If you recall from my previous post we were considering when to get a head CT on a pediatric patient with a closed head injury, and specifically how to approach this with the family. In general I find that its best to be honest and discuss the criteria outlined in the Kuppermann article (you know the one). It investigated risk of CT documented clinically important TBI (ciTBI) in children. A ciTBI is one that lead to death, neurosurgical intervention, stay in the hospital for >2 days and intubation for ≥24 hours. The population split between <2 and >2 years of age.

Children <2 years

If any of the following is positive the risk of ciTBI is 4.4% – so you’ll probably want to get a head CT:

  • If GCS <15
  • Palpable skull fracture
  • Altered mental status

If the first three are negative, and if any of the following are positive consider CT or observation, as the risk of ciTBI is 0.9%:

  • Non-frontal hematoma
  • LOC ≥ 5 sec
  • Severe injury mechanism
    • MVC with patient ejection, death of another passenger, or rollover
    • Pedestrian or bicyclist without helmet struck by a motorized vehicle
    • Fall >3 feet
    • Head struck by a high-impact object
  • Not acting normal per parent

If none of the factors are present than the risk of ciTBI is <0.02%. Ct is not routinely recommended.

Children >2 years

If any of the following is positive the risk of ciTBI is 4.3% – so you’ll probably want to get a head CT:

  • If GCS <15
  • Basilar skull fracture (hemotympanum, raccoon eyes)
  • Altered mental status

If the first three are negative, and if any of the following are positive consider CT or observation, as the risk of ciTBI is 0.9%:

  • LOC ≥ 5 sec
  • History of vomiting
  • Severe headache
  • Severe injury mechanism
    • MVC with patient ejection, death of another passenger, or rollover
    • Pedestrian or bicyclist without helmet struck by a motorized vehicle
    • Fall >5 feet
    • Head struck by a high-impact object

If none of the factors are present than the risk of ciTBI is <0.02%. CT is not routinely recommended.

Recall that the highest risk factors, those associated with >4% chance of clinically important TBI are:

  • GCS score <15
  • Altered mental status
  • Skull fracture apparent on exam (you can feel it, or hemotympanum)

Further exploration of this data in patients with vomiting alone as well as isolated loss of consciousness has been performed and is well worth your time.

Even if there is a parental expectation of a getting a head CT even before you enter the room, I’ve found that most parents understand where you’re coming form when you approach things in a straightforward and honest manner. They just want what’s best for their kid – scan or not after all.

Here is my response to each of the three scenarios:

Case #1

10 year old after a bike accident
The first patient was a school aged male whose bike failed him, and whose helmet was hanging in his garage. He ended up introducing his occiput to the pavement, though his recollection of this event was foggy at best. His sensorium was mired in the same fog.

This patient has altered mental status. Whether or not his GCS is 15 this probably nets him a head CT. This one can be tough, especially in younger patients. Distinguishing AMS from the infant who is “not acting right” per the parents is hard. There is a 4-fold difference in risk between the two, so a hardy understanding of normal childhood development and trust in your gut, and the parents’ experience is key. Observation will also help you tease things out. Kids with TBI and AMS tend to stay that way or get worse – not normalize.

Case #2

7 month old infant falls from mom's arms
An infant, who despite her mother’s best efforts, wriggled free from her arms and fell to the concrete below. The baby cried immediately, and aside from the large hematoma on her forehead, looked great.

In this scenario it is important to determine how far the kid fell. Taking a good history is key. If this baby is looking fine, and fell from >3 feet there is technically a 0.9% of a ciTBI. However if the history signs up, and the baby continues to look well over a 4-6 hour period since the fall, then you can probably be reassured that they fit into the 99.1% of this group.

Case #3

2 ½ year old hit head on concrete - two days ago
A toddler struck the front of his head on the driveway – 2 days ago. A visit to an urgent care, and a ‘medical’ neighbor later – had filled the family with enough information to seek care at my ED as they wondered whether or not their robust toddler needed a head CT.

This one seems like a “no-brainer,” the injury was two days ago! But what about those parents that still demand a scan for their child who is making shadow puppets with the otoscope light? First, it’s important to address their concerns honestly and without pretension. Find out what they are worried about. Perhaps they had a family member who died in a car crash. Or just had an experience where “the doctors missed something.” It’s also important to remember that we aren’t perfect diagnostic machines. Parents do know their children best. And on the flip side, if a situation seems fishy, especially in cases of suspected non accidental trauma, go ahead and get the scan.

 

The bottom line is that you should be familiar with how to explain the current evidence to your patients, and to openly acknowledge the risks, benefits, and parental concerns. Even with zero of the predictors for clinically important traumatic brain injury, there is still a 0.5% chance that the kid has a head bleed – even if they look perfect. Every parent – including this one – views their kid as one in a million.