HEAD TRAUMA

MARK R. ZONFRILLO, MD, MSCE AND SHARON TOPF, RN, BSN, CPEN

BACKGROUND (EPIDEMIOLOGY, EVIDENCE)

One of the leading causes of death and disability in children worldwide is traumatic brain injury (TBI). For children 18 years and younger in the United States, TBI accounts for more than 6,000 deaths, 60,000 hospital admissions, and 600,000 emergency department visits annually. Emergency department visits for TBI have increased in recent years, which is likely a direct result of increased awareness and recognition of mild TBI and concussion. While head computed tomography (CT) is the standard of care to diagnose intracranial hemorrhage and skull fractures following head injury, there has been a movement to avoid unnecessary testing and radiation exposure, particularly in pediatric patients. Prediction rules provide helpful decision-making guidance for emergency physicians, and can decrease testing, promoting cost-effectiveness.

One of the most commonly used set of rules for head injury in children were derived and validated in over 42,000 patients and can accurately predict children with acute head trauma who are at very low risk for a clinically important intracranial injury and who do not require a head CT. These two sets of rules, one for children less than 2 years old and one for children 2 years and older, are based on specific criteria accounting for injury mechanism, and presenting signs and symptoms. Additional studies based on the same cohort have focused on the risk of injury for isolated signs and symptoms, and in certain patient populations with pre-existing conditions which have provided additional guidance on which patients are at low risk for intracranial injury. For children who do not meet the prediction rule criteria, there are certain situations that represent higher risks of injury and for which a CT should be considered. Conversely, observation in the emergency department may be useful to avoid head CTs for children who do not meet all criteria but are still at lower risk. Children who are determined to be low risk typically do not require hospitalization for ongoing neurologic observation beyond their time in the emergency department.

It may be feasible to integrate these head trauma prediction rules into the electronic health record and facilitate risk determination while still maintaining an efficient clinical workflow. These rules may be robustly applied in a shared decision-making process with clinicians and parents of children with head trauma in order to maximize safety and efficient healthcare utilization, and avoid unnecessary testing fueled by parental anxiety or preference.

The overall goal of the head trauma pathway is to standardize patient evaluation and management following acute head trauma through rapid identification of potentially serious intracranial injury, minimization of unnecessary head CT use, and reduction of time to ultimate disposition through a joint clinician–guardian decision-making process.