Best way to diagnose head injuries in children and minimise CT scans

Lady Cilento Children’s Hospital (LCCH) researchers took part in a large Australasian clinical trial, which could see clinicians using fewer CT scans and less radiation exposure when managing children with head injuries.

Head injuries are one of the most common reasons children are taken to Australian emergency departments.

To rule out a serious brain injury, a percentage of these children require a CT scan and while this process is straightforward for serious head injuries, it’s more challenging to determine whether CT scans are necessary for children with milder symptoms.

This could change, following the results of the Australasian research project, according to Associate Professor Jason Acworth, who is the Emergency Department Director at LCCH.

“Most head injuries are mild and don’t need surgery, but a small proportion of children present with mild symptoms when they actually have significant intracranial injuries,” A/Prof Acworth said.

“The aim of this trial was to help us determine which children need or don’t need CT scans to detect these brain injuries,” he said

“This can be a difficult issue for emergency department doctors, because we need to balance the importance of not missing important injuries against reducing radiation exposure as much as possible.

“The preferred course of treatment is to avoid a CT scan in minor head injuries if it is unnecessary.  We are concerned that exposing the developing brain to the radiation dose associated with CT scans is associated with a higher risk of cancer later in life.”

In these cases, clinicians can turn to clinical decision rules, which have been developed to identify children at higher or lower risk of intracranial injuries, aiming to assist clinicians to minimise CT scans while still identifying all relevant injuries.

In a prospective observational study, run across 10 Australian and New Zealand hospitals – including LCCH – and involving 20,137 children, the research team compared three clinical decision rules:

  • The Pediatric Emergency Care Applied Research Network (PECARN, USA)
  • The Canadian Assessment of Tomography for Childhood Head Injury (CATCH) rule
  • The Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE, UK).

The goal was to determine which of these three decision rules provided the best option when it came to deciding which children should have a CT and those children who are at such a low risk that a CT can be safely avoided.

The researchers found that all three rules were good options, but only one, the PECARN from the USA, correctly identified all patients with significant intracranial injuries (requiring neurosurgery).

Based on the research findings, the next step is for the group of emergency physicians to develop national approaches to optimise the management of children with head injuries in Australia and New Zealand.

The Emergency Medicine Foundation (EMF), funded by Queensland Health, awarded A/Prof Acworth an $298,000 grant which enabled the trial to run in Queensland at the former Royal Children’s Hospital and the Mater Children’s Hospital as well as The Townsville Hospital.

The study was run by clinicians involved in the PREDICT network (Paediatric Research in Emergency Departments International Collaborative).

The research was recently published in the prestigious medical journal, The Lancet.


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