Evaluation of minor head injury in children

Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department

BACKGROUND

There is uncertainty about which children with minor head injury need to undergo computed tomography (CT). We sought to prospectively validate the accuracy and potential for refinement of a previously derived decision rule, Canadian Assessment of Tomography for Childhood Head injury (CATCH), to guide CT use in children with minor head injury.

METHODS

This multicentre cohort study in 9 Canadian pediatric emergency departments prospectively enrolled children with blunt head trauma presenting with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. Phys icians completed standardized assessment forms before CT, including clinical predictors of the rule. The primary outcome was neurosurgical intervention and the secondary outcome was brain injury on CT. We calculated test characteristics of the rule and used recursive partitioning to further refine the rule.

RESULTS

Of 4060 enrolled patients, 23 (0.6%) underwent neurosurgical intervention, and 197 (4.9%) had brain injury on CT. The original 7-item rule (CATCH) had sensitivities of 91.3% (95% confidence interval [CI] 72.0%-98.9%) for neurosurgical intervention and 97.5% (95% CI 94.2%-99.2%) for predicting brain injury. Adding "≥ 4 episodes of vomiting" resulted in a refined 8-item rule (CATCH2) with 100% (95% CI 85.2%-100%) sensitivity for neurosurgical intervention and 99.5% (95% CI 97.2%-100%) sensitivity for brain injury.

INTERPRETATION

Among children presenting to the emergency department with minor head injury, the CATCH2 rule was highly sensitive for identifying those children requiring neurosurgical intervention and those with any brain injury on CT. The CATCH2 rule should be further validated in an implementation study designed to assess its clinical impact.

Scandinavian guidelines for initial management of minor and moderate head trauma in children

BACKGROUND

The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim.

METHODS

General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders.

RESULTS

The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children.

CONCLUSIONS

We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma.

Prospective study of validity of neurologic signs in predicting positive cranial computed tomography following minor head trauma

INTRODUCTION

The ability to discriminate among a large number of patients with mild head injury to detect those most likely to have an intracranial abnormality may offer an advantage in mass-casualty situations and when clinical needs exceed diagnostic capabilities.

HYPOTHESIS

In patients with mild head injury (Glasgow Coma Scale score = 13-15), the likelihood of intracranial abnormality, as defined by cranial computed tomography (CT), varies according to presenting neurologic signs and symptoms.

METHODS

This prospective study consisted of 152 patients with blunt head trauma and one or more of the following: initial loss of consciousness (LOC), headache, vomiting, convulsions, or amnesia. All underwent cranial CT within one hour of presentation. Positive CT findings were defined as cerebral contusion, extra-axial hematoma, intra-ventricular or subarachnoid hemorrhage, brain edema, and skull fracture. Clinical findings were tabulated and compared with CT findings.

RESULTS

The most common symptoms were headache (61%) followed by followed by LOC (45%), vomiting (39%), amnesia (29%), and convulsions (4%). Convulsions were the most predictive of a CT positive finding (80%); history of LOC was least predictive (29%). The presence of two or more clinical findings tended to increase the likelihood of intracranial abnormality, but the association was neither consistent nor additive.

CONCLUSIONS

Convulsions occurring in a patient with mild head injury are highly predictive of a positive intracranial finding on CT. Headache, amnesia, and vomiting are each likely to show positive findings in approximately 40-45% of cases. Although the least predictive of the neurologic findings studied, loss of consciousness still correlates with a positive cranial CT in 29% of cases. More than one sign or symptom increases the likelihood of concurrent brain injury.

[Head injuries in children]

Trauma is the reason for 40-60% of emergency callouts concerning children. Approximately half of the children have head injuries. As for adults early recognition of findings indicating an intervention are decisive for the prognosis. In children head injury can be divided into three categories: birth trauma, accidental and non-accidental trauma. This article concentrates on accidental trauma with respect to characteristics of causes, epidemiology, mechanisms of accidents and illustrated morphological findings.

[Emergency ward management of traumatic head injury in children]

BACKGROUND

The controversial situation relating to assessment and management of the traumatic head injury (THI) in children inspired us to study our own patient pool. The aims were to find a significant correlation between skull fracture or clinical symptom and intracranial lesion as well as to determine the importance of each radiological diagnostic method in the initial management of the pediatric THI.

PATIENTS AND METHODS

In 1 year 1,637 children had been treated in the emergency room of pediatric surgery with the diagnosis of THI. Age, sex, injury pattern, symptoms, radiological diagnostic methods, diagnosis, and clinical follow-up had been registered.

RESULTS

A significant correlation between skull fracture or clinical symptom and the intracranial injury in children could not be found, but risk factors exist. Cranial computed tomography is the imaging method of choice. X-ray, ultrasound, and MRI of the head are reserved for a few indications.

CONCLUSION

A management plan for pediatric head and brain injury in the emergency room based on our own and published international results is introduced.

Pediatric injuries: prevention to resolution

Despite improved education and prevention initiatives, trauma remains the leading cause of death in children. A variety of preventative measures have been developed to decrease the morbidity and mortality, and the financial burden on the health care system. This article discusses injury prevention strategies, issues in prehospital care, and key points of initial resuscitation. In addition, the major injury patterns are described with attention paid to the diagnosis and management of patients with multiple traumatic injuries.

Pediatric minor closed head injury

Many studies have found conflicting evidence over the use of clinical indicators to predict intracranial injury in pediatric mild head injury. Although altered mental status, loss of consciousness, and abnormal neurologic examination have all been found to be more prevalent among head-injured children, studies have observed inconsistent results over their specificity and predictive value. Children older than 2 years have been evaluated, managed, and studied differently than those less than 2 years old. Evidence strongly supports a lower threshold to perform a CT scan in younger children because they have a higher risk of significant brain injury after blunt head trauma.

Manifestations neurologiques spectaculaires après traumatisme crânien bénin : étude rétrospective de 51 enfants

Mild head traumas, as a rule, remain a- or paucisymptomatic. In a few cases however, spectacular manifestations develop despite absence of intracerebral lesion. POPULATION, METHODS: We have studied retrospectively 51 such children and contacted their family in order to clarify the follow-up.

RESULTS

The dominant symptoms allowed to categorize the following situations: syncope-like loss of consciousness (11 cases), seizures (6), severe headaches with neurologic signs (15), confusion (8), visual disorders (6), amnesic ictus (5). Recurrences were possible but benign: in 8/11 children in the group "syncopes", in 1/6 in the group "seizures", in 5/21 in the 4 other groups. In the latter 4 groups, 11/21 children developed common migraine. Except for the only case who developed epilepsy later on, scholarship was normal in the 25 cases with sufficient follow-up.

DISCUSSION

Beside syncopes and seizures, the long-lasting episodes suggested a migrainous pathogeny, perhaps at a maturative stage where the trigger of migrainous mechanism is at a low level in the brain.

CONCLUSION

The mildness of the knock, the normality of CT scan including when the symptoms are present and the normality of both consciousness and examination once the symptoms have disappeared allow to avoid further investigations.

Mild head injury: observation or computed tomography? Economic aspects by literature review and decision analysis

OBJECTIVES

To compare the costs of two strategies for acute management of mild head injury: inhospital observation compared with acute computed tomography (CT) and home care.

METHODS

Studies comparing costs for the two strategies that seem to have similar outcomes for patients were systematically reviewed. A decision tree analysis to compare the costs was also constructed, based on Swedish national costs and the risks found in a recent review on mild head injury complications.

RESULTS

No studies were found that directly measured and compared risks, benefits, and costs of the two strategies. In the four studies retrieved, involving 4126 patients, the costs for hospital observation were factual, but a model was used to evaluate costs for the CT strategy. On average, costs were one third lower with CT. Also, the decision tree analysis demonstrated that the CT strategy was one third less expensive than inhospital observation. A sensitivity analysis showed this to be valid for nearly all cases. If these calculations hold true, a change of strategy could result in annual savings of pound 280,000/million inhabitants.

CONCLUSION

The CT strategy seems to cost one third less than hospital observation.

Loss of consciousness: when to perform computed tomography?

OBJECTIVE

To determine the diagnostic value of physical examination (including neurologic exam) for positive computed tomography scan findings in children with closed head injury, Glasgow Coma Scale score 13-15 in the emergency department, and loss of consciousness or amnesia.

DESIGN

Prospective descriptive study.

SETTING

A large, tertiary, pediatric trauma center in San Diego County.

PATIENTS

Children ages 2-16 with an isolated closed head injury, history of loss of consciousness or amnesia, and Glasgow Coma Scale 13-15 who were referred for pediatric trauma evaluation and received a head computed tomography as part of this evaluation.

INTERVENTIONS

A standardized physical examination including skull/scalp exam, pupils, tympanic membrane, and brief neurologic exam was documented on each patient.

MEASUREMENTS AND MAIN RESULTS

Subjects age 2-16 being evaluated by the pediatric trauma team for closed head injury with loss of consciousness or amnesia and Glasgow Coma Scale 13-15 received a standardized physical exam, noncontrast head computed tomography scan, and follow-up telephone call at 4-6 wks. Outcome variables include intracranial injury visualized on computed tomography scan and need for neurosurgical intervention. Ninety-eight subjects were enrolled in the study over a 1-yr period. Computed tomography scans revealed evidence of intracranial injury in 13 of 98 subjects (13%). Normal examination increased the probability of a normal computed tomography scan from.87 pretest to.90 posttest. Four of 38 subjects with normal examination were noted to have evidence of intracranial injury on computed tomography. These four subjects did not require neurosurgical intervention. Two of 98 subjects underwent neurosurgical procedures. One intracranial pressure monitor was placed for decreasing level of consciousness. One subject underwent surgical elevation of a depressed skull fracture.

CONCLUSIONS

Detailed clinical examination is of no diagnostic value in detecting intracranial injuries found on head computed tomography scan. Patients with observed loss of consciousness or amnesia and Glasgow Coma Scale 13-15 should have a head computed tomography scan as part of their evaluation to avoid missing an intracranial injury.

Traumatic brain and spinal cord injury

The management of pediatric head injuries has evolved over the past decade,and a number of significant advances have been made. Evidence-based guide-lines and algorithms for the management of severe pediatric head injuries have recently been published, and all pediatricians who care for children with severe head injuries should be familiar with these guidelines. It is hoped the guidelines will streamline the clinical management of these children and stimulate future research into the many areas that require further investigation.

A decision rule for identifying children at low risk for brain injuries after blunt head trauma

STUDY OBJECTIVE

Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries.

METHODS

We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules.

RESULTS

Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in children < or =2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications.

CONCLUSION

Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children < or =2 years of age), and headache.

Blunt pediatric head trauma requiring neurosurgical intervention: how subtle can it be?

Recent literature on pediatric head injuries has suggested that important intracranial injuries might present to the ED without typical signs or symptoms. The objective of our study was to review our institutional experience with head-injured infants and young children to assess the subtlety of the ED presentation. We performed a retrospective medical record review of head-injured children </=10 years of age who underwent neurosurgical procedures from January 1, 1985, through November 28, 2001. We identified 110 children who met our inclusion criteria. All of the children had at least 2 signs or symptoms indicative of head injury. No single sign or symptom was present in all cases. Altered mental status was identified 85% of the time and was the most common sign or symptom. Eighteen children presented with a Glasgow Coma Scale score of 15 or the absence of abnormal mental status documented, but all of these children had other indications for head computed tomographic scanning. Emergency physicians should feel confident that standard history and physical examination skills are adequate to identify head-injured children who require neurosurgical procedures.

Necessity of hospital admission for pediatric minor head injury

The objective of this study was to evaluate the need for mandatory hospital admission of all pediatric patients with minor head injury (MHI) and negative computed tomographic (CT) scans for head injury. The study was a retrospective chart review of all patients admitted to a pediatric trauma service over a period of 4 years. MHI was defined as blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and a nonfocal neurological examination. Only patients < or = 13 years of age and with a negative head CT scan were included, and during hospitalization all patients were observed for delayed complications. A total of 197 patients met the inclusion criteria. The patients' mean age was 7.1 years, with a range of 2 months to 13 years. The most common mechanisms of injury were being struck by a motor vehicle while walking (82 patients), and falling (75 patients). No complications were observed, and although persistent symptoms occurred in 5 patients, they did not delay discharge. We conclude that pediatric patients with MHI and negative CT scans of the head do not require routine admission for observation for delayed complications.

Pediatric minor head trauma: indications for computed tomographic scanning revisited

BACKGROUND

Although the use of computed tomographic (CT) scanning in severe head trauma is an accepted practice, the indications for its use in minor injury remain ill defined and subjective. We sought to define the incidence and identify risk factors for intracranial injury (ICI) after minor head trauma in children who did not have suspicious neurologic symptoms in the field or on presentation.

METHODS

From January 1, 1992, until April 1, 2000, 569 blunt trauma patients (age < 16 years) with a Glasgow Coma Scale score of 14 or 15 triaged by American College of Surgeons Pediatric Mechanism Criteria at a Level I trauma center received head CT scan. Loss of consciousness (LOC) status was known for 429. This subgroup was retrospectively reviewed for mechanism, age, Injury Severity Score, LOC status, GCS score, associated injuries, and CT scan findings (normal, fracture only, or intracranial injury). Relative risk values for intracranial injury were generated and statistical significance was assessed.

RESULTS

Fourteen percent (62 of 429) of study patients (GCS score of 14 and 15) had ICI. Sixteen percent of patients (35 of 215) with GCS score of 15 and (-)LOC (negative for LOC) had intracranial injury manifesting as subdural hematoma, epidural hematoma, subarachnoid hemorrhage, or brain contusion. Three required surgery for intracranial mass lesions. One patient deteriorated and required intubation and intensive care unit management. Neither (+)LOC (positive for LOC) nor GCS score of 14 increased the likelihood of intracranial injury over those patients without loss of consciousness or with GCS score of 15. Distant injury was also not an independent predictor of ICI for those with GCS scores of 14 or 15, as 84% of the ICI group had head injury only. Skull fracture was a risk factor for ICI but had poor negative predictive value, as 45% of patients with ICI did not have fractures. Similarly, minor craniofacial soft tissue trauma was a significant risk factor (relative risk, 11) that had marginal negative predictive value (0.95), as 14% (9 of 62) of ICI patients did not have superficial craniofacial injury.

CONCLUSION

A normal neurologic exam and maintenance of consciousness does not preclude significant rates of intracranial injury in pediatric trauma patients. Contrary to convention, neither LOC nor mild altered mentation is a sensitive indicator with which to select patients for CT scanning. Skull fractures and superficial craniofacial injury are similarly unreliable. Identification of these patients is important for the occasional case requiring intervention and for the tracking of complications. A liberal policy of CT scanning is warranted for pediatric patients with a high-risk mechanism of injury despite maintenance of normal neurologic status in the field and at hospital screening.

Mandatory admission after isolated mild closed head injury in children: is it necessary?

BACKGROUND/PURPOSE

Children with closed head injuries diagnosed as concussion alone or concussion with brief loss of consciousness are admitted routinely for observation despite a normal central nervous system finding, negative computed tomography (CT) scan, and a Glasgow Coma Score (GCS) of 15. Recent studies have questioned the necessity of such an admission. The purpose of this study was to review a large pediatric database and study the length of stay as well as any required procedures or complications in these children. The hypothesis was that routine admission is unnecessary in this population.

METHODS

The National Pediatric Trauma Registry-Phase II was reviewed for the period from October 1988 to January 1996. Entry criteria included age less than 18 and an isolated closed head injury after blunt trauma with an admission GCS of 15. Variables studied included age, gender, mechanism of injury, length of stay, procedures, and outcome.

RESULTS

A total of 1,033 children met criteria for this study. The average age was 8.3 years. Males predominated at 61.9%. Falls, sports, and motor vehicle crashes were the most common mechanisms of injury. The average length of stay was 1.19 days, and 60 children were not admitted. A total of 583 children had no procedures performed, whereas 386 received a CT scan, and 148 had x-rays. None required neurosurgical intervention, and all were discharged alive.

CONCLUSION

These findings indicate that routine admission may not be necessary for children with isolated mild closed head injuries with a negative CT scan and a normal neurologic finding and allows for a prospective randomized trial to confirm this.

Variation in utilization of computed tomography scanning for the investigation of minor head trauma in children: a Canadian experience

OBJECTIVES

To compare the utilization rates of CT scans in investigating minor head trauma in children in Canada, to identify the injuries determined by these scans, and to identify clinical findings that are highly associated with its diagnosis and the injury itself.

METHODS

A retrospective cohort study involving nine pediatric hospitals in Canada was conducted. A structured data collection method was used. Inclusion criteria included age 16 years or less, history of blunt head trauma, and a Glasgow Coma Scale score (GCS) greater than or equal to 13. Data collected included demographic information, type of injury, relevant clinical information, computed tomography (CT) scan data, and clinical outcome. Clinical findings associated with CT scan and positive CT scan were identified using logistic regression.

RESULTS

One thousand one hundred sixty-four children were included in the study. One hundred seventy-one (15%) had a CT scan, of which 60 (35%) were abnormal. There was a significant difference in the rate of ordering of CT scans among the participating hospitals, but no significant difference in the rate of abnormal CT scans. Mechanism of injury, GCS, and loss of consciousness were significantly related to the presence of an abnormal CT scan.

CONCLUSIONS

Although there is a significant difference in the utilization of CT scans to investigate minor head trauma in children across Canada, there is no significant difference in the frequency of head injuries in these patients. This suggests that it may be possible to determine clinical criteria that are predictive of a head injury in these patients.

Current controversies in the management of minor pediatric head injuries

Each year hundreds of thousands of children receive care in emergency departments after head injury. Minor head injuries account for a majority of these injuries. The prevalence, morbidity, and costs associated with pediatric minor head injuries make it an important topic. We review the management of pediatric minor head injury, emphasizing current areas of controversy, including criteria for neuroimaging, indications for hospitalization, the role of anticonvulsant therapy, and the long-term neurobehavioral sequelae of pediatric minor head injury.

Occult intracranial injury in infants

STUDY OBJECTIVES

The objectives of this study were as follows: (1) to determine whether clinical symptoms and signs of brain injury are sensitive indicators of intracranial injury (ICI) in infants admitted with head trauma, (2) to describe the clinical characteristics of infants who have ICI in the absence of symptoms and signs of brain injury, and (3) to determine the clinical significance of those ICIs diagnosed in asymptomatic infants.

METHODS

We conducted a retrospective analysis of all infants younger than 2 years of age admitted to a tertiary care pediatric hospital with acute ICI during a 6(1/2)-year period. Infants were considered symptomatic if they had loss of consciousness, history of behavior change, seizures, vomiting, bulging fontanel, retinal hemorrhages, abnormal neurologic examination, depressed mental status, or irritability. All others were considered to have occult ICI.

RESULTS

Of 101 infants studied, 19 (19%; 95% confidence interval [CI] 12%, 28%) had occult ICI. Fourteen of 52 (27%) infants younger than 6 months of age had occult ICI, compared with 5 of 34 (15%) infants 6 months to 1 year, and none of 15 (0%) infants older than 1 year. Eighteen (95%) infants with occult ICI had scalp contusion or hematoma, and 18 (95%) had skull fracture. Nine (47%) infants with occult ICI received therapy for the ICI. No infants with occult ICI (0%) (95% CI 0, 14%) required surgery or medical management for increased intracranial pressure. Only 1 subject (5%) with occult ICI had any late symptoms or complications: a brief, self-limited convulsion.

CONCLUSION

We found that 19 of 101 ICIs in infants admitted with head trauma were clinically occult. All 19 occult ICIs occurred in infants younger than 12 months of age, and 18 of 19 had skull fractures. None experienced serious neurologic deterioration or required surgical intervention. Physicians cannot depend on the absence of clinical signs of brain injury to exclude ICI in infants younger than 1 year of age.

Mild head injury in children: identification, clinical evaluation, neuroimaging, and disposition

Pediatric head injury presents in various degrees of severity. Early intervention in the patient with a severe head injury is the key to preventing secondary central nervous system damage. Patients with a head injury are easily identified, often by clinical examination alone. However, patients with a mild head injury present a challenge to practitioners, particularly in identification, knowing what is important in the clinical evaluation, deciding whether to use neuroimaging, and knowing where to send the child for observation. Use of the Glasgow Coma Score, primary survey, and identification of historic and clinical features that are suggestive of severe head injury may guide pediatric nurse practitioners in providing appropriate medical care and disposition.

Minimal head trauma in children revisited: is routine hospitalization required?

OBJECTIVE

Children with a question of occult head injury are routinely hospitalized despite having both normal central nervous system (CNS) and computed tomographic (CT) scan examinations. We determined the incidence of significant CNS morbidity after occult head injury to determine whether or not hospital admission was necessary in children after minimal head trauma.

METHODS

We reviewed the records of children admitted to a level I trauma center with a question of closed head injury, an initial Glasgow Coma Scale equal to 15, a normal neurologic exam, and a normal head CT scan. Children with associated injuries requiring admission were excluded. The endpoints were deterioration in CNS exam, new CT findings, and the need for a prolonged hospital stay.

RESULTS

Sixty-two patients were studied with a mean age of 7 years (range, 1 month to 15 years), and 65% were male. The primary mechanisms of injury were fall (45%) and vehicular crash (23%). The mean injury severity score was 4 +/- 2. The mean length of stay was 1.2 days (range, 1 to 3 days). Prolonged hospitalization occurred in 9 patients (15%). No child developed significant CNS sequelae warranting hospital admission. Total charges for these hospitalizations were $177 874.

CONCLUSIONS

Children undergoing emergency department work-up of occult head injury, who have a normal CNS exam and a normal head CT scan, do not seem to be at risk for significant CNS sequelae. These patients can be discharged home with parental supervision and avoid unnecessary and costly hospitalization.