Pediatric Head CT - Does Vomiting Matter?

Written by Clay Smith

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In pediatric patients with blunt traumatic head injury, none had clinically important traumatic brain injury (ciTBI) or significant injury on CT (TBI-CT) if the only symptom was vomiting <3 times.  It was still extremely low if isolated vomiting 3 or more times: 3/1000 for ciTBI and 6/1000 for TBI-CT.

Why does this matter?
Presence of vomiting was one of the high-risk PECARN features in children >/=2 years.  But subsequent PECARN analyses have shown that observation and withholding CT in such children with isolated vomiting was safe.

Vomiting once, vomiting twice...sold!
This was a secondary analysis of an Australian Pediatric Head Injury Rule study with almost 20,000 patients.  The goal of this study originally was to prospectively compare PECARNCHALICE, and CATCH in a different population from the original studies.  This was a secondary analysis.  They found that in children with isolated vomiting <3 times, the risk of ciTBI was 0/662 and TBI-CT was also 0/662.  In children with isolated vomited 3 or more times, ciTBI was 1/344, 0.3% and TBI-CT was 2/344, 0.6%.  If vomiting was not isolated but was associated with other high risk features, odds of ciTBI and TBI-CT increased dramatically, especially if paired with clinical signs of skull fracture.

Source
Vomiting With Head Trauma and Risk of Traumatic Brain Injury.  Pediatrics. 2018 Apr;141(4). pii: e20173123. doi: 10.1542/peds.2017-3123.

Peer reviewed by Thomas Davis

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