Study: New clinical decision rule for cranial computed tomography

To develop a clinical decision rule for cranial computed tomography (CT), researchers identified records of 1,000 pediatric patients with minor head trauma to see which factors were associated with intracranial injuries, as identified by positive CT findings. Minor head trauma was defined as a history of loss of consciousness or posttraumatic amnesia, and a Glasgow Coma Scale score higher than 12. Falls were the primary cause of minor head trauma (44.4% of total cases), followed by motor vehicle crashes.

The mean age of patients in the study group was 8.9 years; 6.5% (65 of 1,000 subjects) had positive findings on CT, and 9.2% (6 of 65) required neurosurgical intervention. Children under 2 were most likely to have a positive CT finding. Intracranial hemorrhages were the most common types of injuries, and one fifth of children had multiple findings.

Analysis (using recursive partitioning) revealed eight variables in a clinical decision rule for use of cranial CT in minor pediatric head trauma: dizziness, sensory deficit, Glasgow coma score of less than 15, bicycle-related injury, palpable skull defect, mental status change, age younger than 2 years, and signs of basilar skull fracture. Other signs, such as loss of consciousness, amnesia, headache, and vomiting, did not demonstrate as high risk for intracranial injury.

Commentary:

The authors caution that this study needs to be validated prospectively before the clinical decision rule is adopted. I hope this happens soon. It could eliminate more than 40% of the millions of post-traumatic pediatric head CTs, and health care costs, emergency department waits, inconvenience and radiation exposure. A delayed result may be decreased radiation exposure-associated malignancy.

DR. BURKE, section editor for Journal Club, is chairman of the department of pediatrics at Saint Agnes Hospital, Baltimore. He is a contributing editor for Contemporary Pediatrics. He has nothing to disclose in regard to affiliations with, or financial interests in, any organization that may have an interest in any part of this article.