Cranial CT Not Indicated for Most Children With Minor Head Trauma

By Will Boggs MD

November 28, 2019

NEW YORK (Reuters Health) - Most children presenting to the emergency department (ED) with minor blunt head trauma will not require cranial CT scanning, according to a new review.

Among such children, "serious injuries requiring neurosurgery are uncommon," Dr. Lise E. Nigrovic of Boston Children's Hospital and Dr. Nathan Kuppermann of the University of California, Davis, told Reuters Health in a joint email.

"Neuroimaging (i.e., head CT scans) is over-used, particularly given the risks of later malignancy," they added. "Use of evidence-based clinical decision rules and shared decision-making can safely decrease the use of head CT scans."

Dr. Nigrovic and Dr. Kuppermann summarized the best available evidence for the optimal ED management of children with minor blunt head trauma in a state-of-the-art review online November 26 in Pediatrics.

The use of traumatic brain injury (TBI) clinical prediction rules can reduce unnecessary CT scans while minimizing the risk of missing clinically important TBIs, the two note in their report. Reasonable alternatives include the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), the Pediatric Emergency Care Applied Research Network (PECARN) rules, and the Canadian Assessment of Tomography for Childhood Head Injury (CATCH).

The review includes two suggested algorithms (for children younger than 2 years and for children aged 2 years or older) for determining the need for cranial CT. According to these algorithms, CT is recommended for children who present with a Glasgow Coma Scale score of 14, other signs of altered mental status (agitation, somnolence, repetitive questioning, or slow response to verbal communication), or palpable skull fracture (for younger children) or signs of basilar skull fracture (for older children).

For younger children with occipital, parietal, or temporal scalp hematoma, five or more seconds of loss of consciousness, a severe mechanism of injury, or not acting normally according to the parent, the choice of observation versus CT should be based on other clinical factors, the authors advise.

Similarly, the choice between observation and CT for older children with a history of loss of consciousness or vomiting, severe mechanism of injury, or severe headache should be based on such other clinical factors such as physician experience, multiple versus isolated findings, worsening of symptoms or signs after ED observation, and parental preference.

CT is not recommended for the estimated 53% of younger children and 57% of older children not meeting these criteria.

Both the American Academy of Pediatrics and the American College of Emergency Physicians have recommended using the PECARN rules in children with minor blunt head trauma to limit inappropriate CT scans, with observation in a monitored setting as an important strategy to further limit CT use.

Children discharged without a CT scan should have a reliable caregiver with the ability to return to medical attention if their symptoms worsen.

Clinical decision-making for all children with minor blunt trauma should include patient, parental and physician preferences, especially when a course of action is not clear.

"Integration of clinical prediction rules into existing electronic health records can help with real-time implementation," Dr. Nigrovic and Dr. Kuppermann said. "Other tools, such as pocket cards and smart phone calculators, in settings without electronic health records can be helpful. Future work is needed to better integrate patient and parental preferences in the management of minor head trauma in children."

"Clinical prediction rules are meant to augment clinical judgment rather than to replace it," they add. "These should be used hand-in-hand."

Dr. Daniel Corwin of Perelman School of Medicine at the University of Pennsylvania, in Philadelphia, who recently reviewed the acute management of pediatric mild TBI, told Reuters Health by email, "Utilization of a clinical prediction rule, in combination with observation prior to imaging decision and shared decision making with the family, can safely reduce unnecessary CT scans in children presenting to the ED with minor traumatic brain injury."

"These prediction rules, specifically the PECARN rules, have led to a significant reduction in unnecessary head CT in children with head trauma (including at my practice site, Children's Hospital of Philadelphia, where we have shown that reduction in CT usage secondary to implementing the PECARN rules is sustainable across an extended time period)," he said.

"Observation in a monitored setting following TBI can further reduce unnecessary CT scans, as it is incredibly rare for symptoms to present beyond the first 4-6 hours following injury," Dr. Corwin said. "Use of shared decision-making with parents is an important aspect of these decision rules, as it can increase parental knowledge and trust in physicians (and) reduce subsequent health care utilization without increasing CT usage or missed diagnoses."


Pediatrics 2019.