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Isolated loss of consciousness in children with minor blunt head trauma
Lois K Lee1, David Monroe2, Michael C Bachman3
1Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.
Insights
Children with isolated loss of consciousness (LOC) after minor head trauma have a very low risk of clinically important traumatic brain injury (ciTBI). These children do not routinely require computed tomography scans in the emergency department.
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma
- Radiology
Background:
- Loss of consciousness (LOC) is a common reason for head CT in children with blunt head trauma.
- CT scans carry risks, including radiation-induced malignancy.
- The PECARN prediction rules identify children at risk for clinically important traumatic brain injury (ciTBI).
Purpose of the Study:
- To assess the risk of ciTBI in children with isolated LOC after blunt head trauma.
- To determine if isolated LOC alone warrants CT evaluation.
Main Methods:
- Secondary analysis of a prospective, multicenter cohort study of 40,693 children (0-18 years) with blunt head trauma.
- Evaluated children with Glasgow Coma Scale scores of 14-15.
- Defined ciTBI as death, neurosurgery, prolonged intubation, or prolonged hospitalization.
Main Results:
- Isolated LOC occurred in a subset of children with no other PECARN predictors for ciTBI.
- The rate of ciTBI in children with isolated LOC was 0.5%.
- Children with isolated LOC had a significantly lower risk of ciTBI compared to those with LOC and other predictors.
Conclusions:
- Children with minor blunt head trauma and isolated LOC have a very low risk of ciTBI.
- Routine computed tomography evaluation is not necessary for these children.
- This finding can help reduce unnecessary radiation exposure in pediatric patients.
Importance:
A history of loss of consciousness (LOC) is frequently a driving factor for computed tomography use in the emergency department evaluation of children with blunt head trauma. Computed tomography carries a nonnegligible risk for lethal radiation-induced malignancy. The Pediatric Emergency Care Applied Research Network (PECARN) derived 2 age-specific prediction rules with 6 variables for clinically important traumatic brain injury (ciTBI), which included LOC as one of the risk factors.
Objective:
To determine the risk for ciTBIs in children with isolated LOC.
Design, Setting, And Participants:
This was a planned secondary analysis of a large prospective multicenter cohort study. The study included 42 ,412 children aged 0 to 18 years with blunt head trauma and Glasgow Coma Scale scores of 14 and 15 evaluated in 25 emergency departments from 2004-2006.
Exposure:
A history of LOC after minor blunt head trauma.
Main Outcomes And Measures:
The main outcome measures were ciTBIs (resulting in death, neurosurgery, intubation for >24 hours, or hospitalization for ≥2 nights) and a comparison of the rates of ciTBIs in children with no LOC, any LOC, and isolated LOC (ie, with no other PECARN ciTBI predictors).
Results:
A total of 42 412 children were enrolled in the parent study, with 40 693 remaining in the current analysis after exclusions. Of these, LOC occurred in 15.4% (6286 children). The prevalence of ciTBI with any history of LOC was 2.5% and for no history of LOC was 0.5% (difference, 2.0%; 95% CI, 1.7-2.5). The ciTBI rate in children with isolated LOC, with no other PECARN predictors, was 0.5% (95% CI, 0.2-0.8; 13 of 2780). When comparing children who have isolated LOC with those who have LOC and other PECARN predictors, the risk ratio for ciTBI in children younger than 2 years was 0.13 (95% CI, 0.005-0.72) and for children 2 years or older was 0.10 (95% CI, 0.06-0.19).
Conclusions And Relevance:
Children with minor blunt head trauma presenting to the emergency department with isolated LOC are at very low risk for ciTBI and do not routinely require computed tomographic evaluation.
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