Radiography for head trauma in children: what guidelines should we use?

To audit the appropriateness of skill radiography in children attending an accident and emergency (A&E) department with head injuries.

569 children presenting to a large teaching hospital A&E unit were retrospectively audited. The indications for radiography according to British published guidelines and American published guidelines were compared with the actual requests for radiography. The criteria for admission from the two guidelines were also compared with the actual admissions.

50% of children presenting with head injury actually had skull radiography. If British guidelines for the use of skull radiography had been complied with, 63% of children should have had radiography, but if American guidelines had been used, 18% would have required radiography. All the actual fractures identified were in this 18%.

The British guidelines overinvestigate children with head injury. This seems to have been recognised clinically, and the doctors did not adhere to the guidelines. Neither did they adhere to the American guidelines, which would have resulted in a further reduction in radiography. All the fractures identified were covered by the American guidelines. The American guidelines for skull radiography can be safely used in a British A&E unit.