Observation of Minor TBI Prevents Harms

This study regarding the observation of children following minor traumatic brain injury is a little bit oddly spun by its authors and the medical news.

As we all know, most children presenting to the Emergency Department for minor head trauma do not have a clinically significant injury.  Regardless, a significant portion of these children receive non-therapeutic cranial radiation to further assure parents and clinicians alike.  The PECARN group, a few years back, published a rough decision instrument to help classify ~50% of these patients as “very low risk” (<0.05% risk of TBI) to give clinicians a tool to obviate CT scanning.

This group at Boston Children’s prospectively evaluated clinicians’ use of immediate CT scanning versus delayed CT scanning (observation).  They find, of course, that observing children in the ED for a short period, rather than making an immediate decision regarding CT use, resulted in decreased use of CT.  Thusly, the press releases state “Waiting and Watching Can Reduce Use of Brain Scans for Kids in the Emergency Department“.

But, watching and waiting doesn’t benefit the children in this cohort – other than preventing avoidable harms.  The eight children who had CT scans showing clinically important injuries were easily identified by clinicians as requiring immediate CT.  The period of observation doesn’t change the short-term clinical outcome of any of the patients – it only “treats” the risk-aversion of clinicians and parents.  “Watching and waiting” may reduce scans – but discharging the entire observation cohort immediately would have reduced scans even further, without missed cTBI (although the study is underpowered to truly detect all events down to an appropriate “zero-miss” threshold).

While I agree this is an important clinical problem to address, I simply find an odd discordance between the patient-oriented features and the resource utilization-oriented outcome measured.

“Effect of the Duration of Emergency Department Observation on Computed Tomography Use in Children With Minor Blunt Head Trauma”
www.ncbi.nlm.nih.gov/pubmed/23910481