When a child seeks care after a blunt head injury, the stakes are high, as not all injuries that could be fatal without intervention are evident at the time of presentation. A computed tomography (CT) scan of the head can help—but we can’t subject all children to unnecessary imaging that isn’t without its own risk of long-term consequences, either. Clinical decision rules (CDRs), such as those from the Pediatric Emergency Care Applied Research Network (PECARN) and the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) aid providers in determining a child’s risk for clinically important traumatic brain injury (ciTBI). While some components of these CDRs such as seizures and skull fractures may seem more obvious predictors of significant trauma, what about vomiting?
In this month’s Pediatrics (10.1542/peds.2017-3123), Borland et. al. report the prevalence of ciTBI in children presenting to the emergency department with vomiting after head injury. The study is a planned secondary analysis from the Australasian Pediatric Head Injury Rule Study (APHIRST) on 1006 children < 18 years of age with a known head injury. Reassuringly, only 1 child with ciTBI presented with vomiting as the sole symptom. Perhaps more importantly, however, Borland and colleagues identified additional historical and clinical findings that, when present with vomiting, would be more predictive of ciTBI. Using multivariate logistic regression analysis, vomiting in the presence of headache, acting abnormally, altered mental status, or skull fracture was more predictive of ciTBI. With the exception of skull fracture (adjusted OR 80.13), headache, acting abnormally, and altered mental status were associated with a more modest risk with adjusted ORs ranging from 1.86-2.35. How could this influence your practice? For starters, while vomiting continues to be a criterion in both the PECARN and CHALICE CDRs, the prevalence of vomiting as the sole symptom in children with ciTBI was rare in this cohort (and in previously studied cohorts as well). These results add to a growing body of evidence that supports clinical observation of children with head injury and vomiting alone instead of CT imaging. Be sure to check out this article by Borland et. al. to get a better grasp on when you should be concerned for ciTBI in pediatric patients—and when you may be able to forgo that CT scan.