Pediatric Head CT – Does Vomiting Matter?

Written by Clay Smith

Spoon Feed
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 PECARN, CHALICE, 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