Use CT Selectively In Head Injuries

Family Pratice News,  Feb 1, 2000  by Heather Lindsay

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Computed tomography scans are not necessary in many children who have had a minor closed-head injury, according to a new practice guideline issued jointly by the American Academy of Pediatrics and the American Academy of Family Physicians.

The guideline provides an evidence-based approach for managing the child who has had a minor head injury with no loss of consciousness and the child with a head injury who has sustained a brief loss of consciousness. It includes an algorithm to outline the decision-making process.

For a child with no loss of consciousness, observation in the office, emergency department, or at home by a competent individual for at least 24 hours is recommended.

For a child with brief loss of consciousness (less than 1 minute), either imaging or observation in the office, emergency department, home, or hospital are approaches equally supported by current evidence. Choice among these depends on clinical judgment, based on the child and family and the practice setting, said Dr. Charles Homer, chair of the Committee on Quality Improvement of the American Academy of Pediatrics, which helped draft the guideline.

The guideline encourages physicians to obtain emergency consultation and consider emergency imaging in a child who has abnormal results on a skull or eye examination, on a neurological exam, or who exhibits symptoms of intracranial problems that develop during the course of observation.

When imaging is deemed necessary cranial computed tomography is preferable to magnetic resonance imaging; skull radiography is discouraged.

The document, based on a review of the literature and expert consensus, should not be the only reference a physician uses in evaluating head injury and should not override professional judgment, Dr. Homer emphasized.

Dr. Ted Ganiats, a member of the Commission on Clinical Policies and Research of the American Academy of Family Physicians, the committee that cowrote the guideline, also advised against overdependence on it. He explained that the guideline was developed to help physicians understand which factors were important in the management of head trauma, not to dictate treatment.

In an interview, he discussed why the guideline does not recommend routine CT scans for all children with mild dosed-head trauma. "There has long been this sense that a child with head trauma needs an evaluation more for medicolegal reasons [than] because there's a realistic threat to his or her safety" he said.

Getting a CT scan may be the "play it safe" option, but it's also costly inconvenient, distressing for children, and probably beneficial in less than 2% of cases, said Dr. Ganiats of the University of California, San Diego. The scans can trigger risky and unnecessary intervention, he added.

"In a lot of kids, the CT scan will show bleeding, even when intervention isn't necessary, and they'll get needless intervention, which carries a risk of infection and unnecessary surgery trauma," he said.

Other times, a CT scan may reveal a normal variant that can make parents worry that their child has a brain defect, when in fact the child is normal.

Even though a CT scan can detect problems far earlier than observation, that does not necessarily lead to a better outcome. Intervention after symptoms have developed is almost as effective as intervention based on the results of a CT scan, Dr. Ganiats said.

However, Dr. Homer noted that many parents and clinicians may not be willing to accept even a small risk of an adverse outcome and may prefer to use CT imaging. "The evidence does not provide a clear answer as to which course is preferred and that is why the approach is left up to the clinician and the family."

The guideline applies only to the specific population of children for which there is adequate research to support recommendations. These are children 2-20 years old with an isolated minor closed-head injury seen within 24 hours of the injury including those who had temporary loss of consciousness, impact seizure, or vomiting at the time of injury Previous good neurologic health, normal mental status at evaluation, and no physical evidence of skull fracture also are criteria for applying the guideline.

In children who have no loss of consciousness, a CT scan is not necessary since the chance that it will alter the outcome is very small. But it is still an option, dependent on factors such as parental desires, socioeconomic factors, and access to emergency care, Dr. Ganiats said.

For instance, he said, a CT scan is probably unnecessary in a child who meets the guideline's criteria for observation, with no language barrier, whose parents are deemed reliable, and who lives dose to the hospital.

A CT scan might be a good idea in a child with identical clinical symptoms for whom there is a significant language barrier, whose parents may not know what to look for when observing their child for signs of brain damage, who are very concerned and need reassurance that the child is fine, and whose home is 4 hours from the closest hospital.