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Practice Guidelines

Early management of head injury: summary of updated NICE guidance

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g104 (Published 22 January 2014) Cite this as: BMJ 2014;348:g104

Rapid Response:

Re: Early management of head injury: summary of updated NICE guidance

We note the comments from Fryer et al(1) as regards vomiting in relation to CT scanning and observation practices in paediatric head injury.

The GDG considered the CHALICE,(2) CATCH,(3) and PECARN(4) clinical decision rules as potential strategies to guide imaging decisions in paediatric head injury. All three include vomiting as a clinical finding which increases the risk of traumatic brain injury (TBI), and the GDG therefore felt strongly that vomiting should remain in the current NICE guidance (CG176). An in depth review of existing evidence indicated that isolated vomiting in paediatric head injury represents a lower risk of TBI than some other clinical features. The current NICE guidance reflects this, suggesting active observation for children with three or more discreet episodes of isolated vomiting, though patients with persisting vomiting and/or other clinical features should undergo CT scanning.

Subsequent to the publication of the current NICE guidance (CG176) the Pediatric Emergency Care Applied Research Network (PECARN) published further evidence on the association of traumatic brain injuries with vomiting in children with blunt head trauma. This study represents a sub-analysis of 42,114 patients.(5) Of 298 patients who had a CT scan and any vomiting as an isolated finding, 5 (1.7%) had radiologic features of TBI. This increased when vomiting occurred in association with other clinical findings, with CT findings of TBI in 211 of 3284 (6.4%). This demonstrates that though the risk is low, TBI does occur with isolated vomiting. These children may therefore undergo a period of observation prior to imaging decisions, and a CT scan should be performed in the presence of persisting symptoms and/or other clinical features.

The GDG considered the role and duration of observation, and reached consensus that observation should be performed for a minimum of four hours from the time of injury. This is unlikely to result in a substantial increase in admission rates as this relates to the time of injury, not time of Emergency Department presentation. Rather only those children who require ongoing observation and/or a CT scan will require admission. However we urge common sense be employed when considering the necessary period of observation for an individual patient, recognising that some will require observation beyond this time point due to time elapsed between injury and Emergency Department attendance.

References
1. Fryer J, Abrahamson E. Remove isolated vomiting as an automatic indication for computed tomography in children with head injury. BMJ. 2014 Mar 10;348(mar10 15):g2032–g2032.
2. Dunning J, Daly JP, Lomas J-P, Lecky F, Batchelor J, Mackway-Jones K, et al. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006 Nov;91(11):885–91.
3. Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ Can Med Assoc J. 2010 Mar 9;182(4):341–8.
4. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160–70.
5. Dayan PS, Holmes JF, Atabaki S, Hoyle Jr. J, Tunik MG, Lichenstein R, et al. Association of Traumatic Brain Injuries With Vomiting in Children With Blunt Head Trauma. Ann Emerg Med [Internet]. [cited 2014 Mar 25]; Available from: http://www.sciencedirect.com/science/article/pii/S0196064414000213
6. Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: a retrospective cohort study. The Lancet. 2012 Aug;380(9840):499–505.
7. Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. Cancer risk in 680 000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013 May 21;346(may21 1):f2360–f2360.

Competing interests: No competing interests

17 April 2014
Fiona Lecky
Clinical Professor / Honorary Consultant in Emergency Medicine
Mark Lyttle, Carlos Chapin, Susan Latchem, Vicki Pollit, Sarah Hodgkinson on behalf of the GDG
EMRiS, Health Services Research, School of Health and Related Research, University of Sheffield / Salford Royal Hospitals NHS Trust
Regent's Court, Regent Street, Sheffield S1 4DA