Simple tests for head injury may significantly cut down CT utilization

Sep 21, 2009

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When I was a kid, I hit my head a fair bit, including getting knocked out once at football practice. Initial care involved an evaluation, but scans weren’t the norm. Now that they’ve become increasingly common in the evaluation of head injuries in youth, have we gained much?

The Value of CT Scans in Youths Is Questioned in this study in the Lancet (article in NYTimes).

The study, one of the largest of its kind, enrolled 42,412 children ages 18 and younger who sought emergency care at dozens of medical centers after suffering mild head injuries in bike collisions, car crashes, falls and other accidents. Of the total group, 14,969 of the children, or just over one-third, had CT scans, but only 780 of the scans, or about 5 percent, picked up traumatic brain injuries, the study found.

The paper, published online in the Sept. 15 issue of The Lancet, offered a list of six indicators that could be used to determine whether a child was at risk for a serious brain injury, with a separate list for children under 2. The highest risk factors for children of all ages are an altered mental state and signs of a skull fracture.

Other factors to consider are loss of consciousness and whether the child was involved in a serious incident like a car crash. Vomiting and headaches are predictors in older children, while swelling of the scalp and abnormal behavior are warning signs in younger children.

The surprising stat to me was that after triage, only 5% of those who received a CT scan actually showed an issue (we’ll ignore potential false positives).

42,412 went to the emergency room

14,969 had a CT scan (35%)

780 showed traumatic brain injury (1.8% of ER visitors, 5.2% of those scanned)

It would seem that better triage would get us closer than a 1 out of 20 hit rate. But in the current environment, why would a medical staff take the time to run through the 6 indications and risk a bad outcome?