Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines

Schutzman, Sara A.; Barnes, Patrick D.; Duhaime, Anne–Christine; Greenes, David S.; Homer, Charles J.; Jaffe, David M.; Lewis, Roger J.; Luerssen, Thomas G.; Schunk, Jeff E.

doi:10.1542/peds.107.5.983

Cited by 250 publications

(193 citation statements)

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“…The estimated lifetime risk of cancer from a head CT is substantially higher for children than for adults because of a longer latency period and the greater sensitivity of developing organs to radiation. [4][5][6][7] However, intracranial injury may occur without skull fracture, and clinicians must use clinical judgment or decision rules [25][26][27][28] for obtaining CT scan regardless of the presence or absence of skull fracture. In addition, ultrasound can also be performed in young children without the need for sedation.…”

Section: Discussionmentioning

confidence: 99%

Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children

et al. 2013

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WHAT'S KNOWN ON THIS SUBJECT: Head injuries and concern for skull fracture are common in pediatrics. Point-of-care ultrasound is an imaging tool that can be used to diagnose fractures. However, there are scant data regarding the accuracy of point-ofcare ultrasound in skull fracture diagnosis. WHAT THIS STUDY ADDS:Clinicians with focused point-of-care ultrasound training are able to diagnose skull fractures in children with high specificity. Ultrasound may be valuable to diagnose skull fractures in children at the point of care. abstract OBJECTIVE: To determine the test performance characteristics for point-of-care ultrasound performed by clinicians compared with computed tomography (CT) diagnosis of skull fractures. METHODS:We conducted a prospective study in a convenience sample of patients #21 years of age who presented to the emergency department with head injuries or suspected skull fractures that required CT scan evaluation. After a 1-hour, focused ultrasound training session, clinicians performed ultrasound examinations to evaluate patients for skull fractures. CT scan interpretations by attending radiologists were the reference standard for this study. Pointof-care ultrasound scans were reviewed by an experienced sonologist to evaluate interobserver agreement.RESULTS: Point-of-care ultrasound was performed by 17 clinicians in 69 subjects with suspected skull fractures. The patients' mean age was 6.4 years (SD: 6.2 years), and 65% of patients were male. The prevalence of fracture was 12% (n = 8). Point-of-care ultrasound for skull fracture had a sensitivity of 88% (95% confidence interval [CI]: 53%-98%), a specificity of 97% (95% CI: 89%-99%), a positive likelihood ratio of 27 (95% CI: 7-107), and a negative likelihood ratio of 0.13 (95% CI: 0.02-0.81). The only false-negative ultrasound scan was due to a skull fracture not directly under a scalp hematoma, but rather adjacent to it. The k for interobserver agreement was 0.86 (95% CI: 0.67-1.0). CONCLUSIONS:Clinicians with focused ultrasound training were able to diagnose skull fractures in children with high specificity. Pediatrics

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Section: Discussionmentioning

confidence: 99%

Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children

et al. 2013

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“…The results of our questionnaire suggest that many physicians continue to order skull radiographs in this situation, despite existing guidelines indicating that their use should be limited. 3,25 In 2001, the American Academy of Pediatrics published guidelines for the management of children younger than 2 years old with minor head injury. 3 These guidelines were based primarily on expert opinion because few studies have been conducted on the subject.…”

Section: Discussionmentioning

confidence: 99%

“…3,25 In 2001, the American Academy of Pediatrics published guidelines for the management of children younger than 2 years old with minor head injury. 3 These guidelines were based primarily on expert opinion because few studies have been conducted on the subject. The guidelines indicate that skull radiographs should be considered in higherforce mechanisms of injury, when a scalp hematoma is present (particularly if nonfrontal), in falls onto a hard surface, in unwitnessed trauma with the possibility of a significant mechanism, and in vague situations or an absence of history of trauma in a child with signs or symptoms of head trauma.…”

Section: Discussionmentioning

confidence: 99%

“…2 Minor head trauma in young children has been defined as a history or signs of blunt trauma to the scalp, skull, or brain in a patient who is alert or awakens to voice or light touch. 3 The main challenge in the ED management of children with minor head trauma is to determine who is at risk for complications and requires diagnostic imaging for the possibility of an intracranial lesion and/or skull fracture. About 3 to 6% of children suffering from minor head trauma will have intracranial injury.…”

mentioning

confidence: 99%

“…3,24,25 For example, the American Academy of Pediatrics guideline states that skull radiography should be considered in a number of situations, including the presence of a scalp hematoma (particularly if nonfrontal) and a fall onto a hard surface. 3 In contrast, the National Institute for Health and Clinical Excellence (NICE) guidelines state that skull radiography should be performed only when nonaccidental injury is suspected. 25 Given the variation in recommendations among guidelines for minor head trauma in young children, it is conceivable that a variation in practice pattern also exists.…”

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confidence: 99%

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Variation in the use of skull radiographs by emergency physicians in young children with minor head trauma

Carrière

Clément

Gravel

2014

CJEM

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Background: Minor head trauma in young children is a major cause of emergency department visits. Conflicting guidelines exist regarding radiologic evaluation in such cases. Objective: To determine the practice pattern among Canadian emergency physicians for ordering skull radiographs in young children suffering from minor head trauma. Physicians were also surveyed on their willingness to use a clinical decision rule in such cases. Design/Methods: A self-administered email questionnaire was sent to all members of the Pediatric Emergency Research Canada (PERC) group. It consisted of clinical vignettes followed by multiple-option answers on the management plan. The study was conducted using the principles of the Dillman Tailored Design method and included multiple emailings to maximize the response rate. The research protocol received Institutional Review Board approval. Results: A total of 158 of 295 (54%) PERC members responded. Most participants were trained in pediatric emergency medicine and assessed more than 500 children per year. Imaging management for the vignettes was highly variable: 6 of the 11 case scenarios had a proportion of radiograph ordering between 20 and 80%. Ninety-five percent of respondents stated that they would apply a validated clinical decision rule for the detection of skull fracture in young children with minor head trauma. The minimum sensitivity deemed acceptable for such a rule was 98%. Conclusion: Canadian emergency physicians have a wide variation in skull radiography ordering in young children with minor head trauma. This variation, along with the need expressed by physicians, suggests that further research to develop a clinical decision rule is warranted.

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A Clinical Decision Rule for Cranial Computed Tomography in Minor Pediatric Head Trauma

Atabaki¹,

Stiell²,

Bazarian³

et al. 2008

Arch Pediatr Adolesc Med

101

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Evaluation and Management of Children Younger Than Two Years Old With Apparently Minor Head Trauma: Proposed Guidelines

Abstract: We have developed a guideline for the evaluation of children <2 years old with minor HT. The effect of these guidelines on clinical outcomes and resource utilization should be evaluated.

Cited by 250 publications

References 42 publications

Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children

Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children

Variation in the use of skull radiographs by emergency physicians in young children with minor head trauma

A Clinical Decision Rule for Cranial Computed Tomography in Minor Pediatric Head Trauma

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