This document discusses guidelines for when to perform a CT scan or skull x-ray on patients with head trauma. It outlines the Glasgow Coma Scale for assessing consciousness and provides criteria for determining high or medium risk of brain injury requiring CT based on the Canadian CT Head Rule. Signs of basal skull fracture are also noted. Skull x-ray is not recommended when CT is available due to the higher sensitivity of CT. The key guidelines are to first stabilize the patient and then perform CT for high risk patients or those meeting specified criteria, using skull x-ray only if CT is unavailable.

1. When to do CT Scan
When to do Skull X-
ray
MUKESH SAH, MD

2. Objectives
 To be able to identify trauma patients who would need
a CT Scan/Skull xray
 To know when to do CT Scan/Skull x-ray

3. Glasgow Coma Scale
Eye Opening
GCS Peds GCS
Spontaneous 4 Spontaneous
To Verbal Stimuli 3 To Speech
To pain 2 To Pain
None 1 None
Holmes JF, Palchak MJ, MacFarlane T, Kuppermann N. Performance of the Pediatric
Glasgow Coma Scale in children with blunt head trauma. Acad Emerg Med
2005;12(9):814-9.

4. Glasgow Coma Scale
Best Verbal
GCS Peds GCS
Oriented 5 Coos, Babbles
Confused 4 Irritable, Cries
Inappropriate Words 3 Cries to pain
Incomprehensible
Sounds
2 Moans to pain
None 1 None

5. Glasgow Coma Scale
Best Motor
GCS Peds GCS
Follows commands 6 Normal Spont.
Movement
Localizes pain 5 Withdraws to touch
Withdraws to pain 4 Withdraws to pain
Flexion to pain 3 Abnormal Flexion
Extension to pain 2 Abnormal Extension
None 1 None

6. Canadian CT Head Rule
High Risk (For Neurological Intervention)
1. GCS Score <15 at 2 hours after injury
2. Suspected open or depressed fracture
3. Any sign of basal skull fracture
4. Vomiting ≥ 2 episodes
5. Age ≥ 65 years

7. Medium Risk (For Brain Injury on CT)
1. Amnesia before impact ≥ 30 min
2. Dangerous Mechanism (pedestrian occupant
ejected, fall from elevation)
Canadian CT Head Rule

8. Signs of Basal Skull fracture
 Hemotympanum
 Racoon eyes
 CSF otorrhea/ Rhinorrhea
 Battles sign

9. Pediatric

10. CT HEAD is required for children with a minor head
injury PLUS ANY ONE of the following:
High Risk (Need for Neurological Intervention)
1)GCS <15 at 2h after injury
2)Suspected open or depressed skull fracture
3)History of worsening headache
4)Irritability on examination
Medium Risk (Brain Injury on CT Scan)
1)Any sign of basal skull fracture
2)Large, boggy hematoma of scalp
3)Dangerous Mechanisms of Injury (MVC, fall ≥ 3 ft or
down 5 stairs, falling from bicycle without a helmet
Osmond MH, Klassen TP, Wells GA, et al; for the Pediatric Emergency Research
Canada (PERC) Head Injury Study Group. CATCH: A clinical decision rule for the use of
computed tomography in children with minor head injury. CMAJ 2010;182(4):341-8.

11. Skull X-ray
 Skull radiograph is of little benefit when a CT
scan is obtained. It has no added advantage
over CT scan
 Whenever there is facility of CT scan is
available, the patient of head injury should not
undergo Skull radiograph as it can only delay
the diagnosis of an associated intracranial
injury
Chawla H, Malhorata R, Yadav RK, Griwan MS, Paliwal PK, Aggarwal AD,
Diagnostic Utility of Conventional Radiography in Head Injury, J Clin Diagn
Res, 2015 Jun; 9(6):TC13-5. doi: 10.7860/JCDR/2015/13842.6133. Epub 2015
Jun 1

12. WHEN to do it?
Resuscitate First

13. In summary…
 We do not do CT Scan on all traumatic Head Injury
patients
 Skull x-ray may be utilised in the absence of a CT Scan
 Make sure that the patient is stable first

14. Thank You For Your
Attention

15. When compared with autopsy, X-ray
missed 19.1% of fractures while 11.9%
fractures missed in contrast to CT scan.
Chawla H, Malhorata R, Yadav RK, Griwan MS, Paliwal PK, Aggarwal AD,
Diagnostic Utility of Conventional Radiography in Head Injury, J Clin Diagn
Res, 2015 Jun; 9(6):TC13-5. doi: 10.7860/JCDR/2015/13842.6133. Epub 2015
Jun 1