GSW to Head
                        ===========

Stone JL. Civilian cases of tangential GSWs to the head. J Trauma 1996;40:57

        The basic skinny on this article: 168 cases of tangential wounds,
83 (49%) treated solely by EM had normal skull films and were discharged,
85 (51%) had CTs of which  30 were positive including 22 fractures (14 of
which were depressed), 16 contusions or intraparenchymal hematomas, 2
subdurals and one epidural, 15 total patients had there head opened.  The
article states "most pts. with abnormal CTs presented with a normal neuro
exam".  Unfortunately we do not know what those requiring the OR
presented like or what their course was.  Also they did not say if the CT
group had skull films, etc.
        Sounds like both case approaches reported by Dr. Grigsby have
validation by this article.  What would be good to know is the following:
        If the neuro is 100% OK, no worrisome Sx, and skull films
negative are you OK for D/C without a CT.  In this study they do not
fully answer the question as the 49% D/C'ed were not followed and the
other data is not clearly laid out.

One addition, in the Stone article (J Trauma 1996, 40:57) they
describe 4 delayed intracranial problems, 3 were easy as the first CTs
were positive but the last may or may not be a reason to observe, initial CT
normal, seized at 24 hours, CT shows a parietal contusion- what is not
clear is whether there were others reasons to observe this patient.
-- Bob McNamara, M.D.