Sukkin Pungchim, MD. Emergency Medicine Resident, PGY II

Elective Rotation in Emergency Radiology

Ann Emerg Med. 2011;58:315-322

• TBI is the leading cause of death and disability in children > 1 yr

• Cranial CT is diagnostic of choice in blunt head trauma

• Most children presenting to ED after minor head trauma do not require CT scanning, if done >90% Cranial CT shown normal

• Many children with minor head trauma are hospitalized for neurologic observation despite normal ED cranial CT

• Limited pediatric data in necessity of hospitalization

• Identify the frequency of children with minor blunt head injury and normal initial CT results have either traumatic findings in a subsequent neuroimaging or experience neurologic deterioration resulting in the need for neurosurgery

• Study design – Prospective, multicenter observational cohort study at 25 centers

between 2004 and 2006

• Population – Children younger than 18 yr with blunt head trauma and initial GCS of 14

or 15 who had normal cranial CT scan results during ED evaluation

• Data collecting and processing – Documentation of GCS/Vomiting/Isolated head trauma/Multisystem

– Finalized report of Cranial CT or MRI

– Patients D/C from ED followed by phone, mail, medical records review, ED CQI, trauma registry records, country morgue documentation

• Outcome measure – Traumatic findings on subsequent CT or MRI and

– Neurosurgical intervention (eg, craniotomy, ventricular drainage)

• Primary data analysis – Determined NPV for negative (normal) ED CT scan result for identifying

those patients not needing a neurosurgical intervention

– SAS statistical software (version 9.2)

• Sensitivity analyses – Worse-case scenario in those patients D/C from ED but failed to follow-up

93% 7%

83% 17% 39% 61%

6% 2% 6% 2%

• Negative predictive value for neurosurgical intervention of a normal ED CT scan result in a patient with an initial ED GCS 15 was 100% (95% CI 99.97% to 100%)

• Negative predictive value for neurosurgical intervention of a normal ED CT scan result in patients with initial GCS scores of 14 was 100% (95% CI 99.6% to 100%)

• Sensitivity analyses : Worse case scenario

• proportion of patients with GCS 15 but lost follow-up could be another 11 patients

• proportion of patients with GCS 14 but lost follow-up could be another 1 patients

• If this were true : The proportion would increase only from 21/13,543(0.16%) to 33/13,543(0.24%)

– 5% of the patients who were lost to telephone follow-up would need to have traumatic findings on a subsequent CT or MRI (ie, 115 of the 2,302 patients lost to telephone follow-up)

– Highly unlikely, given that this far exceeds the proportion with subsequent traumatic findings on cranial imaging in those admitted

• Not all patients enrolled into the primary study underwent CT

• Patients who did not undergo repeat imaging would have had traumatic findings had they received imaging a second time

• Lost follow-up patients might have traumatic findings identified on CT or MRI at another hospital

• Exact reasons/indications for hospitalization after normal cranial CT not specifically described

• Real-time CT interpretations in many centers could be from radiology resident

• Not assess brain injury in terms of long term neurocognitive function

• Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results – Very low risk for subsequent traumatic findings on neuroimaging

– Extremely low risk of needing neurosurgical intervention

• Routine hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary

• There remain indications for admitting children w/minor head injury – Multisystem trauma

– Symptomatic patients require IV fluids and neurologic observation (18% of hospitalized patient had vomiting documented )

– Others : Social, concern for other injuries

• Many medical center across US, even pediatric centers simply admit for neurologic observation

• Potential to reduce medical costs, reduce hospital crowding, provide more optimal care

• Hospitalized patients were more likely to undergo subsequent neuroimaging because of ease and accessibility

• EP were likely admitting patients with more symptomatic and more severe head trauma despite normal cranial CT results

• Several patients with subsequent traumatic findings found were never hospitalized