To scan or Not to scan . . .

[Annette]

Studying for IM boards. Stupid question in a review book, and I'd like your opinion.

52 yr man has micturition syncope. He falls and gets a head lac (no specifics on where). Wife finds him out cold. When paramedics arrive, he is alert and oriented. Do you scan his head?

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[bartleby]

You did not include some of the details of the case, but if the book describes clear situational syncope w/o epileptiform activity as you mention, and the patient has a completely normal neuro exam with no risk factors for ICH (anticoagulation) you could skip the CT.

Studying for IM boards. Stupid question in a review book, and I'd like your opinion.

52 yr man has micturition syncope. He falls and gets a head lac (no specifics on where). Wife finds him out cold. When paramedics arrive, he is alert and oriented. Do you scan his head?

 

[southerndoc]

You did not include some of the details of the case, but if the book describes clear situational syncope w/o epileptiform activity as you mention, and the patient has a completely normal neuro exam with no risk factors for ICH (anticoagulation) you could skip the CT.

I like the Canadian and New Orleans CT rules. No vomiting, no headache, less than 60 years of age, no CT.

However, let's all keep in mind that she said she is studying for IM boards. Of course they will likely want to CT the patient as part of a syncope workup. I doubt they are up on the EM literature regarding head CT rules.

Annette, I thought you transferred into an EM program??

 

[whasupmd2]

I don't know... I used to follow these rules, but in the past year, I got head CTs on more of a gut feeling on at least 5 cases, 4 or which had traumatic head bleeds, stone cold normal exam, one pt was only 19y/o, all the rest were < 60. One had midline shift with a SDH, the others were traumatic SAH. I'm pretty liberal now on scanning. I know it's anecdotal, but I don't follow these EBM rules for head CTs.

I like the Canadian and New Orleans CT rules. No vomiting, no headache, less than 60 years of age, no CT.

However, let's all keep in mind that she said she is studying for IM boards. Of course they will likely want to CT the patient as part of a syncope workup. I doubt they are up on the EM literature regarding head CT rules.

Annette, I thought you transferred into an EM program??

 

[Annette]

I like the Canadian and New Orleans CT rules. No vomiting, no headache, less than 60 years of age, no CT.

However, let's all keep in mind that she said she is studying for IM boards. Of course they will likely want to CT the patient as part of a syncope workup. I doubt they are up on the EM literature regarding head CT rules.

Annette, I thought you transferred into an EM program??

I thought LOC from trauma= head ct. I didn't realize that there were rules. The answer key said no CT because it isn't needed to w/u situational syncope.

I originally wanted to go into EM, thought about transfering the beginning of my first year, then got bit by the ICU bug.

I use to call the ER Evil Room. Now I'm an attending, I guess I'll have to call it the Employment Department!

 

[anonymousEM]

By New Orleans criteria, with a cut on the head there IS trauma above the clavicles....

 

[NinerNiner999]

Scan. LOC with trauma. Period.

 

[GeneralVeers]

Scan. LOC with trauma. Period.

I agree, LOC with head trauma, you should scan. CT scan is a quick study, and relatively inexpensive.

 

[12R34Y]

so everyone is saying that LOC plus trauma equals head CT........does this take into account that Trauma did NOT CAUSE his syncope? He had micturition syncope and then cut his head?

does this matter?

later

 

[leviathan]

so everyone is saying that LOC plus trauma equals head CT........does this take into account that Trauma did NOT CAUSE his syncope? He had micturition syncope and then cut his head?

does this matter?

later

EBM would say not to if he is
<60,
less than two vomiting episodes
no amnesia 30 mins before incident,
no signs of open or depressed skull #
no signs of basal skull #
no dangeorus mechanism (eg. fall from elevation, major MVA, etc),
GCS is 15 within two hours after injury

 

[Gfunk6]

so everyone is saying that LOC plus trauma equals head CT........does this take into account that Trauma did NOT CAUSE his syncope? He had micturition syncope and then cut his head?

Good point, but we are also worried about a possible subdural after he hit is head following his LOC.

I agree, on IM boards, you should scan.

 

[Eidolon6]

No scan...situational syncope is the most common cause of micturation syncope. Do a thorough neuro exam, take a good history, sew up his lac and send him on his way with f/u.

 

[docB]

I scan these. I've caught enough subdurals, tumors, etc. that I have a low threshold for non con scans. I know it's not good EBM but....

The IM resident might be more likely to find an abnormality on the neuro exam....

I'm and ER doc. The CT is my neuro exam.

 

[bartleby]

The main head CT rules out there are the Canadian (less strict) and New Orleans (more strict). If you scan everyone, you won't miss anything. But this is neither good for you (your length of stay and hence wait time is going to go through the roof) nor your patients (large bills, long waits, a large amount of unnecessary radiation).

The key to this case is the history. What this guy needs is five minutes of teaching about situational syncope while you're suturing his lac shut so he knows what to do next time he starts feeling wifty after taking a piss, not a $700 bill from the radiology department.

 

[drsutter]

Remember, rules are rules, but in reality/practical life, you still CT the patient.

 

[southerndoc]

Remember, rules are rules, but in reality/practical life, you still CT the patient.

By what standards? Sounds suspicious of legal/defensive medicine and not evidence-based medicine.

 

[WilcoWorld]

By what standards? Sounds suspicious of legal/defensive medicine and not evidence-based medicine.

Maybe by the standard of not wanting to miss the >1% of traumatic brain injuries that the Canadian Head CT rules miss?

In any case, I'd probably CT that patient...unless p53 was my in house radiologist, in which case I'd get some sort of intervntional study.

 

[NinerNiner999]

By what standards? Sounds suspicious of legal/defensive medicine and not evidence-based medicine.

This does sound like defensive medicine but, in the long run, it would go down like this:

LAWYER: "So doctor, your patient passed out with what sounded like a 'vasovagal response' as you say, but weren't you be the least bit concerned about bleeding in their brain, even with an obvious laceration and signs of trauma? That is, after all, why we are here today, isn't it?"

DOCTOR: "Evidence-based medicine teaches us that there is a low-risk for CVA-related syncope in the face of a clear history defining the most common cause of syncope, even with secondary signs of trauma."

LAWYER: "Well, doctor, it appears that evidence-based medicine failed to look at the brain of THIS patient, who clearly may still be with us had you identified their source of bleeding."

JURY OF LAY-PEOPLE: Gasp.

DOCTOR: "DAMN YOU - DAMN YOU ALL!"

 

[Annette]

Took the boards 2 days ago, and there wasn't a head CT anywhere on the exam! There was (paraphrased question) a 28 yr female who passed out. Her sister died mysteriously in her sleep at age 32. The EKG (all of them were interpreted for us on the exam- very weird) showed QT prolongation. What do you want to do next? a) send home b) EP study c) implantable defibrillator d) something I don't remember but was obviously wrong

I think I'd explain the risks to the patient, and let them decide (and document the conversation!) If they decide to not CT, I'd give damned good d/c instructions about what to look for, and when to call the ambulance (and document, document, document!)

 

[bartleby]

Remember, rules are rules, but in reality/practical life, you still CT the patient.

A CT Scanner is not a crystal ball which will magically reveal the cause of the patient's problems. Certainly CT has revolutionized EM, as we can radiographically identify things that you previously had to sit on for a day or two before things became clinically obvious, but getting a non-contrast CT on everybody is not the solution to anything.

First of all, while non-contrast CT is good at finding blood, identifying hydrocephalus and allowing general comment on the structure of the brain. Unless accompanied by significant edema, bleeding, or mass effect, parenchymal lesions will not show up reliably on a non-contrast study. So "just getting the CT" if you're seeking to rule out the things which won't show up on it is going to give you false reassurance anyway.

Second, you are supposed to be a physician, which entails using your judgement and ability to do an H&P to care for patients. This is why we get paid more than the dude who runs the CT scanner. A decent neuro exam (not a good one, just decent) takes all of two minutes at the bedside and tells you plenty of stuff that the CT scanner can't, like that the lady you're looking who fell & hit her head with a "normal CT" did so because she is two hours into a stroke.

If you have a 90 y/o lady on coumadin who tripped and fell with LOC & neck pain on waking, your management is quite clear. But to scan every healthy young sober person who stuck his/her head with no LOC, a normal neuro exam, minimal external injury, no progressive headache/vomiting and a low energy mechanism and no signs of skull fx on exam is wasting yours & the patient's time and subjecting them to significant and unneeded ionizing radiation (partiuclarly an issue in children). When you have a working but uninsured person who comes to your ED after a head injury who refuses to pay for a CT out of pocket, you'd damn well better be able to explain why he needs one more than "I do it for everybody...just because".

And I'm sure you all have realized by this point that CT scanners are only as perfect as the brain which interprets the images it produces. While radiologists, bless their hearts, do the best they can, they miss stuff. It goes with the job. Especially when you're p51 and you're distracted thinking about some toe arthrogram you're going to get to do tomorrow. But I digress...

 

[drsutter]

Since i graduated from my residency, i have faithfully abide by this rule: If you have any doubt and would continue to think about a patient after work, you better do everything you can possibly can for that patient so that you can sleep better at night. Many people go to ER because they want to rule out serious life threaning things. If they just have bruises and bumps, most of them would just stay home and take tylenol rather than wait hours in the triage and tests in the ER.

 

[ERMudPhud]

Especially when you're p51 and you're distracted thinking about some toe arthrogram you're going to get to do tomorrow. But I digress...

And oh yeah, I wouldn't scan him.

 

[BKN]

Since i graduated from my residency, i have faithfully abide by this rule: If you have any doubt and would continue to think about a patient after work, you better do everything you can possibly can for that patient so that you can sleep better at night. Many people go to ER because they want to rule out serious life threaning things. If they just have bruises and bumps, most of them would just stay home and take tylenol rather than wait hours in the triage and tests in the ER.

A good rationale, but one that I didn't have in the limited era of diagnostics (graduated '79). Thus, I did stare at the ceiling and go over all of my patients for the first 2 years after residency. What I learned was two things; first I wasn't missing much of substance and second it was too late to do anything about it. So I finally got to sleep. But given I didn't have the choice of any CTs but head (and I had to send them 70 miles to get one), I saved a lot of money for the government and a lot of radiation for my patients with no discernable harm.

To apply that to the original question. An healthy person hits his head with apparent micturition syncope. He's awake when paramedics arrive. Assume that when you examine him he has completely normal mental status and neuro exam. If you scan him there is a chance of minor blood being found (about 5%?). But there's in essentially no chance that you will find a lesion requiring neurosurgical intervention. What's the harm in watchful waiting?

 

[EctopicFetus]

Just curious how this relates to kids. I had an 11 month old slipped fell knocked her head.. When i spoke to mom kid was disoreinted for 10 seconds (this of course became a few minutes once the attending showed up). Anyways a Right temporal bruise is seen but the kid is totally appropriate no vomiting (even the head bruise is non tender but visually is present. Anyways I didnt want to scan the kid (what do i know i am an intern) but my attending was worried.

So long story short.. an 11 month old who fell with unknown period of disorientation (not necessarily LOC) but is now 100% fine..

Attending was worried about mechanism (fall onto hard floor) and disorientation. Anyways im just wondering on your thoughts.

 

[docB]

So long story short.. an 11 month old who fell with unknown period of disorientation (not necessarily LOC) but is now 100% fine..

Attending was worried about mechanism (fall onto hard floor) and disorientation. Anyways im just wondering on your thoughts.

One of the LLSA articles for '06 is the study from UC Davis on pedi head injuries and when you need to scan them. For this case the important thing was that they found that you should scan any kid under 2 with a hematoma. You have to decide if your bruise is really a hematoma or not.

The short on the study was that you should scan kids with altered mental status, clinical signs of skull fx (battle's, raccoon eyes, CSF pouring out, gray matter pouring out, etc.), any vomiting, headache or a kid <2 with a hematoma. The article was in Annals, 10/03.

 

[ERMudPhud]

Just curious how this relates to kids. I had an 11 month old slipped fell knocked her head.. When i spoke to mom kid was disoreinted for 10 seconds (this of course became a few minutes once the attending showed up). Anyways a Right temporal bruise is seen but the kid is totally appropriate no vomiting (even the head bruise is non tender but visually is present. Anyways I didnt want to scan the kid (what do i know i am an intern) but my attending was worried.

So long story short.. an 11 month old who fell with unknown period of disorientation (not necessarily LOC) but is now 100% fine..

Attending was worried about mechanism (fall onto hard floor) and disorientation. Anyways im just wondering on your thoughts.

I had exactly this case in the ED the other day. A well appearing kid running around looking fine and I notice a CT has been ordered. I corner the PA who ordered it and ask if he has discussed it with an attending yet. He was about to present it to an attending who would scan a severed head if the paramedics brought it in so he had ordered the CT. I had him present it to me and then went to see the kid. He had barely a mark on him and was totally fine now. I spent a good long time discussing pros and cons (radiation) with the parents and giving them good after care instructions and sent him home. You could scan him and tell yourself you are being careful and doing what the parents want and if he gets a brain tumor in 20 years you'll never know or you can take the time to have a good discussion with the family and they will leave sooner, cheaper, just as happy, better educated, and without the radiation risk. Toddlers who run into furniture or fall from standing height and look fine now and don't meet the criteria mentioned above don't need scans. If I scanned my 2 years old every time he wacked himself we'd have to have him declared as hazardous waste.

 

[Apollyon]

If I scanned my 2 years old every time he wacked himself we'd have to have him declared as hazardous waste.

As we said in residency (for kids scanned that the attending wanted, where we wouldn't as residents): "That's another kid not going to Harvard."