I’ve previously written about clinically important traumatic brain injuries (ciTBI) a number of times. After the initial publication of the landmark PECARN ciTBI study in 2009 there have been several secondary analyses looking at individual isolated symptoms. See here for isolated loss of consciousness and risk of ciTBI and here for isolated vomiting and risk of ciTBI. A recent study in JAMA Pediatrics looked at isolated parental/guardian report of the child acting abnormally.

Obviously “acting abnormally” is a very subjective thing, colored by the child’s developmental status and the circumstances of the ED visit. With that being said, we should trust parents and guardians, as they are “world experts” in their own children. So, if they say that their child is “not acting like him/herself” we should believe them.

In the aforementioned secondary analysis of the original PECARN ciTBI study the authors again considered the outcomes of ciTBI

  • Death
  • Neurosurgery
  • Intubation for >24 hours
  • Hospitalization for ≥2 nights

…And just good ole TBI on CT imaging in children.

This time the focus was on guardian report of the child acting abnormally with no other concerning findings for TBI. They noted the following;

  • A small subset of the original children were reported as acting abnormally (1297/43,399) – and 411/1297 (31.7%) had this as their only finding
  • Only 1/411 – 0.2% (95% CI, 0-1.3%) had a ciTBI
  • CT scans were performed in 185 children, and only 4 had any sort of TBI at all – 2.2% (95% CI 0.6%-5.4%)

The rates of TBI were higher in children that were reported as acting abnormally AND had another concerning finding (such as vomiting, loss of consciousness etc,.);

  • 29/886 – 3.3% (95% CI 2.2%-4.7%) had ciTBIs
  • 66/674 – 9.8% (95% CI 7.7%-12.3%) had any TBI on CT

Ultimately this study again drives home the point that ciTBI, and TBI in general are rare in children with closed head injury. Isolated report of the child acting abnormally without any other findings is not associated with a significant incidence of TBI. These children are appropriate to observe in the ED in lieu of getting a CT scan. Children with other concerning findings however (GCS <14, LOC, abnormal neuro exam, vomiting, severe mechanism) are more concerning and the threshold to scan should be lower.