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Imaging infants with head injury: effect of a change in policy
J G Browning1, M J Reed, A G Wilkinson
1Accident and Emergency Department, Royal Hospital for Sick Children, Sciennes Road, Edinburgh EH7 5HD, UK. jenbrowning@hotmail.com
Insights
In infants under one year, skull radiographs are often unnecessary for head injuries. New guidelines reduced imaging by 47.5% without missing significant trauma, decreasing radiation exposure.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Trauma Care
Background:
- Head injuries are common in infants presenting to emergency departments.
- Clinical assessment of infants with head trauma is challenging.
- Skull radiographs are unreliable for detecting intracranial injuries in infants.
Purpose of the Study:
- To evaluate the impact of a revised policy on skull radiograph use in infants with head trauma.
- To assess the effectiveness of selective radiograph use in identifying significant injuries.
- To determine the effect of policy changes on radiation exposure.
Main Methods:
- Retrospective cohort study of infants (<1 year) with head trauma.
- Analysis of hospital records and radiology data from two distinct periods (1998-1999 and 2002-2003).
- Comparison of radiograph rates, fracture detection, and missed injuries before and after policy revision.
Main Results:
- Skull radiograph use decreased from 77.3% to 29.5% between the study periods.
- The detection rate of skull fractures remained similar (3.6% vs. 5.4%), with all associated scalp hematomas.
- No significant injuries were missed, and total radiation dose decreased by 9.4 mSv.
Conclusions:
- Selective use of skull radiographs in infants under one year with head trauma is effective.
- Radiographs should be reserved for cases with visible head injury signs or suspected non-accidental injury.
- Policy revision successfully reduced radiation exposure without compromising patient safety.
Objective:
Head injury is one of the commoner injuries presenting to the emergency department (ED). Infants are hard to assess clinically and emphasis has been placed on radiological examination. Skull radiographs, however, are not a reliable indicator of intracranial injury. As a result of this the policy in this ED was revised so that skull radiographs were only to be performed in those infants less than 1 year with visible evidence of head injury or a suspicious history for non-accidental injury.
Methods:
Retrospective cohort study of all infants less than 1 year who presented with head trauma to the ED of a paediatric teaching hospital between 1 August 1998 and 31 July 1999, and between 1 August 2002 and 31 July 2003. Hospital notes and radiology computer systems were examined and data were collected and analysed.
Results:
181 infants aged less than 1 year presenting to the ED in 1998/9 and 190 infants in 2002/3. Altogether 140 (77.3%) infants had a skull radiograph in 1998/9, five (3.6%) identified skull fractures. During 2002/3, 56 (29.5%) infants had a radiograph, a reduction of 47.5%, of which three (5.4%) had skull fractures. All fractures had reported haematomas to their scalp. The change in policy decreased the total radiation dose to the population by 9.4 mSv. No significant injuries were missed as a result of the change in policy.
Interpretation:
In infants under 1 year, unless non-accidental injury is suspected, it is suggested that skull radiographs should only be performed when there are visible signs of a head injury.
