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A decision rule for identifying children at low risk for brain injuries after blunt head trauma
Michael J Palchak1, James F Holmes, Cheryl W Vance
1Division of Emergency Medicine, Department of Internal Medicine, University of California-Davis School of Medicine, 2315 Stockton Boulevard, Davis, CA 95817, USA.
Insights
A decision rule can identify children with blunt head trauma who are at low risk for traumatic brain injuries. Absence of specific symptoms like vomiting or headache helps rule out significant injury.
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma
- Clinical Decision Rules
Background:
- Computed tomography (CT) is standard for evaluating pediatric blunt head trauma.
- Routine CT use presents disadvantages, necessitating risk stratification.
- Identifying low-risk children avoids unnecessary imaging and associated risks.
Purpose of the Study:
- To develop a clinical decision rule for identifying children at low risk of traumatic brain injury (TBI) after blunt head trauma.
- To reduce the need for routine CT scans in select pediatric patients.
Main Methods:
- Observational cohort study of children with blunt head trauma (July 1998-September 2001).
- Evaluated clinical predictors for TBI on CT and TBI requiring acute intervention.
- Utilized recursive partitioning to create decision rules.
Main Results:
- 2,043 children enrolled; 1,271 underwent CT.
- 98 (7.7%) had TBI on CT; 105 (5.1%) had TBI requiring acute intervention.
- Absence of abnormal mental status, skull fracture signs, vomiting, scalp hematoma (in <2yo), or headache identified 97-100% of TBIs. Only 0.3% with none of these predictors had TBI.
Conclusions:
- Key factors for low TBI risk include absence of: abnormal mental status, skull fracture signs, vomiting, scalp hematoma (in young children), and headache.
- This decision rule can help safely reduce CT utilization in pediatric blunt head trauma evaluations.
Study Objective:
Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries.
Methods:
We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules.
Results:
Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in children < or =2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications.
Conclusion:
Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children < or =2 years of age), and headache.
