Patients who reattend after head injury

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7032.707c (Published 16 March 1996) Cite this as: BMJ 1996;312:707

Criteria for performing skull radiography on first attendance need to be better defined

  1. Daniele Coen,
  2. Barbara Omazzi,
  3. Giovanni Pistone
  1. House officer House officer House officer Accident and Emergency Service, Ospedale Civile di Rho, 20017 Rho, Italy

    EDITOR,—We share the frustration that Gordon Murray expresses in his commentary on Miranda Voss and colleagues' study.1 Their paper presents the clinical features of 606 patients who reattended for the consequences of head injury but fails to give a detailed account of the 30 important patients who underwent neurosurgery when they reattended. In the light of this, some of the authors' conclusions may be misleading.

    Firstly, the authors state that patients who reattend are a high risk group in themselves. It could be argued that their level of risk depends on the diagnostic work up performed at their first attendance. The authors state that 16 of the 30 patients who had neurosurgery had a vault fracture on first x ray examination (in additon to loss of consciousness or amnesia). We do not know much about the 14 others except that some, if not most, of them had suffered a penetrating injury. Most centres today would perform emergency computed tomography for all such patients at their first attendance. This does not seem to have been the case in the study, since the authors claim that “none of the 20 patients who underwent computed tomography for a second time showed measurable change from the findings at the first attendance,” which leads us to believe that most of the patients who were operated on had computed tomography for the first time at the time they reattended. One could thus conclude that a vault fracture is an indication for immediate computed tomography and neurosurgical evaluation rather than a predictor of computed tomographic abnormalities and surgery for patients who reattend (as the authors conclude).

    Secondly, Voss and colleagues state that their data “support the continued use of selective skull radiography to identify those at high risk for intracranial complications.” While we accept this statement in principle, we think that it is important to define better the criteria that emergency doctors should follow in requiring skull x ray films. Surely the data presented do not disprove Masters et al's recommendations that skull radiography is unnecessary in patients who present for the first time after a head injury that did not result in loss of consciousness, amnesia, or other neurological abnormalities and that these patients should be sent home with an advice sheet.2 To prevent an epidemic of unnecessary skull radiography it would be helpful to know whether any such patient was among those who underwent neurosurgery on reattendance in the authors' study.


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