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Editor,—Fiona Brown and colleagues1 studied outcomes in 463 children and found no increase in skull fracture in the presence of post-traumatic vomiting (PTV). They concluded that “vomiting alone does not have a role in decision making regarding further investigation of skull or brain”. These conclusions should be applied with caution. Our own series of 5416 patients included 2581 children.2 The incidence of PTV in our study was similar to that of Brown and colleagues (12% versus 15%) but the incidence in children with a skull fracture was 33% (95% CI 20%, 48%). A single episode of vomiting after a head injury in children was associated with a relative risk of fracture of 3.61 (95% CI 1.8, 7.23). In alert children the fracture rate was more or less doubled, although the confidence limits indicated a trend not quite reaching statistical significance. A number of other published studies have demonstrated an association between PTV and skull vault fractures.3–5
Authoritative guidelines, soon to be published, will suggest that the PTV is included as an indication for skull radiography after head injury in adults, and possibly also in children (personal communication, Mr Ian Swann). Vomiting may be regarded as a fairly sensitive, though not very specific, indicator of fracture risk in alert children after head injury. To ignore this symptom is to risk overlooking a fracture of the skull vault, which substantially increases the risk of intracranial complications.
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