The Effect of Observation on Cranial Computed Tomography Utilization for Children After Blunt Head Trauma

• Published in: Pediatrics (Evanston) Vol. 127; no. 6; pp. 1067 - 1073
• Main Authors: NIGROVIC, Lise E, SCHUNK, Jeff E, FOERSTER, Adele, COOPER, Arthur, MISKIN, Michelle, ATABAKI, Shireen M, HOYLE, John, DAYAN, Peter S, HOLMES, James F, KUPPERMANN, Nathan
• Format: Journal Article
• Language: English
• Published: Elk Grove Village, IL American Academy of Pediatrics 01-06-2011
• Subjects: Adolescent; Adult and adolescent clinical studies; Biological and medical sciences; Brain; Child; Child, Preschool; Childrens health; Female; Follow-Up Studies; General aspects; Head injuries; Head Injuries, Closed - diagnostic imaging; Humans; Injuries of the nervous system and the skull. Diseases due to physical agents; Male; Medical sciences; Organic mental disorders. Neuropsychology; Pediatrics; Prospective Studies; Psychology. Psychoanalysis. Psychiatry; Psychopathology. Psychiatry; Risk Assessment; Sensitivity and Specificity; Skull - diagnostic imaging; Tomography; Tomography, X-Ray Computed - utilization; Trauma Centers; Trauma Severity Indices; Traumas. Diseases due to physical agents; Human; computed tomography; Pediatrics; Nervous system diseases; Radiodiagnosis; Craniocerebral; Use; traumatic brain injury; Hemorrhage; clinical observation; Observation; Medical imagery; Skull; Computerized axial tomography; Head trauma; Child
• ISSN: 0031-4005; 1098-4275
• DOI: 10.1542/peds.2010-3373

Children with minor blunt head trauma often are observed in the emergency department before a decision is made regarding computed tomography use. We studied the impact of this clinical strategy on computed tomography use and outcomes.
We performed a subanalysis of a prospective multicenter observational study of children with minor blunt head trauma. Clinicians completed case report forms indicating whether the child was observed before making a decision regarding computed tomography. We defined clinically important traumatic brain injury as an intracranial injury resulting in death, neurosurgical intervention, intubation for longer than 24 hours, or hospital admission for 2 nights or longer. To compare computed tomography rates between children observed and those not observed before a decision was made regarding computed tomography use, we used a generalized estimating equation model to control for hospital clustering and patient characteristics.
Of 42 412 children enrolled in the study, clinicians noted if the patient was observed before making a decision on computed tomography in 40 113 (95%). Of these, 5433 (14%) children were observed. The computed tomography use rate was lower in those observed than in those not observed (31.1% vs 35.0%; difference: -3.9% [95% confidence interval: -5.3 to -2.6]), but the rate of clinically important traumatic brain injury was similar (0.75% vs 0.87%; difference: -0.1% [95% confidence interval: -0.4 to 0.1]). After adjustment for hospital and patient characteristics, the difference in the computed tomography use rate remained significant (adjusted odds ratio for obtaining a computed tomography in the observed group: 0.53 [95% confidence interval: 0.43-0.66]).
Clinical observation was associated with reduced computed tomography use among children with minor blunt head trauma and may be an effective strategy to reduce computed tomography use.