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Commentary on the paper by Reed et al (see page 859)
Over the last year the problem of radiological investigation of the acutely head injured child has been much featured in this journal. We were not so much concerned with what to do with the severely injured—such children are, invariably, intubated and mechanically ventilated, and the most pressing question is to identify whether they need immediate surgery. Head computed tomography (CT) is the obvious investigation. Rather, the real problem arises in the uncooperative 1 to 8 year old who just won’t lie still long enough for CT—is it really worth getting one even if it means endotracheal intubation and a brief anaesthetic, or will a skull x ray suffice, or should the child be admitted for observation until we are sure all is well?
Dunning et al reviewed 16 previously published papers and provided us with a meta-analysis of variables that predict significant intracranial injury in minor head trauma.1 Kupperman commented on this report and presented the broader context of what should or shouldn’t be done in the emergency department with this information.2 Later in the year the CHALICE (children’s head injury algorithm for the identification of significant clinical events) study group presented the implications of applying United Kingdom National Institute of Clinical Excellence (NICE) guidelines to the emergency department management of exactly such children.3 The authors reported the theoretical impact of advocating early CT in place of skull x ray and admission. Data from 10 965 children attending three hospitals between February 2000 and August 2002 were used in the model. Twenty five per cent of the patients had a skull x ray, 0.9% had head CT, and 3.7% were admitted. The authors calculated that adherence to the NICE guidelines would have resulted in a …
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Competing interests: none declared
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