Minor Closed Head Injury – The 3 month old Caveat
We are all accustomed to the issues that surround pediatric head injury.
• Traumatic brain injury is the leading cause of morbidity and mortality worldwide.
• Prompt management of patients with clinically important traumatic brain injury is imperative.
• Head CT is the diagnostic standard in the ED; however, has its own costs (Radiation, false positives, and $$).
• The majority of children with head injury in ED are classified as MINOR head injury (GCS = 14 or 15) and they most often have normal CT findings (>90%) and very rarely require neurosurgical intervention.
• PECARN research has assisted with the reduction of CT scans in the population of MINOR head injury patients.
What PECARN derived and validated (please see pretty figure from article below):
- For Kids > 2 years
- CT if change in mental status, GCS < 15, or signs in basilar skull fracture
- CT or Observe if vomiting, severe headache, LOC, or severe mechanism
- For Kids < 2 years
- CT if change in mental status, GCS < 15, or palpable skull fracture
- CT or Observe if LOC >5sec, non-frontal hematoma, severe mechanism, or parental report of abnormal behavior
What you need to pay particular attention to is that while the PECARN study has a HUGE study population with 25% (10,718) younger than 2 years of age, the younger the child the more difficult the assessment is and the more vulnerable they are.
- The child who is ≤ 3 months of age has a very thin skull (so not much protection)
- The child who is ≤ 3 months of age doesn’t “do” much, making your assessment difficult
- The 2 month old is just starting to interact with the world, may have some improved head control, and may have slightly different cries with different meaning (that only a mother would appreciate), but otherwise your documentation that the child is “vigorous and well appearing” won’t be as reassuring as it will be in a 6 month old child.
- “Observation” may not be terribly useful in this specific age group, as your initial clinical evaluation and your repeat evaluations will carry less weight overall.
- PECARN actually notes this as a reason to lower the threshold to obtain a CT.
Moral of the story – Clinical Guidelines are never perfect, but this one is pretty good… which means that we all should actually know the caveats that are present within it, and not merely say, “this fits minor head injury and doesn’t need a head CT.”
Kuppermann N, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009: Oct 3; 374: 1160-70.