pediatric head trauma: when do you CT?

11 Dec

LANCET Article: Identification of children at very low risk of clinically-important brain injuries after head trauma:

HIGHLIGHTS:

“CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.”

STUDY GROUP:

  • 42,412 patients

  • <18 yo

  • presenting within 24 h of head trauma in 25 North American EDs

  • Glasgow Coma Scale 14-15 .

FINDINGS:

  • 42 412 children
  • CT scans on 14 969 (35.3%);
  • ciTBIs occurred in 376 (0.9%),
  • 60 (0.1%) underwent neurosurgery.

prediction rule for children younger than 2 years:

  • normal mental status,
  • no scalp haematoma except frontal,
  • no loss of consciousness or loss of consciousness for less than 5 s,
  • non-severe injury mechanism (severe mechanism = MVC with ejection/passenger death/rollover, pedestrian/bicyclist without helmet struck by car, fall > 5ft for kids>2 yo, falls >3ft for kids <2yo, head struck by high-impact object)
  • no palpable skull fracture,
  • acting normally according to the parents
  • negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0)
  • sensitivity of 25/25 (100%, 86.3-100.0).

 

The prediction rule for children aged 2 years and older

  • normal mental status,
  • no loss of consciousness,
  • no vomiting,
  • non-severe injury mechanism,
  • no signs of basilar skull fracture,
  • no severe headache
  • negative predictive value of 3798/3800 (99.95%, 99.81-99.99)
  • sensitivity of 61/63 (96.8%, 89.0-99.6).

 

UPTODATE SUGGESTIONS (references include the above article):

Under 2 yos high risk injury get CT.

high risk = neuro deficits, skull fxs, irritability, persisten vomiting, bulging fonanelle, LOC, abuse, predisposing condition, szs.

Otherwise good idea to observe for 4-6 hrs if intermediate risk of injury

 

>2yos:

CT if LOC, sz, skull fx, AMS, focal findings.

Otherwise observe for changes if: questionable LOC, HA, vomiting, HIGH RISK MECHANISM.

 

BOTTOM LINE:

common themes to look out for:

  • AMS
  • LOC
  • non-frontal hematoma
  • signs of skull fx
  • high mechanism
  • seizure
  • vomiting
  • neuro deficits
  • severe headache

if you have NONE of these, probably don’t need to CT if you want to save the kid some radiation. unlikely to miss a clinically important injury.

if your patient has one or some of these findings, back to square one, consider CT.

 

Submitted by J. Rothstein.

 

References: uptodate.com article; Lancet article; picture

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