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Jeff-
 
I have a fairly complete review of the literature on this topic that
might be helpful at-
 
http://www.pediatric-emergency.com/headtrauma.html
 
Deterioration from a normal CT to one that requires neurosurgical
intervention occurs at least less than 1:1000 in patients without
coagulopathy (congenital or due to anti-coagulants), based on the
current literature. I've never seen evidence that the presence of CNS
hardware increases the risk of operable CNS trauma. Observation in the
CT negative patient hasn't been shown to confer any benefit, but the
individual studies have relatively small sample sizes. The issue of
delaying head CT to increase sensitivity has to be weighed against the
fact that there was a NEJM study in the 80's (referenced at the site
above) showing that drainage of subdurals less than four hours post
injury confers a therapeutic benefit compared to drainage that is
delayed.
 
Jay Fisher MD
www.pediatric-emergency.com
 
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