Intended for healthcare professionals

Practice Uncertainties

Is cranial computed tomography unnecessary in children with a head injury and isolated vomiting?

BMJ 2019; 365 doi: (Published 23 May 2019) Cite this as: BMJ 2019;365:l1875
  1. Simon Hardman, paediatric registrar and clinical research fellow1,
  2. Ola Rominiyi, neurosurgical registrar and clinical research fellow1,
  3. David King, paediatric registrar2,
  4. Edward Snelson, paediatric emergency medicine consultant2
  1. 1University of Sheffield, Sheffield, UK
  2. 2Sheffield Children’s Hospital NHS Foundation Trust, Sheffield, UK
  1. Correspondence to simonhardman{at}

What you need to know

  • Computed tomography (CT) neuroimaging for children with head injury carries a small increased risk of malignancy

  • There is limited low quality evidence that vomiting following head injury in children, in the absence of other clinical features, is not frequently associated with intracranial complications

  • In children with minor head injuries and four episodes of isolated vomiting, including one during the observation period, offer review by a clinician experienced in head injury management to decide about further active observation or immediate CT imaging, and involve parents in the decision.

Nearly 35 000 children in the United Kingdom present to emergency departments with head injuries each year.1 These are largely minor injuries with normal or minimally impaired consciousness level. Around 5% have intracranial complications with approximately 1% having clinically important traumatic brain injuries (box 1).12

Box 1


TBI-CT—Traumatic brain injury on CT2

Head injury with any of the following signs on CT:

  • Intracranial haemorrhage or contusion

  • Cerebral oedema, traumatic infarction, diffuse axonal injury, sigmoid sinus thrombosis

  • Midline shift of intracranial contents or signs of brain herniation

  • Diastasis of the skull, pneumocephalus, skull fracture depressed by at least the width of the table of the skull

ci-TBIClinically important traumatic brain injury2

Traumatic brain injury resulting in any of the following:

  • Death

  • Neurosurgical intervention such as intracranial pressure monitoring, elevation of depressed skull fracture, ventriculostomy, haematoma evacuation, lobectomy, tissue debridement, dura repair

  • Intubation for more than 24 hours after injury

  • Hospital admission for two nights or more in association with traumatic brain injury on CT


The use of cranial computed tomography (CT) scans to identify intracranial complications in children with head trauma has increased in developed countries. A third of children with head injuries presenting to emergency departments in the United States receive imaging.3 The associated radiation risk for an individual child is low, but it becomes important at a population level. For …

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