Management of paediatric minor head injuries. Safe discharge?
Date First Published:
August 24, 2011
Last Updated:
April 17, 2013
Report by:
Dr Fiona Hunter, ST4 Emergency Medicine (Yorkhill Hospital. Glasgow, UK)
Search checked by:
Dr Vincent Choudhery, Yorkhill Hospital. Glasgow, UK
Three-Part Question:
In [paediatric patients with minor head injury, GCS 15 and no focal neurological deficit] does a [normal computed tomography brain scan] allow [safe discharge]
Clinical Scenario:
A 7 year old presents to the emergency department following a minor head injury with repeated vomiting. He is GCS 15 on assessment with no focal neurological deficit. Cranial CT scan is normal. You would like to know if he can be safely discharged to a capable parent.
Search Strategy:
Medline 1948-11/12 (week 1) using the OVID interface.
Search Details:
[head injury.mp OR head trauma.mp OR exp craniocerebral trauma] AND [exp patient admission OR exp observation OR patient discharge OR exp hospitalisation] AND [exp child OR exp pediatrics OR exp child, preschool/OR exp infant OR exp infant, newborn] AND [exp tomography, xray, computed OR ct head.mp OR ct brain.mp] limit to English language AND humans
Outcome:
Altogether 98 papers were found in Ovid and Cochrane, of which 91 were irrelevant or of insufficient quality. A further 2 papers were found by scanning the references of relevant papers. All relevant papers are summarised in the table.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Management of accidental minor head injuries in children: a prospective outcomes study. Dias MS, Lillis KA, Calvo C et al. 2004, USA | 215 Patients with head injury >2-year-old, GCS >12 and at least one of following: more than brief LOC, significant amnesia, >1 episode of vomiting, persistent lethargy | Prospective cohort | Follow-up phone call at 1 day post-discharge | No abnormalities on CT scan. Two children returned due to persistent vomiting, repeat scans normal in both cases | Poor follow-up rate. Telephone follow-up abandoned after 2 months |
| Evaluation of minor head injury in children. Mitchell KA, Fallat ME, Raque GH et al. 1994, USA | 401 Patients <18 years with GCS >12 who were admitted for observation following head injury; 218 of the children had a CT scan, the rest of the children only had skull x-ray. 51 Patients had GCS 15, normal neuro exam and normal radiological exam | Retrospective review. | Follow-up to document occurrence and duration of symptoms | No adverse events in the subset of patients with normal GCS, neuro exam and radiological investigations | Small subset applicable to question. Radiological examination was CT or plain x-ray or both. Limited follow-up |
| The use of cranial CT scans in the triage of pediatric patients with mild head injury. Davis RL, Hughes M, Gubler KD et al. 1995, USA | 400 Patients <18 years with GCS >12 and negative CT scan following head injury | Retrospective case-series study. | Readmission or death within 1 month of head injury | Four patients were readmitted. One patient taking coumarin was found to have a subdural haematoma and required surgery. One child was admitted with a symptomatic haemorrhagic contusion. One child was readmitted following a seizure but the repeat scan was normal. The fourth child was admitted with ‘concussion symptoms’ and admitted for observation but not rescanned | Only 78% had a GCS of 15 on admission. Of the four readmitted patients the original GCS is not stated; 76 (18%) of the normal CT scans were subsequently read as abnormal in the formal report. Follow-up relied on a statewide database |
| Closed head injuries in children: is hospital admission always necessary?. Dahl-Grove DL, Chande VT, Barnoski A. 1995 USA | 62 Patients with closed head injury <18 years, GCS >12 and normal cranial CT scan |
Retrospective review. | ED and hospital course, radiographic studies and follow-up | 56/62 Patients had GCS 15 on attendance. No patients developed any neurological deterioration | Small study. Criteria for cranial CT scan and subsequent admission could not be determined by chart review. No long-term follow-up |
| The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Schunk JE, Rodgerson JD, Woodward GA. 1996 USA | 313 Patients with head injury <18 years, GCS 15, no focal neurological deficit and cranial CT scan | Retrospective review. | Results of CT scans, disposition and outcome | Of the 300 patients with no intracranial injury on CT 159 were discharged and 141 were admitted. Three discharged patients re-attended, none had a new ICI on repeat scan. Of the 141 admitted patients, five had repeat scan: two normal, one small contusion–managed conservatively, two showed skull fractures | Study centre is major referral centre for paediatric trauma so may be selection bias. No departmental protocol for obtaining a CT scan. Poor documentation of symptoms noted. No formal follow-up |
| Minimal head trauma in children revisited: is routine hospitalisation required?. Roddy SP, Cohn SM, Moller BA et al. 1998, USA | 62 Patients with head injury <16 years, normal neurological exam, normal CT scan | Retrospective review. | Deterioration in CNS exam, new CT findings, need for prolonged (>24 h) hospital stay | No child developed any significant CNS sequelae | Small study. Few infants included. Author suggests that non-verbal children should be excluded from safe discharge. No long-term follow-up |
| How should we manage children after mild head injury?. Mandera M, Wencel T, Bazowski P et al. 2000, Poland | 166 Patients <18 years, with head injury and GCS >12 on admission | Retrospective review. | Subsequent deterioration | 95 (57%) Patients had GCS of 15 on attendance. Only 28 (17%) had normal CT scan. Six patients with a normal initial scan had a haematoma present on a subsequent scan | High proportion of children had neurological symptoms at presentation. High proportion of abnormal CT scans and need for surgical intervention as tertiary referral centre |
| Mandatory admission after isolated mild closed head injury in children: is it necessary?. Adams J, Frumiento C, Shatney-Leach L et al. 2001, USA | 1033 Patients <18 years with head injury and GCS of 15. 386 Patients had a cranial CT |
Retrospective review. | Length of stay and any required procedures or complications | No neurosurgical intervention required in any of the patients | No breakdown of study results. No follow-up. Focal neurology not mentioned |
| Should patients with normal cranial CT scans following minor head injury be hospitalized for observation? Ros SP, Ros MA. 1989, USA | 73 Patients <18 years with a history of minor head injury GCS >12, and a normal CT scan | Retrospective review | Complications/adverse events | No neurological complications and no re-attendances following discharge | Small, retrospective study |
| Necessity of hospital admission for pediatric minor head injury. Spencer MT, Baron BJ, Sinert R et al. 2003, USA | 197 Patients with head injury, age <14 years and GCS 15, no focal neurological signs on exam and normal CT scan | Retrospective review | Delayed inhospital complications defined as focal neurological deficit, intracranial bleeding, worsening mental status or recurrent seizures | None of the 197 patients had delayed complications resulting from their head injury. Five patients had persistent symptoms: three headache, two vomiting. One patient had repeat scan due to vomiting but this was normal | No long-term follow-up. Included patients with concomitant trauma |
| Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation? Holmes JF, Borgialli DA, Nadel FM, et al. 2011, USA | 13 543 Patients <18 years presenting after head injury with GCS >13 and normal CT scan to 25 centres over a 2-year period | Prospective cohort study | Need for repeat imaging and neurosurgical intervention | Of 11 058 patients discharged from the ED, 197 (2%) had a subsequent CT or MRI scan, five of these showed an abnormality and no children needed neurosurgical intervention. Of the 2485 patients admitted to hospital, 137 (6%) received a subsequent CT or MRI scan, 16 or these were reported as abnormal and no children required neurosurgical intervention | Only 79% of discharged patients followed up successfully by phone or letter although medical record and morgue review was carried out for the remainder |
Author Commentary:
With the exception of the study by Mandera et al, in which six patients developed intracranial haematomas following an initial normal scan, the number of paediatric patients developing complications following a head injury with a normal scan and a presenting GCS greater than 12 is thankfully small. When the data are available, the risks appear to be even lower for patients who have attended with a GCS of 15. The Mandera study was carried out at a tertiary referral centre and appears to have selected a higher risk population than the other studies with a very high incidence of abnormal scan, abnormal neurological examination findings and the need for neurosurgical intervention.<br><br>The study by Holmes et al provides great reassurance by demonstrating an extremely low risk of developing injury that is detectable with radiological investigation; no patients from a study population of 13 543 children with minor head injuries required neurosurgical intervention.
Bottom Line:
In patients with minor head injuries and no known bleeding risks, who are GCS 15 on arrival, have no focal neurological deficit on examination and who have had an normal CT scan, hospital admission is unnecessary if a capable parent is willing to take the child home.
References:
- Dias MS, Lillis KA, Calvo C et al.. Management of accidental minor head injuries in children: a prospective outcomes study.
- Mitchell KA, Fallat ME, Raque GH et al.. Evaluation of minor head injury in children.
- Davis RL, Hughes M, Gubler KD et al.. The use of cranial CT scans in the triage of pediatric patients with mild head injury.
- Dahl-Grove DL, Chande VT, Barnoski A. . Closed head injuries in children: is hospital admission always necessary?.
- Schunk JE, Rodgerson JD, Woodward GA. . The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department.
- Roddy SP, Cohn SM, Moller BA et al.. Minimal head trauma in children revisited: is routine hospitalisation required?.
- Mandera M, Wencel T, Bazowski P et al.. How should we manage children after mild head injury?.
- Adams J, Frumiento C, Shatney-Leach L et al.. Mandatory admission after isolated mild closed head injury in children: is it necessary?.
- Ros SP, Ros MA.. Should patients with normal cranial CT scans following minor head injury be hospitalized for observation?
- Spencer MT, Baron BJ, Sinert R et al.. Necessity of hospital admission for pediatric minor head injury.
- Holmes JF, Borgialli DA, Nadel FM, et al. . Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?