Vomiting and serious head injury in children
Report by Jim Barnard, Senior House Officer Search checked by Simon Carley, Specialist Registrar
Clinical scenario
A 4 year old boy presents to the emergency department after a one metre fall onto a carpeted floor. The child has vomited three times in the past hour but is otherwise well. Clinical examination is unremarkable. You wonder how significant the vomiting is.
Three part question
In [a child with a minor head injury] does [vomiting] predict [intracranial injury]?
Search strategy
Medline 1966–07/00 using the OVID interface. ([exp brain injury OR exp craniocerebral trauma OR exp haematoma, epidural OR exp haematoma, subdural OR intracranial haematoma.mp OR head injury.mp.] AND [exp vomiting OR vomiting.mp. OR emesis.mp.] AND [child OR pediatrics OR paediatric$.mp. OR paediatric$.mp]) LIMIT to human AND English AND abstracts.
Search outcome
Altogether 53 papers were found of which 41 were irrelevant to the question or of insufficient quality for inclusion. The remaining 13 papers are shown in table 1. An additional paper of relevance was recently published in this journal, but was not currently indexed on Medline.
Comments
The papers listed in table 1 give varied opinions on the significance of vomiting following paediatric head injury, and it is difficult to draw firm conclusions. Some of the studies combine paediatric and adult cases, this is likely to lead to some bias in the reported significance of vomiting. Distinction should be drawn between the identification of skull fracture and intracranial lesions. The identification of skull fracture is in itself a proxy marker for serious injury and cannot be considered a gold standard outcome. Those papers specifically looking at intracranial lesions rather than just skull fractures are also inconclusive.
Clinical bottom line
Vomiting does not seem to be an independent risk factor for skull fracture or intracranial haematoma in the paediatric population.
Report by Jim Barnard, Senior House Officer Search checked by Simon Carley, Specialist Registrar
