Had an interesting case handed over to me recently, that raised some questions. The presentation was that the patient had opened his door and been allegedly assaulted by “these two dudes”. He had apparently lost consciousness. He complained of severe facial pain, especially over the left zygomatic arch. His GCS was 15, and he was very anxious.
Injuries obvious were a swollen lip and a slight movement in one of the teeth. Although there was tenderness over the zygomatic arch, there was no deformity or swelling.
There were no other injuries.
Facial X-rays were normal.
On neurological examination, he had diplopia that changed in direction frequently i.e. totally inconsistent. A CT was recommended by a colleague.
So what are the indications for a scan in this man?
The Canadian CT Head rule can be applied here for low pretest probability patients and you should have this on a wall somewhere.
It involves
-the age of the patient (>65)
-dangerous mechanism
-amnesia for >30 minutes
-vomiting
-not attaining GCS of 15 within 2 hours of injury (this is sometimes difficult to do as these patients are often intoxicated as well), and
-features of base of skull fracture
I use a little memory prompt to remind me. It may help you. In those minor head injury patients I find I have to ‘HAGLE’ with the radiology registrar to get a scan. So if the patient has any of the below, it may be prudent to scan.
Age and anticoagulants + ‘HAGLE’
H-Headache – if they have a significant headache
A-Amnesia
G-GCS still <15
L-Loss of consciousness at any time
E-Emesis i.e. vomiting
Good luck getting the scan.
Oh, his scan was normal.
