Pedtriac patients who present to the emergency department (ED) with blunt head trauma and initial Glasgow Coma Scale (GCS) scores of 14 or 15 and normal CT results generally do not require hospitalization, according to a study published online June 17 in Annals of Emergency Medicine.
Traumatic brain injury is the leading cause of death and injury in children older than one year and ED physicians rely on CT to identify intracranial hemorrhage in patients who present with blunt head trauma.
Many children with GCS scores of 14 or 15 and normal CT results are hospitalized for neurologic observation. Existing data indicate that hospitalization of adult patients with blunt head trauma and normal CT results is unnecessary. However, extrapolating the data to pediatric patients may not be appropriate.
The researchers sought to determine the frequency with which children with minor blunt head trauma and normal initial CT findings have traumatic findings identified on subsequent studies or require neurosurgery.
The authors leveraged the Pediatric Emergency Care Applied Research Network and enrolled 13,543 children aged 18 years old or younger with minor blunt head trauma who were treated in 25 emergency departments across the U.S. from June 2004 to September 2006. The patients' median age was about nine years old, and 63 percent were boys.
James F. Holmes, MD, MPH, of the University of California, Davis department of emergency medicine, and colleagues conducted telephone and mail surveys and medical records reviews one week after ED discharge to determine subsequent neuroimaging and the occurrence of neurologic complications.
Ninety-three percent of the patients enrolled in the study had a GCS score of 15 and a normal CT result in the ED. Of these patients, 83 percent were discharged, and 17 percent were hospitalized. Among discharged patients, 2 percent underwent subsequent neuroimaging and none required neurosurgical intervention.
Among hospitalized children with GCS scores of 15 and normal CT results, 6 percent underwent further neuroimaging studies, but none required neurosurgical intervention.
The authors calculated a negative predictive value of 100 percent for neurosurgical intervention of normal CT results in children with an initial GCS score of 15.
Data were similar for the 959 children with initial GCS scores of 14. Researchers also calculated a negative predictive value of 100 percent for neurosurgical intervention of normal CT results in this population.
Holmes et al reported subsequent traumatic findings of 0.5 percent among hospitalized patients with GCS scores of 15 and 1 percent among hospitalized patients with GCS scores of 14.
The researchers concluded, “Currently, no evidence suggests that these patients benefit from acute hospitalization, although further outpatient evaluation and follow-up for post-concussive symptoms is likely warranted.” They acknowledged that some patients with blunt head trauma and normal CT results are hospitalized for other reasons such as other injuries or an inability to tolerate fluids.
Holmes and colleagues stressed that decreasing the hospitalization rate may reduce costs and hospital crowding as well as provide patients with more optimal care. They urged physicians to apply the findings to practice.
"One of the goals in the evaluation of children with minor head trauma is to try to avoid CT scan use, if possible. If you do a CT scan and the scan is negative, and the child is well, then for goodness sakes let the child go home," said study senior author Nathan Kuppermann, MD, a professor of pediatrics and emergency medicine and chair of the department of emergency medicine in the UC Davis School of Medicine.