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Three Part Question

In [a child with a head injury] does [vomiting] predict [intracranial injury]?

Clinical Scenario

A 4 year old boy presents to the emergency department following a 1 metre fall onto a carpeted floor. The child has vomited 3 times in the last hour but is otherwise well. Clinical examination is unremarkable. You wonder how significant the vomiting is.

Search Strategy

Medline 1966-07/00 using the OVID interface.
[exp brain injury OR exp craniocerebral trauma OR exp haematoma, epidural OR exp haematoma, subdural OR intracranial haematoma.mp OR "head injury".mp] AND [exp vomiting OR vomiting.mp OR emesis.mp] AND [child OR pediatrics OR paediatric$.mp OR paediatric$.mp] LIMIT to Human AND English AND abstracts.

Search Outcome

Altogether 53 papers were found of which 41 were irrelevant to the question or of insufficient quality for inclusion. The remaining 12 papers are shown in the table. An additional paper of relevance was recently published in this journal, but was not currently indexed on Medline.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Gorman DF, 1987, England	5768 head injuries in all age groups 6685 head injuries in all age groups	Retrospective case note review Prospective patient study	Presence of skull fracture	More common in vomiting children (p<0.005). 7% of all patients vomited. 25.7% of patients with skull fracture vomited	Not specific to children Skull fracture is only a proxy outcome for intracranial problems
Hugenholtz H, et al, 1987, Canada	96 children (GCS 13-15) < 16 yrs 29 children (GCS 8-12) < 16 yrs	Prospective consecutive case series retrospective study of case notes over the previous 2 years	Presence of skull fracture with GCS>12	No difference	Small sample size Skull fracture is only a proxy outcome for intracranial problems
			Presence of skull fracture GCS 8-12	Less common in vomiting children
Chan KH, et al, 1989, Hong Kong	12072 paediatric head injury cases <16 years. Development of intracranial complications manifested during the first 48 hours of injury	Retrospective case note review	Probability of IC complication with impaired conciousness + skull fracture +	62% if vomiting vs 74% if not vomiting	Retrospective audit Identification of risk factors is dependant on accurate documentation (which is unlikely)
			Probability of IC complication with normal consciousness + no skull fracture +	0.08% if vomiting vs 0.14% if vomiting
			Probability of IC complication with impaired conciousness + no skull fracture +	12% if vomiting vs 18% if no vomiting
			Probability of IC complication with no impaired conciousness + skull fracture +	1% if vomiting vs 2% if no vomiting
Ando S, et al, 1992, Japan	147 patients with head injury, all ages, analysed by age group	Prospective cohort study	Presence of skull fracture	No difference between children vomiting and not vomiting	Small study Results not specific to paediatric patients
			Presence of IC haematoma on CT	No difference between children vomiting and not vomiting
Dietrich AM, et al, 1993, USA	324 consecutive trauma patients in an urban childrens hospital requiring CT scanning Mean age 7.1 years	Prospective cohort study	Risk of IC haematoma age <2	76/191 patients with no IC lesion had vomited. 10/36 patients with IC lesion had vomited	Small cohort, low event rate
			Risk of IC haematoma age >2	12/39 patients with no IC lesion had vomited. 0/3 patients with IC lesion had vomited
Duus BR, 1993, Denmark	1876 patients mean age 27.5 (19.9 yrs)	Retrospective case note review	Presence of IC complication	1.2% if vomiting vs 0.2% if not vomiting	Intracranial complication not defined Retrospective All age groups
Schunk JE, et al, 1996, USA	508 patients aged <18 undergoing CT scan for head trauma. 179 excluded for decreased GCS,depressed skull #, bleeding diathesis or develpmental delay.	Retropsective case note review	Abnormal CT findings	5.5% if vomiting vs 3.4% if not vomiting	No protocol for CT request, inclusion based on physician request Referral bias (major trauma centre)
Arienta C, et al, 1997, Italy	10,000 patients with head injury aged between 6 and 95 years (median age 31 years)	Prospective cohort study	Abnormal CT result	4 of 213 patients with single episode of vomiting had abnormal CT result. 6 of 14 patients with repeated vomiting had an abnormal CT result	Not specific to the paediatric population Low event rate
Hsiang JN, et al, 1997, Hong Kong	1360 patients with mild head injury older than 11 years of age	Prospective cohort study	Radiographic abnormailty in GCS 13 group	4 patients with vomiting vs 11 patients with no vomiting (p=1)	Not specific to paediatric population
			Radiographic abnormality in GCS 14 group	8 patients with vomiting vs 16 patients with no vomiting (p=0.68)
			Radiographic abnormailty in GCS 15 group	30 patients with vomiting vs 93 with no vomiting (p=0.924)
Miller EC, et al, 1997, USA	2143 patients of all ages with a history of head injury within 2 hours of arrival at the emergency department	Prospective cohort study	Abnormal CT scan	15% if vomiting vs 5% if not (p<0.001). 20% if nauseous vs 9% if not (p<0.001)	Not specific to paediatric population
Quayle KS, et al, 1997, USA	322 consecutive paediatric patients with head injury. All patients had xray and CT	Prospective cohort study	Odds ratio for vomiting predicting intracranial injury	1.51 (95% CI=0.67 – 3.37)	Non trivial injuries excluded Resultant event rate for IC injury is therefore increased Not all patients had the gold standard investigations
			Postive predictive value for vomiting predicting intracranial injury	10.9%
			Negative predictive value for vomiting predicting intracranial injury	92.5%
Nee P, et al, 1999, UK	5416 consecutive patients with head injury, over one year period	Prospective cohort study	Incidence of vomiting in children	12%	Skull fracture is only a proxy outcome for intracranial problems Methods suggest that additional follow up data was collected, but it is not reported
			Sensitivity of detecting skull fracture if child and vomiting	33.3%
			Specificity of detecting skull fracture if child and vomiting	93.3%
			Likelihood ratio for child and vomiting (our calc)	4.9
Brown FD, et al, 2000, UK	563 patients aged 0-13 with minor head injury presenting to a paediatric A+E	Prospective cohort study	Incidence of vomiting	15.8%	Only minor head injury patients included Not all patients were x-rayed or scanned Very few patients with significant intracranial pathology
			Incidence of skull fracture	<1%
			Incidence of skull fracture + vomiting	0%

Comment(s)

The papers listed above give varied opinions on the significance of vomiting following paediatric head injury, and it is difficult to draw firm conclusions. Some of the studies combine paediatric and adult cases, this is likely to lead to some bias in the reported significance of vomiting.

Clinical Bottom Line

Vomiting does not appear to be an independent risk factor for skull fracture or IC haematoma in the paediatric population.

Level of Evidence

Level 2 - Studies considered were neither 1 or 3.

References

1. Gorman DF. The utility of post-traumatic skull X-rays. Arch Emerg Med 1987;4(3):141-150.
2. Hugenholtz H, Izukawa D, Shear P, et al. Vomiting in children following head injury. Childs Nerv Syst 1987;3(5):266-270.
3. Chan KH, Yue CP, Mann KS. The risk of intracranial complications in pediatric head injury. Results of multivariate analysis. Childs Nerv Syst 1990;6(1):27-29.
4. Ando S, Otani M, Moritake K. Clinical analysis of post-traumatic vomiting. Acta Neurochir (Wien) 1992;119(1-4):97-100.
5. Dietrich AM, Bowman MJ, Ginn-Pease ME, et al. Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography? Ann Emerg Med 1993;22(10):1535-1540.
6. Duus BR, Boesen T, Kruse KV, et al. Prognostic signs in the evaluation of patients with minor head injury. Br J Surg 1993;80(8):988-991.
7. Schunk JE, Rodgerson JD, Woodward GA. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Paed Emerg Care 1996;12(3):160-165.
8. Arienta C, Caroli M, Balbi S. Management of head injured patients in the emergency department: a practical protocol. Surg Neurology 1997;48(3):213-219.
9. Hsiang JN, Yeung T, Yu AL, et al. High-risk mild head injury. J Neurosurg 1997;87(2):234-238.
10. Miller EC, Homes JF, Derlet RW. Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients. J Emerg Med 1997;15(4):453-457.
11. Quayle KS, Jaffe DM, Kuppermann N, et al. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? Pediatrics 1997;99(5):E11.
12. Nee PA, Hadfield JM, Yates DW, et al. Signficance of vomiting after head injury. J Neurol Neurosurg Psychiatry 1999;66(4):470-473.
13. Brown FD, Brown J, Beattie TF. Why do children vomit after minor head injury? J Accid Emerg Med 2000;17:268-271.