Imaging the less seriously head injured child

Each year, three and a half million children attend an accident and emergency department (AE hospital admission is required in approximately one tenth.2 Head injury accounts for 15% of deaths from 1–15 years of age and 25% from 5–15 years,3 and is arguably the principal public health challenge of childhood. Our aim is to define the terms of reference, emphasise dependence on an informed clinical approach, in order to identify those that require imaging as part of immediate management. Because a large proportion of patients attend out of hours and are seen by junior doctors, practice guidelines for x ray examination (and/or hospital admission) have been developed.4 It is recognised, however, that these are widely ignored and skull radiographs, 2–9% of which show evidence of fracture,5 are used inappropriately as a triage tool. Severity of head injury is impossible to define in absolute terms. Classifications of severity vary according to speciality group.4 Minor head injury is one where the causative mechanism is non-violent, full consciousness and recall have been retained throughout, and neurological features and vomiting are absent (table 1), as are clinical or radiographic evidence of skull fracture. Less serious head injury is therefore a diagnosis of exclusion.6 The clinical challenge is to use all available information to distinguish early the child in whom complications of brain injury are more likely, from the majority with superficial injury (table 1). Cogent radioprotective and financial evidence is detailed by the Royal College of Radiologists.7 View this table: Table 1 The two extremes of the continuum between “simple head injury” and “potential/actual brain injury”1-150 The central question to answer is whether there is evidence of brain injury, as opposed to superficial injury. History should focus on the mechanism of injury as …