Vomiting is not an accurate discriminator for serious head injury in children
Date First Published:
March 1, 2000
Last Updated:
October 18, 2002
Report by:
Jim Barnard, Senior House Officer (Manchester Royal Infirmary)
Search checked by:
Simon Carley, Manchester Royal Infirmary
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.
Search Details:
[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.
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):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| The utility of post-traumatic skull X-rays. 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 |
| Vomiting in children following head injury. Hugenholtz H, Izukawa D, Shear P, 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 | ||||
| The risk of intracranial complications in pediatric head injury. Results of multivariate analysis. Chan KH, Yue CP, Mann KS. 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 | ||||
| Clinical analysis of post-traumatic vomiting. Ando S, Otani M, Moritake K. 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 | ||||
| Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography? Dietrich AM, Bowman MJ, Ginn-Pease ME, 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 | ||||
| Prognostic signs in the evaluation of patients with minor head injury. Duus BR, Boesen T, Kruse KV, et al. 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 |
| 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 | 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) |
| Management of head injured patients in the emergency department: a practical protocol. Arienta C, Caroli M, Balbi S. 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 |
| High-risk mild head injury. Hsiang JN, Yeung T, Yu AL, 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) | ||||
| Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients. Miller EC, Homes JF, Derlet RW. 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 |
| Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? Quayle KS, Jaffe DM, Kuppermann N, 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 | 10.90% | ||||
| Negative predictive value for vomiting predicting intracranial injury | 92.50% | ||||
| Signficance of vomiting after head injury. Nee PA, Hadfield JM, Yates DW, 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 | 33.30% | ||||
| Specificity of detecting skull fracture if child and vomiting | 93.30% | ||||
| Likelihood ratio for child and vomiting (our calc) | 4.9 | ||||
| Why do children vomit after minor head injury? Brown FD, Brown J, Beattie TF. 2000, UK | 563 patients aged 0-13 with minor head injury presenting to a paediatric A+E | Prospective cohort study | Incidence of vomiting | 15.80% | 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% |
Author Commentary:
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.
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:
- Gorman DF.. The utility of post-traumatic skull X-rays.
- Hugenholtz H, Izukawa D, Shear P, et al.. Vomiting in children following head injury.
- Chan KH, Yue CP, Mann KS.. The risk of intracranial complications in pediatric head injury. Results of multivariate analysis.
- Ando S, Otani M, Moritake K.. Clinical analysis of post-traumatic vomiting.
- Dietrich AM, Bowman MJ, Ginn-Pease ME, et al.. Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography?
- Duus BR, Boesen T, Kruse KV, et al.. Prognostic signs in the evaluation of patients with minor head injury.
- Schunk JE, Rodgerson JD, Woodward GA.. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department.
- Arienta C, Caroli M, Balbi S.. Management of head injured patients in the emergency department: a practical protocol.
- Hsiang JN, Yeung T, Yu AL, et al.. High-risk mild head injury.
- Miller EC, Homes JF, Derlet RW.. Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients.
- 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?
- Nee PA, Hadfield JM, Yates DW, et al.. Signficance of vomiting after head injury.
- Brown FD, Brown J, Beattie TF.. Why do children vomit after minor head injury?