Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?

James F Holmes Jr, Dominic A. Borgialli, Frances M. Nadel, Kimberly S. Quayle, Neil Schambam, Art Cooper, Jeff E. Schunk, Michelle L. Miskin, Shireen M. Atabaki, John D. Hoyle, Peter S. Dayan, Nathan Kuppermann

Research output: Contribution to journalArticle

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Abstract

Study objective: Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results. Methods: We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention. Results: Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%). Conclusion: Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.

Original languageEnglish (US)
Pages (from-to)315-322
Number of pages8
JournalAnnals of Emergency Medicine
Volume58
Issue number4
DOIs
StatePublished - Oct 2011

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Craniocerebral Trauma
Nervous System
Glasgow Coma Scale
Hospitalization
Tomography
Observation
Hospital Emergency Service
Magnetic Resonance Imaging
Postal Service
Confidence Intervals
Telephone
Neuroimaging
Pneumocephalus
Skull Fractures
Intracranial Hemorrhages
Brain Edema
Quality Improvement
Medical Records
Observational Studies
Cohort Studies

ASJC Scopus subject areas

  • Emergency Medicine

Cite this

Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation? / Holmes Jr, James F; Borgialli, Dominic A.; Nadel, Frances M.; Quayle, Kimberly S.; Schambam, Neil; Cooper, Art; Schunk, Jeff E.; Miskin, Michelle L.; Atabaki, Shireen M.; Hoyle, John D.; Dayan, Peter S.; Kuppermann, Nathan.

In: Annals of Emergency Medicine, Vol. 58, No. 4, 10.2011, p. 315-322.

Research output: Contribution to journalArticle

Holmes Jr, JF, Borgialli, DA, Nadel, FM, Quayle, KS, Schambam, N, Cooper, A, Schunk, JE, Miskin, ML, Atabaki, SM, Hoyle, JD, Dayan, PS & Kuppermann, N 2011, 'Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?', Annals of Emergency Medicine, vol. 58, no. 4, pp. 315-322. https://doi.org/10.1016/j.annemergmed.2011.03.060
Holmes Jr, James F ; Borgialli, Dominic A. ; Nadel, Frances M. ; Quayle, Kimberly S. ; Schambam, Neil ; Cooper, Art ; Schunk, Jeff E. ; Miskin, Michelle L. ; Atabaki, Shireen M. ; Hoyle, John D. ; Dayan, Peter S. ; Kuppermann, Nathan. / Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?. In: Annals of Emergency Medicine. 2011 ; Vol. 58, No. 4. pp. 315-322.
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abstract = "Study objective: Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results. Methods: We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention. Results: Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93{\%}) with GCS scores of 15 and 959 (7{\%}) with GCS scores of 14. Of 13,543 patients, 2,485 (18{\%}) were hospitalized, including 2,107 of 12,584 (17{\%}) with GCS scores of 15 and 378 of 959 (39{\%}) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79{\%}), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2{\%}) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05{\%}) had abnormal CT/MRI scan results and none (0{\%}; 95{\%} confidence interval [CI] 0{\%} to 0.03{\%}) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6{\%}) received subsequent CT or MRI; 16 (0.6{\%}) had abnormal CT/MRI scan results and none (0{\%}; 95{\%} CI 0{\%} to 0.2{\%}) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100{\%} (95{\%} CI 99.97{\%} to 100{\%}). Conclusion: Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.",
author = "{Holmes Jr}, {James F} and Borgialli, {Dominic A.} and Nadel, {Frances M.} and Quayle, {Kimberly S.} and Neil Schambam and Art Cooper and Schunk, {Jeff E.} and Miskin, {Michelle L.} and Atabaki, {Shireen M.} and Hoyle, {John D.} and Dayan, {Peter S.} and Nathan Kuppermann",
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T1 - Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?

AU - Holmes Jr, James F

AU - Borgialli, Dominic A.

AU - Nadel, Frances M.

AU - Quayle, Kimberly S.

AU - Schambam, Neil

AU - Cooper, Art

AU - Schunk, Jeff E.

AU - Miskin, Michelle L.

AU - Atabaki, Shireen M.

AU - Hoyle, John D.

AU - Dayan, Peter S.

AU - Kuppermann, Nathan

PY - 2011/10

Y1 - 2011/10

N2 - Study objective: Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results. Methods: We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention. Results: Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%). Conclusion: Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.

AB - Study objective: Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results. Methods: We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention. Results: Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%). Conclusion: Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.

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