Continuing onward with the top ten articles presented at the recent AAP NCE in San Diego is yet another secondary analysis of the original PECARN study on clinically important TBI (ciTBI). This time looking at children with isolated loss of consciousness (LOC). The outcomes were ciTBI which resulted in death, neurosurgery, intubation for >24 hours, or hospitalization for ≥2 nights and a comparison of the rates of ciTBIs in children with no LOC, any LOC, and isolated LOC (ie, with no other PECARN ciTBI predictors). They defined LOC as seen in Table 1:
The bottom line
Loss of consciousness is common in head injuries presenting to the ED, but unless it occurs with other worrisome symptoms or historical factors the risk of clinically important traumatic brain injuries is very low and CT scans are likely not necessary.
What they did
Recall that the original study had 42,412 children of which 15.4% had LOC (6.286). The authors of this study included children with blunt head trauma evaluated within 24 hours of injury and GCS >14. They excluded the those with very minor trauma, and those who were significantly injured. In summary they noted the following:
- The prevalence of ciTBI with any history of LOC was 2.5% and for no history of LOC was 0.5% (difference, 2.0%; 95% CI, 1.7-2.5)
- The ciTBI rate in children with isolated LOC, with no other PECARN predictors, was 0.5% (95% CI, 0.2-0.8; 13 of 2780)
- When comparing children who have isolated LOC with those who have LOC and other PECARN predictors (see Table 1 above), the risk ratio for ciTBI in children younger than 2 years was 0.13 (95% CI, 0.005-0.72) and for children 2 years or older was 0.10 (95% CI, 0.06-0.19)
What you can do
- Recognize that up to 1 in 7 children with head injuries may have LOC
- Know that if LOC is the only presenting historical factor the overall risk of ciTBI is very low (<1/200) and not getting a CT scan in lieu of observation may be warranted for many patients
- Recognize that if patients have other symptoms/historical factors AND LOC then the risk of ciTBI is higher, and you may want to consider getting a CT scan
- Know that parents may be very alarmed by witnessing a LOC. Spend time providing reassurance and be thorough in your evaluation and provision of anticipatory guidance.