Should hospitals without neurosurgical capability be observing these kids? In a single coverage ED, how does one prevent the dreaded CT report "suboptimal scan due to motion artifact"? Not part of the study, but how were the c-spines addressed?
Sorry for the delay- I've been teaching a class at the med school, and it turns out that remembering the details of renal excretion is more challenging than anticipated!
To your first question, I'm leaning toward yes- you could observe them, but I suppose it ultimately depends on just how far away the nearest hospital with neurosurg and how high your suspicion is. In the initial PECARN study, of 42,412 kids, while 376 had clinically important TBI, only 60 required neurosurgery (308 were admitted for 2 days + and 8 were intubated as their clinically important outcome). So chances are very small it will come to needing neurosurgery emergently.
Regarding the motion artifact thing- I hate that. Typically, kids under 6 months will stay still or can have their heads taped down, but over that through toddler-hood, it is a problem. I've mostly solved it by doing very few head CTs! I also think that, while I may miss something very small, I'm unlikely to miss a large, clinically relevant bleed because of motion. However, if your pre-test probability is high, a good scan is important. I don't think ketamine for sedation is mainstream yet for this indication, but the absolute ban on use of ketamine in head trauma was lifted a few years ago, so that's an easy option. If you need a good review on this exact topic to convince staff, see Annals EM Jan 2015 page 52. I always had used thiopental as sedation for these kids, and still tend to in the absence of contraindications.
C-spine issues were not addressed at all. Since the head trauma study focused on minor head injury, and peds c-spine injuries are so rare in this setting outside of a frank axial load, that makes sense. There was an interesting article in March Annals EM which argued for clinical clearance or plain films in most kids with potential neck injury (anyone with <24.9% risk of injury), but I think we're all hoping PECARN gives us some specific criteria tailored to children for clearing the c-spine soon!
To join the conversation, you need to subscribe.
Sign up today for full access to all episodes and to join the conversation.
Michael D., D.O. - April 3, 2015 6:08 PM
Should hospitals without neurosurgical capability be observing these kids?
In a single coverage ED, how does one prevent the dreaded CT report "suboptimal scan due to motion artifact"?
Not part of the study, but how were the c-spines addressed?
ilene c. - April 16, 2015 1:16 PM
Sorry for the delay- I've been teaching a class at the med school, and it turns out that remembering the details of renal excretion is more challenging than anticipated!
To your first question, I'm leaning toward yes- you could observe them, but I suppose it ultimately depends on just how far away the nearest hospital with neurosurg and how high your suspicion is. In the initial PECARN study, of 42,412 kids, while 376 had clinically important TBI, only 60 required neurosurgery (308 were admitted for 2 days + and 8 were intubated as their clinically important outcome). So chances are very small it will come to needing neurosurgery emergently.
Regarding the motion artifact thing- I hate that. Typically, kids under 6 months will stay still or can have their heads taped down, but over that through toddler-hood, it is a problem. I've mostly solved it by doing very few head CTs! I also think that, while I may miss something very small, I'm unlikely to miss a large, clinically relevant bleed because of motion. However, if your pre-test probability is high, a good scan is important. I don't think ketamine for sedation is mainstream yet for this indication, but the absolute ban on use of ketamine in head trauma was lifted a few years ago, so that's an easy option. If you need a good review on this exact topic to convince staff, see Annals EM Jan 2015 page 52. I always had used thiopental as sedation for these kids, and still tend to in the absence of contraindications.
C-spine issues were not addressed at all. Since the head trauma study focused on minor head injury, and peds c-spine injuries are so rare in this setting outside of a frank axial load, that makes sense. There was an interesting article in March Annals EM which argued for clinical clearance or plain films in most kids with potential neck injury (anyone with <24.9% risk of injury), but I think we're all hoping PECARN gives us some specific criteria tailored to children for clearing the c-spine soon!