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Clinical algorithm and resource use in the management of children with minor head trauma
Marianne Beaudin1, Dickens Saint-Vil, Alain Ouimet
1Division of Pediatric General Surgery, CHU Sainte Justine, Montreal (Quebec) Canada H3T 1C5.
Insights
Guidelines for minor head injury are lacking. Skull x-rays and CT scans are often unnecessary, with observation in the emergency room being a more appropriate management for many pediatric patients.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Trauma Care
Background:
- Management of minor head injury lacks clear guidelines, leading to variable imaging use.
- Discrepancies exist in patient disposition, with some discharged from the emergency room (ER) and others admitted.
Purpose of the Study:
- To propose and implement a new protocol for managing minor head injuries.
- To evaluate the utility of skull x-rays and computed tomography (CT) scans in pediatric minor head injury cases.
Main Methods:
- Retrospective evaluation of 417 pediatric patients with minor head injury (fall < 1 m) from January 2004 to December 2005.
- Analysis of data including imaging studies (skull x-ray, CT scan), patient age, and outcomes (admission, observation).
Main Results:
- Only 10% of skull x-rays and CT scans were positive for skull fracture.
- Of positive imaging results, only a subset led to hospital admission.
- Emergency room observation was utilized for some patients, with a portion eventually admitted.
Conclusions:
- Skull x-rays and CT scans for minor head injury often yield low positive rates and may not impact management.
- Emergency room observation appears to be a reasonable approach for many pediatric patients with minor head injury.
- The study suggests a need for revised guidelines to optimize imaging utilization and patient management.
Purpose:
There are no clear guidelines for the management of minor head injury, including the use of skull x-rays and computed tomography (CT) scans of the head. This is reflected in clinical practice by a wide variability in imaging study use and by the fact that some patients are discharged home from the emergency room (ER), whereas others are admitted to the hospital with or without a period of observation before admission. To address this issue, we proposed and applied a new protocol for minor head injury at our institution.
Methods:
Between January 2004 and December 2005, 417 patients presented to the emergency department at our institution with minor head injury. All of them had fallen from less than 1 m. Every chart was retrospectively evaluated, and pertinent data were extracted.
Results:
The mean age of the patients was 9.8 months (2 weeks to 32 months). One hundred fifty-three had a skull x-ray, and 13 had a CT scan of the head. Of the 153 patients who had a skull x-ray, only 15 had a skull fracture. Of these 15 patients, 3 also had a CT scan of the head that confirmed the diagnosis of skull fracture. Of the 13 CT scans that were done, only these 3 were positive. Eleven patients were kept in the ER for 6 hours for close observation, and 5 of these were eventually admitted. Overall, 8 patients were admitted to the hospital for observation. Of these 8 patients, 7 had a skull x-ray, from which 5 were positive. Only 2 of the admitted patients had a CT scan, and they were both positive for a skull fracture. One of the CT also demonstrated a subdural hematoma along with subarachnoid hemorrhage. These 2 patients also had a positive skull x-ray. None of the patients that were admitted had headaches or neurologic impairments. The mean age of the patients admitted was 3.8 months (2 weeks to 12 months). The mean hospital stay was 1.2 days (1-3 days).
Conclusion:
Only 10% of the skull x-rays and CT scans were positive for a skull fracture, which led to an admission in half of these patients. The other half was mainly discharged from ER after being observed. Several patients underwent a skull x-ray that we feel was not necessary in the management of their minor head injury. For those who had a head CT scan, only one revealed additional information and none of them had an impact on the final management. Observation in the ER could have been reasonable for most cases.
