Head injuries do not always require a CT scan

Prof Dr. Max J. Coppes is momenteel hoogleraar kindergeneeskunde

aan de Universiteit van Nevada, Reno School of Medicine and medisch directeur van het Renown Kinderziekenhuis in Reno (staat Nevada). Max J Coppes werd in Leiden tot arts opgeleid en vervolgens in Utrecht tot kinderarts.  In 1988 vertrok hij voor een jaar naar Toronto om zijn opleiding tot kinderoncoloog te voltooien, maar is sindsdien in Noord Amerika gebleven.  Hij werkte naast Toronto respectievelijk in Cleveland,Max J Coppes Calgary, Washington DC, Vancouver, en nu dus Reno.  Hij is bovendien met Nederland verbonden als lid van de raad van commissarissen van het recentelijk geopend Prinses Maxima Centrum voor kinderkanker in Utrecht. Een kinderoncoloog die bijna een vluchtchirurg werd, is hij net zo comfortabel in een benedictijnenklooster als in een internationale meeting met over 10,000 gedelegeerden. Head injuries

Head injuries do not always require a CT scan

Seeing one of your children develop symptoms (loss of consciousness, vomiting, dizziness, headache, or swelling on the skull) immediately after a head injury is an extremely alarming experience for a parent, regardless of the nature of the head injury. Rightfully so, the first reaction is to rush the child to an emergency department for careful examination. Most of us expect that the examination will include a CT scan of the head to determine whether the head injury caused bleeding, a serious condition that may require surgical intervention. Until recently the risk of a CT scan (exposure to radiation from the radiologic exam and for young children sedation or anesthesia to allow for the CT scan to happen) were considered minimal compare to the risk of missing an intracranial bleed. It is thus not surprising that most, if not all, young children who experience symptoms after a head injury are exposed to CT examination. This occurs about half-a-million of times each year in our country.

More recently we have come to better appreciate the hazards of CT scans, especially in young children. One head CT scan exposes a child to the equivalent of 140 chest X-rays. While studies suggest that having undergone one single head CT scan is extremely unlikely to increase a child’s risk of developing cancer over their lifetime, we do know that radiation exposure, especially in very young children, is not entirely harmless. So we need to balance the risks associated with radiation exposure against the risk of traumatic brain injury that could cause permanent damage or death if not identified early.

A national study of over 50,000 children found that, if children only experienced loss of consciousness after a head injury and no other symptoms, the likelihood of a serious brain injury was very low. In fact, pediatric emergency doctors noted that this likelihood was about 0.2%; that is only one in every 500 children presenting with only loss of consciousness, regardless of its duration. In other words, we expose 499 children to unnecessary radiation exposure to identify one child that actually benefits from the procedure. The same principle holds true for children who only develop one of the other symptoms (vomiting, dizziness, headache, or swelling on the skull). In other words, if a child only develops one of these symptoms, we need to carefully determine whether to expose that child to radiation. Pediatric emergency physicians have come up with an alternative approach that minimizes unnecessarily exposing children to radiation: observation (up to 6 hours) before deciding whether to do a head CT. This may not always be ‘convenient’ for busy parents or busy emergency departments, but let’s keep what is best for the child at the center of our decisions. As a parent, ask the emergency department physician to explain why a CT scan is recommended and whether he/she has considered observation, and if not, why not. In Reno, we are fortunate to have a true pediatric emergency department at Renown Children’s hospital. These experts have your child’s best interest in mind and at heart.  They are also aware of the latest national recommendation specific for children and the need to use whenever possible Low Dose CT scanners for children. 

Dr Max J Coppes
Physician-in-Chief Renown CHILDREN’S Hospital
Nell J Redfield Chair of Pediatrics, UNR Med