A decision rule for identifying children at low risk for brain injuries after blunt head trauma

Received 14 November 2002; received in revised form 10 April 2003; accepted 14 April 2003.

Abstract

Study objective

Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries.

Methods

We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules.

Results

Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in children ≤2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications.

Conclusion

Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children ≤2 years of age), and headache.

a Division of Emergency Medicine, Department of Internal Medicine, University of California–Davis School of Medicine, Davis, CA, USA

b Department of Pediatrics, University of California–Davis School of Medicine, Davis, CA, USA

c Department of Radiology, University of California–Davis School of Medicine, Davis, CA, USA

d Department of Emergency Medicine, Oregon Health Sciences University, School of Medicine, Portland, OR, USA

Address for reprints: Nathan Kuppermann, MD, MPH, University of California–Davis Medical Center, PSSB 2100, 2315 Stockton Boulevard, Sacramento, CA 95817-2282; 916-734-1535, fax 916-734-7950

This article is dedicated to the memory of our beloved friend and colleague, James Seidel, MD, PhD, who was a tireless and vocal advocate for the health and welfare of children.

Author contributions: MJP and NK conceived the study and obtained funding for the study. MJP, NK, REG, JFH, JWS, and RWD designed the study. MJP, NK, JFH, CWV, REG, BAS, and MJH participated in data collection, SLWG participated in radiographic interpretation, NK and MJP analyzed and interpreted the data, and MJP and NK drafted the manuscript. All authors participated in manuscript review and revision. MJP takes responsibility for the paper as a whole.

Presented in part at the 3rd National Congress for Emergency Medical Services for Children, Dallas, TX, April 2002, the Pediatric Academic Society national meeting, Baltimore, MD, May 2002, and the Society of Academic Emergency Medicine national meeting, St. Louis, MO, May 2002.

Supported by a Hibbard E. Williams Grant, University of California–Davis School of Medicine; Faculty Research Grant, University of California–Davis School of Medicine; and a Children's Miracle Network Grant.

PII: S0196-0644(03)00425-6

doi:10.1067/S0196-0644(03)00425-6

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