Can we abolish skull x rays for head injury?

We would like to comment on the paper by Reed et al in which they describe the introduction of head injury guidelines which pre‐date but essentially mirror those subsequently issued by NICE.¹ In particular we are surprised at their conclusions.

Their data show that following the introduction of these guidelines the number of CT scans performed doubled, but that this additional scanning did not reveal any additional intra‐cranial abnormality. Furthermore their data also suggest that, contrary to NICE guidance, vomiting is not a useful indicator for CT scanning. It is also apparent that this guidance did not reduce admissions, and yet admission avoidance is often cited as a reason for adopting the NICE guidelines.

The authors also fail to acknowledge the very considerable radiation dose associated with CT head scanning. In particular they have chosen to express radiation exposure in terms of dose per total number of head injuries rather than in the dose per child scanned. This latter figure is what matters to the child who has a CT scan, and is equivalent to 100 chest x rays worth of radiation.²

In summary this paper demonstrates that the NICE guidance on head injury in children is flawed, and that its implementation unnecessarily exposes some children to very high doses of radiation. Such concerns were expressed when this guidance was first released.³ Furthermore it has been shown recently that head injuries in children can be safely managed using a combination of skull x rays and limited CT scanning.⁴

We would therefore suggest that Reed et al are mistaken in concluding that in paediatric head injury skull x rays should be abandoned and CT scanning used more extensively. It is also apparent that NICE should review its guidance on this subject as a matter of urgency.