Next up from the top ten articles presented at the recent AAP NCE in San Diego is a secondary analysis from the PECARN head injury study published in Lancet in 2009. I’m sure that most have you have seen a child who hit their head with vomiting as their only symptom. The authors compared children with isolated vomiting versus those with vomiting and something else. That something else is further elaborated by the following “extensive definition:”

Patient less than 18 years old with:

  • No history of LOC
  • GCS/Pediatric GCS score of 15
  • No signs of altered consciousness (eg, sleepiness, agitation)
  • No palpable skull fracture or signs of basilar skull fracture
  • Acting normally per parent/guardian
  • No scalp hematoma or other traumatic scalp finding (eg, abrasion or laceration)
  • No headache (for patients 2–18 y)
  • No seizure after the head trauma
  • No neurologic deficits (eg, motor or sensory abnormalities)
  • No amnesia (for patients 2–18 y)

The two outcomes of the study were:

Clinically important traumatic brain injury (ciTBI)

  • Death
  • Neurosurgical procedure
  • Intubation for at least 24 hours
  • Hospitalization for 2 or more nights because of the head trauma in association with TBI on cranial CT

Traumatic brain injury on CT, defined as “any acute traumatic intracranial finding or a skull fracture depressed by at least the width of the skull.”

Association of traumatic brain injuries with vomiting in children with blunt head trauma

Dayan PS, Holmes JF, Atabaki S, Hoyle J Jr, Tunik MG, Lichenstein R, Alpern E, Miskin M, Kuppermann N; Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Annals of Emergency Medicine, 2014

The bottom line

The risk of TBI in children with head injury and isolated vomiting is very low, and thus many children can be observed in lieu of obtaining a head CT

What they did

The authors performed a secondary analysis of the original 42,112 patients in the original Lancet study and compared 815 patients with isolated vomiting and 4,577 patients with non-isolated vomiting. They found:

  • ciTBI in 2/815 (0.2%; 95% CI 0% to 0.9%) in the isolated vomiting group versus 114 of 4,577 (2.5%; 95% CI 2.1% to 3.0%) with nonisolated vomiting (difference -2.3%, 95% CI -2.8% to -1.5%)
  • Noting that many patients diddid get a CT, they found “garden variety” TBI on CT in 5 of 298 (1.7%; 95% CI 0.5% to 3.9%) with isolated vomiting versus 211 of 3,284 (6.4%; 95% CI 5.6% to 7.3%) with nonisolated vomiting (difference -4.7%; 95% CI -6.0% to -2.4%)
  • No significant independent associations between prevalence of either outcome with respect to timing of vomiting or proximity to last episode of vomiting

What you can do

  • Do a thorough H&P and assess for all of the items on the extensive definition lis
  • Use those to help you determine if the child has isolated vomiting or if there is something else
  • If there are other concerning findings the risk of ciTBI is 2.5% versus 0.2% – so you should strongly consider ordering a head CT
  • If the child has isolated vomiting consider observation in the ED – the length of that observation os dependent on the child and your and the parents’ comfort. Note that blood accumulating inside the skull will generally do bad things within 4-6 hours in the cranium with closed sutures.