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Published on: April 13, 2013
Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for
James F Holmes1, Dominic A Borgialli, Frances M Nadel
1Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA.
Insights
Children with minor head trauma and normal CT scans have a very low risk of complications. Hospitalization for observation after a normal CT scan in these pediatric patients is generally not necessary.
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma
- Diagnostic Imaging
Background:
- Children with minor blunt head trauma often undergo hospitalization despite normal cranial computed tomography (CT) scans.
- Glasgow Coma Scale (GCS) scores of 14 or 15 define minor blunt head trauma in the emergency department (ED).
Purpose of the Study:
- To determine the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results.
- To evaluate the necessity of hospitalization for neurologic observation in pediatric patients with minor head trauma and normal CT findings.
Main Methods:
- Prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma.
- Analysis of patients with initial GCS scores of 14 or 15 and normal cranial CT scan results during ED evaluation.
- Follow-up assessment for neurologic outcomes, subsequent neuroimaging, and neurosurgical interventions in hospitalized and discharged patients.
Main Results:
- Over 13,500 children with GCS 14-15 and normal CT scans were enrolled; 18% were hospitalized.
- Less than 1% of discharged patients and 0.6% of hospitalized patients required subsequent neuroimaging.
- No patients required neurosurgical intervention, yielding a 100% negative predictive value for neurosurgical intervention in this cohort.
Conclusions:
- Children with minor blunt head trauma (GCS 14-15) and normal CT scans have a very low risk of subsequent neuroimaging findings or neurosurgical intervention.
- Routine hospitalization for neurologic observation in pediatric patients with minor head trauma and normal CT scans is largely unnecessary.
Study Objective:
Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results.
Methods:
We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention.
Results:
Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%).
Conclusion:
Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.
