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Identifying Clinical Symptoms Associated With Increased Incidence of Intracranial Injury May Reduce CT Scan Use

Question

  • In pediatric patients with head trauma and loss of consciousness, when should a head CT scan be obtained to evaluate for intracranial injury?

Clinical Bottom Lines

  1. CT use may be safely reduced in pediatric patients with minor head trauma, normal GCS and loss of consciousness by limiting head CT to patients with any of six symptoms: headache, emesis, intoxication, signs of trauma above the clavicles, posttraumatic seizure, or short-term memory loss.
  2. The presence of any of the six criteria was significantly associated with an abnormal CT scan (P<0.05) and was 100% sensitive (95%CI 73-100%) and specificity of 25.5% (95%CI 19-33%). The LR+ is 1.5, but the LR- is 0.


Summary of Key Evidence

  1. Prospective questionnaire was given to children 5-17 yrs of age with major mechanisms of injury resulting in minor head trauma and LOC. The questionnaire assessed for 6 clinical symptoms (above) which could be associated with increased incidence of intracranial head injury.1
  2. 175 patients were evaluated by questionnaire and then received a CT scan of the head. Fourteen (8%) of the head CT scans were positive.
  3. In this study, CT scan use could have been safely reduced by 23%, eliminating readiation exposure, sedation risk, and health care costs.
Finding
Number of Children
No. with intracranial injury or skull fracture
Likelihood Ratio
Patients
175
14
Age, y, mean
12.8
11.4
Headache
61
7
1.49
Emesis
34
6
2.46
Drug or EtOH intoxication
11
1
1.15
Trauma above clavicles
96
15
1.96
Post-traumatic seizure
6
0
---
Short-term memory deficits
18
2
1.44

 


Additional Comments

  • Confidence intervals are wide in this study due to the low power from the small study population. More than 1000 patients are needed to get CI 95-100%.
  • This study did not assess any patients by CT scan without loss of consciousness.
  • There have been few studies available that focus on CT need after injury in the pediatric population. More need to be done in order to assure that this is a safe set of guidelines for practice. Similar studies have been completed in adult populations and have helped establish the clinical guidelines set by the American College of Emergency Physicians.2
  • There are numerous benefits to limiting CT scans, most notably reduction in radiation and medical costs.

Citation

  1. Haydel MJ, Shembekar AD. Prediction of Intracranial Injury in Children Aged Five Years and Older With Loss of Consciousness After Minor Head Injury Due to Nontrivial Mechanisms. Annals of Emergency Medicine. 2003; 42:507-514.
  2. Haydel MJ, Preston CA, Mills TJ, et al. Indications For Computed Tomography in Patients with Minor Head Trauma. New England Journal of Medicine. 2000; 343: 1200-1205.

CAT Author: Mori Stern, MD

CAT Appraisers: John Frohna, MD

Date appraised: April 28, 2004

Last updated July 3, 2004
Department of Pediatrics and Communicable Diseases
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