Board Review: The Use of CT in Children with Head Trauma

Photo: Wikimedia Commons

Originally Published: Modern Resident, Feb/Mar 2011

Original Author: Michael Holman, MSIII
Georgetown University School of Medicine

Submitted by: Rachel Engle, DO, Communications Committee Chair  

Every year, more than 650,000 children are seen in emergency departments across North America for mild head injuries, about half of which will receive CT scans. In fact, in the last decade, the pediatric population saw the largest increase in use of diagnostic CT. It has been estimated that the attributable lifetime risk of death from cancer ranges from 0.065% per head CT in neonates to 0.005% per scan in teens.

Although several studies have developed methods and rules to reduce the use of pediatric CT scans, only the 2009 PECARN study has been validated. The PECARN prediction rules identify children that are at low-risk for a clinically important traumatic brain injury and do not need to be scanned. Rules apply if the patient presents within 24 hrs of the traumatic event and has a Glasgow Coma Scale score of >14. For patients meeting all clinical criteria, the negative predictive value for clinically-important TBI is minimal (below). For those who do not meet all six criteria, the decision to scan is recommended, but ultimately should be based on the clinical judgment.

Less than 2 years of age

  1. normal mental status
  2. no scalp hematoma, except frontal
  3. loss of consciousness < 5 sec.
  4. non-severe injury mechanism
  5. no palpable skull fracture
  6. acting normally according to guardian

* NPV = 100%, Sensitivity = 100%

Between 2 and 18 years of age

  1. normal mental status
  2. no loss of consciousness
  3. no vomiting
  4. non-severe mechanism
  5. no signs of basilar skull injury
  6. no severe headache

*NPV = 99.95%, Sensitivity = 96.8%

References:

  1. Brenner, David J., Hall, Eric J. Computed Tomography – An Increasing Source of Radiation Exposure. N Engl J Med. 2007;357: 2277-84.
  2. Kuppermann, Nathan, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. For the Pediatric Emergency Care Applied Research Network (PECARN). Lancet. 2009; 374: 1160-70.
  3. Osmond, Martin H, et al., CATCH: a clinical decision tool for the use of computed tomography in children with minor head injury. CMAJ. 2010; 182: 341-348.