Accid EmergMed 1996;13:80-85 Computerised tomography and acute traumatic head injury: time for change?

The aim was to reconsider the "Guidelines for initial management of head injury in adults" particularly with respect to the indications for computerised tomographic (CT) scanningsuggested by "a group of neurosurgeons" over a decade ago and still followed in some accident and emergency (A&E) departments. These recommendations are placed in the context of more recent research and the increased number ofA&E departanents with on-site rapid access to a CT scanner but without a resident neurosurgical facility. A case can be made for an updated policy with more liberal indications for CT scanning of acutely head injured adults in periphTable 1 Guidelines for initial management after head injury in adults2 For skull x ray examination after recent head injury 1 Loss of consciousness or amnesia at any time 2 Neurological symptoms or signs 3 Cerebrospinal fluid or blood from the nose or ear 4 Suspected penetrating injury 5 Scalp bruising or swelling For admission to a general hospital 1 Confusion or any other depression of the level of consciousness at the time of examination 2 Skull fracture 3 Neurological symptoms or signs 4 Difficulty in assessing the patient for example, alcohol, epilepsy, or other medical condition 5 Lack of a responsible adult to supervise the patient; other social problems Note brief amnesia after trauma with full recovery is not sufficient indication for admission. Relatives or friends of patients sent home should receive written advice about changes that would require the patient to be returned urgently to hospital. For consultation with a neurosurgeon 1 Fractured skull with any of the following: confusion or worse impairment of consciousness, one or more epileptic fits, or any other neurological symptoms or signs 2 Coma continuing after resuscitation even if no skull fracture 3 Deterioration in level of consciousness 4 Confusion or other neurological disturbances persisting for more than eight hours, even if there is no skull fracture 5 Depressed fracture of the skull vault 6 Suspected fracture of the base of skull (cerebrospinal fluid rhinorrhoea or otorrhoea, bilateral orbital haematoma, mastoid haematoma, or evidence of penetrating type of injury such as spike or gunshot) eral A&E departments. However, calculating the cost-efficiency ofmore frequent use of what is now a common but relatively expensive resource would remain a