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Review Suggests EDs Use CT Scans Too Often in Children with Head Injuries

ST. LOUIS – Computerized tomography (CT) scans appear to be overused in children with head injuries, according to a new study that notes only 7% of the scans identified traumatic brain injuries.

The study, published as correspondence recently in the New England Journal of Medicine, looked at records of more than 43,000 children evaluated for head trauma in EDs.

Researchers from the Washington University School of Medicine in St. Louis and the University of California Davis School of Medicine reviewed data collected from 2004-06 from the EDs of 25 US hospitals. They determined that cranial CT was performed in 37% of the children, including 32% of those under age 2, 32% of those between 2 and 12, and 53% of those between 13 and 17.

Traumatic brain injuries were identified in a very small percentage of children who underwent imaging, suggesting CT scans may be overused during diagnosis, according to first author Kimberly S. Quayle, MD, professor of pediatrics at Washington University. Another 3% of children with CT scans had skull fractures without brain injuries.

“The original study was designed to identify children at low risk for brain injury who do not require CT scans because of the concerns of radiation and the costs of unnecessary testing,” Quayle said. “Criteria that suggest a low risk of traumatic brain injury and observing a child before resorting to a CT scan can reduce the use of unnecessary scans.”

Of all the children who were evaluated, 78 (0.2%) died.

“The rate of traumatic brain injury as seen on CT was 5% for children with mild injuries, 27% for those with moderate injuries, and 65% for those with severe injuries,” according to the report. “Overall, subdural hematoma was the most common injury, followed by subarachnoid hemorrhage and cerebral contusion, with great variability according to age and GCS [Glasgow Coma Scale] score Nearly half of children with traumatic brain injuries on CT had more than one type of brain injury.”

The study also points out that children brought to the ED with head trauma are likely to have suffered a fall, especially if they are younger than 2. Falls were the most common causes of head injuries in children ages 12 and younger, accounting for 77% of injuries in children under 2, and 38% in those 2-12.

“Head injuries in adolescents most often were caused by assaults, sports activities and motor-vehicle crashes,” Quayle said. In fact, 24% of the head-trauma cases in teenagers were due to assault, 19% were sports-related and 18% were caused by motor-vehicle accidents.

Among children who suffered brain injuries as a result of motor-vehicle accidents, fewer than half wore seat belts; children with head injuries caused by bicycle crashes wore helmets less than 20% of the time, the authors point out.

Traumatic brain injuries are the leading cause of death and medical complications in children older than 1 year.