Watching Head Injury Without CT

CT scans required less often with longer emergency room observation

(RxWiki News) Head injuries are scary for parents. Hundreds of thousands of children go to the hospital each year for head injuries but fortunately, few of those injuries are serious.

Physicians often order computed tomography, or CT scans, to diagnose brain injuries. CT scans can help doctors see if there is serious damage. However, CTs also expose children to unhealthy radiation, which can increase the child's risk for tumors.

New research has found that longer observation in the emergency department can help avoid unnecessary CTs. This practice can protect children from needless exposure to radiation while preventing further problems.

"Go to the ER for pediatric head injuries."

Deborah Schonfeld, MD, from Boston Children’s Hospital, and colleagues conducted this study to look at the effect of the emergency department observing children with minor head injuries on CT scans.

The researchers watched 1,381 children with head injuries at an emergency room. All children were under 18 years of age with an injury in the previous 24 hours. Children with very minor injuries were excluded. Children with other serious disorders such as brain tumors were also excluded.

This study lasted from April 27, 2011 to December 31, 2012.

The researchers gathered information about whether each child was “observed” in the ER or “nonobserved.”

In this study, “observed” referred to children that physicians chose to watch for a period of time before deciding whether to order a CT scan. “Nonobserved” children meant that physicians either decided immediately to order a CT scan or immediately released.

The researchers also gathered information from the physicians about how the symptoms changed while the patients were observed. Medical records were reviewed for seven days following the emergency room visit to see if the child received additional care.

The study found that, overall, 20 percent (271) children had a CT performed and one child had a cranial MRI (magnetic resonance imaging). Forty-nine percent (676) of the children were observed prior to making a decision about CT. Of the remaining 51 percent (705), 34 percent (240) of the children had a CT scan immediately. Sixty-six percent (465) of those children were immediately discharged.

The researchers found that older children were more likely to be observed prior to a decision being made about ordering a CT scan. They also found that intermediate-level injuries were more often held in the emergency room for observation.

Most of the children’s symptoms, including vomiting, severe headaches and abnormal behavior, improved during observation.

The researchers determined that the longer a child was observed in the emergency department, the less likely they were to have a CT scan. When symptoms resolved, the patients were sent home from the hospital.

The authors stated that due to long life expectancies, children are more sensitive to radiation than adults. Radiation in childhood, the researchers said, increases a child's risk for leukemia and brain cancer.

By observing the children for longer periods in the emergency department, physicians can reduce the exposure to radiation and risk for cancer.

“As emergency physicians, we must balance the possibility of missing a clinically significant traumatic brain injury with the future risk of malignancy associated with ionizing radiation exposure,” Lise Nigrovic, MD, MPH, one of the study's authors, said in a press release.

“Observation prior to CT decision-making has the potential to further reduce CT rates without missing children with significant injuries, further improving the emergency care of children with minor blunt head injury.”

Chris Galloway, MD, the Medical Director at DaVita Clinical Research agrees. 

"CT scans are fast, accurate, and can reduce your ER length of stay," he explains. "That doesn't mean they are always the best choice. This is particularly important in our pediatric population where we want to minimize radiation exposure while not missing diagnoses.

"This study demonstrates that in a low risk pediatric head injured population, observation is often all that is needed to rule out serious head injury negating the need for radiation. This will increase the length of time you are in the ER and needs to be a combined risk evaluation decision made between the parents and caregivers." Galloway told dailyRx News.

The researchers noted that their research had several imperfections, such as collecting data from only one institution and relying on medical records. They noted additional research should be done to verify their results.

This study was published in the August edition of the Annals of Emergency Medicine.

The research was funded by a Childhood Research Grant from the Hood Foundation and a House Officer Development Award from Boston Children’s Hospital. The authors reported no conflict of interest. 

Review Date: 
August 7, 2013