Pediatric Head Trauma: What's Changed?
Abstract & Commentary
By John Shufeldt, MD, JD, MBA, FACEP, Chief Executive Officer, NextCare, Inc.; Attending Physician/Vice Chair, Department of Emergency Medicine, St. Joseph's Hospital and Medical Center, Mesa, AZ, is Editor for Urgent Care Alert.
Dr. Shufeldt reports no financial relationship to this field of study.
Synopsis: The use of CT has increased substantially in the evaluation of children with head trauma from 1995 to 2003.
Source: Blackwell CD, et al. Pediatric head trauma: Changes in use of computed tomography in emergency departments in the United States over time. Ann Emerg Med. 2007;49:320-324.
The object of this original study was to describe the use of cranial computed tomography (CT) in the evaluation of children with head trauma. Head injury is very common in the pediatric population; however, despite its frequent occurrence, inconsistency exists in the clinical criteria used to determine the need for CT scanning.
The study design was a cross-sectional analysis of data obtained from the National Hospital Ambulatory Medical Care Survey from 1995 to 2003. This data set is from approximately 600 emergency departments across the United States and represents approximately 25,000 patient visits. Patients identified for use in this study were between 0 and 18 years old and had either a chief complaint or discharge diagnosis of head trauma (ICD-9-CM codes of skull fracture, concussion, intracranial hemorrhage, other brain injury, and head injury not otherwise specified). Researchers collected demographic data, discharge diagnosis, use of head CT, and disposition.
Ultimately, 2747 patients were included in the study. The results of this study were that the use of CT imaging for head trauma in children rose from 12.8% in 1995 to 28.6% in 2000 and then decreased slightly to 22.4% from 2001 through 2003. In general, CT scanning was used most often (32%) in the oldest age group, 10 to 18-year-olds. No difference in utilization existed between teaching and non-teaching hospitals; however, CT scanning was used more frequently in general emergency departments as opposed to pediatric-specific emergency departments.
Blackwell and colleagues hypothesize that this upward trend may be due to lower thresholds for ordering scans and improvements in CT scanning software and hardware. Despite the increased use of CT scanning, there are no data that support widespread utilization in children with head injuries, and Blackwell et al conclude that further study is needed to identify objective criteria for cranial CT in head-injured children, as well as to evaluate the impact of increased CT use on patient outcomes.
Commentary
Pediatric head injuries often present to urgent care centers which typically do not have the luxury of cranial CT scanning. The dilemma, of course, is how to manage those individuals with seemingly minor head injuries who have a GCS of 14 or 15. Unfortunately, the jury is still out. In one study of 313 head-injured children, there were no reliable indicators of intracranial injury.1 In another study on head-injured children, Simon and colleagues concluded that neither loss of consciousness nor decreased GCS was a sensitive indicator of a positive CT scan.2
In some respects, the non-uniformity is not all that bad. Since there are no clear guidelines, no bright line standard of care exists for those children with historically trivial head injuries, normal exams, and responsible parents. The take-home point is that the children's guardians should be given informed consent about CT scanning, its efficacy, risks, and costs. If the parents elect to have the child's head scanned, the provider should arrange transport to the appropriate emergency department. On the other hand, if they elect to expectantly observe the child, document that in the chart along with any necessary follow-up and/or instructions on what signs and symptoms the parents should be looking for.
Until proven criteria are in practice to aid in the decision making on whether or not to order a cranial CT, we have to rely on historical information, thorough exam, and informed consent. The following are recommendations from Rosen's Emergency Medicine:
Children < 3 months old:
• Consider CT unless asymptomatic, low-risk history and physical exam, no scalp hematoma, and trivial traumatic mechanism;
Children 3 months to 2 years old:
• No imaging if normal neurological exam, no symptoms, no scalp hematoma;
• Imaging if abnormal neurological exam, moderate or high-risk injury or physical exam findings;
Children > 2 years old:
• No imaging if normal neurological exam, no symptoms, no scalp hematoma;
• Consider imaging if normal neurological exam, low- or moderate-risk injury or physical exam findings.
• Imaging if abnormal neurological exam, moderate or high-risk injury or physical exam findings.3
References
- Oman JA, et al. Performance of a decision rule to predict need for computed tomography among children with blunt head trauma. Pediatrics. 2006;117:e238-e246.
- Simon B, et al. Pediatric minor head trauma: Indications for computed tomographic scanning revisited. J Trauma. 2001;51:231-237.
- Marx J, et al. Rosen's Emergency Medicine, Concepts and Clinical Practice, Philadelphia, Mosby Elsevier, 2006, p.369.
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