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Clinical predictors of computed tomographic abnormalities following pediatric traumatic brain injury
M L Ramundo1, T McKnight, J Kempf
1Department of Pediatric Emergency Medicine, Children's Hospital Medical Center of Akron, OH 44308, USA.
Insights
Clinical signs like suspected abuse, focal motor deficits, and pupillary asymmetry help predict head computed tomography (CT) abnormalities in children after head injury. Judicious use of head CT can reduce morbidity and intensive care costs.
Area of Science:
- Pediatric Emergency Medicine
- Neuroradiology
- Clinical Decision Making
Background:
- Head injuries are common in children presenting to emergency departments.
- Head computed tomography (CT) is frequently used for diagnosis and disposition planning.
- Predictive clinical criteria for CT abnormalities are needed to optimize resource allocation and patient care.
Purpose of the Study:
- To prospectively evaluate clinical features predicting head CT abnormalities in pediatric head injury.
- To correlate CT findings with patient disposition and outcomes.
Main Methods:
- Prospective study of 300 children (<19 years) with head injury over nine months.
- Comparison of presenting clinical signs with emergent head CT results.
- Recording of patient disposition post-imaging.
Main Results:
- Suspected abuse was >50% predictive of CT abnormalities in both age groups (<2 and >2 years).
- Focal motor deficit and pupillary asymmetry were >67% predictive in both age groups.
- Abnormal CTs led to emergent neurosurgery (30%) or intensive monitoring; normal CTs led to routine observation or discharge.
Conclusions:
- No single clinical feature definitively predicts head CT abnormalities.
- Children with suspected abuse, focal motor deficits, or pupillary asymmetry warrant head CT.
- Judiciously ordered emergent CT can reduce morbidity and unnecessary intensive care.
Abstract:
Children commonly seek attention in emergency departments following head injury. Head computed tomography (CT) is often used to decide subsequent disposition. Clinical criteria predicting CT abnormalities would allow effective and timely treatment and minimize unnecessary procedures depleting overburdened medical resources. We prospectively compared presenting clinical features with subsequent emergent head CT in 300 children less than 19 years old over a nine-month period. The disposition of patients following imaging was also recorded. Only suspected abuse was more than 50% positively predictive in children below age two and those above age two. Two signs were more than 67% positively predictive in both age groups: focal motor deficit and pupillary asymmetry. Patients with abnormal CTs were the only children to undergo emergent neurosurgery (30%) and were nearly five times as likely to be intensively monitored. Children with normal CTs were nearly five times as likely to be observed in a routine department or at home. We conclude that no single clinical feature can predict with certainty an abnormality on immediate head CT. However, children suspected of being abused, and those with focal motor deficits or pupillary asymmetry, should be imaged. Finally, emergent CT when judiciously ordered likely reduces unforeseen morbidity and minimizes costly intensive care observation.