No Need for Admission in Children with Minor Head Trauma

ABSTRACT & COMMENTARY

Source: Roddy SP, et al. Minimal head trauma in children revisited: Is routine hospitalization required? Pediatrics 1998;101:575-577.

Investigators from the yale university school of Medicine report findings from a chart review of patients admitted to their hospital with closed head injury, an initial Glasgow Coma Scale score (GCS) equal to 15, a normal neurologic exam, and a normal head computed tomographic (CT) scan. From June 1992 through June 1995, 277 pediatric patients younger than age 16 with a normal head CT were admitted to the trauma service. After excluding children with associated injuries requiring admission, 62 children were identified who had an isolated closed head injury with a GCS of 15 and a normal neurologic exam. These children ranged in age from 1 month to 15 years, and 65% were male. Primary mechanisms of injury were fall (45%), vehicular crash (23%), pedestrian struck (13%), and bicycle-related accidents (8%). Of note, only 50% of these patients had a loss of consciousness.

Roddy and colleagues asked the question as to whether admission was necessary for these 52 patients. The defined end points were deterioration in neurologic exam, new CT findings, and the need for a prolonged hospital stay greater than 24 hours. All patients continued to have a GCS of 15 until discharge. Only two children had repeat CT scans the following day, and both were negative. Nine patients had a prolonged hospital stay, four with potential CNS problems (3 with nausea, and 1 with a delay in the interpretation of the CT). There was no reason identified for three patients, one child had knee pain, and the last child remained in the hospital because of social issues.

Roddy et al state that since no neurologic complications evolved, none of these children needed to be admitted. They conclude that mandatory admission of head-injured children with a normal neurologic exam and negative imaging studies is not warranted. They do caution not to apply their findings to infants, as they did not have many infants in their study. They also discuss the need for admission when issues of abuse and neglect are encountered.

COMMENT BY NIEL MIELE, MD, FAAP

Although it has been shown that head-injured adults who present with a normal neurologic exam, a normal head CT scan, and no other findings do not require intervention,1 there are some who will admit a child for 24 hours of observation despite a negative work-up. Roddy et al show that mandatory admission is not necessary for these patients, as long as parental anxiety regarding neurologic sequelae is relieved, and there are no social issues to consider.

Oddly, 31 of these patients had a CT examination performed despite no loss of consciousness, a GCS of 15, and a normal neurologic examination. Suggested criteria for when a head CT might be warranted include: head trauma in a child younger than 1 year of age with localized swelling or history of significant trauma, question of depressed fracture or penetrating trauma, and the possibility of a foreign body.2 It is not stated whether any of these 31 children met these criteria; they may denote one more area where hospital charges may be reduced. (Dr. Miele is an Attending in the Pediatric Emergency Department at Temple University Children's Medical Center in Philadelphia.)

References

    1. Shackford SR, et al. J Trauma 1992;33:385-391.

    2. Schutzman S. Injury-Head. In: Fleisher GR, Ludwig S, eds. Textbook of Pediatric Emergency Medicine. Baltimore, MD; 1993:272-273.