CT Scans Overused in Emergency Assessment of Pediatric Head Trauma?

Brian Hoyle

May 12, 2010

May 12, 2010 (Vancouver, British Columbia) — A pair of studies presented here at the Pediatric Academic Societies 2010 Annual Meeting indicates that the observation of children with blunt head trauma can, in many cases, reduce the need for a computed tomography (CT) scan without compromising outcome and without undue radiation exposure to the child.

CT scanning has been growing in popularity for the diagnosis of neurologic injury over the past 2 decades. However, CT use has been questioned, especially for young children in the time-critical atmosphere of the emergency department, because it can increase the risk for malignancy. This risk is greatest in the first 10 years of life.

The issue of whether to observe before using CT or to perform CT as the first course of action for a child with a head injury is debatable, and was the subject of a study by a team from Inova Fairfax Hospital for Children in Falls Church, Virginia.

"A significant number of children receiving CT scans . . . do not appear to have clinical justification for the procedure," poster presenter Rebecca S. Kriss, MD, from the Department of Pediatrics at Inova Fairfax Hospital for Children, said in an interview with Medscape Pediatrics.

In the study, electronic records were reviewed for 394 children, 1 month to 5 years of age, who received a head CT at a large suburban emergency department between February 2008 and February 2009. Child's age, chief complaint, history, results of physical examination, indication for and results of the CT scan, number of scans, and outcome were examined.

The historic data included a slew of "red flags" that heightened indication for a CT scan. These included loss of consciousness, altered mental state, signs of fracture, hematoma, seizure, pain upon awaking, suspected nonaccidental trauma, indication of increased intracranial pressure, and an abnormal neurologic exam.

Of the 236 patients who received a CT scan, abnormalities were evident in 89 (38%). Moreover, 20% of the 236 children received more than 1 CT scan; 6% received 6 to 20 scans. Overall, 40% of the children who received a CT scan lacked red flag indicators of head trauma.

Of the 236 head injuries evaluated by CT, 23 were judged to be significant. Only 3 cases required immediate action, all of which presented with red flag indicators.

The Virginia team's observations were supported by findings from a second study, presented by Lise E. Nigrovic, MD, MPH, from Children's Hospital Boston and assistant professor of pediatrics at Harvard Medical School, in Massachusetts, who announced the results of a subanalysis of a prospective observational study of children who had sustained a blunt head injury.

Dr. Nigrovic's team analyzed the records of 40,113 children with blunt head trauma. Presenting symptoms were compared in patients who were observed before receiving a CT scan (n = 5,433) and in those who were not observed before receiving a scan (n = 34,680). Observation led to a significantly lower CT rate without affecting patient outcome.

"A decision to do a CT scan is usually made quickly, sometimes as the patient is being transported to the hospital. A neurological consult is usually not even done before the [emergency department] physician orders a CT," Dr. Kriss told Medscape Pediatrics.

For some children, the prompt decision proves to be the correct one. But for a sizable number of children, a wait-and-see approach, with careful monitoring of symptoms, can be the best course.

"These are great data. There can be a big difference in the condition of a child at presentation and 24 or 48 hours later," said Russell T. Migita, MD, clinical director of emergency medicine at Seattle Childrens' Hospital in Washington.

The studies were funded by the Health Resources and Services Administration/Maternal and Child Health Bureau, the National Institute of Neurological Disorders and Stroke, and the Inova Fairfax Hospital for Children. The authors have disclosed no relevant financial relationships.

Pediatric Academic Societies (PAS) 2010 Annual Meeting: Poster sessions 4400.1 and 4400.33. Presented May 4, 2010.

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