Journal Club: CT in head trauma, parenting styles, and whether to vaccinate

Is CT necessary for all head trauma?

Given that <10% of computed tomography (CT) scans in children with minor head trauma show traumatic brain injuries, investigators set out to determine if prediction rules could identify pediatric patients at low risk for serious injury who might not need a CT scan after blunt head trauma. The prospective study was conducted in patients aged <18 years who presented in 25 North American emergency departments within 24 hours of head trauma with Glasgow Coma Scale scores of 14 to 15. Data for almost 42,500 children, some of whom underwent CT scans, were analyzed, with the derivation cohort comprising most participants and the validation population comprising the remainder. Participants' mean age was 7.1 years, and one-quarter of the children were aged <2 years. The primary causes of injury were falls from a height or from ground level or running into a stationary object.

Investigators derived and validated age-specific prediction rules for clinically important traumatic brain injury (ciTBI), which included death, neurosurgery, intubation for >24 hours, or hospital admission for at least 2 nights. For children aged <2 years, the investigators assessed the negative predictive value of a rule for ciTBI consisting of normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for <5 seconds, nonsevere injury mechanism, no palpable skull fracture, and normal behavior (according to parents). For children aged at least 2 years, the investigators assessed the negative predictive value of a rule for ciTBI consisting of normal mental status, no loss of consciousness, no vomiting, nonsevere injury mechanism, no signs of basilar skull fracture, and no severe headache.

Commentary

If you see children in an emergency department setting, you'll want to track down this article for a close look. The authors recognize that CT scanning for minor head injury continues to become more common. This practice is not without risk, however, and this study shows that CT scanning may be avoidable in up to 25% of a selected group of patients. The authors analyzed a large group of patients with mild head injury (the derivation group) to devise a set of clinical rules. They tested the rules in another large group (the validation group). Abiding by the investigators' findings may spare many children from the effects of ionizing radiation with minimal risk of physicians missing clinically significant head injuries. -MB