To describe variation in the clinical management of minor head trauma in children among primary care and emergency physicians.
A survey of pediatricians, family physicians, and emergency physicians drawn from a random sample of members of the American Academy of Pediatrics, the American Academy of Family Physicians, and the appropriate American Medical Association specialty listings, respectively. Physicians were given clinical vignettes describing children presenting with normal physical examination results after minor head trauma. Different clinical scenarios (brief loss of consciousness or seizures) were also presented. Information was gathered on initial and subsequent management steps most commonly used by the physician.
Surveys were returned by 765 (51%) of 1500 physicians. Of these, 303 (40%) were pediatricians, 269 (35%) family practitioners, and 193 (25%) emergency physicians. For minor head trauma without complications, observation at home was the most common initial physician management choice (n = 547, 72%). Observation in office or hospital was chosen by 81 physicians (11%). Head computed tomographic (CT) scan was chosen by 7 physicians (1%) and skull x-ray by 24 physicians (3%) as the first management option. Most physicians (n = 445, 80%) who initially chose observation at home would obtain a CT scan if the patient showed clinical deterioration. In the original scenario, if the patient had also sustained a loss of consciousness, 383 physicians (58%) altered management. Of these, 120 (18%) chose CT, 13 (2%) chose skull x-ray, 1 (1%) chose magnetic resonance imaging, 141 (21%) chose inpatient observation, and 125 (19%) chose a combination of CT scanning and observation. With seizures, 595 (90%) altered management, with 176 physicians (27%) choosing CT scan, 5 (1%) skull x-ray, 60 (9%) inpatient observation, and 299 (45%) a combination of radiological evaluation and observation.
Most physicians surveyed chose clinic or home observation for initial management of minor pediatric head trauma. Clinical management was more varied when patients had sustained either loss of consciousness or seizures. Further study of the appropriate management of minor head trauma in children is needed to guide physicians in their care.
HEAD TRAUMA is extremely common in the pediatric population; by a conservative estimate, it affects about 375,000 US children annually.1 These injuries result in approximately 100,000 hospital admissions per year and are a frequent cause of emergency department and physician office visits for children.2,3 A large proportion of head injuries in adults and children are minor in nature.4 Some studies have demonstrated excess mortality even among patients with apparently minor head injury, along with relatively high rates of abnormalities on computed tomographic (CT) scanning.5-7 Efforts designed to determine the predictors of abnormal CT scans among patients with minor head trauma (MHT) have been inconclusive.8-10
Aggressive management of moderate to severe head trauma has been shown to improve outcomes. However, appropriate evaluation and treatment of MHT in both adults and children remains controversial and recommendations from studies that have focused on MHT have varied.5,6,11-16 Interpretation of the existing literature on head trauma is difficult because there is substantial variation in the categorization of head injury in these studies, as well as differences in the clinical examination results, radiological outcomes, and clinical outcomes reported.
As many as 18% of patients with MHT can have intracranial abnormalities detected by CT scan. Thus, some authorities advise CT scanning for all patients with MHT who have experienced loss of consciousness or amnesia.5,6,12 The utility of CT scanning to identify patients who might be safely discharged for home observation shortly after injury has also been discussed, as both a means of alleviating clinicians' concerns about safety and of avoiding unnecessary inpatient hospital costs.5,6,12,13 In contrast, a recent prospective study found no intracranial injuries among neurologically normal children with isolated MHT with loss of consciousness.11 Another report concluded that previously healthy children older than 2 years with normal examination results and no evidence of depressed skull fracture may be safely discharged after physical examination alone.10
No clear guidelines, therefore, exist for physicians to use in treating children with MHT, and little information is available regarding the current practices of primary care physicians with regard to these children. We therefore conducted a survey to determine current practice among pediatricians, emergency physicians, and family physicians for pediatric MHT.
We conducted a survey of a national sample of pediatricians, family physicians, and emergency physicians using clinical vignettes to determine current practice. We obtained a random sample of 500 office-based pediatricians through the American Academy of Pediatrics membership files. Random samples of 500 emergency physicians and 500 family physicians were obtained through membership lists of the American Medical Association and the American Academy of Family Physicians, respectively. Each of these members were sent a survey on the management of MHT. The survey consisted of a self-administered questionnaire composed of 6 clinical questions and 7 demographic questions. We collected information on selected actions that the clinicians might take in response to a clinical scenario. One of 2 case histories was provided, involving either a 3-year-old girl who fell 5 ft (1.5 m) from a slide or a 15-year-old boy who collided with another player and bumped his head while playing baseball. Half of each random sample of physicians was sent the questionnaire involving the 3-year-old girl while the other half received the questionnaire involving the 15-year-old boy. In each vignette, the child is evaluated in the office or emergency department 1 hour after the injury, and in each case the child is appropriately responsive with normal neurological examination results. Prior to distribution, the surveys were pilot tested for usability on a group of 20 office-based pediatricians and revised for clarity.
Respondents were asked to answer based on their anticipated actual practice. Each of the respondents answered a set of questions on initial, subsequent, and follow-up treatment for the patient as presented. Additionally, respondents were asked about changes in management strategy if the patient had initially presented with a history of brief loss of consciousness, impact seizure, or a hematoma. Respondents were also asked to choose a management strategy in reaction to either an abnormality on an initial diagnostic study or changes in the clinical status of the patient. The respondents were provided with definitions of what constituted a cause for concern in each modality (eg, cause for concern in a skull x-ray included presence of skull fracture).
For American Academy of Pediatrics and American Medical Association members, a total of 3 mailings and 1 reminder postcard were sent during the period of April through August 1995. The American Academy of Family Physicians conducted the family physician arm of the survey, which included 2 mailings and a postcard reminder.
We calculated frequencies of various demographic characteristics and responses. The χ2 test was used to compare proportions of different responses to the scenarios.
Surveys were returned by 765 (51%) of 1500 physicians. Sixty-one percent of pediatricians responded (n = 303), representing 39.6% of the total sample. Fifty-four percent of family physicians (n = 269) and 39% of emergency physicians (n = 193) responded and represented 35.2% and 25.2% of the total, respectively. Seventy-two subjects could not be located (no forwarding address), 1 physician was deceased, and 5 respondents were excluded because they indicated that the survey was not relevant to their practice. The response rate did not vary by scenario among the physician types.
Demographic characteristics of the respondents are listed in Table 1. The median total time in practice was 13 years, and median time in the present practice site was 8 years. Age and sex data were not collected. More than 90% of the respondents were in primarily clinical positions. About 70% of pediatricians and family physicians were in private practice; most emergency physicians responding (82%) worked in general emergency departments. Twenty-nine percent of respondents practiced in rural locales, 34% in suburban, and 36% in urban settings. Family physicians were more likely to practice in rural settings (50% vs 18% of pediatricians and emergency physicians, respectively).
Characteristics of Survey Respondents by Specialty Type*
Management choices under baseline scenario
Physicians were asked to choose a single option as their usual first management choice in the baseline case of MHT without loss of consciousness, seizure, or hematoma on examination (Table 2). Single-choice responses were given by 661 physicians (86%); the remainder chose more than one option. Observation at home was the most common initial management choice (n=547, 71%). Of these, 393 (72%) would have parents observe their children at home for 6 to 24 hours. Eighty-one physicians (11%) chose observation in clinic or hospital, usually for 1 to 6 hours. Few physicians selected any radiological evaluation: 24 (3%) selected skull x-rays, 7 (1%) a CT scan, and none chose a magnetic resonance imaging scan. Though asked to identify a single first treatment choice, the remaining respondents (14%) selected more than 1 option. Eighty-two of the physicians who chose multiple options (11% of total) selected observation in a clinical setting followed by observation at home; the remainder selected other management combinations.
Initial Management Choices of Survey Respondents Under Baseline Scenario*
Little variation was evident across physician specialties. Emergency physicians were more likely than pediatricians or family physicians to observe patients in the hospital or clinic setting rather than at home (16% vs 9%, P=.02), and were more likely to obtain skull x-ray films (6% vs 2%, P=.04). Family physicians who observed patients in a clinical setting were more likely than other physicians to do so for more than 6 hours. Rural, suburban, and urban physicians were also compared and few differences were identified in their initial management choices. Suburban pediatricians were less likely to obtain skull x-ray films (P<.01) and more likely to recommend observation at home (P<.001) than were urban and rural pediatricians.
Respondents were also asked what they would do if either an abnormality was uncovered in the first management strategy, or the patient's clinical condition changed following the first management decision. The responses are listed in Table 3. Most physicians (n=445, 80%) who had chosen to observe at home would opt for CT scan in the case of neurologic deterioration, as would most who chose observation in the office or hospital (n=67, 74%). Of those choosing skull x-ray initially, most (n=18, 69%) would obtain a CT scan in the case of abnormality. About 10% of physicians who had chosen to observe at home initially would admit children with deteriorating clinical status to the hospital. Among physicians choosing 2 or more options, most selected CT scan followed by observation in the office or hospital setting. There was no significant variation in the second management choices with regard to physician type.
Second Management Choices of Respondents Following Clinical Deterioration or Abnormality in First Choice*
Variation was observed based on which clinical vignette was presented to the physician surveyed. Although the absolute differences were small, more physicians obtained skull x-ray films for the 3-year-old child than for the 15-year-old (3% vs 1.5%,
P=.05) and were more likely to observe the 3-year-old in the office or hospital (14% vs 8 %, P<.001). Physicians were also more likely to consult a neurologist for the younger patient (4% vs 2%, P=.03) when confronted by an abnormality with the first choice of intervention.
Management with loss of consciousness, seizure, or hematoma
Physicians were then asked whether they would alter therapy given alternative scenarios: presence of a 2-cm subcutaneous hematoma on examination, history of loss of consciousness of less than 60 seconds, or history of seizure in association with the injury. More variation in management was notable in response to the different scenarios (Table 4) than to the baseline scenario. Overall, 383 physicians (58%) answered that they would alter their management given history of loss of consciousness, while 595 (90%) would alter management after an impact seizure. Only 181 (27%) would change their management if a hematoma was present.
Management Under Different Case Scenarios*
More physicians chose to obtain CT scans of the head in the case of loss of consciousness, seizure, or hematoma than in the baseline case. This was particularly pronounced for seizure and loss of consciousness (27% and 18% vs 1%). More physicians chose skull x-ray films in the case of hematoma (13% vs 1% to 3% for all other scenarios). Patients were more often admitted to the hospital or observed in clinic in the case of loss of consciousness (21% vs 9% to 11%), and neurosurgeons or neurologists were more frequently consulted when seizure was reported (6% vs 2%). Many physicians chose several management options for the alternative scenarios, especially for the case of seizures, where 299 (45%) had multiple responses. Most of these were combinations of CT scan and observation.
Our data show that, in the case of MHT, there seems to be general agreement regarding management. Overall, 82% of physicians chose a form of observation as clinical management in the baseline scenario, and of those the majority chose observation at home rather than in the clinic or hospital setting. Only a small proportion of physicians chose to obtain x-ray or CT studies in this context. There were some differences by physician type; the finding that emergency physicians were more likely than the office-based physicians to observe the patients themselves and to obtain skull x-ray films may indicate true differences in philosophy or training, or may simply reflect greater access to observation wards or rooms and to radiology facilities.
While few regional variations were observed, it seems that some suburban physicians felt more comfortable with home observation without radiological intervention than those in rural or urban areas. This may reflect greater proximity to follow-up care or improved continuity of care with patients in these settings. Perhaps more interesting is the difference in management of the 3-year-old and 15-year-old patients. More physicians chose to obtain x-ray films in the younger child, and they were also more likely to observe the younger patient in hospital or obtain neurologic consultation. Both pediatricians and family practitioners were less likely to discharge the younger patient for home observation; only emergency physicians showed no differences in their treatment choices under the 2 vignettes. This may reflect their somewhat greater overall tendency to observe patients or perform diagnostic testing than the other physicians. Although the relative differences between the groups were significant, the absolute differences were small. Home management was the dominant management approach for all populations surveyed.
As the cases became more complex, there was considerably more variation in the responses. Under the loss of consciousness and seizure scenarios, physicians were more likely to observe patients in the office or hospital or to obtain CT scans. History of seizure seemed to be the scenario of most concern to the physicians: under this scenario, 90% changed management from observation, instead selecting CT, admission for observation, or neurology consultation. This is consistent with a previous study of the management of moderate head trauma in children among Canadian emergency physicians, which found that 74% of physicians surveyed would admit a patient who had experienced a seizure after head injury.17
Our study has several limitations. The response rate raises concerns that the respondents may not be representative of the general population of primary care physicians. No assumptions can be made about the practices of the nonrespondents. The consistency of the general study findings across groups, however, makes response bias somewhat less of a concern. Further, the low response rate may actually increase the validity of the results, because those physicians who chose to respond may take the issue of management of MHT more seriously than those who did not respond. In any case, the variation in the results of the survey demonstrates the need for further study and evaluation of this issue. In addition, discrepancies may exist between the actual and reported behavior of the respondents. A previous study has shown, however, that responses to clinical vignettes do reflect actual practice.18
Despite controversy about the appropriate evaluation and management of MHT in children, the physicians surveyed in this study generally chose home or office or hospital observation as a first management choice for children with normal examination results and simple MHT. Greater variation exists in the management of MHT with loss of consciousness, seizure, or hematoma, with many physicians performing radiological evaluations and admitting patients for observation. Further study of the most appropriate management of these patients is needed. In particular, the best available data on the management and outcomes of MHT in children should be synthesized and made available for practitioners to use, and variations in management should be closely studied to improve understanding of this clinical entity.
Accepted for publication July 9, 1998.
Corresponding author: Mary E. Aitken, MD, MPH, Center for Applied Research and Evaluation, Arkansas Children's Hospital, 800 Marshall St, Little Rock, AR 72202 (e-mail: firstname.lastname@example.org).
Editor's Note: This seems to be a prime area for development of a clinical practice guideline.—Catherine D. DeAngelis, MD
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