There are rules and then there are rules

Tuesday, January 20, 2009

A helmet to helmet hit and down went running back Willis McGahee, knocked out for few seconds on the playing field. The next thing he remembers is waking up in a room being wheeled out to an ambulance. All goes well after time in the CT scanner, an MRI machine and an overnight stay in the hospital. For an NFL athlete, it’s routine care but for the rest of the world, it may be a little exorbitant. While McGahee’s tests may have been appropriate, high tech isn’t necessarily that standard of care.

Minor head injuries are a routine occurrence. From toddlers falling against tables to kids bumping heads playing ball to an elderly person falling down, people lead with their heads. Usually, a few stars are seen, a headache happens and all is well. Sometimes it isn’t so clear. The person may be knocked out for a few seconds, may vomit and perhaps may have some loss of memory but by the time the doctor visits the bedside, everything is back to normal. The diagnosis of a concussion is made.

But now what? What do you do with somebody who acts and appears normal, even though there was a history of a head injury? Who will have bleeding in their brain and who won’t? Who needs a CT scan and who just needs to go home?

Less than a generation ago, CT scans didn’t exist and observation was the key to head injury care. If the patient did well, they went home; if not, a neurosurgeon visited. Now CT scans can be found in even the smallest hospital but just because the machine is there doesn’t mean that it should be used indiscriminately. Putting aside the cost, the radiation risk of an unneeded test is significant.

While scientific studies can provide guidelines as to who needs imaging, patients and their families want more than the doctor’s opinion; they want the reassurance of hard evidence like an x-ray or CT. Every case needs to be considered individually, but here are a couple of guidelines that a doctor may use to decide: “CT or no CT, that is the question.”

The Canadian CT Head Rule says that a CT scan is required if any of the following exist:
High risk for needing an operation

• the person is not fully awake and responsive within 2 hours after injury
• there is a suspected depressed skull fracture
• there is a suspected fracture of the base of the skull (bruising of both eyes, blood behind the eardrum, or spinal fluid running from the ears or nose)
• vomiting occurs more than 2 times
• the patient is older than 65
Medium risk for brain injury
• amnesia before impact of greater than 30 minutes
• dangerous mechanism (being hit by a car, being thrown from a car, falling more than 5 stairs)

The New Orleans Criteria say that a CT scan is required with any one of the findings in a person who is fully awake:

• headache
• vomiting
• older than age 60
• drug or alcohol intoxication
• amnesia
• visible trauma above the collarbone
• seizure

But rules are made to be broken and they need to be applied based on the patient’s specific situation. Communication between physician, patient and family allows the right treatment pathway to be followed while hopefully meeting everybody’s expectations. And you thought winning a Super Bowl was hard.

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