A prospective population-based study of pediatric trauma patients with mild alterations in consciousness (Glasgow Coma Scale Score of 13-14)

OBJECTIVE: Considerable controversy surrounds the appropriate evaluation of children with mild alterations in consciousness after closed head trauma ( Glasgow Coma Scale [GCS] score of 13-14). The objective of the current stud y was to determine the incidence of intracranial lesions in pediatric patie nts with a field CCS score of 13 or 14 after closed head injuries. METHODS: The current study is a population-based, multicenter prospective s tudy of all patients to whom emergency medical services responded during a 12-month period. The setting was urban Los Angeles County, encompassing a p atient population of 2.3 million children, 13 designated trauma centers, an d 94 receiving hospitals. RESULTS: In the pediatric age group (<15 yr old), 8488 patients were transp orted by emergency medical services for injuries. Of these, 209 had a docum ented field CCS score of 13 or 14. One hundred fifty-seven patients were ta ken to trauma centers, and 135 (86%) underwent computed tomography. Forty-t hree patients (27.4%) had abnormal results on computed tomographic scans, 3 0 (19.1%) had an intracranial hemorrhage, and 5 required an operative neuro surgical procedure for hematoma evacuation. Positive and negative predictiv e values of deteriorating mental status (0.500 and 0.844, respectively), lo ss of consciousness (0.173 and 0.809), cranial fracture (0.483 and 0.875, a nd extracranial injuries (0.205 and 0.814) were poor predictors of intracra nial hemorrhage. CONCLUSION: Pediatric patients who have mild alterations in consciousness i n the field have a significant incidence of intracranial injury. The great majority of these patients will not require operative intervention, but the implications of missing these hemorrhages can be severe for this subgroup of head-injured patients. Because clinical criteria and cranial x-rays are poor predictors of intracranial hemorrhage, it is recommended that all chil dren with a GCS score of 13 or 14 routinely undergo screening via non-contr ast-enhanced computed tomography.