Observation of Pediatric Blunt Head Traumas Reduced CTs

Children with minor blunt head trauma who report to the emergency department may be able to forego unnecessary computed tomography (CT) scans by undergoing observation, a new study indicated.

In fact, researchers, led by Deborah Schonfeld, MD, of Boston Children’s Hospital, found that the more time spent under observation, the less likely a child was to undergo CT.

“Head trauma is a very common reason for pediatric emergency department visits,” Schonfeld said. “Although cranial CT is the gold standard for diagnosis of traumatic brain injury, significant traumatic brain injury is rare and CTs expose children to radiation, which increases the lifetime risk of cancer.”

To avoid unnecessary radiation exposure, Schonfeld said that management strategies are needed to reduce unnecessary CTs in this pediatric population.

“Clinical observation prior to CT decision-making allows the clinician to selectively scan only those children whose symptoms do not resolve or improve over a period of time,” Schonfeld said.

Schonfeld and colleagues performed a cohort study of 1,381 children with blunt head trauma and a Glasgow Coma Scale score of 14 or greater. Emergency department observation time was defined as the time of the initial physician assessment to the time when the decision to order a CT was made.

Of the children enrolled in the study, 49 percent were observed and 20 percent had a CT performed. Physicians were more likely to have ordered a CT among children in higher PECARN traumatic brain injury risk groups (4 percent of children in the very low traumatic brain injury group; 26 percent in the intermediate-risk group, and 69 percent in the high-risk group).

“As we had hypothesized, patients who were observed in the emergency department underwent fewer CT scans,” Schonfeld said. “Longer observation times led to progressive decreases in CT rates in all children at risk for [traumatic brain injury] after minor blunt head trauma.”

Adjusting for time from injury, patient age, sex, physician type, and study period, each hour of observation time was associated with a time-dependent decrease in CT rate (adjusted OR=0.31; 95 percent CI, 0.25-0.37). This time-dependent decrease in CT was consistent across the three traumatic brain injury risk groups (high risk: OR= 0.11, 95 percent CI, 0.05-0.24; intermediate risk: OR=0.28, 95 percent CI, 0.21-0.36); low risk: OR=0.47, 95 percent CI, 0.31-0.73).

“Observation prior to CT decision making appears to be a safe and effective approach for the management of children with minor blunt head trauma,” Schonfeld said. “Evidence-based guidelines for the care of children with minor blunt head trauma should include clinical observation.”