"Only a small percentage of children with blunt head trauma really have something serious going on," says Doctor Lise Nigrovic, who co-led the study with Doctor Nathan Kuppermann, chair of the Department of Emergency Medicine at UC Davis. "If you can be watched in the ED for a few hours, you may not need a CT." This change in practice would not only be cost-saving, but is better medicine, the researchers say.
Nigrovic and colleagues analyzed the outcomes of children presenting at 25 different emergency departments, as part of a large prospective study conducted by the Pediatric Emergency Care Applied Research Network (PECARN). Of 40,113 children whose records could be analyzed, 5,433 (14 percent) were observed before making a decision about CT use.
Overall, the children who were observed had a lower rate of CT than those not observed (31 vs. 35 percent). When the researchers matched the observed and non-observed groups for severity of head injury and the practice style of different hospitals, this difference was more pronounced: The likelihood of a CT scan in the observed group was about half that of similar non-observed patients (odds ratio, 0.53). In particular, children whose symptoms improved during observation were less likely to eventually have CT.
Allowing for an observation period did not compromise safety, the study found: Clinically important traumatic brain injury -- resulting in death, neurosurgical intervention, intubation for more than 24 hours or hospital admission for two nights or more -- was equally uncommon in the observed and non-observed groups (0.75 vs. 0.87 percent).
Nigrovic and Kuppermann note that cranial CT itself presents additional risks for children. Children's growing brain tissue is more sensitive to ionizing radiation than adults', and because of their longer life expectancy, their lifetime risk of developing a radiation-induced malignancy is greater.
"CT isn't bad if you really need, but you don't want to use it in children who are at low risk for having a significant injury," says Nigrovic. "For parents, this means spending a couple of extra hours in the ED in exchange for not getting a CT. It's the children in the middle risk groups – those who don't appear totally normal, but whose injury isn't obviously severe – for whom observation can really help."
MEDICA.de; Source: Children's Hospital Boston