Well said, Dr Fisher! I share your concern about relying solely on clinical
criteria. I have also had one case that I will never forget.This was a
infant with a "minor" head trauma, whom I scanned because of a small
cephalhematoma, that ended up having an operable EDH.
Dr. Mann, I would exercise caution,especially in the pre-verbal (<2
year )age group. An adolescent who has sustained a minor BHT, & denies
HA/n/v/dizzyness/blurred vision/diplopia/tinnitus...., has had no LOC and
has a GCS of 15 with a normal neurologic exam is probably, truly "low risk"
for any "operable" ICI. When it comes to this younger age group, I believe,
all the above "subjective" historical parameters cannot be adequately
addressed. My personal preference is to keep a lower "scanning" threshold in
the pre-verbal child.
Servadei F et al [ J Neurol Neurosurg Psychiatry 51: 526-528,1988] in their
study of minor head injuries and risk for ICI, studied an ADULT cohort of
patients. For reasons I stated above, one has to be careful in extrapolating
adult data in the younger child. Morover, their objective was to evaluate
the predictive value of skull fx as a risk for ICI.
This is ENTIRELY different from trying to answer the "million dollar"
question, which is ..." Can I safely send home a child with a BHT without a
CT, who has minimal to no symptoms, a GCS of 15 and a normal neurologic
The largest PEM series of patients ( and NOT neurosurgical data, which BTW
has significant referral bias ) is by Dietrich et al (see Dr. Fischer's
site). She had a prospective cohort of 322 patients, 11 (4.7%) of whom, with
a GCS of 15 + normal neuro. exam, had an ICI. Let us assume, from other
studies, say 0.2% need surgical intervention (see Miller et al. Ann of Emerg
Med. 1996). To answer the above question adequately, one would need to
enroll prospectively, all these "low" risk patients and obtain a head CT on
all of them. To collect data on say 30 patients with "significant" ICI, one
would have to enroll 15,000 "low risk" patients. Then may be, one could
evaluate individual predictor variables like duration of LOC etc in this
cohort of patients. Hmm.....
Overall, Jeff, the risk is small, but the consequences are grave. Just like
the Fever/OB debate, it depends on how "risk" averse one is. I believe, the
BHT instructions that we give parents are "nerve wracking" to begin with.[ I
am referring to ....wake the child up Q 2-3 hours!.] On top of that, if we
add the uncertainty of ICI to the mix, I am not sure that most parents would
opt for the NON-CT route, especially if there is any question about the
whole picture.Now, if you have a 23 hour observation unit etc, the Mx may be
different, of course.
Jay Pershad, MD
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