesia and a GCS
score greater than 12) remain controversial. Recommendations vary from
routine admission without computed tomographic (CT) scanning to
mandatory CT scanning and admission to CT scanning without admission
for selected patients. Previous reports examining this issue have
included patients with associated non-CNS injuries who confound the
interpretation of the data and affect outcome. We hypothesized that
patients with MHI and no other reason for admission with normal
neurologic examinations and normal CT scans would have a negligible
risk of neurologic deterioration requiring surgical intervention. To
validate this hypothesis we studied 2766 patients with an isolated MHI
admitted to seven trauma centers between January 1, 1988, and December
31, 1991. There were 1898 male patients and 868 female patients; injury
was blunt in 99%. A neurologic examination and a CT scan were performed
on 2166 patients; 933 patients had normal neurologic examinations and
normal CT scans and none required craniotomy; 1170 patients had normal
CT scans and none required craniotomy; 2112 patients had normal
neurologic examinations and 59 required craniotomy. The sensitivity of
the CT scan was 100%, with positive predictive value of 10%, negative
predictive value of 100%, and specificity of 51%. The use of CT alone
as a diagnostic modality would have saved 3924 hospital days, including
814 ICU days, and $1,509,012 in hospital charges. Based on these data,
we believe that CT scanning is essential in the management of patients
with MHI and that if the neurologic examination is normal and the scan
is negative patients can be safely discharged from the emergency room.
Michael W. Parra, MD 
Trauma Research Director 
Broward General Medical Center/Level I Trauma CenterFort Lauderdale, FL

--- On Sat, 11/15/08, trauma-list-request at trauma.org <trauma-list-request at trauma.org> wrote:
From: trauma-list-request at trauma.org <trauma-list-request at trauma.org>
Subject: trauma-list Digest, Vol 65, Issue 15
To: trauma-list at trauma.org
Date: Saturday, November 15, 2008, 7:00 AM

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Today's Topics:

   1. Re: trauma-list Digest, Vol 65, Issue 14 (Zawisza at xtra.co.nz)
Yes I agree it's a waste of time. Especially ICU admission. In most parts of
the world they probably don't even get picked up. I certainly don't scan
patients with GCS 15 because I don't see the point of irradiating their
brains esp when young, just so I could tell them they have a bleed (should one
get picked up) but we won't do anything about it anyway. They can easily be
observed on a ward with hourly obs over night. Should we be re scanning them?
I'm not sure- again more radiation in an asymptomatic patient. Are we
treating the patient or the picture?
If they live close by and have good home support- i.e. someone who can keep an
eye on them then the chances of ther being a late bleed are small and even if it
happens it's rarely sudden. I had one patient who fell off a horse, LOC 15
min, amnesia etc but was absolutelly fine in the ED. We scanned him the
following day because he was on warfarin, observed in AAU over night. Scan was
normal and he was discharged home. Represented 6 weeks later with a large
subdural which needed draining (no other trauma)- he was getting worsening
headaches for 1 week prior to that and for a couple of days noticed having
problems driving. He mada a full recovery.
trat the patient you wont go wrong.

Martin Sosnowski MB, ChB, FRCS Ed, FCEM
Consultant EM
Wanganui
NZ

----- Original Message ----- From: <trauma-list-request at trauma.org>
To: <trauma-list at trauma.org>
Sent: Friday, November 14, 2008 1:00 AM
Subject: trauma-list Digest, Vol 65, Issue 14

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> Today's Topics:
> 
>   1. RE: head injury (Sherry, Scott :LPH Trauma)
> 

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trauma-list Digest, Vol 65, Issue 15 " CT and Head Trauma"