Emergency Radiology-Emergency Medicine Interdepartment Conference Ann Emerg Med. 2011;58:315-322 Sukkin Pungchim, MD. Emergency Medicine Resident, PGY II Elective Rotation in Emergency Radiology

1. Sukkin Pungchim, MD.
Emergency Medicine Resident, PGY II
Elective Rotation in Emergency Radiology
Ann Emerg Med. 2011;58:315-322

2. • TBI is the leading cause of death and disability in children > 1 yr
• Cranial CT is diagnostic of choice in blunt head trauma
• Most children presenting to ED after minor head trauma do not
require CT scanning, if done >90% Cranial CT shown normal
• Many children with minor head trauma are hospitalized for
neurologic observation despite normal ED cranial CT
• Limited pediatric data in necessity of hospitalization

3. • Identify the frequency of children with minor blunt head
injury and normal initial CT results have either traumatic
findings in a subsequent neuroimaging or experience
neurologic deterioration resulting in the need for
neurosurgery

4. • Study design
– Prospective, multicenter observational cohort study at 25 centers
between 2004 and 2006
• Population
– Children younger than 18 yr with blunt head trauma and initial GCS of 14
or 15 who had normal cranial CT scan results during ED evaluation
• Data collecting and processing
– Documentation of GCS/Vomiting/Isolated head trauma/Multisystem
– Finalized report of Cranial CT or MRI
– Patients D/C from ED followed by phone, mail, medical records review, ED
CQI, trauma registry records, country morgue documentation

5. • Outcome measure
– Traumatic findings on subsequent CT or MRI and
– Neurosurgical intervention (eg, craniotomy, ventricular drainage)
• Primary data analysis
– Determined NPV for negative (normal) ED CT scan result for identifying
those patients not needing a neurosurgical intervention
– SAS statistical software (version 9.2)
• Sensitivity analyses
– Worse-case scenario in those patients D/C from ED but failed to follow-up

6. 93% 7%
17% 83% 39% 61%
6% 2% 6% 2%

7. • Negative predictive value for neurosurgical intervention of a
normal ED CT scan result in a patient with an initial ED GCS 15
was 100% (95% CI 99.97% to 100%)
• Negative predictive value for neurosurgical intervention of a
normal ED CT scan result in patients with initial GCS scores of 14
was 100% (95% CI 99.6% to 100%)

8. • Sensitivity analyses : Worse case scenario
•  proportion of patients with GCS 15 but lost follow-up could be
another 11 patients
•  proportion of patients with GCS 14 but lost follow-up could be
another 1 patients
• If this were true : The proportion would increase only from
21/13,543(0.16%) to 33/13,543(0.24%)
– 5% of the patients who were lost to telephone follow-up would need
to have traumatic findings on a subsequent CT or MRI (ie, 115 of the
2,302 patients lost to telephone follow-up)
– Highly unlikely, given that this far exceeds the proportion with
subsequent traumatic findings on cranial imaging in those admitted

9. • Not all patients enrolled into the primary study underwent CT
• Patients who did not undergo repeat imaging would have had
traumatic findings had they received imaging a second time
• Lost follow-up patients might have traumatic findings identified
on CT or MRI at another hospital
• Exact reasons/indications for hospitalization after normal
cranial CT not specifically described
• Real-time CT interpretations in many centers could be from
radiology resident
• Not assess brain injury in terms of long term neurocognitive
function

10. • Children with blunt head trauma and initial ED GCS scores of 14 or
15 and normal cranial CT scan results
– Very low risk for subsequent traumatic findings on neuroimaging
– Extremely low risk of needing neurosurgical intervention
• Routine hospitalization of children with minor head trauma after
normal CT scan results for neurologic observation is generally
unnecessary
• There remain indications for admitting children w/minor head injury
– Multisystem trauma
– Symptomatic patients require IV fluids and neurologic observation
(18% of hospitalized patient had vomiting documented )
– Others : Social, concern for other injuries

11. • Many medical center across US, even pediatric centers simply
admit for neurologic observation
• Potential to reduce medical costs, reduce hospital crowding,
provide more optimal care
• Hospitalized patients were more likely to undergo subsequent
neuroimaging because of ease and accessibility
• EP were likely admitting patients with more symptomatic and
more severe head trauma despite normal cranial CT results
• Several patients with subsequent traumatic findings found were
never hospitalized