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    Deciding whether to use CT scan with trauma

    Pediatric minor head trauma in your office, clinic, or emergency department

    Computed tomography to evaluate pediatric minor head trauma has risen sharply in the last decade, causing concern about long-term effects of ionizing radiation and the associated risk of cancer. Prediction rules can help clinicians balance the need to identify traumatic brain injury with the need to avoid unnecessary imaging.

    Traumatic brain injury (TBI) is a leading cause of death and disability in the United States, affecting children disproportionately; nearly half a million emergency department (ED) visits for head trauma are made annually by children aged 0 to 14 years.1 A common dilemma facing the physician is how to manage the relatively well-appearing child with minor blunt head trauma and a Glasgow Coma Scale (GCS) score of 15 who presents to an ambulatory care setting.

    Practitioners and the public alike have become increasingly aware of the consequences of head trauma in children as well as of the potential long-term deleterious effects of computed tomography (CT) radiation on the young brain.1,2 Although not known empirically, lethal cancer rates from a single CT of the head have been estimated to be as high as 1 in 1,500 for infants aged 1 year and younger and 1 in 5,000 for older children.2-7

    In deciding whether or not to obtain a CT scan in the child with minor blunt head trauma, the clinician must weigh the immediate risk of missing a clinically important TBI (ciTBI) against the long-term risk of exposure to ionizing radiation. In addition to clinical findings, multiple factors such as increasing public awareness of the consequences of TBI, parental expectations and preferences regarding CT use, clinician risk tolerance, and the present medicolegal climate complicate the decision for immediate neuroimaging.1,6

    Review of the literature

    Several investigators have reported clinical prediction rules for imaging in pediatric minor head trauma in large observational studies, with varying designs, cohorts, and decision-rule performance.7-10

    Some of these have been multicenter in design and have included thousands of children with minor head trauma.7,9,10 The inherent tension in these studies lies between the need to identify a ciTBI and the desire to avoid unnecessary CT imaging.

    Determining what defines a clinically important injury is challenging; all would agree that identifying children who require neurosurgery is essential. Other children may not need neurosurgical intervention, but require intensive monitoring of the TBI as an inpatient. Still others may develop postconcussive syndrome and will need ongoing evaluation and outpatient therapy.11,12


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