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5 year old previously healthy male referred to the ED for vomiting after he fell 2.5 feet while jumping from the couch. No other injurys noted and no other pain reported. He denies a headache and parents report he is acting baseline. His exam is reassuring (no, really....)
What would you do next? Which Clinical Decision Rule (CDR) do you use? PECARN? CHALICE? CATCH?
What if he vomited 3 times? 5 times?
A secondary analysis of the Australasian Paediatric Head Injury Rule Study attempted to determine the prevalence of traumatic brain injuries in children who vomit after head injury and identify variables from published CDRs that increased risk. Vomited characteristics were correlated with CDR predictors and the presence of clinically important traumatic brain injury (ciTBI) or traumatic brain injury on computed tomography (TBI-CT).
Of the 19 920 children enrolled, 3389 (17.0%) had any vomiting. With isolated vomiting, only 1 (0.3%; 95% CI 0.0%-0.9%) had ciTBI and 2 (0.6%; 95% CI 0.0%-1.4%) had TBI-CT. Predictors of increased risk of ciTBI with vomiting included: signs of skull fracture, altered mental status, headache, and acting abnormally.
Bottom Line:
TBI-CT and ciTBI are uncommon in children presenting with head injury with isolated vomiting (vomiting without other CDR predictors) and observation without imaging appears appropriate.
References
Borland ML, Dalziel SR, Phillips N, Dalton S, Lyttle MD, Bressan S, Oakley E, Hearps SJC, Kochar A, Furyk J, Cheek JA, Neutze J, Babl FE; Paediatric Research in Emergency Department International Collaborative group. Vomiting With Head Trauma and Risk of Traumatic Brain Injury. Pediatrics. 2018 Apr;141(4).