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Three Part Question

In [children who have sustained a mild or minor head injury with a GCS of 14-15] do [clinical findings] predict [intra-cranial injury on computerised tomography]?

Clinical Scenario

It is 7 pm on a busy weekend shift. A 5 year old boy is brought to the emergency department by his mother following an unobserved fall from a trampoline. He was found in a dazed state, it is not known if there was a period of unconsciousness. He has a moderate sized contusion to his occiput but no focal neurology. His GCS is 15 but appears to have little recollection of events leading up to his fall. There are no clinical signs of a skull fracture. You consider it appropriate to CT him on the basis of his scalp haematoma, apparent retrograde amnesia and the possibility of loss of consciousness. The on-call radiologist doesn't want to do the scan and thinks it more appropriate to admit for neurological observation. You are conflicted between the knowledge that a number of children who present in this way will have intra-cranial injury (ICI), some of whom will require neurosurgery versus the unnecessary admission of the majority of children who will not have ICI.

Search Strategy

[(exp brain injuries OR exp craniocerebral trauma OR exp head injuries, closed) OR (head trauma.mp) OR (head injur$.mp)] AND [(exp adolescence OR exp child OR exp child of impaired parents OR exp child, abandoned OR exp child, exceptional OR exp child, hospitalized OR exp child, institutionalized, OR exp child, preschool OR exp child, unwanted OR exp disabled children OR exp homeless youth or exp infant or exp only child or child$.mp) OR (exp pediatrics OR pediatric$.mp OR paediatric$.mp)] AND (exp tomography scanners, x-ray computed OR exp tomography, x-ray computed OR tomography.mp OR CT scan$.mp) AND (exp prospective studies OR prospective.mp OR prospectively.mp)
Ovid Medline 1985-week 4 Oct. 2007

Search Outcome

347 papers were found ten of which were considered relevant and of sufficient quality to address the question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Dietrich AM 1993 USA	n=322 all head trauma children scanned in 12 month period Mean age of 7.1 years. 20% <2 years old. 62% male	Prospective cohort.	CT brain GCS 15	11/195 had ICI (5%)	Not restricted to mild trauma. Not clear if all head trauma seen was scanned. Not clear if truly prospective. Incomplete clinical data. No available data on interventions required for those with minor head injury
Quayle KS et al 1997 USA	321 'non-trivial' head injuries 98% of whom got brain CT 42% < 2 yrs old.	Prospective cohort.	ICI but neurologically normal.	16/266 (6%)	Minor head injuries were selected out. 99 of 410 children had incomplete data. Inconsistencies between CT and plain films in showing skull fracture.
Greenes DS et al 2001 USA	n=422 infants <2 yrs (mean age = 11.2 months). Asymptomatic, no sign of depressed or base of skull fracture.	Prospective data collection. Single hospital.	ICI	13/422 (3%) one of whom had evacuation of extra-dural haematoma.	Probable under-estimation of ICI due to discretionary imaging: only 18% of patients had CT brain. Reliance on skull x-ray to risk stratify for ICI.
			Scalp haematoma and ICI	12/46 patients had ICI.
			Two week follow up on discharged infants	No sequelae.
Wang MY 2000 USA	157 of 209 children with on scene paramedic assessed GCS 13-14 had brain CT.	Prospective Multi centered metropolitan.	ICI	30/157 (19%)	Data not available for 52 patients. No data on focal neurology.
			Difference between GCS 13 & 14	No significant difference in rate of skull fracture or ICI.
			Change in GCS	60% of those with ICI had improvement in score in transit or the ED.
			Loss of consciousness (LOC)	67% with ICI had no recorded LOC.
			M&M	3% recieved neurosurgery. All survived.
Murgio A et al 2001 Brazil, France, Hong Kong, Spain	294 out of sub group 3,710 minor head injured children were CT scanned.	Prospective observational.	CT abnormality (fracture,ICI).	55/3,710 (1.5%)	Not restricted to minor trauma. Indications for CT scanning not clear.
			CT abnormality in those scanned.	55/294 (19%)
Boran BO et al 2006 Turkey	n= 421 All children (<17yrs, mean age 5.1 yrs) during one year period with head injury and GCS 15 had plain skull x-ray and CT.	Prospective. Single hospital.	ICI	34/421 (8.1%)	Some skull fractures classed as ICI (figures adjusted in this report).
			ICI or skull fracture.	37/421 (8.8%)
			Neurosurgery.	16/37 (43%) or 3.8% overall
			ICI/Skull fracture on plain film.	11/38 (29%)
			ICI/KOed.	14/23 (61%)
			ICI/Seizure.	5/6 (83%)
			ICI at 24 hours with linear skull fracture.	1/28 children who had no ICI on initial CT showed extra-dural haematoma.
Dunning J et al 2006 England	Of 22,772 children with head injury 744 (3.2%) were selected for CT scan.	Multlicentered. Prospective cohort. Multiple historical, clinical and mechanistic factors prospectively documented.	ICI or depressed skull fracture.	281/22,772 (1.2%)	Not restricted to minor trauma. Selective scanning based on Royal College of Surgeons guidelines (1999).
			CT abnormality in those scanned.	281/744 (37.8%)
			ICI and >5 mins LOC & scanned/LOC and scanned.	95/213 (PPV 0.45)
			ICI and amnesia & scanned/amnesia and scanned.	62/288(PPV 0.22)
			ICI and ? NAI & scanned/?NAI and scanned.	20/61 (PPV 0.33)
Palchak MJ 2004 USA	n=2043 all head injuried children (91% had GCS 14-15).	Prospective observational.	CT brain	1271/2043 (63%)	Not restricted to minor head injury. Physician selected CT imaging. Record of presence or abscence of LOC unreliable in many cases. Younger children unable to describe headache,LOC or amnesia. not all LOC or amnesia patients got CTed.
			ICI	98/1271 (7.7%)
			Isolated LOC (no vomiting headache,fracture,seizure,scalp haematoma, mental alteration or neurology) and ICI.	0%
			Isolated LOC and/or amnesia and ICI.	0%
			Follow up 88% of 2043.	88% none of whom had sequela.
Da Dalt L et al 2006 Italy	n =3,806 all blunt trauma. Grouped into 5 catagories according clinical risk for ICI Discretionary CT brain n=79. 10 day follow up by phone for all discharged patients.	Prospective data entry.	ICI/Scanned	22/79	Very low scan rate, the number scanned from each risk group not shown. Real lCI rate probably underestimated. Difficult differentiating minor from major head trauma in group analysis. Headache and amnesia difficult to articulate for younger children. Children discharged with no CT considered to have no ICI.
			(Headache, <30seconds LOC, impact seizure or non-prolonged vomiting but no drowsiness or amnesia) and ICI.	0/22
			LOC>30 seconds, prolonged headache, drowsiness or amnesia.	3/22
			GCS 14-15 and ICI/all ICI.	11/22 (50%)
Oman JA et al 2006 USA	n=1,666 children with blunt head trauma who were CTed. Median age 11.3 yrs. 64% male.	Multi-center, prospective data entry. Application of decision instrument derived from NEXUS II data base containing 7 variables. Skull fracture, altered alertness, persistent vomiting, scalp haematoma, neurological deficit, abnormal behaviour, and coagulopathy.	Clinically important ICI.	138/1,666 (8.3%)	Not restricted to mild head injury. Study applied only to those who were CTed. Difficult to isolate children with normal or near normal GCS. retrospective application of rule requires external validation.
			Absence of all variables in decision rule.	2/138 missed. One due to clinical error
			Sensitivity of decision rule.	98.6% NPV 99.1%

Comment(s)

The emergent imaging of children with minor head trauma remains conflicted between the need to differentiate ICI versus minimisation of radiation exposure to a large number of young brains. The consequences of ICI in otherwise clinically normal children who have had a head injury remain unclear. Up to 8% of children with a GCS of 15 following head injury will show radiographic ICI on brain CT (Boran), up to almost half of these may receive neurosurgery or be offered prophylactic anti-convulsant therapy. Ten prospective studies representing more than 10,000 children with minor or mild head injury clearly demonstrate that intra-cranial injury occurs in the absence of altered GCS and/or focal neurology. It is also clear that an improvement of GCS to 15 does not mitigate against ICI (Murgio). Interestingly LOC of less than 5 minutes or amnesia with no other findings has been shown to be low risk for ICI (Palchak) Two papers show those infants who have no focal signs and no altered mental state but have a significant scalp haematoma are at increased risk of ICI. There appears to be a stronger association of ICI with non-frontal haematoma and the younger end of this age spectrum. Clinical or radiological evidence of skull fracture is also shown to significantly increase the risk of ICI. Direct evidence supporting mandatory scanning in coagulopathic children is limited.

Editor Comment

This replaces the earlier version published Emerg Med J 2001;18(6):469-70.

Clinical Bottom Line

There is no study which adequately differentiates on clinical grounds those children with mild head injury who require intervention from the majority who can be managed conservatively. All head injured children who have a GCS of < 15 should undergo cranial CT. In order not to miss surgically important brain injuries all children GCS 15 with a head injury and a history of >30 seconds of LOC or clinical findings of amnesia, drowsiness, persistant vomiting, skull fracture or focal neurology should also have a brain CT. Asymptomatic infants less than two years of age who have head injury and a scalp haematoma or are suspected to have recieved NAI should also undergo cranial CT. Although the evidence is limited there should be a low threshold for imaging children with coagulopathy and head injury.

References

1. Dietrich AM, Bowman MJ, Ginn-Pease ME et al Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography? Ann Emerg Med 1993;22(10):1535-40.
2. Quayle KS, Jaffe DM, Kuppermann N et al Diagnostic testing for acute head injury in children: When are head computed tomography and skull radiographs indicated? Pediatrics April 2001 17(2)88-92
3. Greenes DS, Schutzman SA. Clinical significance of scalp abnormalities in asymptomatic head-injured infants. Pediatr.Emerg.Care 17(2) April 2001 88-92
4. Wang MY, Griffith P, Sterling J et al A prospective population-based study of pediatric trauma patients with mild alterations in consciousness (Glasgow coma scale score of 13-14) Neurosurgery 2000;46(5):1093-99.
5. Murgio A, Patrick PD,Andrade FA et al International study of emergency department care for pediatric traumatic brain injury and the role of CT scanning Child's Nerv Syst (2001) 17:257-262
6. Boran BO,Boran P,Barut N et al Evaluation of mild head injury in a pediatric population Pediatr Neurosurg 2006; 42 :203-07
7. Dunning J, Daly JP, Lomas J-P Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head in in children Arch.Dis.Child 2006;91;885891
8. Palchak MJ, Holmes JF, Vance CW et al Does an isolated history of loss of consciousness or amnesia predict brain injuries in children after blunt head trauma? Pediatrics 2004 113;6 e507-13
9. Da Dalt L, Marchi AG, Laudizil et al Predictors of intracranial injuries in children after blunt head trauma European J Pediatr 2006 165:142-48
10. Oman JA, Cooper RJ, Holmes JF et al. Performance of a decision rule to predict need for computed tomography among children with blunt head trauma Pediatrics 2006 Feb 117;2 e238-46