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Three Part Question

In [paediatric patients with minor head injury, GCS 15 and no focal neurological deficit] does a [normal computed tomography brain scan] allow [safe discharge]

Clinical Scenario

A 7 year old presents to the emergency department following a minor head injury with repeated vomiting. He is GCS 15 on assessment with no focal neurological deficit. Cranial CT scan is normal. You would like to know if he can be safely discharged to a capable parent.

Search Strategy

Medline 1948-11/12 (week 1) using the OVID interface.

[head injury.mp OR head trauma.mp OR exp craniocerebral trauma] AND [exp patient admission OR exp observation OR patient discharge OR exp hospitalisation] AND [exp child OR exp pediatrics OR exp child, preschool/OR exp infant OR exp infant, newborn] AND [exp tomography, xray, computed OR ct head.mp OR ct brain.mp] limit to English language AND humans

Search Outcome

Altogether 98 papers were found in Ovid and Cochrane, of which 91 were irrelevant or of insufficient quality. A further 2 papers were found by scanning the references of relevant papers. All relevant papers are summarised in the table.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Dias et al, 2004, USA	215 Patients with head injury >2-year-old, GCS >12 and at least one of following: more than brief LOC, significant amnesia, >1 episode of vomiting, persistent lethargy	Prospective cohort	Follow-up phone call at 1 day post-discharge	No abnormalities on CT scan. Two children returned due to persistent vomiting, repeat scans normal in both cases	Poor follow-up rate. Telephone follow-up abandoned after 2 months
Mitchell et al, 1994, USA	401 Patients <18 years with GCS >12 who were admitted for observation following head injury; 218 of the children had a CT scan, the rest of the children only had skull x-ray. 51 Patients had GCS 15, normal neuro exam and normal radiological exam	Retrospective review.	Follow-up to document occurrence and duration of symptoms	No adverse events in the subset of patients with normal GCS, neuro exam and radiological investigations	Small subset applicable to question. Radiological examination was CT or plain x-ray or both. Limited follow-up
Davies et al, 1995, USA	400 Patients <18 years with GCS >12 and negative CT scan following head injury	Retrospective case-series study.	Readmission or death within 1 month of head injury	Four patients were readmitted. One patient taking coumarin was found to have a subdural haematoma and required surgery. One child was admitted with a symptomatic haemorrhagic contusion. One child was readmitted following a seizure but the repeat scan was normal. The fourth child was admitted with ‘concussion symptoms’ and admitted for observation but not rescanned	Only 78% had a GCS of 15 on admission. Of the four readmitted patients the original GCS is not stated; 76 (18%) of the normal CT scans were subsequently read as abnormal in the formal report. Follow-up relied on a statewide database
Dahl-Grove et al 1995 USA	62 Patients with closed head injury <18 years, GCS >12 and normal cranial CT scan	Retrospective review.	ED and hospital course, radiographic studies and follow-up	56/62 Patients had GCS 15 on attendance. No patients developed any neurological deterioration	Small study. Criteria for cranial CT scan and subsequent admission could not be determined by chart review. No long-term follow-up
Schunk et al 1996 USA	313 Patients with head injury <18 years, GCS 15, no focal neurological deficit and cranial CT scan	Retrospective review.	Results of CT scans, disposition and outcome	Of the 300 patients with no intracranial injury on CT 159 were discharged and 141 were admitted. Three discharged patients re-attended, none had a new ICI on repeat scan. Of the 141 admitted patients, five had repeat scan: two normal, one small contusion–managed conservatively, two showed skull fractures	Study centre is major referral centre for paediatric trauma so may be selection bias. No departmental protocol for obtaining a CT scan. Poor documentation of symptoms noted. No formal follow-up
Roddy et al, 1998, USA	62 Patients with head injury <16 years, normal neurological exam, normal CT scan	Retrospective review.	Deterioration in CNS exam, new CT findings, need for prolonged (>24 h) hospital stay	No child developed any significant CNS sequelae	Small study. Few infants included. Author suggests that non-verbal children should be excluded from safe discharge. No long-term follow-up
Mandera et al, 2000, Poland	166 Patients <18 years, with head injury and GCS >12 on admission	Retrospective review.	Subsequent deterioration	95 (57%) Patients had GCS of 15 on attendance. Only 28 (17%) had normal CT scan. Six patients with a normal initial scan had a haematoma present on a subsequent scan	High proportion of children had neurological symptoms at presentation. High proportion of abnormal CT scans and need for surgical intervention as tertiary referral centre
Adams et al, 2001, USA	1033 Patients <18 years with head injury and GCS of 15. 386 Patients had a cranial CT	Retrospective review.	Length of stay and any required procedures or complications	No neurosurgical intervention required in any of the patients	No breakdown of study results. No follow-up. Focal neurology not mentioned
Ros and Ros, 1989, USA	73 Patients <18 years with a history of minor head injury GCS >12, and a normal CT scan	Retrospective review	Complications/adverse events	No neurological complications and no re-attendances following discharge	Small, retrospective study
Spencer et al, 2003, USA	197 Patients with head injury, age <14 years and GCS 15, no focal neurological signs on exam and normal CT scan	Retrospective review	Delayed inhospital complications defined as focal neurological deficit, intracranial bleeding, worsening mental status or recurrent seizures	None of the 197 patients had delayed complications resulting from their head injury. Five patients had persistent symptoms: three headache, two vomiting. One patient had repeat scan due to vomiting but this was normal	No long-term follow-up. Included patients with concomitant trauma
Holmes et al, 2011, USA	13 543 Patients <18 years presenting after head injury with GCS >13 and normal CT scan to 25 centres over a 2-year period	Prospective cohort study	Need for repeat imaging and neurosurgical intervention	Of 11 058 patients discharged from the ED, 197 (2%) had a subsequent CT or MRI scan, five of these showed an abnormality and no children needed neurosurgical intervention. Of the 2485 patients admitted to hospital, 137 (6%) received a subsequent CT or MRI scan, 16 or these were reported as abnormal and no children required neurosurgical intervention	Only 79% of discharged patients followed up successfully by phone or letter although medical record and morgue review was carried out for the remainder

Comment(s)

With the exception of the study by Mandera et al, in which six patients developed intracranial haematomas following an initial normal scan, the number of paediatric patients developing complications following a head injury with a normal scan and a presenting GCS greater than 12 is thankfully small. When the data are available, the risks appear to be even lower for patients who have attended with a GCS of 15. The Mandera study was carried out at a tertiary referral centre and appears to have selected a higher risk population than the other studies with a very high incidence of abnormal scan, abnormal neurological examination findings and the need for neurosurgical intervention.

The study by Holmes et al provides great reassurance by demonstrating an extremely low risk of developing injury that is detectable with radiological investigation; no patients from a study population of 13 543 children with minor head injuries required neurosurgical intervention.

Editor Comment

CNS, central nervous system; ED, emergency department; GCS, Glasgow coma scale

Clinical Bottom Line

In patients with minor head injuries and no known bleeding risks, who are GCS 15 on arrival, have no focal neurological deficit on examination and who have had an normal CT scan, hospital admission is unnecessary if a capable parent is willing to take the child home.

References

1. Dias MS, Lillis KA, Calvo C et al. Management of accidental minor head injuries in children: a prospective outcomes study. Journal of Neurosurgery 2004;101(1):38-43.
2. Mitchell KA, Fallat ME, Raque GH et al. Evaluation of minor head injury in children. Journal of Pediatric Surgery 1994;29(7):851-4.
3. Davis RL, Hughes M, Gubler KD et al. The use of cranial CT scans in the triage of pediatric patients with mild head injury. Pediatrics 1995;95(3):345-9.
4. Dahl-Grove DL, Chande VT, Barnoski A. Closed head injuries in children: is hospital admission always necessary?. Pediatric Emergency Care 1995;11(2):86-8.
5. Schunk JE, Rodgerson JD, Woodward GA. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Pediatric Emergency Care 1996;12(3):160-5.
6. Roddy SP, Cohn SM, Moller BA et al. Minimal head trauma in children revisited: is routine hospitalisation required?. Pediatrics 1998;101(4 Pt 1):575-7.
7. Mandera M, Wencel T, Bazowski P et al. How should we manage children after mild head injury?. Childs Nerv System 2000;16(3):156-60.
8. Adams J, Frumiento C, Shatney-Leach L et al. Mandatory admission after isolated mild closed head injury in children: is it necessary?. Journal of Pediatric Surgery 2001;36(1):119-21.
9. Ros SP, Ros MA. Should patients with normal cranial CT scans following minor head injury be hospitalized for observation? Pediatr Emerg Care 1999;5:216–18.
10. Spencer MT, Baron BJ, Sinert R et al. Necessity of hospital admission for pediatric minor head injury. Am J Emerg Med 2003 Mar;21(2):111-4.
11. Holmes JF, Borgialli DA, Nadel FM, et al. Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation? Ann Emerg Med 2011: 58:315–22.