Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA, USA.
Ann Emerg Med. 2011 Oct;58(4):315-22. doi: 10.1016/j.annemergmed.2011.03.060. Epub 2011 Jun 16.
Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results.
We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention.
Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%).
Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.
在急诊科（ED）中，初始格拉斯哥昏迷量表（GCS）评分为 14 或 15 的轻度钝性头部创伤儿童，尽管头部计算机断层扫描（CT）检查结果正常，仍经常住院治疗。我们旨在确定轻度钝性头部创伤和正常 ED CT 扫描结果儿童的神经并发症发生率。
我们对 2004 年至 2006 年间 25 个中心的 18 岁以下患有钝性头部创伤（包括孤立性头部或多系统创伤）的儿童进行了前瞻性、多中心观察队列研究。在这个子研究中，我们分析了初始 GCS 评分为 14 或 15 且 ED 评估期间头部 CT 扫描结果正常的个体。异常影像学检查结果定义为任何颅内出血、脑水肿、气颅或任何颅骨骨折。具有正常 CT 扫描结果且住院的患者接受随访以确定神经结局；从 ED 出院回家的患者通过电话/邮件随访以评估后续神经影像学、神经并发症或神经外科干预。
纳入了 GCS 评分为 14 或 15 且 ED CT 扫描结果正常的儿童（13543 例），包括 GCS 评分为 15 的 12584 例（93%）和 GCS 评分为 14 的 959 例（7%）。在 13543 例患者中，2485 例（18%）住院，包括 GCS 评分为 15 的 2107 例（17%）和 GCS 评分为 14 的 378 例（39%）。从 ED 出院回家的 11058 例患者中，成功完成了 8756 例（79%）的电话/邮件随访，其余患者进行了病历、持续质量改进和太平间检查。197 例（2%）儿童接受了后续 CT 或磁共振成像（MRI）检查；5 例（0.05%）CT/MRI 扫描结果异常，无一例（0%；95%置信区间 [CI] 0%至 0.03%）接受神经外科干预。在 2485 例住院患者中，137 例（6%）接受了后续 CT 或 MRI 检查；16 例（0.6%）CT/MRI 扫描结果异常，无一例（0%；95% CI 0%至 0.2%）接受神经外科干预。初始 GCS 评分为 14 或 15 且 CT 扫描正常的儿童接受神经外科干预的阴性预测值为 100%（95% CI 99.97%至 100%）。
初始 ED GCS 评分为 14 或 15 且头部 CT 扫描结果正常的钝性头部创伤儿童发生后续神经影像学创伤性发现的风险极低，需要神经外科干预的风险极低。对于 CT 扫描结果正常的轻度头部创伤儿童，在急诊科进行神经观察后的住院治疗通常是不必要的。
