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Emergency Medicine

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Clinical criteria can identify children with blunt head trauma who are unlikely to need CT scans

Emergency department clinicians typically order cranial computed tomography (CT) for patients with blunt head trauma in order to rule out serious intracranial injury. However, most adults and children with blunt head trauma end up having a minor injury that requires no specific therapy. An ongoing study recently identified seven clinical criteria that can identify children at low risk for important intracranial injury (ICI) and thus unlikely to need CT scans. The National Emergency X-Radiography Utilization Study II (NEXUS II) is a multicenter, prospective, observational study of all blunt head trauma victims who had cranial CT as part of their ED evaluation. It is supported in part by the Agency for Healthcare Research and Quality (HS09699).

Researchers found that children with blunt head trauma who did not have any of seven risk factors were at low risk for ICI and unlikely to need CT. The seven factors were: evidence of significant skull fracture; altered level of alertness; neurologic deficit; persistent vomiting; presence of scalp hematoma (swelling); abnormal behavior; and coagulopathy (blood coagulation problems). For adults, age over 65 years is another risk factor. The researchers defined ICI as one that required neurosurgical intervention or was likely to be associated with significant long-term neurologic impairment.

They used the seven factors to identify ICI in 1,666 children with blunt head trauma. A total of 205 of the children had evidence of traumatic injury on head CT; 67 cases were injuries that did not require therapeutic intervention and 138 (8.3 percent) had findings that met criteria for ICI. When applied to the pediatric cohort, the 7-factor decision instrument correctly identified 136 of 138 cases. Thus, two pediatric cases with ICI were not identified using this approach, but neither required neurosurgical intervention. The decision instrument identified all 25 cases of clinically important ICI out of 309 children under 3 years of age. At least one of the seven NEXUS II risk criteria was present in each child with significant ICI.

More details are in "Performance of a decision rule to predict need for computed tomography among children with blunt head trauma," by Jennifer A. Oman, M.D., Richelle J. Cooper, M.D., M.S.H.S., James F. Holmes, M.D., and others, in the February 2006 Pediatrics 117(2), pp. e238-e246.

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