Unnecessary Scans Lead to Unnecessary Re-scans: Evaluating Clinical Management of Low and Intermediate Risk Pediatric Traumatic Brain Injuries

Background: The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide an algorithm to select patients with mild head trauma at highest risk for clinically important traumatic brain injury (ciTBI) in whom computed tomography (CT) would facilitate management. Failure to follow PECARN criteria exposes children to unnecessary radiation and contributes to increasing hospital costs, length of stay, and parental anxiety. We sought to evaluate the subsequent allocation of resources to low and intermediate risk group patients who underwent an initial Head CT - which was not indicated by PECARN guidelines but which identified cranial or intracranial injury.

Methods: We conducted a retrospective review of children ≤16 years old with head injury (GCS ≥14) between 2016 and 2021. Children with neurological deficits, penetrating head trauma, anticoagulation, or non-accidental trauma were excluded. Demographics, imaging results, PECARN risk category, and need for neurosurgical intervention were collected.

Results: There were 70 low risk patients who had positive findings on CT, however none demonstrated clinically significant progression on repeat imaging that necessitated medical or surgical intervention. Of 319 intermediate risk patients with evidence of skull fracture or intracranial injury on CT, only one required intervention. The decision to intervene was made based on clinical changes and was not influenced by repeat imaging.

Discussion: Despite PECARN guidelines, cross-sectional imaging remains overused. Identification of small foci of clinically non-actionable intracranial bleeding in patients who do not meet initial PECARN criteria frequently prompts further cross-sectional imaging without benefit. This suggests that routine interval imaging may not be necessary in the neurologically stable child with low-risk injury.

Type of study: Retrospective cohort study.

Level of evidence: Level III.