Study questions need for ped CT after head trauma

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Physicians may not need to routinely order CT studies for pediatric patients with bleeding disorders after blunt head trauma, according to a study published online Jan. 11 in the The Journal of Pediatrics.

Intracranial hemorrhage (ICH) represents a potentially life-threatening complication for children with congenital or acquired bleeding disorders, and these children face increased risk for ICH even after minor head trauma, offered Lois K. Lee, MD, MPH, from the division of emergency medicine at Children’s Hospital in Boston, and colleagues.  Lee and colleagues found institutional guidelines but no published standard clinical practice guidelines on the use of CT after head trauma.

The researchers designed a prospective study to measure the frequency of CT after blunt head trauma in children with bleeding disorders compared with children without bleeding disorders and determine the prevalence of ICH on CT as reported by an attending radiologist.

The study focused on children under the age of 18 years evaluated within 24 hours of blunt head trauma at any of the 25 emergency departments participating in the Pediatric Emergency Care Applied Research Network between June 2004 and September 2006. Of the 43,904 patients presenting with non-trivial blunt head trauma over the course of the study, researchers identified 230 patients who met study criteria and had been diagnosed with hemophilia, platelet disorders, anticoagulation therapy, von Willebrand disease, “unknown” or “other.”

All children with and without bleeding scores presented with seemingly minor trauma, defined with Glasgow Coma Scale (GCS) scores of 14 or 15; consequently, researchers analyzed the remaining data for this subset of the population.

“Children with bleeding disorders presented with a lower prevalence of symptoms and signs of ICH than did the children with GCS scores of 14 to 15, but without bleeding disorders,” wrote Lee.

However, children with bleeding disorders were twice as likely to have a CT ordered than their peers with cranial CT obtained in 80.9 percent of children with bleeding disorders compared with 35.3 percent of children without bleeding disorders. Multivariate regression analysis indicated that children under the age of two years with bleeding disorders had 42-fold higher odds of a head CT than same-aged children without bleeding disorders. For children over the age of two years, those with bleeding disorders had 23-fold higher odds of cranial CT than those without disorders.

Despite the higher imaging rates, ICH was found in only 2 of the 186 children with bleeding disorders who underwent CT, and both patients presented with signs and symptoms of ICH that would have warranted cranial imaging, reported the authors. Although children with hemophilia are at risk for delayed presentation of ICH, no delayed bleeding was reported in follow-up calls conducted one week to three months post-visit. The rate of ICH among children without bleeding disorders was 4.4 percent vs. 1.1 percent among children with bleeding disorders.

The results suggest that symptomatically silent ICH among children with bleeding disorders are very uncommon, summed Lee and colleagues, who added “the low rate of ICH suggests that they may not routinely require cranial CT imaging after minor head trauma in the absence of signs or symptoms of ICH.”