Head Injury CT Indications in Children

Aka: Head Injury CT Indications in Children, CT Head Indications in Pediatric Head Injury, PECARN Pediatric Head Injury Algorithm, PECARN, Pediatric Head Injury Algorithm, Pediatric Head Trauma Algorithm, Head Imaging Indications after Closed Head Injury in Childrem

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II. Indications

  1. Pediatric Head Trauma decision tool on whether to perform neuroimaging

III. Approach

  1. CT Head in all moderate and Severe Head Trauma
    1. CT Head has a higher Test Sensitivity for Intracranial Hemorrhage than MRI Head
    2. Discuss CT-associated Radiation Exposure with parents
    3. Other advanced imaging (MRI, SPECT) is not recommended (cost, sedation)
    4. Skull XRays are not recommended (low Test Sensitivity: 63%)
  2. Guidelines below apply to minor Head Trauma only
    1. Blunt Head Trauma
    2. Patient remains awake and alert
  3. Delayed Intracranial Hemorrhage following minor head injuries is rare beyond 6 hours in children
    1. Hamilton (2010) Pediatrics 126(1): e33-9 [PubMed]

IV. Cause: Severe mechanism of Injury (used in criteria below)

  1. Motor vehicle crash with ejection
  2. Death of another passenger
  3. Rollover
  4. Fall greater than 3 feet (>5 feet if over age 2 years)
  5. Unhelmeted pedestrian
  6. Bicyclist struck by motorized vehicle
  7. Head struck by high impact object (e.g. baseball)

V. Protocol: Age <2 years old

  1. CT Head indications (4.4% risk of clinically important TBI)
    1. GCS 14 or less or other signs of Altered Level of Consciousness
      1. Agitation or Somnolence or
      2. Repetitive questions or slow response to questions
    2. Palpable Skull Fracture
  2. Additional CT Head Indications or Observation for 4-6 hours (0.9% risk of clinically important TBI)
    1. Occipital, parietal or temporal scalp Hematoma (non-frontal) or
    2. History of loss of consciousness of 5 seconds or more or
    3. Severe mechanism of injury or
    4. Not acting normally per parent
  3. Additional features which may warrant CT Head (not part of PECARN guidelines)
    1. Worsening symptoms or signs in the emergency department or
    2. Age <3 months
      1. Younger children are less likely to be symptomatic
    3. Bulging Fontanelle
    4. Three to four episodes of Vomiting after injury
    5. Seizure
  4. Interpretation if all criteria negative
    1. Risk of missed clinically important TBI: <0.02%

VI. Protocol: Age 2 or more years old

  1. CT Head indications (4.3% risk of clinically important TBI)
    1. GCS 14 or less or other Altered Level of Consciousness signs or
    2. Basilar Skull Fracture
  2. Additional CT Head Indications or Observation for 4-6 hours (0.9% risk of clinically important TBI)
    1. Loss of consciousness or
    2. History of Vomiting or
    3. Severe mechanism of injury or
    4. Severe Headache
  3. Additional features which may warrant CT Head (not part of PECARN guidelines)
    1. Worsening symptoms or signs in the emergency department
    2. Seizure
    3. Delayed presentation for severe or progressive Headache after Head Injury (without prior imaging)
  4. Interpretation if all criteria negative
    1. Risk of missed clinically important TBI: <0.05%

VII. Precautions

  1. Difficult balance between risk of missing a clinically important TBI and ionizing radiation exposure
    1. Positive PECARN indications for Head CT have a 1% risk of clinically important TBI
    2. Single Head CT in children and adolescents has an associated cancer risk of 0.025%
    3. ED Observation for 2-3 hours is a reliable and safe strategy for children with low and moderate risk head injuries
      1. Schonfeld (2013) Ann Emerg Med 62(6): 597-603 [PubMed]
    4. Current practice of avoiding Head CT in children with mild TBI (Concussion) and without red flags is safe and effective
      1. Moore (2024) Ann Emerg Med 83(4): 327-39 [PubMed]
  2. Skull Fracture is associated with an intracranial injury in 15-30%
    1. Scalp Hematoma (see below) predicts Fracture (>80% sensitivity)
    2. Higher risk Fractures
      1. Depressed Skull Fracture
      2. Basilar Skull Fracture
      3. New Skull Fracture <24 hours
  3. Isolated Non-frontal Scalp Hematoma
    1. High risk factors for important Traumatic Brain Injury (9% risk of serious CT Head finding)
      1. Younger age (especially <3 months old)
      2. Large Hematoma >3 cm
      3. Severe mechanism of injury
    2. Low risk factors (0.5% risk of serious CT Head finding if all criteria met)
      1. Criteria present in PECARN
        1. No loss of consciousness (or <5 seconds)
        2. Acting normally per parent or guardian
        3. Pediatric GCS 15
        4. No signs of altered consciousness (no Sleepiness or Agitation)
        5. No palpable Skull Fracture
        6. No severe mechanism of injury
      2. Criteria in addition to PECARN
        1. No signs of Basilar Skull Fracture
        2. No neurologic deficits
        3. No Vomiting after the Head Trauma
        4. No Seizure after the Head Trauma
    3. Approach
      1. Consider longer observation in isolated non-frontal scalp Hematoma
      2. Consider Skull XRay or Ultrasound instead of CT Head where radiology is skilled in pediatric Head Trauma
    4. References
      1. Claudius, Behar and Dayan in Herbert (2015) EM:RAP 15(3): 2-3
      2. Dayan (2014) Ann Emerg Med 64(2): 153-62 [PubMed]

VIII. Findings

  1. High Acuity CT Findings
    1. Midline Shift
    2. Depressed Skull Fracture greater than the width of the skull
    3. Epidural Hematoma
  2. Lower Acuity CT Findings
    1. Extra-axial Hematoma
    2. Cerebral Contusion
    3. Subdural Hematoma
      1. However, see acute Subdural Hematoma for precautions
  3. References
    1. Greenberg (2021) Acad Emerg Med 28:1409-20 [PubMed]

IX. References

  1. Kuppermann (2009) Lancet 374(9696):1160-70
  2. Lumba-Brown (2018) JAMA Pediatr 172(11):e182853 [PubMed]
  3. Schutzman (2001) Pediatrics 107:983-93 [PubMed]

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