Posttraumatic skull films: who needs them?

An effort has been under way for years to make the ordering of skull films in trauma more medically rational. Because the vast majority of skull films have no significant impact on patient management, effort had centered on increasing the yield by limiting radiographs to those who have one or more "high-yield criteria." The publically promulgated high-yield criteria, however, were insufficiently sensitive to pick up some rare occult injuries. Emphasis recently has shifted to low-yield findings (scalp laceration, scalp hematoma, dizziness, headache, and asymptomatic). Although by common practice the presence of one or more of these low-yield findings often results in a skull film, omitting them appears to be extremely safe provided that the patient has no other clinically suspicious findings. Additionally, skull films are no longer the procedure of choice in patients with a neurosurgical emergency. A patient management strategy reflecting recent research is soon to be released with the FDA Skull Panel's final report.