Evaluation of head injury in a pediatric emergency department - Pretrauma and posttrauma system

Objective: To determine if trauma center protocols affect the number of tes ts and consultations performed and the length of time spent in the emergenc y department err hospital. Design: A retrospective review and comparison of treatment for children wit h isolated head injury admitted to the emergency department before trauma c enter designation (group 1, 1985), and 5 years after implementation of trau ma center protocols (group 2, 1991). Setting: Urban children's hospital, level I trauma center. Results: One hundred sixty-five children met the enrollment criteria in 198 5 and 162 met the criteria in 1991. Falls were the predominant mechanism of injury (55%) for both years. For patients with moderate injury (Glasgow Co ma Scale score, 9-12) or severe injury (Glasgow Coma Scale score, <9), ther e was no difference in radiographic or laboratory evaluation. For patients with minimal head injury (Glasgow Coma Scale score, 15,no loss of conscious ness, amnesia, seizure, focal neurologic findings, or persistent symptoms) and minor head injury (Glasgow Coma Scale score, >12, and loss of conscious ness or amnesia), more radiologic and laboratory studies were done in 1991 that showed no clinically siginificant abnormalities. Patients with minimal head injury in group 2 were 14 times more likely to have cranial computed tomographic scans performed (95% confidence interval [CI], 3.4 -67); 11 tim es more likely to have cervical spine radiographs (95% CT, 2.2-76.6); and 2 3 times more likely to have hepatic enzymes obtained (95% CI, 3-491). These differences persisted when analyzed by both the age of the patient and mec hanism of injury. Conclusions: Application of trauma system protocols to isolated head injury patient evaluation results in increased use of laboratory and radiologic s ervices. These practices have the potential to increase the cost of medical care without significantly improving outcome.