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Indication for head CT in children with mild head injury
  1. Andrew Munro, Specialist Registrar in Emergency Medicine,
  2. Ian Maconochie, Paediatric Consultant in Emergency Medicine
  1. Department of Emergency Medicine, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
  1. Correspondence to: Kevin Mackway-Jones, Consultant (kevin.mackway-jones{at}man.ac.uk)

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Report by Andrew Munro, Specialist Registrar in Emergency Medicine Checked by Ian Maconochie, Paediatric Consultant in Emergency Medicine

Clinical scenario

It is 9 pm on a Saturday, a 5 year old boy is brought to the emergency department by his mother after an unobserved fall on a trampoline. The mechanism is unclear but he was playing with an older boy. He was not thought to have cried immediately. He has a moderate sized contusion to his occiput but no focal neurology. He has a GCS of 14, opening his eyes to voice only. No skull fracture is identified on plain films. You consider it appropriate to use computed tomography on the basis of his GCS, scalp haematoma and the possibility of loss of consciousness. The on call radiologist thinks it more appropriate to admit for neurological observation. You are concerned that there is an incidence of intracranial injury (ICI) in this group, but have no data to support an argument for early head scanning.

Three part question

In [children who have sustained a mild or minor head injury with a GCS=13–15] do [clinical findings] predict [intracranial injury on computed tomography]?

Search strategy

Medline 1985–08/01 using the OVID interface. {[(exp brain injuries OR exp craniocerebral trauma OR exp head injuries, closed) OR (head trauma.mp) OR (head injur$.mp)] AND [(exp adolescence OR exp child OR exp child of impaired parents OR exp child, abandoned OR exp child, exceptional OR exp child, hospitalized OR exp child, institutionalized, OR exp child, preschool OR exp child, unwanted OR exp disabled children OR exp homeless youth or exp infant or exp only child or child$.mp) OR (exp pediatrics OR pediatric$.mp OR paediatric$.mp)] AND (exp tomography scanners, x-ray computed OR exp tomography, x-ray computed OR tomography.mp OR CT scan$.mp) AND (exp prospective studies OR prospective.mp OR prospectively.mp)} LIMIT to (human AND english language AND yr=1985–2001).

Search outcome

Altogether 194 papers were found of which five were considered relevant and of sufficient quality to include (see table 9).

Table 9

Comment(s)

While no paper directly answered the question, five prospective studies clearly demonstrate ICI occurring in the absence of altered GCS and/or focal neurology. It is also clear that ICI occurs in children whose GCS has improved.

There seems to be no consistent linear relation between other clinical factors and predictability of ICI. Two papers showed that in infants who have no focal signs and no altered mental state the presence of significant scalp haematoma was an indication of increased risk of ICI. The full significance of ICI in asymptomatic head injured children is not clear however as many as one in six asymptomatic infants with ICI may be given neurosurgery.

Clinical bottom line

All head injured children who have a GCS of < 15 should undergo cranial CT. Asymptomatic infants who have head injury and a scalp haematoma should also undergo cranial CT.

Report by Andrew Munro, Specialist Registrar in Emergency Medicine Checked by Ian Maconochie, Paediatric Consultant in Emergency Medicine

References

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