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Brain Teasers

Many children with head injuries can forgo CT scans

Roughly half of U.S. children taken to emergency departments for a head injury receive a CT scan, often to ease parents’ concerns. Yet true traumatic brain injury is uncommon. A multicenter study of more than 40,000 children with minor blunt head trauma, led by Children’s Hospital Boston and UC Davis, shows that allowing a period of observation can reduce the use of head CT by as much as half without compromising care—and without exposing children to ionizing radiation. Results appear in the June issue of Pediatrics.

“Only a small percentage of children with blunt head trauma really have something serious going on,” says Lise Nigrovic, an HMS assistant professor of pediatrics at Children’s Hospital Boston, who co–led the study with Nathan Kuppermann, chair of the Department of Emergency Medicine at UC Davis. “If you can be watched in the emergency department for a few hours, you may not need a CT.”

After analyzing the outcomes of children at 25 different emergency departments, Nigrovic, Kuppermann, and colleagues found that the children who were observed had a lower rate of CT than those not observed. When the researchers matched the observed and nonobserved groups for severity of head injury and hospital practice style, this difference was more pronounced: The likelihood of a CT scan in the observed group was about half that of similar nonobserved patients. In particular, children whose symptoms improved during observation were less likely to eventually be scanned.

Allowing for an observation period did not compromise safety, the study found: Clinically important traumatic brain injury—resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for two or more nights—was equally uncommon in the observed and nonobserved groups (0.75 versus 0.87 percent).

Nigrovic and Kuppermann note that cranial CT scans present risks for children, whose growing brain tissue is more sensitive to ionizing radiation than that of adults. “There is a clear need to develop appropriate and safe guidelines for decreasing the number of inappropriate head CT scans that we do on children,” says Kuppermann. “The results of this analysis demonstrate that a period of observation before deciding to use head CT scans on many injured children can spare children from inappropriate radiation while not increasing the risk of missing important brain injuries.”

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