Research In Action

Mild traumatic brain injuries are very common in children. When children come to the emergency department (ED) after a head injury, one of our biggest concerns as ED doctors is the potential for a bleed inside the brain. Although the definitive way to evaluate for bleeding is a computed tomography (CT) scan, obtaining these studies is not without risk. Unnecessary CT scans of the brain can potentially lead to brain tumors later in life, especially in the youngest children.

Because of this risk, in 2009 the Pediatric Emergency Care Applied Research Network (PECARN) published a set of low risk criteria, based on a study of 42,000 children in 25 EDs across North America (including those at Children's Hospital of Philadelphia), whereby children were at such low risk for a bleed that a CT scan was unnecessary [1]. Prior to publishing the rule, CT scans for head injury were as high as 62% in some EDs (while bleeds occurred in less than 1% of those children).  

Various studies have shown that the implementation of these guidelines can reduce the incidence of unnecessary CT scans without leading to missed head bleeds [2,3]. But, as with any improved clinical guidelines, they are only as good as their continued use. To evaluate the sustainability of these guidelines, we created a clinical pathway at CHOP, based on the 2010 PECARN guidelines, and conducted a study that was recently published in Pediatric Emergency Care to demonstrate that the minimized rate of CT scans was sustainable across five years:

• Our CT rates for mild head injury patients continuously decreased over that period, from 8.3% two years after our pathway was published to 4.9% in 2016.
• We also demonstrated that watching children to observe for symptom progression, rather than immediately obtaining a CT scan, did not prolong a patient’s length of stay in the ER.

When a CT Scan Is Needed

These results do not mean that a CT scan should be skipped for all children with a mild traumatic brain injury. Some children will not meet the low risk criteria and may obtain a CT scan, and we are committed to making those scans as safe as possible. At CHOP, we use a low-dose radiation protocol to minimize radiation to the growing brain.

Sources

[1] Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, et al. Identification of Children at Very Low Risk of Clinically-Important Brain Injuries After Head Trauma: A Prospective Cohort Study. Lancet. 2009; 274: 1160-1170.

[2] Nigrovic LE, Stack AM, Mannix RC, Lyons TW, Samnaliev M, Bachur RG, Proctor MR. Quality Improvement Effort to Reduce Cranial CTs for Children With Minor Blunt Head Trauma. Pediatrics. 2015; 136: 227-233.

[3]Jennings RM, Burtner JJ, Pellicer JF, et al. Reducing Head CT Use for Children With Head Injuries in a Community Emergency Department. Pediatrics. 2017; 139 pii: e20161349.