Authors: Erik Hess, MD (UAB)
Comment on: Hess, Homme et al. Effect of the Head Computed Tomography Choice Decision Aid in Parents of Children With Minor Head TraumaA Cluster Randomized Trial. JAMA Open.
Each year, 450,000 children present to U.S emergency departments for evaluation of head trauma. Physicians obtain head computed tomography (CT) scans in 37%-50% of these patients, with less than 10% showing evidence of traumatic brain injury and only 0.2% that require neurosurgical treatment. In order to avoid unnecessary CT scans and to limit radiation exposure, the Pediatric Emergency Care Applied Research Network (PECARN) developed 2 clinical prediction rules, one for children less than 2 years of age and one for children 2-18 years of age. Each of these clinical prediction rules consist of 6 readily available factors that can be assessed from the history and physical examination. If none of these risk factors are present, a CT scan is not indicated. If either of 2 high risk factors such as altered mental status or signs of a skull fracture are present, CT scanning is indicated. If 1 or 2 non-high risk factors such as vomiting or a history of loss of consciousness are present, then either CT scanning or observation are recommended, depending on considerations such as parental preference, clinician experience and/or symptom progression. This study designed a decision aid, “Head CT Choice” to educate parents about the difference between a concussion – which does not show up on a CT scan – and a more serious brain injury causing bleeding in or around the brain. The decision aid also shows parents their child’s risk for a serious brain injury – less than 1% risk in the majority of patients in the trial – and what to observe their child at home for should they opt not to obtain a CT scan, along with the advantages and disadvantages of CT scanning versus home observation. This trial did not observe a difference in the rate of head CT scans obtained in the ED but did find that parents who were engaged in shared decision-making using Head CT Choice were more knowledgeable about their child’s risk for serious brain injury, has less difficulty making the decision because they were clearer about the advantages and disadvantages of the diagnostic options, had greater trust in their clinician and were more involved by their clinician in decision-making. Parents also less frequently sought additional testing within 1 week of the emergency department visit.