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Decision Rules for Children with Head Trauma Can Prevent Unnecessary CTs
A large multicenter study provides robust support for avoiding head CT scans in children at low risk.
A robust clinical decision rule for identifying children with head trauma who are at low risk for intracranial injury could eliminate unnecessary radiation exposure from computed tomography (CT) scans. In a multicenter North American study, researchers enrolled 42,412 children (age, 
18 years) with mild head trauma (defined as Glasgow Coma Scale score >13) to derive and validate decision rules for two age groups: <2 years and 
2 years.
The study outcome was complicated head trauma (defined as neurosurgery, death from traumatic brain injury, intubation for >24 hours, or hospital admission for 2 nights). The investigators defined rules (based on a derivation group of children) for avoiding CT in the two age groups (see table).
In the validation group of 2216 children younger than 2 years, the rule had 100% sensitivity and negative predictive value. In the validation group of 6411 children 2 years and older, the rule had 96.8% sensitivity and 99.5% negative predictive value.
Comment: This large, high-quality, multicenter study is sufficient to change practice. We should no longer obtain head CT scans for children designated as "safe" by the above criteria. However, the converse is not true. Clinicians should not use these criteria to trigger a scan in a child whom they otherwise would not image. As always, extra caution is still advisable in children younger than 3 months, in whom clinical evaluation is less reliable.
Published in Journal Watch Emergency Medicine September 25, 2009
Citation(s):
Kuppermann N et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet 2009 Sep 15; [e-pub ahead of print]. (http://dx.doi.org/10.1016/S0140-6736(09)61558-0)
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- T Criteria
J Ross Hester, PA-CH, Edcom Associates Holistic Health, 28 Sep 2009 1:45 PM EST
Having more standardized criteria should both minimize "needless" radiation exposure and help lower evaluation costs for all concerned, assuming the... [more] - Decision Rules for avoiding CT
Jeannine U. Babineaux, Christus St. Patrick School-Based Health, 1 Oct 2009 2:35 PM EST
As an NP who works in a school-based health center, I find this to be an extremely useful tool. Seldom... [more]
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