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To evaluate whether clinical features associated with head injury in children can be correlated with an abnormal computed tomography (CT) scan.
Three hundred and eleven children aged 14 years or younger admitted with a diagnosis of acute head injury were studied retrospectively.
A Glasgow Coma Scale (GCS) score of 12 or lower and the presence of fo...
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Citations
... In addition, there are 1.4 million annual hospitalizations for TBI [2]. A report of loss of consciousness is frequently considered an indication for obtaining a brain CT scan in the evaluation of patients with blunt head trauma [3][4][5]. In the USA, physicians routinely obtain CT scans for patients with abnormal Glasgow Coma Scale (GCS) scores and/or LOC. ...
Abstract Background A report of loss of consciousness (LOC) is frequently considered reason enough to obtain a computed tomography (CT) scan in the evaluation of head trauma. We conducted this study to reduce exposure to radiation from CT, while still not overlooking clinically significant injuries. Objective The objective of the study is to determine the correlation between LOC status and brain CT scan results in patients with blunt head trauma and to determine whether there is a subset of patients for whom CT scan need not be performed, without missing clinically significant intracranial injuries. Methods This is a retrospective study conducted in the emergency department of an inner-city hospital. The patient population included patients ranging between 13 and 35 years of age, with blunt head trauma, who presented to the emergency department (ED) between January 2010 and December 2013. Patients were divided into two groups: “LOC” group and “no LOC” group. The results of brain CT scans from each group were compared with LOC status. For study purposes, “clinically significant” were those that required interventions or ICU hospitalization of at least 24 h or extended hospitalization. The results were analyzed using chi-square calculations. Results During the study period, 494 patients were identified as having suffered head trauma. Of these, 185 (37.5%) reported LOC and 309 (62.5%) did not lose consciousness. In the LOC group, 15 (8.1%) had significant CT findings compared to 1.3% (4/309) of those without LOC (p
... Perbandingan antara laki-laki dan perempuan (sex ratio) pada penelitian ini adalah 321 : 182 (1,7 : 1) dengan kelompok usia terbanyak antara 6-10 tahun (29,6%), rasio laki-laki dan perempuan tidak jauh berbeda dengan penelitian Reed dengan rasio laki-laki : perempuan = 1,8 : 1. hal ini diasumsikan bawa anak laki-laki lebih aktif dibandingkan anak perempuan. [13][14][15] American Academy of Pediatric (AAP) menyatakan bahwa rata-rata usia yang sering mengalami cedera antara 2 sampai 20 tahun. Namun dari penelitian Kimberly, usia yang dijumpai terjadi cedera kepala adalah usia kurang dari 12 tahun dengan rata-rata usia 4 tahun 10 bulan. ...
... Dari kepustakaan pada anak di atas 5 tahun jarang terjadi perdarahan intrakranial kecuali benturan yang sangat kuat, namun pada anak < 1 tahun sering terjadi perdarahan intrakranial (shaken baby sindrom). [12][13] Terapi yang diberikan pada umumnya tidak ada yang khusus (65,6%) namun pada kasus cedera sedang sampai berat, pasien mendapat pengobatan citikolin. Dari kepustakaan tidak ada obat khusus, namun bila terdapat perdarahan atau edema serebri maka obatobatan yang diberikan untuk mengatasi edema atau perdarahan tersebut. ...
Latar belakang. Cedera kepala merupakan salah satu penyebab anak dibawa ke rumah sakit. Pada umumnya
trauma terjadi karena kecelakaan lalu lintas. Di Amerika sekitar 300.000-400.000 anak dirawat karena
cedera. Di Indonesia hanya ada data sporadis.
Tujuan. Mendapatkan gambaran karakteristik klinis pada anak dengan cedera kepala di RS Dr. Cipto
Mangunkusumo.
Metode. Studi deskriptif retrospektif dengan data sekunder diambil dari data catatan medik dari bulan
Januari 2004 - Juli 2005.
Hasil. Selama kurun waktu penelitian ditemukan jumlah kasus trauma kepala pada anak usia
... The evidence level was upgraded due to a large effect of one of the studies for the important outcome of ICI. The strength of the recommendation was, however, by the task force perceived as strong, when considering the seriousness of the potential intracranial complication and the health economic impact of missing a patient with a neurosurgical lesion [22,[48][49][50][51][52][53][54][55][56][57][58][59][60]. The evidence was initially of high quality, but downgraded due to limitations in study design (selection bias), indirectness (lack of description of outcome measures and follow-up) and inconsistency (large differences in prevalence of risk factors and likelihood ratios). ...
... There was no upgrading of the evidence level. The recommendation was perceived as strong when considering the relatively low prevalence of the predictive factors compared to the severe influence on patient outcome if the patients with ICI or a neurosurgical lesion were missed; (a) [8,22,48,[51][52][53][61][62][63][64][65][66][67][68][69][70][71][72][73], (b) [22, 48, 49, 51-53, 55, 63-65, 67-78]. ...
Background
The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim.
Methods
General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders.
Results
The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children.
Conclusions
We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma.
... Use of CT scans can be limited to children with ongoing specific symptoms and/or focal neurological signs. The implementation of guidelines in the management of head injuries in children could have a substantial effect on clinical practice and health-care costs (22). ...
Background: Minor head trauma accounts for 70% to 90% of all head traumas. Previous studies stated that minor head traumas were associated with 7% - 20% significant abnormal findings in brain computed tomography (CT)-scans. Objectives: The aim of this study was to reevaluate clinical criteria of taking brain CT scan in patients who suffered from minor head trauma.
Patients and Methods: We enrolled 680 patients presented to an academic trauma hospital with minor head trauma in a prospective manner. All participants underwent brain CT scan if they met the inclusion criteria and the results of scans were compared with clinical examination finding.
Results: Loss of consciousness (GCS drop or amnesia) was markedly associated with abnormal brain CT scan (P < 0.05). Interestingly, we found 7 patients with normal clinical examination but significant abnormal brain CT scan.
Conclusions: According to the results of our study, we recommend that all patients with minor head trauma underwent brain CT scan in order not to miss any life-threatening head injuries
... Palchak et al. claimed that an isolated LOC, or isolated LOC and/or amnesia without any other clinical symptoms like vomiting, seizure, new onset headache, radiologic signs of skull fracture, altered mental status, neurologic deficit, and scalp hematoma is not related to presence of abnormal finding in brain CT scan. 4 On the other hand, some previous studies identified LOC as predictor of abnormal findings in brain CT scan of children with minor head trauma. 20,[37][38][39][40][41][42][43] Dunning et al. also reported that there is a statistical relation between LOC and TBI. 19 In our study, LOC was seen in 18 cases (8.3%) and correlation between LOC and abnormal CT findings was not significant. ...
Introduction: Minor blunt head trauma is a common reason for children to present to the emergency department (ED). Crania computed tomography (CT) is the choice for evaluating children with blunt head trauma in the ED, but few shows abnormal findings. In this study, we aim to evaluate CT findings in children with blunt head trauma and clinical symptoms to identify clinical predictors of abnormal CT scans. Methods: In this prospective study, 218 children under 2 years of age (121 male and 97 female with mean age of 11.24 ± 4.31 months) with compliant of minor blunt head trauma visiting the ED between April 2011 and April 2014 were included. Physical examination and clinical symptoms, as well as CT findings and patients’ outcome were evaluated. Results: Physical examinations were normal in 95.9%, and clinical symptoms were present only in 25.7% including vomiting in 16.1%, loss of consciousness (LOC) in 8.3%, ear/nose bleeding in 4.1% and seizure in 5.5%. CT scan was requested in 189 cases (86.7%) of which, 7.9% were abnormal including linear fracture in 5.3%, subgaleal hematoma in 1.1% and depressed fracture, subcutaneous hematoma and intracranial hemorrhage (ICH) each in 0.5%. Among all cases, 89.0% were discharged from ED with no further observation, 6.0% discharged after 48 h observation and 5.0% were hospitalized. There was a significant correlation between abnormal CT findings and having any clinical symptoms, vomiting and Ear/nose bleeding. Conclusion: In children under 2 years old with minor blunt head trauma, most CT scans are unnecessary. Considering clinical symptoms as predictors of abnormal CT scans we can reduce unnecessary ones.
... 7 Contusion was the most frequent finding in cases with positive CT scan findings present in 8/21 ( %) cases followed by EDH ( 6/21), depressed fracture ( 6/21), acute SDH (5/21) and brain oedema (5/21). These Findings are similar to study conducted by Ng et al 8 where contusion 35% was most common CT finding followed by depressed skull fracture 26% and EDH 14%. According to Fundaro et al, EDH was found in 20% and depressed skull fracture and SDH in 14% of cases. ...
... In the study conducted on 311 children of head injury, SM Ng et al concluded that a GCS of less than 12 and presence of focal neurological deficits were the two strong predictors of abnormal CT scan. 8 They also concluded that 95% cases of abnormal CT scan and 100% cases of intracranial injury can be identified by presence or absence of nine clinical findings. ...
Background: Head injury in pediatric age is a major cause of mortality and disability. Clinical selection of cases prior to ordering CT scan would be desirable to avoid unnecessary radiation exposure and risk of malignancy. Methods: An observational study of 50 pediatric cases of head injury that underwent CT scan as part of routine diagnostic work up. Correlation of CT scan findings with GCS scores and clinical profile done. Results: Contusion was the most frequent finding in cases with positive CT scan findings and majority (94%) of patients could be managed conservatively. Among the mild head injury cases only 1 (3.8%) had positive CT scan findings whereas 16 (80%) with moderate head injury and almost all (100%) subjects with severe head injury had positive CT scan findings. Conclusions: Careful clinical selection based on GCS score before ordering CT scan can help reduce radiation exposure among pediatric patients and pressure on limited resources. Studies with larger sample size would be warranted.
... In one class III study including 311 children with head trauma, acute ataxia was the presenting feature in 5% [21]. Nine of these 14 patients with ataxia underwent CT scanning, which was abnormal in five cases. ...
... This method would not be expected to accurately identify all intracranial injuries and would potentially affect estimates of sensitivity and specificity (Whiting et al., 2004). The prevalence of intracranial injury varied widely between studies (ranged from 0.5 (Rosenorn et al., 1991) to 78.1% in adults and 0.6 to 54.6% (Ng et al., 2002) in children and infants). This is likely to be due to differences in patient selection criteria, adequacy of reference standards and definitions of intracranial injury. ...
... Ng, S.M., Toh, E.M., and Sherrington, C.A. (2002). Clinical predictors of abnormal computed tomography scans in paediatric head injury. ...
Clinical features can be used to identify which patients with minor brain injury need CT scanning. A systematic review and meta-analysis was undertaken to estimate the value of these characteristics for diagnosing intracranial injury (including the need for neurosurgery) in adults, children, and infants. Potentially relevant studies were identified through electronic searches of several key databases, including MEDLINE, from inception to March 2010. Cohort studies of patients with minor brain injury (Glasgow Coma Score [GCS], 13-15) were selected if they reported data on the diagnostic accuracy of individual clinical characteristics for intracranial or neurosurgical injury. Where applicable, meta-analysis was used to estimate pooled sensitivity, specificity and likelihood ratios. Data were extracted from 71 studies (with cohort sizes ranging from 39 to 31,694 patients). Depressed or basal skull fracture were the most useful clinical characteristics for the prediction of intracranial injury in both adults and children (positive likelihood ratio [PLR], >10). Other useful characteristics included focal neurological deficit, post-traumatic seizure (PLR >5), persistent vomiting, and coagulopathy (PLR 2 to 5). Characteristics that had limited diagnostic value included loss of consciousness and headache in adults and scalp hematoma and scalp laceration in children. Limited studies were undertaken in children and only a few studies reported data for neurosurgical injuries. In conclusion, this review identifies clinical characteristics that indicate increased risk of intracranial injury and the need for CT scanning. Other characteristics, such as headache in adults and scalp laceration of hematoma in children, do not reliably indicate increased risk.
... these include: Gcs equal to or less than 12, focal neurological deficit, loss of consciousness, ataxia, amnesia, drowsiness, headache, seizure or vomiting. 5,6 in children less than 2 years of age, ctB should be considered in all patients presenting with: ...
... • altered mental status • focal neurological findings • scalp swelling/haematoma, and • unwitnessed trauma or unclear/inconsistent mechanism of injury. 2,6 A lower threshold for imaging is also justified in children with haemophilia or those on anticoagulants. 7 in cases where the mechanism of injury is deemed to be associated with suspicion of high risk for significant hi, referral to a hospital emergency department may be indicated. ...
... A united Kingdom Emergency medicine Research group has developed a clinical decision rule for the identification of children who should undergo ctB after hi. 8 Although the CHALICE (Children's Head injury Algorithm for the Prediction of important clinical Events) guidelines have not been adequately validated in different populations, they are helpful for the management of children less than 16 years of age with head trauma 7 ( Table 4). Table 2. Guidelines for return for medical assessment in mild head injuries 6 • Unusual or confused behaviour • Severe or persistent headache which is not relieved by paracetamol (irritability in a baby) • Frequent vomiting • Bleeding or discharge from the ear or nose • A fit or convulsion, or spasm of the face or arms or legs • Difficulty in waking up* • Difficulty in staying awake • Any signs or symptoms of concern to parents * Parents do not need to wake their child during the night if the child has sustained a mild head injury Table 3. Indications for referral and transfer to hospital Three or more discrete episodes of vomiting 5 ...
Traumatic head injury is a common occurrence in the paediatric population, with the majority of patients sustaining only mild head injury.
This article outlines the management of mild head injuries in children.
A careful history including time of injury, the mechanism of injury, and any loss of consciousness or seizure activity; a thorough examination including a Glascow Coma Scale (GCS) score; and observation should be appropriate for most patients. Only a small number of injuries require further examination/imaging with computerised tomography. Indicators for transfer to hospital include GCS equal to or less than 12, focal neurological deficit, clinical evidence of skull fracture, loss of consciousness for more than 30 seconds, ataxia, amnesia, abnormal drowsiness, persistent headache, seizure following initial normal behaviour or recurrent vomiting. Postconcussive symptoms frequently occur after minor head injuries and parents and other family members should be aware of what symptoms to expect, and possible duration. Regular follow up until all symptoms have resolved is mandatory, with clear guidelines for stepwise resumption of physical activity.
... Less than 10% of these CT scans, however, are diagnostic of traumatic brain injury (TBI) [Figures 1 and 2]. [19][20][21] A CT scan is probably recommended for all patients with mild head injury because one in five will have an acute lesion detectable by the scan [Tables 8 and 9]. [22] Limitations These type of studies are meant to collect and analyze data relating to childhood injuries, with the aim of disseminating information to relevant authorities and agencies for appropriate actions, for example, public education programs and school education programs. ...
In children, majority of the head injuries are minor and management of critically ill children depend on a team approach using well-rehearsed, systematic management protocols that can be implemented within hours after injury. This study was carried out to ascertain the epidemiology and management of know the demographic profile and etiology of paediatric head injury in our setting, to know the clinical and radiological characteristics of head injury patients and to know the treatment options and outcome in paediatric head injuries.
Details of all children (age <16 years) with head injury seen in 1 year from 01.04.2005 to 31.03.2006 were retrospectively reviewed. Demographic profile, clinical details, investigations, treatment offered, and outcome were noted in a proforma. All data were analyzed by appropriate SPSS 11.0 statistical software tools.
There were total 43 patients. Young male children were more commonly affected in present series with a mean age of 7.67 years (median - 5.010 years), range 6 months-16 year. Fall (65.11%) was the most common mode of injury followed by road traffic accidents (RTAs) (25.6%). Mild head injuries (65.11%) were most common. Most common complaint was loss of consciousness and all the patients with severe head injury presented loss of consciousness. All patients with mild head showed good recovery; with moderate head injury, nine patients showed good recovery and three patients recovered with moderate disability. Patients with severe head injury (three patients) had 100% mortality.
In urban areas of Nepal, RTAs like vehicular crashes, motor cycle accidents, and pedestrian hit by moving vehicle are more common and in rural areas fall from height are commoner. We need to develop child safety legislations and risk-specific intervention programs in Nepal.
