So, what is really distracting? According to NEXUS (multiple links here), it is any long bone fracture, visceral injury requiring surgical consultation, lacs >10cm, degloving injuries, crush injuries, large burns, or anything causing functional impairment. Do these requirements dictate the need for head CT as well?
In the ongoing debate of EM vs Trauma for selective imaging, comes this paper. From April 2014 – September 2014, the authors looked at 330 patients with mild TBI (GCS 13 or higher), to determine if distracting injuries were truly an indication for head CT. Patients were excluded if 18 months or younger of age, over age 60, moderate/severe or progressive headache, 2 or more episodes of vomiting, +LOC, amnesia, seizure or antiepileptic use, intoxication, uncontrolled hypertension, anticoagulated, had a neurologic deficit, penetrating injury, or craniofacial deformity.
Of 184 patients with fractures & severe pain (90 lower limb, 56 upper limb, 36 thoracolumbar, and 2 pelvis fractures – note there were NO cervical fractures noted), 2 (1.1%) had brain edema on CT, while of the 146 patients with no fractures/dislocations and no/mild pain, only 1 (0.7%) had brain edema on CT. No patient in any group had any neurologic symptoms at 1 month or 3 month follow up.
For many of us, this confirms our practice. Please share with your pan-scanning colleagues.
EM in Focus 