Pediatrics: Clinical observation could cut head CT in ED

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Clinical observation of children that present to the ED with minor blunt head trauma may offer a safe and an effective strategy for reducing head CT for some patients, according to a study published May 9 in Pediatrics.

As CT use in radiology and emergency departments continues to spike, researchers have thoroughly scrutinized their institutions’ CT utilization in an attempt to lower patients’ exposures to radiation. The most sensitive group to ionizing radiation, pediatrics, has warranted particular attention regarding appropriate use of CT.

“Implementation of prediction rules may decrease unnecessary CT scans by identifying children who are at very low risk for clinically important TBI [traumatic brain injury] for whom CT scans could be obviated,” noted Lise E. Nigrovic, MD, MPH, from the division of emergency medicine at Children’s Hospital Boston, Harvard Medical School, in Boston.

The authors sought to go beyond the effects of prediction rules, instead investigating the frequency with which children presenting to the ED were placed under observation, instead of immediate CT, and to assess the effects of this strategy on CT utilization.

A total of 40,113 pediatric patients presenting with minor blunt head trauma were included in the retrospective multi-institution study. In 14 percent of these cases, physicians opted to observe the patients prior to making a decision regarding CT.

Various patient factors contributed to physicians’ choices to image immediately or hold off for observation. Children who were younger and more likely to have severe mechanisms of injury more frequently underwent observation. Patients that were vomiting, had altered mental status or presented with a history of loss of consciousness likewise were more likely to be assigned to clinical observation.

Among children who were observed from time of admission, 31 percent eventually underwent CT scans, compared with 35 percent of patients whose clinicians made immediate decisions regarding the exam.

Nigrovic and colleagues found that clinical observation prior to a decision on CT was associated with an 11 percent reduction in CT utilization. However, the authors acknowledged that this figure did not control for important differences between groups.

Of the 5,433 children placed under clinical observation, 3,744 were eventually discharged without a CT, although 26 of these patients later returned to a facility for CT. After controlling for differences, the odds of patients having a clinically important traumatic brain injury did not vary significantly between the clinical-observation and no-observation groups.

“In our large, multicenter, prospective study of pediatric head trauma, we found that observation before making a decision regarding CT use was common (14 percent of patients) and was associated with approximately one-half the adjusted odds of obtaining a CT scan compared with non-observed patients,” Nigrovic and colleagues wrote.

“Not only did the patients who were observed have a significantly lower rate of overall CT use,” Nigrovic and colleagues continued, “but these patients also had a similar rate of clinically important TBI, even after adjusting for factors associated with TBI.”

The authors also noted that CT use was lower for patients whose symptoms improved during the period of observation. Moreover, patients who were at intermediate risk for clinically important traumatic brain injury were more likely to be placed under observation, whereas physicians whose patients were at high and low risk levels were significantly more likely to make an immediate decision regarding CT.

Acknowledging the importance of additional studies to verify their findings, the authors concluded, “Clinical observation before making a decision regarding CT scan use seems to be a safe and potentially effective strategy to manage a subset of children with minor blunt head trauma. This clinical strategy may prove to reduce unnecessary exposure to the long-term risks of ionizing radiation, while minimizing the risk of missing clinically important TBIs.”