CLINICAL PATHWAY FOR EVALUATION THE ADULT AND PEDIATRIC PATIENT WITH CLOSED HEAD INJURY

Decisions related to neuroimaging for children with mild closed head injury (CHI) are complicated by the potential need for sedation and the inherent risk of radiation exposure. Depending on their age, children can be up to 10 times more radiosensitive than adults, and the risk of subsequent cancer deaths can be as high as 1:1000.1 In children aged <2 years, up to 20% of traumatic brain injuries are caused by child abuse,2 but as children advance in age, the mechanisms of injury parallel those of adults with traumatic brain injury.3

The highest incidence of intracranial injury (ICI) in apparently mild CHI is found in infants aged <12 months.4-6 The overall rate of ICI and the ultimate need for neurosurgical intervention in children with mild CHI is about the same as in adults,4 although pediatric guidelines have historically included observation as an approach in the management of children with mild CHI.7

Infants with CHI are challenging to evaluate because they often have little or no clinical findings, even in the setting of ICI. Loss of consciousness is not present in almost 50% of infants with ICI, and many infants have little more than a scalp hematoma on physical examination.8,9 In general, the younger the child, the lower the threshold for obtaining imaging studies should be. The greater the severity and number of signs and symptoms, the stronger the consideration should be for emergency department transfer and imaging studies.

A number of clinical decision rules for the management of CHI in children have been published over the past 2 decades.4,8-12 The 3 largest high-quality studies are the Pediatric Emergency Care Applied Research Network (PECARN) Pediatric Head CT Rule, developed in the United States8 (see Table); the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), developed in the United Kingdom;10 and the Canadian Assessment of Tomography for Childhood Head Injury (CATCH).13 Among these 3 clinical decision rules, only PECARN has a separate algorithm for children aged <2 years. In PECARN, the decision tree directs immediate CT in the presence of any of the high-risk variables (4% risk of ICI) and offers the options of observation or CT in the presence of the lower-risk variables (1% risk of ICI).8 Because prolonged observation periods are not typically feasible in the Urgent Care setting, children who are at any risk according to the PECARN rule should be transferred to the emergency department.

Table. PECARN Pediatric Head CT Decision Rule8

High-Risk Variables: CT Recommended if Any Are Present

·       GCS score <15

·       Altered mental status: agitation, somnolence, repetitive questioning, verbally slow to respond.

·       Palpable skull fracture if aged <2 years

·       Suspected basilar skull fracture

Lower-Risk Variables: Transfer to ED for Observation or CT if Any Are Present

LOC (≥5 sec if aged <2 years)

Severe headache

Vomiting

Nonfrontal scalp hematoma if aged <2 years

Abnormal behavior (per parent) if aged <2 years

Severe mechanism of injury: MVC with ejection, death of passenger, rollover, being struck by vehicle, fall >5 ft (1.5 m) (or >3 ft [0.9 m] if aged <2 years), head struck by high-impact object

Abbreviations: CT, computed tomography; ED, emergency department; GCS, Glasgow Coma Scale; LOC, loss of consciousness; MVC, motor vehicle crash; PECARN, Pediatric Emergency Care Applied Research Network.

© 2022 EB Medicine

References

  1. Smith-Bindman R, Lipson J, Marcus R, et al. Radiation dose associated with common computed tomography examinations and the associated lifetime attributable risk of cancer. Arch Intern Med. 2009;169(22):2078-2086. (Retrospective; 1119 patients)
  2. Reece RM, Sege R. Childhood head injuries: accidental or inflicted? Arch Pediatr Adolesc Med. 2000;154(1):11-15. (Retro­spective; 287 patients)
  3. Centers for Disease Control and Prevention. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations and Deaths 2002-2006 (Blue Book). Available at: https://www.cdc.gov/traumaticbraininjury/tbi_ed.html. Ac­cessed April 10, 2022. (Statistical data)
  4. Pandor A, Goodacre S, Harnan S, et al. Diagnostic manage­ment strategies for adults and children with minor head injury: a systematic review and an economic evaluation. Health Technol Assess. 2011;15(27):1-202. (Meta-analysis; 93 studies)
  5. Greenes DS, Schutzman SA. Clinical indicators of intracranial injury in head-injured infants. Pediatrics. 1999;104(4 Pt 1):861- 867. (Prospective; 608 patients)
  6. Dayan P, Holmes J, Schutzman S, et al. Association of traumatic brain injuries with scalp hematoma characteristics in patients younger than 24 months who sustain blunt head trauma. Pediatr Emerg Care. 2008;24:727. (Secondary analysis; 42,412 patients)
  7. Preboth M. AAFP and AAP issue a practice parameter on the management of minor closed head injury in children. Am Fam Physician. 1999;60(9):2698, 2700, 2703-2695. (Position state­ment)
  8. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain inju­ries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective; 42,412 patients)
  9. Mower WR, Hoffman JR, Herbert M, et al. Developing a deci­sion instrument to guide computed tomographic imaging of blunt head injury patients. J Trauma. 2005;59(4):954-959. (Prospective; 13,728 patients)
  10. Dunning J, Daly JP, Lomas JP, et al. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006;91(11):885-891. (Prospective; 22,772 patients)
  11. Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003;42(4):492-506. (Observational cohort; 2043 patients)
  12. Pickering A, Harnan S, Fitzgerald P, et al. Clinical decision rules for children with minor head injury: a systematic review. Arch Dis Child. 2011;96(5):414-421. (Systematic review; 79,740 patients)
  13. Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010;182(4):341-348. (Prospec­tive; 3866 patients)

Excerpted from Pochick K., Management of closed head Injuries in Urgent Care. Evidence-Based Urgent Care. 2022 May 1;1(2). Reprinted with permission of EB Medicine. Learn more about Evidence-Based Urgent Care and get a free sample issue at https://www.ebmedicine.net/urgent-care-info 

Abbreviations: CHI, closed head injury; CT, computed tomography; ED, emergency department; GCS, Glasgow Coma Scale; LOC, loss of consciousness; TBI, traumatic brain injury; UC, Urgent Care.

Please see the Clinical Pathway for Evaluating the Pediatric Patient With Closed Head Injury/Traumatic Brain Injury for class of evidence definitions

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.

Copyright ©2022 EB Medicine. www.ebmedicine.net. No part of this publication may be reproduced in any format without written consent of EB Medicine.

Abbreviations: CHI, closed head injury; CT, computed tomography; ED, emergency department; GCS, Glasgow Coma Scale; LOC, loss of consciousness; MVC, motor vehicle crash; TBI, traumatic brain injury; UC, Urgent Care.

Class of Evidence Definitions

Each action in the clinical pathways section of Evidence-Based Urgent Care receives a score based on the following definitions.

Class I

• Always acceptable, safe

• Definitely useful

• Proven in both efficacy and effectiveness

Level of Evidence:

• One or more large prospective studies are present (with rare exceptions)

• High-quality meta-analyses

• Study results consistently positive and compelling

Class II

• Safe, acceptable

• Probably useful

Level of Evidence:

• Generally higher levels of evidence

• Non-randomized or retrospective studies: historic, cohort, or case control studies

• Less robust randomized controlled trials

• Results consistently positive

Class III

• May be acceptable

• Possibly useful

• Considered optional or alternative treatments

Level of Evidence:

• Generally lower or intermediate levels of evidence

• Case series, animal studies, consensus panels

• Occasionally positive results

Indeterminate

• Continuing area of research

• No recommendations until further research

Level of Evidence:

• Evidence not available

• Higher studies in progress

• Results inconsistent, contradictory

• Results not compelling

This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care.