Avoid CT in Kids at Very Low Risk of Brain Injury

Children at very low risk of brain injuries

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Identification of children at very low risk of clinically-important brain injuries after head trauma:
a prospective cohort study

Lancet 2009; 374: 1160–70

Purpose

To identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.

The prediction rule for children < 2 years 

• Normal mental status 
• No scalp haematoma except frontal 
• Loss of consciousness < 5 s 
• Non-severe injury mechanism
• No palpable skull fracture 
• Normal behavior per patient 

Severe mechanism of injury: 

• motor vehicle crash with patient ejection
• death of another passenger, rollover
• pedestrian or bicyclist without helmet struck by a motorised vehicle
• falls of more than 0.9 m
• head struck by a high-impact object

NPV: 100% 
Sensitivity: 100% 

The prediction rule for children > 2 years

• Normal mental status
• No loss of consciousness
• No vomiting
• Non-severe injury mechanism
• No signs of basilar skull fracture
• No severe headache

Severe mechanism of injury:

• motor vehicle crash with patient ejection
• death of another passenger, rollover
• pedestrian or bicyclist without helmet struck by a motorised vehicle
• falls of more than 1.5 m
• head struck by a high-impact object

NPV: 99.95%
Sensitivity: 96.8%

Neither rule missed neurosurgery in validation populations

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4月24日 補充 中文摘要 (by zeno)

兒童頭部外傷，若是六項因素都沒有，可以不用切CT ！
Tintinalli's Emergency Medicine, 7E, p891

一、小於2歲的預測因子

1. 意識改變（昏迷指數14分或有躁動、嗜睡、重複問相同問題、反應變慢）
2. 除了前額之外的區域有頭皮血腫
3. 失去意識5秒以上
4. 嚴重的受傷機制（汽機車相撞且被彈射出去、車子翻覆或其他乘客死亡、走路或騎腳踏車被行進中的車輛撞到、從大於0.9公尺的高度跌落、頭部被高速物體擊中）
5. 觸診可摸到顱骨骨折
6. 主要照顧者注意到有行為異常

二、2歲以上的預測因子

1. 意識改變（昏迷指數14分或有躁動、嗜睡、重複問相同問題、反應變慢）
2. 嘔吐
3. 有失去意識
4. 嚴重的受傷機制（汽機車相撞且被彈射出去、車子翻覆或其他乘客死亡、走路或騎腳踏車被行進中的車輛撞到；從大於1.5公尺的高度跌落、頭部被高速物體擊中）
5. 熊貓眼、耳後區域瘀血等顱底骨折的表徵
6. 嚴重頭痛 

 (99.95-100% 陰性預測值； 96-8100% 敏感度)