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Original Investigation | Journal Club

Isolated Loss of Consciousness in Children With Minor Blunt Head Trauma

Lois K. Lee, MD, MPH1; David Monroe, MD2; Michael C. Bachman, MD3; Todd F. Glass, MD4; Prashant V. Mahajan, MD, MPH, MBA5; Arthur Cooper, MD6; Rachel M. Stanley, MD, MHSA7; Michelle Miskin, MS8; Peter S. Dayan, MD, MSc9; James F. Holmes, MD, MPH10; Nathan Kuppermann, MD, MPH10,11 ; for the Traumatic Brain Injury (TBI) Working Group of the Pediatric Emergency Care Applied Research Network (PECARN)
[+] Author Affiliations
1Division of Emergency Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
2Department of Emergency Medicine, Howard County General Hospital, Columbia, Maryland
3Departments of Emergency Medicine and Pediatrics, Newark Beth Israel Medical Center, Newark, New Jersey
4Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
5Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
6Department of Surgery, Columbia University Medical Center at Harlem Hospital, New York, New York
7Department of Emergency Medicine, University of Michigan School of Medicine, Ann Arbor
8Department of Pediatrics, University of Utah, Salt Lake City
9Division of Emergency Medicine, Morgan Stanley Children’s Hospital, Columbia University College of Physicians and Surgeons, New York, New York
10Department of Emergency Medicine, University of California, Davis School of Medicine
11Department of Pediatrics, University of California, Davis School of Medicine
JAMA Pediatr. 2014;168(9):837-843. doi:10.1001/jamapediatrics.2014.361.
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Importance  A history of loss of consciousness (LOC) is frequently a driving factor for computed tomography use in the emergency department evaluation of children with blunt head trauma. Computed tomography carries a nonnegligible risk for lethal radiation-induced malignancy. The Pediatric Emergency Care Applied Research Network (PECARN) derived 2 age-specific prediction rules with 6 variables for clinically important traumatic brain injury (ciTBI), which included LOC as one of the risk factors.

Objective  To determine the risk for ciTBIs in children with isolated LOC.

Design, Setting, and Participants  This was a planned secondary analysis of a large prospective multicenter cohort study. The study included 42 412 children aged 0 to 18 years with blunt head trauma and Glasgow Coma Scale scores of 14 and 15 evaluated in 25 emergency departments from 2004-2006.

Exposure  A history of LOC after minor blunt head trauma.

Main Outcomes and Measures  The main outcome measures were ciTBIs (resulting in death, neurosurgery, intubation for >24 hours, or hospitalization for ≥2 nights) and a comparison of the rates of ciTBIs in children with no LOC, any LOC, and isolated LOC (ie, with no other PECARN ciTBI predictors).

Results  A total of 42 412 children were enrolled in the parent study, with 40 693 remaining in the current analysis after exclusions. Of these, LOC occurred in 15.4% (6286 children). The prevalence of ciTBI with any history of LOC was 2.5% and for no history of LOC was 0.5% (difference, 2.0%; 95% CI, 1.7-2.5). The ciTBI rate in children with isolated LOC, with no other PECARN predictors, was 0.5% (95% CI, 0.2-0.8; 13 of 2780). When comparing children who have isolated LOC with those who have LOC and other PECARN predictors, the risk ratio for ciTBI in children younger than 2 years was 0.13 (95% CI, 0.005-0.72) and for children 2 years or older was 0.10 (95% CI, 0.06-0.19).

Conclusions and Relevance  Children with minor blunt head trauma presenting to the emergency department with isolated LOC are at very low risk for ciTBI and do not routinely require computed tomographic evaluation.

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