A period of clinical observation in the emergency department for children with blunt head trauma can decrease utilization of cranial CT scans, a secondary analysis of a large study showed.
In children who were observed before the clinician determined whether the scan was needed, the rate of CT use was 31.3% compared with 35% in children without a period of observation. This represents a significant difference of −3.9% (95% CI −5.3 to −2.6), according to Lise E. Nigrovic, MD, of Harvard Medical School in Boston, and colleagues.
However, the rate of clinically important brain injury was similar in those observed and those not observed, at 0.75% and 0.87%, for a difference of −0.1% (95% CI −0.4 to 0.1), the researchers reported in the June Pediatrics.
The use of cranial CT in the emergency department has been increasing even though procedure carries risks for later malignancy, particularly in young patients whose tissues are more susceptible to the effects of ionizing radiation.
Nigrovic and colleagues analyzed data from a prospective cohort study that included 40,113 patients younger than 18 years presenting with head trauma.
"Clinically important" traumatic brain injury was one that resulted in death, the need for neurosurgery, intubation for more than a day, or hospitalization for two nights or longer.
The median age of the children was 5.6 years and almost two-thirds were boys. A total of 14% of the patients were observed and 86% were not.
When the researchers looked at clinical characteristics of children who were observed, they found that these patients were more likely to be younger and to have had a mechanism of injury that was more severe, such as being thrown from a vehicle in an accident.
Observed children also were more likely to have lost consciousness, to have altered mental status, and to have vomited, the researchers reported.
The unadjusted 3.9% difference in rate of CT use represented 39 fewer scans for each 1,000 patients and an 11% relative reduction in the rate of CT use compared with the baseline of 35% CT use in the unobserved group, according to the researchers.
Among the 5,433 children who were observed, 69% were discharged without having had a scan, but 26 later returned to a healthcare facility and had a scan.
Four of the children who later were given a scan had signs of trauma, but only one of these cases was deemed clinically important. The child was hospitalized for two nights but required no further intervention.
Among the 34,680 children who were not observed, 65% were discharged without having a scan and 81 later had scans. The scans for three of those children showed trauma, but none of the children had clinically important injuries.
After adjustment for clinical findings and hospital setting, the likelihood of having a CT scan was lower by about one half in the observed group (OR 0.53, 95% CI 0.43 to 0.66).
The authors noted that the likelihood of having a clinically important injury was similar for the observed and unobserved groups (OR 0.81, 95% CI 0.57 to 1.17).
"Clinical observation before making a decision regarding CT scan use seems to be a safe and potentially effective strategy to manage a subset of children with minor blunt head trauma," the researchers observed.
Limitations of the study included its observational design and the possibility of residual confounding despite adjustment for multiple clinical factors. In addition, the researchers had no information about possible delays in neurosurgery for children in the observation group.
Further work will be needed to establish the optimal duration of observation and to explore the effects of this approach on rates of CT use as well as emergency-department length of stay, they noted.
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