UMEM Educational Pearls

 

Parents will often bring children to the ED for evaluation after a minor head injury.  Vomiting has been considered a risk factor for traumatic brain injury (TBI).  Is isolated vomiting clinically significant?
 
A PECARN study looked at children < 18 years.
 
Isolated vomiting with minor head trauma was defined as: No history of LOC, GCS of 15, no altered consciousness (ie sleepiness, agitation), no palpable skull fracture or signs of basilar skull fracture, acting
normally per parent/guardian, no scalp hematoma or other traumatic scalp finding (ie abrasion or laceration), no headache (for patients 2-18 y), no seizure after the head trauma, no neurological deficits
(eg, motor or sensory abnormalities) and no amnesia (for patients 2-18 y).
 
42,112 children were enrolled.
5,557 (13.2%) had a history of vomiting, of whom 815 of 5,392 (15.1%) with complete data had isolated vomiting.
Clinically important TBI (death, neurosurgical procedure, intubation for at least 24 hours for TBI, or hospitalization for 2 or more nights because of the head trauma in association with TBI on cranial CT) occurred in 2 of 815 patients with isolated vomiting compared with 114 of 4,577 with non isolated vomiting.
Of patients with isolated vomiting for whom CT was performed, TBI on CT occurred in 5 of 298 compared with 211 of 3,284 with non isolated vomiting
 
There was no association found with timing of onset or time since the last episode of vomiting.
 
Bottom line: TBI on CT is uncommon and clinically important traumatic brain injury is very uncommon in children with minor blunt head trauma when vomiting is their only sign or symptom. Observation in the emergency department before determining the need for CT appears appropriate for these children to observe for deterioration.

References

 

Dayan et al.  Association of Traumatic Brain Injuries With Vomiting in Children With Blunt Head Trauma.  Annals of Emergency Medicine. Article in press.  Available for view Feb 14, 2014.