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Another pearl from EM Lit of Note. Bottom line: Retro review of CT head obtained for trauma divided into <24 hours and >24 hours time of presentation. The delayed presenters had a HIGHER percentage of positive CT and had a similar amount of patients requiring NES intervention.
We discussed this the other day. First Care obtained a head CT on a patient several days after a minor head injury. We presumed it was not indicated. Then I read this paper.
Unfortunately I cannot find in the paper a description of time to presentation. It is grouped into less than 24 hours and greater than. I wonder if the likelihood of positive CT scan decreases as time from injury to presentation increases.
In any event, this poses difficult questions. Should we obtain more CTs on the delayed presenters? They are as likely to have positive findings. In addition, the NICE guideline is 70% sensitive, versus its comforting 98% in the less than 24 hour group.
Would be a good article to discuss for journal club. Would love to see some comments.
I think this does make me more likely to scan the late comers. Usually if they are relatively asymptomatic from the head injury and are there for other issues, then I may forego the CT head, but I usually make that a shared-decision-making option. But often, people come in with persistent vomiting or headache, and those people get scans because really, thats what they are there for, and really, I don’t have X-ray eyesight. It’s the in-betweens that I think I will now have better reason to scan, or at lease some numbers to discuss with patients.
Of course, as you said, the risk of finding something bad decreases with time for two reasons. As said in the article, if you had something that required NES, then you would be dead. But the other is after 4 days to a week, our imaging modality becomes less sensitive as the blood breaks down. So even if it was there, we probably missed it.
Great article, btw.