0939 Emergency Room management of paediatric head trauma

A useful article in a recent issue of the Lancet provides guidelines for management and possible reduction in resort to CT scan. The latter aspect appears to have been a major driver of the research, with the authors drawing on published estimates of the cancer risks following CT scan in children (given as between 1/1000 and 1/5000 cranial CT scans; risk increasing as age decreases). Current US estimates are that approximately 50% of children assessed for head trauma undergo CT. The published study included children from 25 North American emergency departments; all were <18 presenting within 24 hours of head trauma with GCS scores of 14-15. Children were excluded if the trauma was trivial (e.g. ground level fall with only abrasions and/or lacerations and no neurological signs or symptoms) and also if they had penetrating trauma or known neurological problems. The subjects were divided into groups above and below 2 years of age, and the outcome of interest was clinically important traumatic brain injury (ciTBI) defined as death from the injury, neurosurgery, intubation for >24 hours or hospital admission for ≥2 nights. Overall 42412 children were enrolled, a large group in a derivation study and a smaller group in a validation study. In the validation study, for children <2 yrs of age with normal mental status, no scalp haematoma except frontal, no loss of consciousness or only <5sec, non-severe injury mechanism, no palpable skull fracture and acting normally according to the parents, the negative predictive value and sensitivity for ciTBI were 100%. For those ≥2 yrs with normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar fracture and no severe headache, the negative predictive value was 99.95% and sensitivity was 96.8%. Twenty-four percent of those <2 yrs of age who had CT scans were in the low risk group identified by the clinical rules (i.e. CT could have been avoided using these rules) and 20% of the ones ≥2 yrs were in the low risk group.

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Lancet 2009; 374: 1160-70
Br J Radiol 2008; 81: 362-78
AJR Am J Roentgenol 2001; 176: 289-96