Minor Head Trauma (< 18 years) - Curbside
Minor Head Trauma (< 18 years)
Editors: Dan Imler, MD, Nat Wharton
Inclusion Criteria  (Any one criteria present)
  • Head trauma in the past 24 hours
Exclusion Criteria
  • Known brain tumors or ventricular shunts (VP)
  • Coagulopathy or bleeding disorder
  • Toxic appearance
  • Glasgow Coma Scale score < 14
  • Trivial injury mechanisms (ground-level falls or walking / running into stationary objects)
  • Pre-existing neurological disorders complicating clinical assessment
  • Penetrating trauma

Consider neurology or neurosurgery consult

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Evidence
Total Notes: 11
Evidence

1 Minor Head Trauma

Minor head trauma is very common in infants and children (500,000 emergency department visits, 37,000 hospitalizations and greater than 2000 deaths per year). It is the most common cause of death and disability in developed countries. However, only a fraction of these individuals will have clinically important traumatic brain injury (ciTBI). CT provides very good sensitivity in identifying ciTBI, but this comes at the cost of radiation exposure to developing brains. The lifetime risk of death from cancer related to the radiation from one head CT is 1 in 1500 in a one year old infant and 1 in 5000 in a 10 year old child. Key to a provider’s approach should be identifying which patients are at risk for ciTBI and only obtaining imaging on those subset of patients. A clinical decision analysis looking at this issue for children less than 2 years identified that children with risk of ciTBI greater than 0.9 percent would benifit from CT neuroimaging.

Providers should also take great care to remember that significant intracranial injury may present with minor symptoms (5 percent have TBI, 1 percent have ciTBI, 0.1 - 0.6 required neurosurgical intervention), especially in patients less than 2 years old, and that vigilance is required to identify these patients.



References:
  1. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines.
    Schutzman SA, Barnes P, Duhaime AC, Greenes D, Homer C, Jaffe D, Lewis RJ, Luerssen TG, Schunk J
    Pediatrics. 2001;107(5):983.
  2. Pediatric head injuries: can clinical factors reliably predict an abnormality on computed tomography?
    Dietrich AM, Bowman MJ, Ginn-Pease ME, Kosnik E, King DR
    Ann Emerg Med. 1993;22(10):1535.
  3. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated?
    Quayle KS, Jaffe DM, Kuppermann N, Kaufman BA, Lee BC, Park TS, McAlister WH
    Pediatrics. 1997;99(5):E11.
  4. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department.
    Schunk JE, Rodgerson JD, Woodward GA
    Pediatr Emerg Care. 1996;12(3):160.
  5. Risk factors in the outcome of children with minor head injury.
    Hahn YS, McLone DG
    Pediatr Neurosurg. 1993;19(3):135.
  6. Outcome from head injury related to patient's age. A longitudinal prospective study of adult and pediatric head injury.
    Luerssen TG, Klauber MR, Marshall LF
    J Neurosurg. 1988;68(3):409.
  7. Traumatic Brain Injury in the United States: Emergency Department Visits, Hospitalizations, and Deaths, Centers for Disease Control and Prevention
    Langlois JA, Rutland-Brown W, Thomas KE.
    National Center for Injury Prevention and ControlAtlanta 2004.
  8. Estimated risks of radiation-induced fatal cancer from pediatric CT.
    Brenner D, Elliston C, Hall E, Berdon W
    AJR Am J Roentgenol. 2001;176(2):289.
  9. Pediatric traumatic brain injury and radiation risks: a clinical decision analysis.
    Hennelly KE, Mannix R, Nigrovic LE, Lee LK, Thompson KM, Monuteaux MC, Proctor M, Schutzman S
    J Pediatr. 2013 Feb;162(2):392-7.

2 Mechanism

  1. Falls
  2. Motor vehicle crashes
  3. Pedestrian and bicycle accidents
  4. Projectiles
  5. Assaults
  6. Sports-related trauma
  7. Abuse

Non-accidental trauma should be suspected and evaluated in any infant that presents with even mild head trauma as the potential for future and worse injury is significant.



References:
  1. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
    Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL, Pediatric Emergency Care Applied Research Network (PECARN)
    Lancet. 2009;374(9696):1160.
  2. The implications of NICE guidelines on the management of children presenting with head injury.
    Dunning J, Daly JP, Malhotra R, Stratford-Smith P, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K, Children's Head injury Algorithm for the Identification of significant Clinical Events Study (CHALICE Study)
    Arch Dis Child. 2004;89(8):763.

3 Exclusion criteria

Our exclusion criteria reflect similar criteria as used in the large multicenter trials that derived validated decision rules for minor head trauma in children.

Regarding patients with ventricular (VP) shunts and bleeding disorders, these patients were evaluated in a separate analysis of the PECARN head trauma study. The results showed a similar risk (1 percent) as the controls (0.9 percent) for ciTBI. However, there were very low numbers of these patients which continues to make it unclear the exact nature of their risk for ciTBI.



References:
  1. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
    Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL, Pediatric Emergency Care Applied Research Network (PECARN)
    Lancet. 2009;374(9696):1160.
  2. The prevalence of traumatic brain injuries after minor blunt head trauma in children with ventricular shunts.
    Nigrovic LE, Lillis K, Atabaki SM, Dayan PS, Hoyle J, Tunik MG, Jacobs ES, Monroe D, Wootton-Gorges SW, Miskin M, Holmes JF, Kuppermann N, Traumatic Brain Injury (TBI) Working Group of the Pediatric Emergency Care Applied Research Network (PECARN)
    Ann Emerg Med. 2013 Apr;61(4):389-93.
  3. Intracranial hemorrhage after blunt head trauma in children with bleeding disorders.
    Lee LK, Dayan PS, Gerardi MJ, Borgialli DA, Badawy MK, Callahan JM, Lillis KA, Stanley RM, Gorelick MH, Dong L, Zuspan SJ, Holmes JF, Kuppermann N, Traumatic Brain Injury Study Group for the Pediatric Emergency Care Applied Research Network (PECARN)
    J Pediatr. 2011;158(6):1003.

4 Age-related factors

Children less than 2 years old with ciTBI may be more difficult to identify than older individuals as they are often non-verbal, appear asymptomatic, may have significant injuries with apparently minor trauma and are at higher risk of abuse. Because of these differences, the risk factors to identify ciTBI are specific to this population.



References:
  1. Evaluation and management of children younger than two years old with apparently minor head trauma: proposed guidelines.
    Schutzman SA, Barnes P, Duhaime AC, Greenes D, Homer C, Jaffe D, Lewis RJ, Luerssen TG, Schunk J
    Pediatrics. 2001;107(5):983.
  2. Head injury in very young children: mechanisms, injury types, and ophthalmologic findings in 100 hospitalized patients younger than 2 years of age.
    Duhaime AC, Alario AJ, Lewander WJ, Schut L, Sutton LN, Seidl TS, Nudelman S, Budenz D, Hertle R, Tsiaras W
    Pediatrics. 1992;90(2 Pt 1):179.

5 Primary risk factors (<2 years)

In the PECARN study patients with GCS 14,  signs of altered mental status, or a palpable skull fracture represented 13.9 percent of their population and a 4.4 percent risk of ciTBI. Given this high risk of of ciTBI, any patient with one of these factors should have immediate intracranial imaging with CT or MRI.

Skull fractures are present in ~10 percent of children (< 2 years) after minor head trauma. A vast proportion of these are linear of which 15 to 30 percent of patients will have ICI.

Seizures are a significant predictor of ciTBI and any patient with a seizure post-head injury should have an immediate brain imaging.



References:
  1. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
    Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL, Pediatric Emergency Care Applied Research Network (PECARN)
    Lancet. 2009;374(9696):1160.
  2. Pediatric minor head trauma.
    Schutzman SA, Greenes DS
    Ann Emerg Med. 2001;37(1):65.
  3. Clinical significance of scalp abnormalities in asymptomatic head-injured infants.
    Greenes DS, Schutzman SA
    Pediatr Emerg Care. 2001;17(2):88.
  4. Do children require hospitalization after immediate posttraumatic seizures?
    Holmes JF, Palchak MJ, Conklin MJ, Kuppermann N
    Ann Emerg Med. 2004;43(6):706.
  5. Prevalence of Brain Injuries and Recurrence of Seizures in Children With Posttraumatic Seizures.
    Badawy MK, Dayan PS, Tunik MG, Nadel FM, Lillis KA, Miskin M, Borgialli DA, Bachman MC, Atabaki SM, Hoyle JD, Holmes JF, Kuppermann N, Kuppermann N,
    Acad Emerg Med 2017 May;24(5):595-605.

6 Secondary risk factors (<2 years)

In the PECARN study patients with occipital or parietal or temporal scalp hematoma, history of LOC ≥5 seconds, severe mechanism of injury, or not acting normally per parent represented 32.6 percent of their population and a 0.9 percent risk of ciTBI. Given this risk of ciTBI, their recommendation was for observation versus CT on the basis of other clinical factors including: physician experience, multiple versus isolated findings, worsening symptoms or signs after emergency department observation, age less than 3 months and parental preference.

The characteristics of scalp hematomas in young children may be predictive of underlying ciTBI. These particularly include young age, larger size, nonfrontal location and severe mechanisms of injury. These factors were validated both in the PECARN study and the "scalp" score. However, providers should take away from these studies that most of the patients with scalp hematomas did NOT have ciTBI and that the hematoma should be taken in context with other risk factors for determining the need for brain imaging.

Loss of consciousness (LOC) occurs relatively frequently (~5 percent) in patients with minor head trauma. The longer the LOC, the higher the association with ciTBI. However, once again, most patients with LOC did NOT have ciTBI in the validated studies on the subject.

The predictive risk of vomiting for ciTBI is inconclusive. In a large study it occurred in up to 13 percent of patients, with a risk of ciTBI of 0.04 percent with no vomiting, 0.2 percent if isolated and 2.5 percent if other factors for ciTBI were present. In addition, there are conflicting studies looking at the risk associated with the frequency of vomiting. We advocate for neuroimaging if a patient presents with persistent vomiting after head trauma or vomiting in the setting of other risk factors for ciTBI.



References:
  1. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
    Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL, Pediatric Emergency Care Applied Research Network (PECARN)
    Lancet. 2009;374(9696):1160.
  2. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas.
    Dayan PS, Holmes JF, Schutzman S, Schunk J, Lichenstein R, Foerster LA, Hoyle J Jr, Atabaki S, Miskin M, Wisner D, Zuspan S, Kuppermann N, Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN)
    Ann Emerg Med. 2014;64(2):153.
  3. Validation of a clinical score to predict skull fracture in head-injured infants.
    Bin SS, Schutzman SA, Greenes DS
    Pediatr Emerg Care. 2010 Sep;26(9):633-9.
  4. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children.
    Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K, Children's head injury algorithm for the prediction of important clinical events study group
    Arch Dis Child. 2006;91(11):885.
  5. A decision rule for identifying children at low risk for brain injuries after blunt head trauma.
    Palchak MJ, Holmes JF, Vance CW, Gelber RE, Schauer BA, Harrison MJ, Willis-Shore J, Wootton-Gorges SL, Derlet RW, Kuppermann N
    Ann Emerg Med. 2003;42(4):492.
  6. Association of traumatic brain injuries with vomiting in children with blunt head trauma.
    Dayan PS, Holmes JF, Atabaki S, Hoyle J Jr, Tunik MG, Lichenstein R, Alpern E, Miskin M, Kuppermann N, Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN)
    Ann Emerg Med. 2014;63(6):657.
  7. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury.
    Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G, Bailey B, Chauvin-Kimoff L, Pusic M, McConnell D, Nijssen-Jordan C, Silver N, Taylor B, Stiell IG, Pediatric Emergency Research Canada (PERC) Head Injury Study Group
    CMAJ. 2010;182(4):341.
  8. Characteristics of children with vomiting after minor head trauma: a case-control study.
    Da Dalt L, Andreola B, Facchin P, Gregolin M, Vianello A, Battistella PA
    J Pediatr. 2007;150(3):274.

7 Primary risk factors (>2 years)

In the PECARN study patients with GCS 14, signs of altered mental status, or signs of basiler skull fracture represented 14.0 percent of their population and a 4.3 percent risk of ciTBI. Given this high risk of of ciTBI, any patient with one of these factors should have immediate intracranial imaging with CT or MRI.

Seizures are a significant predictor of ciTBI and any patient with a seizure post-head injury should have an immediate brain imaging.



References:
  1. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
    Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL, Pediatric Emergency Care Applied Research Network (PECARN)
    Lancet. 2009;374(9696):1160.
  2. Do children require hospitalization after immediate posttraumatic seizures?
    Holmes JF, Palchak MJ, Conklin MJ, Kuppermann N
    Ann Emerg Med. 2004;43(6):706.
  3. Prevalence of Brain Injuries and Recurrence of Seizures in Children With Posttraumatic Seizures.
    Badawy MK, Dayan PS, Tunik MG, Nadel FM, Lillis KA, Miskin M, Borgialli DA, Bachman MC, Atabaki SM, Hoyle JD, Holmes JF, Kuppermann N, Kuppermann N,
    Acad Emerg Med 2017 May;24(5):595-605.

8 Secondary risk factors (>2 years)

In the PECARN study patients with history of LOC, history of vomiting, or severe mechanism of injury or severe headache represented 27.7 percent of their population and a 0.9 percent risk of ciTBI. Given this risk of ciTBI, their recommendation was for observation versus CT on the basis of other clinical factors including: physician experience, multiple versus isolated findings, worsening symptoms or signs after emergency department observation and parental preference.

Loss of consciousness (LOC) occurs relatively frequently (~5 percent) in patients with minor head trauma. The longer the LOC, the higher the association with ciTBI. However, once again, most patients with LOC did NOT have ciTBI in the validated studies on the subject.

The predictive risk of vomiting for ciTBI is inconclusive. In a large study it occurred in up to 13 percent of patients, with a risk of ciTBI of 0.04 percent with no vomiting, 0.2 percent if isolated and 2.5 percent if other factors for ciTBI were present. In addition, there are conflicting studies looking at the risk associated with the frequency of vomiting. We advocate for neuroimaging if a patient presents with persistent vomiting after head trauma or vomiting in the setting of other risk factors for ciTBI.

Headache likewise is a common symptom after minor head trauma in patients both with and without ciTBI. The PECARN study showed a slight increased risk in patients reporting severe headache (1.1 percent ciTBI). Once again, given that most patients with headache do NOT have ciTBI, this symptom should be taken in context of the rest of the patient’s risk factors.



References:
  1. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
    Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL, Pediatric Emergency Care Applied Research Network (PECARN)
    Lancet. 2009;374(9696):1160.
  2. Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children.
    Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K, Children's head injury algorithm for the prediction of important clinical events study group
    Arch Dis Child. 2006;91(11):885.
  3. A decision rule for identifying children at low risk for brain injuries after blunt head trauma.
    Palchak MJ, Holmes JF, Vance CW, Gelber RE, Schauer BA, Harrison MJ, Willis-Shore J, Wootton-Gorges SL, Derlet RW, Kuppermann N
    Ann Emerg Med. 2003;42(4):492.
  4. Association of traumatic brain injuries with vomiting in children with blunt head trauma.
    Dayan PS, Holmes JF, Atabaki S, Hoyle J Jr, Tunik MG, Lichenstein R, Alpern E, Miskin M, Kuppermann N, Traumatic Brain Injury Study Group of the Pediatric Emergency Care Applied Research Network (PECARN)
    Ann Emerg Med. 2014;63(6):657.
  5. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury.
    Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G, Bailey B, Chauvin-Kimoff L, Pusic M, McConnell D, Nijssen-Jordan C, Silver N, Taylor B, Stiell IG, Pediatric Emergency Research Canada (PERC) Head Injury Study Group
    CMAJ. 2010;182(4):341.
  6. Characteristics of children with vomiting after minor head trauma: a case-control study.
    Da Dalt L, Andreola B, Facchin P, Gregolin M, Vianello A, Battistella PA
    J Pediatr. 2007;150(3):274.

9 Severe mechanism

Severe mechanism is not well defined in all studies looking at minor head trauma. We use the PECARN criteria to define this variable. In patients with only severe mechanism as their positive historical finding their risk of ciTBI is 0.3 percent.



References:
  1. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
    Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL, Pediatric Emergency Care Applied Research Network (PECARN)
    Lancet. 2009;374(9696):1160.
  2. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms.
    Nigrovic LE, Lee LK, Hoyle J, Stanley RM, Gorelick MH, Miskin M, Atabaki SM, Dayan PS, Holmes JF, Kuppermann N, Traumatic Brain Injury (TBI) Working Group of Pediatric Emergency Care Applied Research Network (PECARN)
    Arch Pediatr Adolesc Med. 2012 Apr;166(4):356-61.

10 Observation period

There are many different opinions regarding the length of time to observe patients after a head injury to ensure that no worsening symptoms will arise. Although some providers advocate for a shorter observation time, other believe a 4 - 6 hours observation period for patients with at least one secondary factor appears reasonable. In the PECARN study the median observation period for intermediate risk patients was 3 hours. In another single center prospective observational study the median observation period was 2.5 hours.

Given that none of the observed intermediate risk patients in the PECARN study had identified ciTBI, an observation period between 2 and 6 hours appears reasonable.

In addition, the use of an observation period has been shown to decrease the rate of CT scan utilization without associated increase in ciTBI.



References:
  1. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
    Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL, Pediatric Emergency Care Applied Research Network (PECARN)
    Lancet. 2009;374(9696):1160.
  2. Effect of the duration of emergency department observation on computed tomography use in children with minor blunt head trauma.
    Schonfeld D, Fitz BM, Nigrovic LE
    Ann Emerg Med. 2013 Dec;62(6):597-603.
  3. The effect of observation on cranial computed tomography utilization for children after blunt head trauma.
    Nigrovic LE, Schunk JE, Foerster A, Cooper A, Miskin M, Atabaki SM, Hoyle J, Dayan PS, Holmes JF, Kuppermann N; Traumatic Brain Injury Group for the Pediatric Emergency Care Applied Research Network.
    Pediatrics. 2011 Jun;127(6):1067-73.
  4. Incidence of delayed intracranial hemorrhage in children after uncomplicated minor head injuries.
    Hamilton M, Mrazik M, Johnson DW
    Pediatrics. 2010;126(1):e33.

11 Neuroimaging

Skull radiographs were previously commonly used to identify skull fractures in infants with head trauma. Although skull radiographs may be useful in very specific settings with highly trained pediatric radiologists, their general use is not recommended as they have no ability to identify ciTBI. CT is the most common method of neuroimaging has it has excellent sensitivity and specificity for ciTBI. Rapid MRI is evolving as an additional methodology for imaging these patients although it may require sedation and delay to diagnosis in some populations.



References:
  1. Skull radiograph interpretation of children younger than two years: how good are pediatric emergency physicians?
    Chung S, Schamban N, Wypij D, Cleveland R, Schutzman SA
    Ann Emerg Med. 2004;43(6):718.