The guidelines were implemented in pediatric emergency rooms. But Dr. Rebecca Jennings, a pediatric hospitalist at Seattle Children’s Hospital and assistant professor of pediatrics, wanted to encourage their use in community hospitals as well.
She and her colleagues designed an education project to try to reduce unnecessary head CTs on children, reaching out both to E.R. doctors and to general pediatricians in the community. “We wanted to emphasize to the generalists that they should be referring patients for evaluation of their head trauma and not for a head CT,” Dr. Jennings said. It’s important for doctors to help parents understand, she said, that “part of the evaluation is observation.”
Dr. Jennings was the first author on a study published this year in the journal Pediatrics, in which an education program offered by a children’s hospital reduced the CT scan rate to 17.4 percent from 29.2 percent.
“A head CT does not diagnose concussion,” Dr. Jennings said. “The head CT is to look for a brain bleed or a skull fracture primarily, and so often with these families the E.R. physician will say, yes, your child did have a concussion and give concussion counseling, but your child is well enough that we think the risk of having a brain bleed or skull fracture is quite low.”
Mind you, even for the children whose head trauma is clearly more serious — the children who do need to get head CTs, and whose head CTs actually show some evidence of injury, a similar set of complicated decisions looms. The good news is that even these children will mostly do very well (again, we aren’t talking here about children with devastating injuries).
Dr. Jacob Greenberg, a neurosurgical resident at Washington University, St. Louis, said that the issue for neurosurgeons managing these hospitalized patients with known traumatic brain injury is still, “is there something really scary going on that we’re missing?” With Dr. David Limbrick, the chief of pediatric neurosurgery at Washington University School of Medicine as senior author, a multidisciplinary group published a study in JAMA Pediatrics earlier this year in which they looked only at children who had evidence of traumatic brain injury on head CT scans, and who were therefore mostly being sent to intensive care. “The impression we had was the vast majority of these kids were doing fine,” Dr. Greenberg said. “Did they really have to go to the I.C.U.?”
When they looked closely at how these children were being managed, he said, they found that there was not necessarily a close correlation between whether the children were at high risk and whether they were in fact getting I.C.U. monitoring.
Again, they developed a risk scale — this one taking into account the head CT findings — and were able to show that together with the child’s general neurological status, such findings as a depressed skull fracture or a shift in the midline of the brain on CT allowed them to identify the children at higher risk, who really belonged in the I.C.U.
In an email, Dr. Greenberg said that the hope was that this risk score will be viewed as a tool to aid — rather than replace — physician judgment in caring for these children. “These management decisions are complex and we don’t want our work to minimize the role of a thoughtful physician evaluating an individual child,” he wrote. “Rather, we hope that this score will help give a stronger evidence-based foundation to the decisions that physicians make and potentially help reduce some of the variations in practice that we found.”
Head injuries in children scare everyone, from parents to neurosurgeons. If I had taken my toddler to the emergency room, three decades ago, he might well have gone for head imaging for no other reason than that his mother was in medical school and worried. It’s taken great time and care to bring the weight of evidence to these decisions, and the result, for most parents and children nowadays, should be some greater degree of comfort and reassurance.