Pediatric minor head trauma: indications for computed tomographic scanning revisited.

BACKGROUND: Although the use of computed tomographic (CT) scanning in severe head trauma is an accepted practice, the indications for its use in minor injury remain ill defined and subjective. We sought to define the incidence and identify risk factors for intracranial injury (ICI) after minor head trauma in children who did not have suspicious neurologic symptoms in the field or on presentation.
METHODS: From January 1, 1992, until April 1, 2000, 569 blunt trauma patients (age < 16 years) with a Glasgow Coma Scale score of 14 or 15 triaged by American College of Surgeons Pediatric Mechanism Criteria at a Level I trauma center received head CT scan. Loss of consciousness (LOC) status was known for 429. This subgroup was retrospectively reviewed for mechanism, age, Injury Severity Score, LOC status, GCS score, associated injuries, and CT scan findings (normal, fracture only, or intracranial injury). Relative risk values for intracranial injury were generated and statistical significance was assessed.
RESULTS: Fourteen percent (62 of 429) of study patients (GCS score of 14 and 15) had ICI. Sixteen percent of patients (35 of 215) with GCS score of 15 and (-)LOC (negative for LOC) had intracranial injury manifesting as subdural hematoma, epidural hematoma, subarachnoid hemorrhage, or brain contusion. Three required surgery for intracranial mass lesions. One patient deteriorated and required intubation and intensive care unit management. Neither (+)LOC (positive for LOC) nor GCS score of 14 increased the likelihood of intracranial injury over those patients without loss of consciousness or with GCS score of 15. Distant injury was also not an independent predictor of ICI for those with GCS scores of 14 or 15, as 84% of the ICI group had head injury only. Skull fracture was a risk factor for ICI but had poor negative predictive value, as 45% of patients with ICI did not have fractures. Similarly, minor craniofacial soft tissue trauma was a significant risk factor (relative risk, 11) that had marginal negative predictive value (0.95), as 14% (9 of 62) of ICI patients did not have superficial craniofacial injury.
CONCLUSION: A normal neurologic exam and maintenance of consciousness does not preclude significant rates of intracranial injury in pediatric trauma patients. Contrary to convention, neither LOC nor mild altered mentation is a sensitive indicator with which to select patients for CT scanning. Skull fractures and superficial craniofacial injury are similarly unreliable. Identification of these patients is important for the occasional case requiring intervention and for the tracking of complications. A liberal policy of CT scanning is warranted for pediatric patients with a high-risk mechanism of injury despite maintenance of normal neurologic status in the field and at hospital screening.