Skull X-ray in trauma To do or not

Skull X-ray in trauma To do or not

Skull X-ray in trauma To do or not to do? Dr Pauline Louw No head injury is so serious that it should be despaired of nor so trivial that it can be ignored. Introduction Head injury common presentation to EC

Most mild TBI (70-90% worldwide) 8% of Mild TBI has intracranial pathology (95% CI 3-13%) 1% of these will require neurosurgical intervention Does plain Scull X-ray have a place in the assessment of mild TBI in the EC??

Does this patient need a CT head? Depressed skull fracture Does this patient need a CT head? Does this patient need a CT head? Leptomeningeal cyst Traumatic meningocele

Cerebrocranial erosion Cephalhydrocele Meningocele Spuria Growing fracture Linear skull fracture Does this patient need a CT head? Right parietal

fracture Does this patient need a CT head? Pneumocephalus Does this patient need a CT head? Normal X-ray

Does this patient need a CT head? A B Guidelines Different guidelines available: North America No SXR, CT choice

ACEP No SXR, CT choice Europe (EBIC) CT choice NICE CT choice, SXR for NAI and per discussion SIGN CT but pro SXR where risk factors present Australia No SXR, Use Canadian CT rule SA WC guidelines Consensus in most guidelines = CT choice, No SXR ?MRI emerging modality to use in future

Canadian CT rule Validated rule 100% Sensitive 2 risk groups High risk: At risk for neurosurgical intervention CT mandatory

Medium risk May have clinically important injury on CT, but not at risk for neurosurgery intervention CT/observation depending on resources Canadian CT rule Inclusion: Minor head injury, GCS 13-15 Witnessed LOC, confusion or amnesia

Exclusion No trauma experienced Younger than 16 GCS <13 On warfarin or coagulopathy Has obvious open skull fracture Canadian CT rule

High risk: Failure to reach GCS of 15 within 2 hours Suspected open or depressed skull fracture Sign of basal skull fracture Vomiting more than once Age over 65 Medium risk Retrograde amnesia >30 min

Dangerous mechanism New Orleans Criteria Recommend CT after minor TBI if: GCS=15 and one of the following Headache Vomiting Age >60 years Drug or alcohol intoxication

Deficits in short term memory Seizure Evidence of injury above clavicle 100% Sensitive Western Cape What are the Western Cape guidelines? What are the WC indications for CT scan?

What are the place of SXR in WC ECs? SXR Studies

Multitude of studies looked at abolishing SXR From as early as 1977 and early 1980s Included adult and paediatric population Still ongoing studies - 2008 Consensus in most countries other still debating especially in areas with limited CT access Most concluded that SXR is not needed

Cost effectiveness of CT Less than 10% of CT scans in Mild TBI positive findings, thus > 90% CTs normal Are we wasting money with all these normal CTs? Compare CT vs. admission for observation Discharge safely vs. lack of supervision at home CT alone vs. CT and SXR + extra radiation

Guidelines vs. CT all MRI in TBI Emerging modality to use Controversial 10-20% missed injuries from CT MRI 30% more sensitive than CT in picking up intracranial injury in acute mild TBI Not shown yet if picking up additional injuries would change acute management of TBI

Currently need more studies in EC timeframe No current EBM recommendations MRI in TBI Advantages Useful in sub-acute/chronic and limited acute setting Better soft tissue definition Better at

Detecting DAI Small areas of contusion Subtle neuronal damage Posterior fossa: Cerebellum and brainstem

MRI in TBI Disadvantages Not widely available and accessible Patient monitoring problem Long imaging time Foreign bodies Patient safety (pacemakers, previous ferromagnetic foreign bodies)

Cost constraints Insensitive to acute SAH, parenchymal haemorrhage and fracture compared to CT Patient motion artefacts MRI images MRI images

Positron Emission Tomography (PET) Important Points on SXR Not all skull fractures have intracranial injury Not all intracranial injuries have a skull fracture Objective not to diagnose skull fracture but risk for intracranial injury SXR low diagnostic yield

Fractures easily missed or over diagnosed SXR give false sense of reassurance if normal Summary CT modality of choice in whole spectrum of TBI No place for EC Skull X-ray in trauma MRI starting to gain favour, but limitations issue

So when do we use Skull X-ray? Trauma Foreign body Penetrating injuries (slot fracture and compound) Growing fracture in child less than 1 year Medical Multiple myeloma

Paeds NAI as part of skeletal survey Multiple Myeloma ? References Reed MJ, Browning JG, Wilkinson AG. Can we abolish skull xrays for head

injury? Arch Dis Child 2005;90:859864 Glauser J. Head injury: Which patients need imaging? Which test is best? Clevelend Clin J Med 2004;71(4):353-357 Coles JP. Imaging after brain injury. Br J Anaesth 2007; 99: 4960 Lee B, Newberg A. Neuroimaging in traumatic brain injury. NeuroRx 2005;2(2): 372-382 ACEP/CDC. Clinical Policy: Neuroimaging and decision making in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 2008;52:714-748 NICE clinical guideline 56: Head injury: Triage, assessment, investigation and

early management of head injury in infants, children and adults. NICE update 2007 Stiell IG, Wells G et al. Canadian CT head rule for patients with minor head injury. Lancet 2001;357:1391-6

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