- Email: [email protected]
Computed Tomography and Basilar Skull Fracture
CORRESPONDENCE
Moonlighting Revisited To the Editor. As practicing emergency physicians in the Pacific Northwest, we read with interest the recent editorial by Kellermann (July 1995;26:83-84). Those of us involved in teaching emergency medicine in the state of Washington applaud Dr Kellermann's comments. Moonlighting in emergency medicine demeans those of us who have sacrificed time and energy to train in the specialty and demoralizes those of us who help train physicians in the specialty of emergency medicine. Most important, we consider it unethical to place patients in the care of physicians with training in other specialties (or with no specialty training) when the patients expect to receive specialty care in emergency medicine. The statement, "in Seattle, the University of Washington,.. does not support an emergency medicine residency training program," however, is incorrect. In July 1995, two University of Washington residents joined the Madigan Army Medical Center (MAMC) emergency medicine residents in an affiliated training program. Four University of Washington residents will join the program in July 1996. The University of Washington Academic Medical Center (UWAMC) is a joint venture comprising the University of Washington Medical Center, Harborview Medical and Trauma Center, and Children's Medical Center. The MAMC/UWAMC affiliation is a first step toward the eventual development of a joint program training military and civilian emergency physicians in Washington state. The combined support of the MAMC military medical command, the dean of the University of Washington Medical Center, and the Washington chapter of the American College of Emergency Physicians has been instrumental in the evolution of this program. The lack of properly trained emergency physicians can result in the substandard care often provided by moonlighters. The University of Washington, through the MAMC/UWAMC affiliation, now supports an emergency medicine residency program. We are confident that in the near future this program will bring the same high-quality emergency medical care enjoyed in the greater
102
Seattle/Tacoma area to other regions of the state and, yes, even to Moses Lake.
LawrenceA Wilson, MD, MAJ, USAMC Departmentof EmergencyMedicine Madigan Army Medical Center Tacoma, Washington Richard 0 Cummins,MD, MPH UWAMC EmergencyMedicine Service Seattle, Washington [Editor's note: The views statedin this letter are those of the authors and do not necessarily reflect the opinion of the US Army.] i
Computed Tomography and Basilar Skull Fracture To the Editor. I read with enthusiasm the recent article by Kadish and Schunk [July 1995;26:37-41). The authors retrospectively reviewed 239 patients with basilar skull fractures (BSFs) and subcategerized a group of patients as having "simple BSFs" who met the following criteria: normal neurelogic examination findings, Glasgow Coma Scale (GCS) score of 15, and computed tomography (CT) of the head negative for intracranial pathology. The authors suggested that this group is at low risk for complications and that hospitalization may not be necessary. I have many questions for the authors about their data analysis. Beyond the authors' immediate objectives, their study raises many questions for emergency physicians caring for head-injured patients in general. I had hoped that this study would aid me in my daily practice; however, I found no clinical applicability to the practicing community emergency specialist. The authors note that of the 239 patients found to have BSFs, 51 (21%) had no clinical findings of BSF and their BSFs were diagnosed solely on the basis of CT findings, whereas 188 (79%) had clinical signs of BSF. The following were considered clinical signs of BSF: hemotympanum, cerebrospinal fluid rhinerrhea, blood in the ear not associated with local trauma, cranial nerve palsy, raccoon eyes, or Battle's sign. Later, the authors analyze their data comparing GCS score or abnormal neurologic
findings and indicate that 30 of the 144 patients with normal neurologic findings and GCS score of 15 had CT scans demonstrating intracranial pathology. My question for the authors is, what percent of these patients are a part of the 51 patients (21%) with no clinical findings of BSF and with CT findings as the sole indicator of BSF? This is an extremely important analysis point that has been overlooked; most clinicians would not have ordered CT of the head in a patient with normal neurologic findings, a GCS score of 15, and no clinical findings. Even though CT is now widely available and our hospital has 24-hour CT capability, not every patient with a head strike can undergo CT. The authors list many limitations to their study, and aside from the inherent problems with retrospective studies, the reasons the CT scan of the head was obtained would be of the most interest in these patients. None of the 30 patients with intracranial injury required neurosurgery. Although this study does not address this question, it would be most clinically relevant to determine which patients with head strikes (minor head injury without loss of consciousness or amnesia) had intracranial injury (intracerebral, subdural, epidural, subarachnoid hemorrhages) requiring emergency craniotomy. A study evaluating clinical predictors in head-injured pediatric patients found that no single characteristic consistently identified intracranial injury. 1 This study gives outcomes in patients who underwent CT and the associated historical and clinical findings but does not give clear selection criteria of patients with head trauma requiring CT or reveal the outcomes of patients with head trauma in whom CT was not performed. Similarly, on evaluation of the ability to predict positive CT findings on the basis of patient complaints and examination findings, there was a high correlation of acute abnormalities; however, 29.2% of the acutely positive scans were in the remote or low prediction category. 2 Conversely, others have determined that excluding CT in patients with minor head injuries is safe. 3 In this study patients were admitted for observation, but no guidelines existed for determination of which patients would undergo CT.
ANNALS OF EMERGENCY MEDICINE
27:1 J A N U A R Y
1996
CORRESPONDENCE
Finally, in their study the authors made a tremendous effort to decrease the rate of hospitalization of patients with BSFs. However, I cannot imagine a community hospital such as the one in which I practice following these recommendations. This conclusion, if reproduced, would best be applied in a tertiary referral center such as the one in which this study was performed. The authors recommend CT for head-injured patients with normal neurologic findings and normal mental status in whom BSF is suspected, yet never give objective reasons for the CT. We are expected to practice at the lOOth percentile in caring for head-injured patients. Further studies may help us all practice at this level, but until then serious intracranial injuries may be missed, some in patients with insignificant mechanisms of injury and nondiagnostic examination findings.
PauIA Wil/ette, DO Department of EmergencyMedicine William W Backus Hospital Norwich, Connecticut 2. Dietrich AM; et al: Pediatric head injuries: Can clinical factors reliably"predict an abnormality oft computed tomography? Ann Emerg Med 1993;22:1535-1540. 2. Rein~s WR, Zwemer FL Jr: Clinical prediction of emergency cranial tomography results. Ann Emerg Med 1994;23:1271-1278. 3. Duss BR, et ah The role of neuroimagmg in the initial management of patients with minor head inju U. Ann Emerg Med 1994;23:1279-1283.
Last, a prominent reviewer echoed Dr Willette's sentiments about outpatient follow-up of children with BSFs. Dr Sydney @ellis, editor of Pediatric Notes, said, " . . . all I can say is that it will be a cold day in hell when I send home from the emergency department a child with a basal skull fracture... " However, we believe that with increasing scrutiny of the health care system, reevaluation of our "standard" practice is essential. Clearly further prospective studies are needed to support our findings and better delineate the outcomes of children with BSFs.
juries [July 1995;26:1-5]. It is clear to us, after reviewing the article and discussing its contents with one of the authors that the authors assessed 30 different predictors of ankle fracture but did not actually assess the Ottawa ankle rules. The Ottawa ankle rules were developed and tested in a series of studies that derived the rules (750 patients) 1, validated them (1,485 patients} 2, implemented the rules locally (593 patients}3,4, and implemented the rules in a multicenter trial of eight community and teaching hospitals (200 physicians, 6,489 patients). 5 The Ottawa ankle rules have proved to be highly sensitive for clinically significant fractures, to be easy to use by many physicians with varying experience, and to yield large reductions in the use of ankle radiography. The rules have been validated successfully in the United States 6,7 and are being widely assessed and implemented. The Ottawa ankle rules are easy for physicians to learn but must be presented in a simple pictorial fashion on handouts, pocket cards, or posters (Figure). The data-collection form used at William Beaumont Hospital did not use such a format; instead, some 30 different variables (most of which were unrelated to the Ottawa ankle rules) were
Howard A Kadish, MD Pediatric EmergencyMedicine University of Utah Medical Center Primary Children's Medical Center Salt Lake City, Utah
II
I
The "Real" Ottawa Ankle Rules To the Editor. We thank Dr Lucchesi and colleagues for attempting to validate our decision rules for the use of radiography in acute ankle in-
Figure. Ottawa ankle rules.
In reply: We appreciate Dr Willette's insightful and interesting comments on our study of basilar skull fracture (BSF) in children. Of the 30 patients with normal neurologic findings, Glasgow Coma Scale score of 15, and no intracranial injury, 24 had clinical signs of BSF. Six had no clinical signs but underwent computed tomography (CT) because of persistent vomiting, persistent headache, prolonged loss of consciousness, or seizure. Our study was neither designed nor intended to determine which historical features indicate increased likelihood of intracranial injury but to investigate intracranial injury in patients with BSF. We offer no guidelines on which head-injured children should undergo CT of the head, other than our recommendation that any patient with a BSF, regardless of neurologic status, should undergo CT of the head.
JANUARY 1996
A Poster~ edge of let' malle
~AoNo~P
......
~terier je or tip medial ,lleolus
C Base, fifth metat
27:1 ANNALS OF EMERGENCY MEDICINE
tvicular
Lateral view
Medial view
An ankle radiographic series is only required if there is any pain in the malJeolar zone and any of these findings is present: (1) bone tenderness at A (2} bone tenderness at B (3) inability to bear weight both immediately and in the ED A foot radiographic series is only required if there is any pain in midfoot zone and any of these findings is present: (1) bone tenderness at C (2) bone tenderness at D (3) inability to bear wieght both immediately and in the ED
1 O3
Moonlighting Revisited To the Editor. As practicing emergency physicians in the Pacific Northwest, we read with interest the recent editorial by Kellermann (July 1995;26:83-84). Those of us involved in teaching emergency medicine in the state of Washington applaud Dr Kellermann's comments. Moonlighting in emergency medicine demeans those of us who have sacrificed time and energy to train in the specialty and demoralizes those of us who help train physicians in the specialty of emergency medicine. Most important, we consider it unethical to place patients in the care of physicians with training in other specialties (or with no specialty training) when the patients expect to receive specialty care in emergency medicine. The statement, "in Seattle, the University of Washington,.. does not support an emergency medicine residency training program," however, is incorrect. In July 1995, two University of Washington residents joined the Madigan Army Medical Center (MAMC) emergency medicine residents in an affiliated training program. Four University of Washington residents will join the program in July 1996. The University of Washington Academic Medical Center (UWAMC) is a joint venture comprising the University of Washington Medical Center, Harborview Medical and Trauma Center, and Children's Medical Center. The MAMC/UWAMC affiliation is a first step toward the eventual development of a joint program training military and civilian emergency physicians in Washington state. The combined support of the MAMC military medical command, the dean of the University of Washington Medical Center, and the Washington chapter of the American College of Emergency Physicians has been instrumental in the evolution of this program. The lack of properly trained emergency physicians can result in the substandard care often provided by moonlighters. The University of Washington, through the MAMC/UWAMC affiliation, now supports an emergency medicine residency program. We are confident that in the near future this program will bring the same high-quality emergency medical care enjoyed in the greater
102
Seattle/Tacoma area to other regions of the state and, yes, even to Moses Lake.
LawrenceA Wilson, MD, MAJ, USAMC Departmentof EmergencyMedicine Madigan Army Medical Center Tacoma, Washington Richard 0 Cummins,MD, MPH UWAMC EmergencyMedicine Service Seattle, Washington [Editor's note: The views statedin this letter are those of the authors and do not necessarily reflect the opinion of the US Army.] i
Computed Tomography and Basilar Skull Fracture To the Editor. I read with enthusiasm the recent article by Kadish and Schunk [July 1995;26:37-41). The authors retrospectively reviewed 239 patients with basilar skull fractures (BSFs) and subcategerized a group of patients as having "simple BSFs" who met the following criteria: normal neurelogic examination findings, Glasgow Coma Scale (GCS) score of 15, and computed tomography (CT) of the head negative for intracranial pathology. The authors suggested that this group is at low risk for complications and that hospitalization may not be necessary. I have many questions for the authors about their data analysis. Beyond the authors' immediate objectives, their study raises many questions for emergency physicians caring for head-injured patients in general. I had hoped that this study would aid me in my daily practice; however, I found no clinical applicability to the practicing community emergency specialist. The authors note that of the 239 patients found to have BSFs, 51 (21%) had no clinical findings of BSF and their BSFs were diagnosed solely on the basis of CT findings, whereas 188 (79%) had clinical signs of BSF. The following were considered clinical signs of BSF: hemotympanum, cerebrospinal fluid rhinerrhea, blood in the ear not associated with local trauma, cranial nerve palsy, raccoon eyes, or Battle's sign. Later, the authors analyze their data comparing GCS score or abnormal neurologic
findings and indicate that 30 of the 144 patients with normal neurologic findings and GCS score of 15 had CT scans demonstrating intracranial pathology. My question for the authors is, what percent of these patients are a part of the 51 patients (21%) with no clinical findings of BSF and with CT findings as the sole indicator of BSF? This is an extremely important analysis point that has been overlooked; most clinicians would not have ordered CT of the head in a patient with normal neurologic findings, a GCS score of 15, and no clinical findings. Even though CT is now widely available and our hospital has 24-hour CT capability, not every patient with a head strike can undergo CT. The authors list many limitations to their study, and aside from the inherent problems with retrospective studies, the reasons the CT scan of the head was obtained would be of the most interest in these patients. None of the 30 patients with intracranial injury required neurosurgery. Although this study does not address this question, it would be most clinically relevant to determine which patients with head strikes (minor head injury without loss of consciousness or amnesia) had intracranial injury (intracerebral, subdural, epidural, subarachnoid hemorrhages) requiring emergency craniotomy. A study evaluating clinical predictors in head-injured pediatric patients found that no single characteristic consistently identified intracranial injury. 1 This study gives outcomes in patients who underwent CT and the associated historical and clinical findings but does not give clear selection criteria of patients with head trauma requiring CT or reveal the outcomes of patients with head trauma in whom CT was not performed. Similarly, on evaluation of the ability to predict positive CT findings on the basis of patient complaints and examination findings, there was a high correlation of acute abnormalities; however, 29.2% of the acutely positive scans were in the remote or low prediction category. 2 Conversely, others have determined that excluding CT in patients with minor head injuries is safe. 3 In this study patients were admitted for observation, but no guidelines existed for determination of which patients would undergo CT.
ANNALS OF EMERGENCY MEDICINE
27:1 J A N U A R Y
1996
CORRESPONDENCE
Finally, in their study the authors made a tremendous effort to decrease the rate of hospitalization of patients with BSFs. However, I cannot imagine a community hospital such as the one in which I practice following these recommendations. This conclusion, if reproduced, would best be applied in a tertiary referral center such as the one in which this study was performed. The authors recommend CT for head-injured patients with normal neurologic findings and normal mental status in whom BSF is suspected, yet never give objective reasons for the CT. We are expected to practice at the lOOth percentile in caring for head-injured patients. Further studies may help us all practice at this level, but until then serious intracranial injuries may be missed, some in patients with insignificant mechanisms of injury and nondiagnostic examination findings.
PauIA Wil/ette, DO Department of EmergencyMedicine William W Backus Hospital Norwich, Connecticut 2. Dietrich AM; et al: Pediatric head injuries: Can clinical factors reliably"predict an abnormality oft computed tomography? Ann Emerg Med 1993;22:1535-1540. 2. Rein~s WR, Zwemer FL Jr: Clinical prediction of emergency cranial tomography results. Ann Emerg Med 1994;23:1271-1278. 3. Duss BR, et ah The role of neuroimagmg in the initial management of patients with minor head inju U. Ann Emerg Med 1994;23:1279-1283.
Last, a prominent reviewer echoed Dr Willette's sentiments about outpatient follow-up of children with BSFs. Dr Sydney @ellis, editor of Pediatric Notes, said, " . . . all I can say is that it will be a cold day in hell when I send home from the emergency department a child with a basal skull fracture... " However, we believe that with increasing scrutiny of the health care system, reevaluation of our "standard" practice is essential. Clearly further prospective studies are needed to support our findings and better delineate the outcomes of children with BSFs.
juries [July 1995;26:1-5]. It is clear to us, after reviewing the article and discussing its contents with one of the authors that the authors assessed 30 different predictors of ankle fracture but did not actually assess the Ottawa ankle rules. The Ottawa ankle rules were developed and tested in a series of studies that derived the rules (750 patients) 1, validated them (1,485 patients} 2, implemented the rules locally (593 patients}3,4, and implemented the rules in a multicenter trial of eight community and teaching hospitals (200 physicians, 6,489 patients). 5 The Ottawa ankle rules have proved to be highly sensitive for clinically significant fractures, to be easy to use by many physicians with varying experience, and to yield large reductions in the use of ankle radiography. The rules have been validated successfully in the United States 6,7 and are being widely assessed and implemented. The Ottawa ankle rules are easy for physicians to learn but must be presented in a simple pictorial fashion on handouts, pocket cards, or posters (Figure). The data-collection form used at William Beaumont Hospital did not use such a format; instead, some 30 different variables (most of which were unrelated to the Ottawa ankle rules) were
Howard A Kadish, MD Pediatric EmergencyMedicine University of Utah Medical Center Primary Children's Medical Center Salt Lake City, Utah
II
I
The "Real" Ottawa Ankle Rules To the Editor. We thank Dr Lucchesi and colleagues for attempting to validate our decision rules for the use of radiography in acute ankle in-
Figure. Ottawa ankle rules.
In reply: We appreciate Dr Willette's insightful and interesting comments on our study of basilar skull fracture (BSF) in children. Of the 30 patients with normal neurologic findings, Glasgow Coma Scale score of 15, and no intracranial injury, 24 had clinical signs of BSF. Six had no clinical signs but underwent computed tomography (CT) because of persistent vomiting, persistent headache, prolonged loss of consciousness, or seizure. Our study was neither designed nor intended to determine which historical features indicate increased likelihood of intracranial injury but to investigate intracranial injury in patients with BSF. We offer no guidelines on which head-injured children should undergo CT of the head, other than our recommendation that any patient with a BSF, regardless of neurologic status, should undergo CT of the head.
JANUARY 1996
A Poster~ edge of let' malle
~AoNo~P
......
~terier je or tip medial ,lleolus
C Base, fifth metat
27:1 ANNALS OF EMERGENCY MEDICINE
tvicular
Lateral view
Medial view
An ankle radiographic series is only required if there is any pain in the malJeolar zone and any of these findings is present: (1) bone tenderness at A (2} bone tenderness at B (3) inability to bear weight both immediately and in the ED A foot radiographic series is only required if there is any pain in midfoot zone and any of these findings is present: (1) bone tenderness at C (2) bone tenderness at D (3) inability to bear wieght both immediately and in the ED
1 O3