Background: Management of children with minor head trauma often includes a period of emergency department (ED) observation to determine the need for cranial computed tomography (CT). We explored the relationship between cranial CT use and observation.
Methods: This was a planned sub-analysis of a prospective observational study at 10 pediatric EDs. Children<18 years-old with Glasgow Coma Scale (GCS) scores ≥14 were enrolled. Clinicians documented if they planned to observe prior to CT decision. We used the PECARN definition of a clinically important traumatic brain injury (ciTBI)--either intubation for greater than 24 hours, ≥ 2 day hospitalization, requiring neurosurgical intervention or death following head trauma. We measured the total length of stay (LOS) as time from ED arrival to hospital discharge. We compared median time [hours] and rate differences (RD) with the Hodges-Lehmann method. Controlling for hospital cluster effects using a generalized linear model with mixed effects, we estimated adjusted cranial CT use with multivariable logistic regression.
Results: Of 20,137 children enrolled, 19,481 (97%) had GCS scores ≥14 and documented observation status; 6,167 (32%) had a planned observation. Using the PECARN traumatic brain injury (TBI) risk stratification: 19% of the very low-risk, 41% of intermediate-risk, and 66% of high-risk patients were observed. The median total LOS in the observed group (4.1 hours) was longer than the not observed (1.8 hours), (RD 2.2 hours, [95% CI: 2.2 - 2.3 hours]). The overall cranial CT rate was 9%, and 0.8% had ciTBI. The cranial CT rate was higher in those observed (20.5%) than those not observed (4.1%), (RD 16.3%, [95% CI: 15.3 – 17.4%]). The ciTBI rate was higher in those observed (1.8%) compared to those not observed (0.4%), (RD 1.5%, [95% CI: 1.1 - 1.8%]). After adjusting for PECARN TBI risk group, patient, and hospital characteristics, cranial CT use was significantly associated with seizure (adjusted OR 2.5, [95%CI: 1.8-3.5]), planned observation (adjusted OR 3.3, [95% CI: 2.9 - 3.7]), intermediate risk (adjusted OR 4.4, [95%CI: 3.7-5.3]), and high risk mechanism (adjusted OR 23.6, [95% CI: 19.3 – 28.9).
Conclusion: In a setting with a low overall cranial CT rate in children with minor head injury, planned observation, seizure, intermediate and high-risk mechanism was associated with increased CT use.