Pediatric Head Injury ===================== þ New Study for kids under 2 who don't need CT: - 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 - no palpable skull fracture, and - acting normally according to the parents [Kuppermann, N., J. F. Holmes, et al. (2009). "Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study." Lancet 374(9696): 1160-1170.] BACKGROUND: 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. METHODS: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights). FINDINGS: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the 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, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. 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, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81- 99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT- imaged patients aged 2 years and older were in this low- risk group. Neither rule missed neurosurgery in validation populations. INTERPRETATION: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. FUNDING: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services. þ Which kids to CT? - Canadian study [SAEM 2004] - CATCH study. - Patients 0-16: GCS 13-15 with LOC, amnesia, confusion, . . - 28 clinical findings surveyed; endpoint craniotomy or intubation, secondary any finding on CT; used 14-day call as proxy for negative CT. - Palchak (Ann Emerg Med, 2003; 42:492) + Abnormal mental status, signs of skull fracture, vomiting, headache, scalp hematoma < 2 years - Oman (Pediatrics 2006; 117:238) + Altered mental status, signs of skull fracture, neuro deficit, persistent vomiting, scalp hematoma - Atabaki (Arch Ped Adoles Med 2008; 162:439) + Bicycle mechanism, age < 2 years, GCS<15, sensory deficit, dizziness, signs of skull fracture þ Vomiting after mild head injury is related to migraine. - if mild head injury and persistent vomiting, enquire about family hx of migraines. - [Jan MMS, Camfield PR, Gordon K, Camfield CS. Vomiting after minor head injury is related to migraine. J Pediatr 1997;130:134-7.] See Also þ Characteristics of Pediatric Head Injury - often develop vomiting and seizures from head injury, even minor. - single seizure after head injury _not_ an indication for anticonvulsants. - if child can eat/drink and no focal deficits, and reliable parents, can go home with instructions, because poor PO intake so common in head injury. - diffuse injury and swelling much more common than localized cerebral hematomas þ "Minor" head injury THE USE OF CRANIAL CT SCANS IN THE TRIAGE OF PEDIATRIC PATIENTS WITH MILD HEAD INJURY Davis, R.L., et al, Pediatrics 95(3):345, March 1995 BACKGROUND: Studies have reported that CT scanning can be employed to identify which adults with mild head injuries can be safely discharged from the ED. However, it is not known if prolonged follow-up would have identified cases with deterioration after discharge, or if the results can be extrapolated to the pediatric population. METHODS: The authors, from Harborview Medical Center in Seattle, reviewed findings in 400 children aged 0-17 with mild blunt head injury, a GCS score of 13-15, and absence of intracranial injury on the initial CT scan in order to assess the prevalence of intracranial complications developing within 30 days after injury. RESULTS: Although initial CT scans were negative according to the ED interpretation, abnormalities were noted on the formal radiology interpretation in 18% (most commonly fractures [39], minimal swelling/edema [13], or intracranial contusions [5]). None of the 290 hospitalized patients developed evidence of intracranial bleeding during the hospitalization. Of the 110 patients discharged from the ED, on follow-up, including evaluation of data from a statewide reporting system, four (1%) were readmitted during the following 30 days, including one on chronic coumadin therapy who developed a subdural hematoma requiring neurosurgery, one with a symptomatic hemorrhagic contusion requiring only observation, and two patients observed for concussive symptoms. There were no deaths or long-term sequelae. CONCLUSIONS: These findings suggest that CT scanning can reliably identify those children with mild head injury and nonfocal neurologic examination who can be safely discharged from the ED if competent observation is available in the home. PEDIATRIC BASILAR SKULL FRACTURE: DO CHILDREN WITH NORMAL NEUROLOGIC FINDINGS AND NO INTRACRANIAL INJURY REQUIRE HOSPITALIZATION? Kadish, H.A., et al, Ann Emerg Med 26(1):37, July 1995 METHODS: This retrospective study, from the University of Utah School of Medicine in Salt Lake City, reviewed findings in 233 patients aged 0.2-17 years hospitalized for basilar skull fractures in order to determine the need for hospitalization of those with "simple" fractures (i.e., normal neurologic examinations, Glasgow Coma Scale scores of 15, and absence of intracranial pathology on CT scanning). RESULTS: None of the children received prophylactic antibiotics. A subgroup of 114 patients (49%) had "simple" basilar skull fractures. The diagnosis was based solely on CT findings in 14% of these patients. Repeat CT scanning was unchanged in 21/22 patients (one demonstrated a small contusion not noted on the initial CT). Complications in patients with "simple" basilar skull fractures included vomiting during the hospital stay in 6%, "late" CSF fistula in 3%, fever without an identifiable source in 2% and meningitis in 1% (one case). Two patients sustained iatrogenic complications. Seventy-three percent of the patients with "simple" basilar skull fractures were hospitalized for less than 48 hours, and 5% were discharged from the ED and seen in follow-up on the following day. None of the children with "simple" basilar skull fractures developed delayed intracranial hemorrhage or required a neurosurgical intervention. CONCLUSIONS: The authors indicate that these retrospective findings support routine performance of CT scanning in children with basilar skull fractures, and suggest that those with "simple" fractures appear to be at low risk for complications and may not require hospital admission. EVALUATION OF MINOR HEAD INJURY IN CHILDREN Mitchell, K.A., et al, J Ped Surg 29(7):851, July 1994 BACKGROUND: Up to 80% of pediatric head injuries resulting in hospitalization are classified as minor, but 3% of such patients eventually require operative intervention. Liberal policies of admission and observation are often advocated for these patients. METHODS: The authors, from the University of Louisville School of Medicine, retrospectively reviewed the hospital records of 401 children aged three days to 17 years admitted with isolated minor head injuries and Glasgow Coma Scale scores above 12 to determine if historical or clinical characteristics were capable of identifying those not requiring hospitalization. RESULTS: The initial GCS score was 15 in the majority of the patients (93%). Most (86%) underwent skull radiography (64%) and/or CT scanning (54%), and these studies demonstrated signs of injury in 118 of these 343 patients. There were no neurologic complications in the 51 patients with histories compatible with minor head injury, no or only brief loss of consciousness (LOC), no symptoms of head injury, and no radiographic abnormalities. The most common final diagnosis was concussion (71%). The only clinical finding that correlated significantly with a positive CT was a deep scalp laceration. CT scans showed abnormalities in 26% of the patients with documented LOC as well as in 45% of those without LOC. Operative intervention was required in six patients (elevation of depressed skull fractures). CONCLUSIONS: The authors suggest that children with histories compatible with isolated minor head trauma with brief or no LOC, a GCS score of 15, and normal radiographic findings may be safely discharged from the ED to the care of responsible parents if prospective validations studies are supportive. ------------------------------------------------------ Part of the ratioanle for identifying skull fractures in children even in the absence of intracranial pathology is the occurence of unique syndromes in this age group such as the occurence of 'growing fractures', leptomeningeal cysts and diastaic fractures (I believe this point has been raised by John). The identification of basilar skull fracture, on the other hand, probably does not alter management and, in any case, is better identified on CT scan rather than by plain skull radiography. The utility of antibiotic prophylaxis for the latter group has not been demonstrated and many of the latter patients can be safely sent home (2). (2) Kadish HA, Schunk JE Pediatric basilar skull fracture: do children with normal neurologic findings and no intracranial injury require hospitalization? Ann Emerg Med 1995 Jul;26(1):37-41 STUDY OBJECTIVE: To delineate complications in patients with basilar skull fractures (BSFs) and normal neurologic findings, including computed tomography (CT) scans without intracranial injury, and to assess the need for hospitalization. DESIGN: Retrospective chart review. PARTICIPANTS: All emergency department patients with the ED diagnosis or hospital discharge diagnosis of BSF. Patients were included if they had a clinical or radiographic diagnosis of BSF. A subgroup of patients ("simple BSF") with normal neurologic examination findings in the ED, Glasgow Coma Scale scores of 15, and cranial CT scans without intracranial pathology was specifically analyzed. RESULTS: We included 239 patients in the study. One hundred fourteen patients (48%) were included in the "simple BSF" subgroup. In this subgroup, vomiting (6%) was the most common complication, meningitis (1%) the most serious. There were no cases of delayed intracranial hemorrhage, and no patient with "simple BSF" required surgery. CONCLUSION: Given the relatively low frequency of serious complications, our study suggests that some patients with BSFs may not require hospital admission.