The Effect of Observation on Cranial Computed Tomography Utilization for Children After Blunt Head Trauma

Abstract

WHAT'S KNOWN ON THIS SUBJECT:Emergency-department observation of children with minor blunt head trauma for symptom progression before making a decision regarding computed tomography may decrease computed tomography use. The actual impact of this strategy on computed tomography use and clinical outcomes, however, is unknown. WHAT THIS STUDY ADDS:Clinicians currently observe some children with head trauma before deciding whether to obtain a cranial computed tomography scan. Patients who were observed had a significantly lower rate of overall cranial computed tomography use after adjusting for markers of head injury severity.abstract OBJECTIVE: Children with minor blunt head trauma often are observed in the emergency department before a decision is made regarding computed tomography use. We studied the impact of this clinical strategy on computed tomography use and outcomes. METHODS:We performed a subanalysis of a prospective multicenter observational study of children with minor blunt head trauma. Clinicians completed case report forms indicating whether the child was observed before making a decision regarding computed tomography. We defined clinically important traumatic brain injury as an intracranial injury resulting in death, neurosurgical intervention, intubation for longer than 24 hours, or hospital admission for 2 nights or longer. To compare computed tomography rates between children observed and those not observed before a decision was made regarding computed tomography use, we used a generalized estimating equation model to control for hospital clustering and patient characteristics. RESULTS: Of 42 412 children enrolled in the study, clinicians noted if the patient was observed before making a decision on computed tomography in 40 113 (95%). Of these, 5433 (14%) children were observed. The computed tomography use rate was lower in those observed than in those not observed (31.1% vs 35.0%; difference: Ϫ3.9% [95% confidence interval: Ϫ5.3 to Ϫ2.6]), but the rate of clinically important traumatic brain injury was similar (0.75% vs 0.87%; difference: Ϫ0.1% [95% confidence interval: Ϫ0.4 to 0.1]). After adjustment for hospital and patient characteristics, the difference in the computed tomography use rate remained significant (adjusted odds ratio for obtaining a computed tomography in the observed group: 0.53 [95% confidence interval: 0.43-0.66] Minor blunt head trauma is a common reason for children to present to the emergency department, 1 although the prevalence of traumatic brain injury (TBI) is low. [2][3][4][5] Cranial computed tomography (CT) is the reference standard for emergently diagnosing TBI in children. Clinicians frequently include an emergent CT in the diagnostic evaluation of children with nontrivial blunt head trauma who present to the emergency department. Furthermore, emergency-department utilization of cranial CT has increased substantially over the last decade. 6,7 Cranial CT is not without risks. Most important are the long-term risks of lethal malignancy induced from the ionizing rad...

When is it safe to forgo abdominal CT in blunt-injured children?

“…A similar approach to the utilization of head CT among blunt injured children has led to a decrease in CT use. 14 We found that a similar decrease in abdominal CT utilization may be achieved with our criteria that stratifies patients into low risk and at-risk groups.…”

Imaging Evidence and Recommendations for Traumatic Brain Injury: Conventional Neuroimaging Techniques

“…For children with mild TBI (GCS scores of 14 and 15), clinical observation before making a decision to obtain NCCT is therefore an effective strategy in reducing unnecessary radiation exposure for young children (class IIa recommendation). Additional studies will be necessary to determine the optimal duration of clinical observation to measure the impact on CT utilization, the total length of the ED stay, as well as the overall costs [133].…”

Compliance with the PECARN and AEP guidelines in diagnostic approach of mild head trauma in patients younger than 24 months old

“…1,5,13 These guidelines are useful for assessing the different levels of risk in children with MHT, leading to a reduction in the rate of CT use. 14 Of these guidelines, the one developed based on the largest cohort of patients was that of the Pediatric Emergency Care Applied Research Network (PECARN), which is considered the most valid for infants as well as older children. 1,15 While none of the international clinical guidelines recommends the use of skull radiography to assess patients with MHT, this test is often used in emergency departments and several authors support its use for the detection of skull fractures, as the presence of a skull fracture in an infant is a risk factor for traumatic brain injury, and possibly the most relevant following changes in the level of consciousness.…”