Pediatrik Kafa Travmasında Seçici Bilgisayarlı Tomografi Kullanımı: İki Yaş Altı Çocuklarda Klinik Zorluklar ve Öneriler
Öz
Amaç: İki yaşından küçük çocuklarda kafa travmaları, acil servislerde sıkça karşılaşılan kritik bir halk sağlığı sorunudur. Bu yaş grubunun benzersiz anatomik ve fizyolojik özellikleri nedeniyle, doğru klinik değerlendirme ve uygun yönetim zorluğunu korumaktadır. Bu çalışma, iki yaş altındaki pediatrik kafa travmalı hastaların epidemiyolojik özelliklerini, klinik bulgularını, görüntüleme yöntemlerini ve klinik sonuçlarını değerlendirmeyi amaçlamıştır. Ek olarak, uluslararası klinik kılavuzlara uyum düzeyini belirleyerek gereksiz bilgisayarlı tomografi (BT) kullanımını azaltmaya yönelik pratik öneriler sunmayı hedeflemiştir.
Materyal ve Metod: Retrospektif gözlemsel tipteki bu çalışmada, 1 Ocak – 31 Aralık 2015 tarihleri arasında bir üçüncü basamak eğitim ve araştırma hastanesi acil servisine kafa travması ile başvuran 0–24 ay arası 2,074 pediatrik hastanın verileri incelendi. Hastaların demografik bilgileri, travma mekanizmaları, klinik bulguları, Glasgow Koma Skalası (GKS) skorları, BT görüntüleme endikasyonları ve sonuçları ile klinik takipleri toplandı. Veriler tanımlayıcı istatistikler, lojistik regresyon ve ROC analizi kullanılarak değerlendirildi.
Bulgular: Çalışmaya dahil edilen 2,074 hastada en yaygın travma mekanizması düşmeydi (%64,6). Hastaların %64,6’sına BT görüntüleme yapılmış olsa da, klinik olarak anlamlı intrakraniyal bulgular yalnızca %10,4 oranında saptandı. Pozitif BT bulguları için en güçlü belirleyiciler bilinç kaybı (OR=1,75) ve saçlı deri hematomu (OR=1,62) idi. ROC analizi, klinik değerlendirmenin tek başına görüntüleme kararı vermede orta düzeyde güvenilir olduğunu gösterdi (AUC=0,72).
Sonuç: Uluslararası kılavuzların varlığına rağmen, iki yaş altı pediatrik kafa travmalarında BT görüntüleme halen aşırı kullanılmaktadır. Gereksiz radyasyon maruziyetini en aza indirmek, hasta güvenliğini artırmak ve klinik sonuçları iyileştirmek için PECARN gibi yapılandırılmış klinik karar protokollerinin uygulanması ve hem sağlık profesyonellerine hem de ailelere yönelik hedeflenmiş eğitim programları kritik öneme sahiptir. Gelecekteki çalışmalar, hızlı-sekanslı MR gibi alternatif görüntüleme yöntemlerini ve yapılandırılmış gözlem protokollerinin uygulanabilirliğini ve etkinliğini daha ayrıntılı incelemelidir. Nihayetinde, gereksiz BT görüntülemenin azaltılması; kılavuzlara bağlılık, yapılandırılmış eğitim stratejileri, aktif ebeveyn katılımı ve daha güvenli görüntüleme teknolojilerinin araştırılmasını içeren çok yönlü bir yaklaşım gerektirerek, pediatrik kafa travmalarında optimal bakım ve hasta güvenliğini sağlayacaktır.
Anahtar Kelimeler
Pediatrik Kafa Travması Bilgisayarlı Tomografi PECARN Kılavuzları Acil Servis Radyasyon Maruziyeti
Etik Beyan
Etik Kurul Onayı Bu çalışma için Kurumsal Eğitim Planlama Kurulu'ndan onay alınmıştır (Onay No: 50, Tarih: 09.02.2016). Çalışmanın retrospektif niteliği nedeniyle bilgilendirilmiş onam alınmasına gerek duyulmamıştır.
Kaynakça
- 1. Greenes DS, Schutzman SA. Clinical significance of scalp abnormalities in asymptomatic head-injured infants. Pediat-rics. 1999;104(4):861-7.
- 2. Schutzman SA, Barnes P, Mantello M, Scott RM. Epidural hematomas in children. Pediatrics. 2001;107(5):983-93.
- 3. Dayan PS, Holmes JF, Schutzman S, Schunk J, Lichenstein R, Foerster LA, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med. 2014;64(2):153-62.
- 4. Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Jou-bert G, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010;182(4):341-8.
- 5. Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013;346:f2360.
- 6. Miglioretti DL, Johnson E, Williams A, Greenlee RT, Wein-mann S, Solberg LI, et al. The use of computed tomography in pediatrics and the associated radiation exposure and es-timated cancer risk. JAMA Pediatr. 2013;167(8):700-7.
- 7. Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukemia and brain tumors: a retrospecti-ve cohort study. Lancet. 2012;380(9840):499-505.
- 8. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, et al. Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-70.
- 9. Atabaki SM, Stiell IG, Bazarian JJ, Sadow KE, Vu TT. A clinical decision rule for cranial computed tomography in minor pe-diatric head trauma. Arch Pediatr Adolesc Med. 2008;162(5):439-45.
- 10. Babl FE, Borland ML, Phillips N, Cheek JA, Dalziel SR, Oakley E, et al. Accuracy of PECARN, CATCH, and CHALICE head in-jury decision rules in children: a prospective cohort study. Lancet. 2017;389(10087):2393-2402.
- 11. Jennings RM, Burtner JJ, Pellicer JF, Nair DK, Bradford MC, Shaffer M, et al. Reducing head CT use for children with mi-nor head injuries in the emergency department. Pediatrics. 2020;145(6):e20193632.
- 12. Nigrovic LE, Stack AM, Mannix RC, Lyons TW, Samnaliev M, Bachur RG. Quality improvement effort to reduce cranial CT for minor blunt head trauma in children. Pediatrics. 2015;136(2):e474-82.
- 13. Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Pediatrics. 2018;141(5):e20173104.
- 14. Quayle KS, Powell EC, Mahajan P, Hoyle JD Jr, Nadel FM, Badawy MK, et al. Epidemiology of blunt head trauma in children in U.S. emergency departments. N Engl J Med. 2014;371(20):1945-7.
- 15. Borland ML, Dalziel SR, Phillips N, Cheek JA, Neutze J, Babl FE, et al. Vomiting as a predictor of intracranial injury in children with minor blunt head trauma. Pediatrics. 2018;142(4):e20183028.
- 16. Atabaki SM, Hoyle JD Jr, Schunk JE, Monroe DJ, Alpern ER, Quayle KS, et al. Comparison of prediction rules and clini-cian suspicion for identifying children with clinically impor-tant brain injuries after blunt head trauma. Acad Emerg Med. 2016;23(5):566-75.
- 17. Cicogna A, Minca G, Posocco F, Corno F, Basile C, Da Dalt L, et al. Non-ionizing imaging for the emergency department assessment of pediatric minor head trauma. Front Pediatr. 2022;10:881461.
- 18. Trenchs V, Curcoy AI, Castillo M, Badosa J, Luaces C, Pou J, et al. Minor head trauma and linear skull fracture in infants: cranial ultrasound or computed tomography? Eur J Emerg Med. 2009;16(3):150-2.
- 19. Cohen AR, Caruso PA, Duhaime AC, Klig JE. Feasibility and safety of rapid-sequence brain MRI in the evaluation of children with head trauma. J Neurosurg Pediatr. 2015;16(4):440-6.
- 20. Mehta H, Acharya J, Mohan AL, Tobias JD, Leach JL. Minimi-zing radiation exposure in evaluation of pediatric head tra-uma: use of rapid-sequence MRI. J Pediatr. 2019;205:213-7.
- 21. Lindberg DM, Stence NV, Grubenhoff JA, Lewis T, Mirsky DM, Miller AL, et al. Feasibility and accuracy of fast MRI versus CT for traumatic brain injury in young children. Pediatrics. 2019;144(4):e20190419.
- 22. Nigrovic LE, Schunk JE, Foerster A, Cooper A, Miskin M, Atabaki SM, et al. The effect of observation on cranial com-puted tomography utilization for children after blunt head trauma. Pediatrics. 2011;127(6):1067-73.
Selective Computed Tomography Use in Pediatric Head Trauma: Clinical Challenges and Recommendations for Children Under Two Years
Öz
Background: Head trauma in children under two years of age is a significant public health concern frequently encountered in emergency departments. Due to the unique anatomical and physiological characteristics of this age group, accurate clinical evalua-tion and appropriate management remain challenging. This study aimed to examine the epidemiological characteristics, clinical presentations, imaging practices, and clinical outcomes of pediatric head trauma cases in this vulnerable age group. Additionally, it assessed adherence to established international clinical guidelines and sought to provide practical suggestions to minimize the unnecessary use of computed tomography (CT) imaging.
Materials and Methods: In this retrospective observational study, medical records of 2,074 pediatric patients aged 0–24 months who presented to the emergency department of a tertiary care training and research hospital with head trauma between January 1, 2015, and December 31, 2015, were analyzed. Data collected included patient demographics, mechanisms of injury, clinical findings, Glasgow Coma Scale (GCS) scores, indications for CT imaging and results, and clinical follow-up information. All data were analyzed using descriptive statistics, logistic regression, and receiver operating characteristic (ROC) curve analysis.
Results: Falls were the most common mechanism of injury, accounting for 64.6% of cases. CT scans were performed in 64.6% of the patients; however, clinically significant intracranial injuries were detected in only 10.4%. Loss of consciousness (OR=1.75) and scalp hematoma (OR=1.62) were identified as the strongest independent predictors of positive CT findings. ROC analysis demonst-rated moderate predictive performance (AUC=0.72), indicating that clinical assessment alone provides limited accuracy in guiding imaging decisions.
Conclusions: Despite well-established international guidelines, CT scans continue to be overused in pediatric head trauma cases among children under two years of age. Implementing structured clinical decision tools such as the Pediatric Emergency Care Applied Research Network (PECARN) criteria, along with targeted educational programs for healthcare providers and parents, is critical to minimizing unnecessary radiation exposure, enhancing patient safety, and improving clinical outcomes. Future studies should investigate alternative imaging modalities, such as rapid-sequence MRI, and structured observation protocols to better determine their practicality and effectiveness. Ultimately, reducing unnecessary CT use requires a multifaceted approach that includes strict adherence to guidelines, structured educational initiatives, active parental involvement, and exploration of safer imaging methods. Such a comprehensive strategy will help ensure optimal care and improved patient safety in pediatric head trauma.
Anahtar Kelimeler
Pediatric Head Trauma Computed Tomography PECARN Guidelines Emergency Department Radiation Exposure
Etik Beyan
Ethical Considerations Approval for this study was obtained from the Institutional Educational Planning Board (Approval No: 50, Date: 09.02.2016). Due to the retrospective nature of the study, informed consent was not required.
Kaynakça
- 1. Greenes DS, Schutzman SA. Clinical significance of scalp abnormalities in asymptomatic head-injured infants. Pediat-rics. 1999;104(4):861-7.
- 2. Schutzman SA, Barnes P, Mantello M, Scott RM. Epidural hematomas in children. Pediatrics. 2001;107(5):983-93.
- 3. Dayan PS, Holmes JF, Schutzman S, Schunk J, Lichenstein R, Foerster LA, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med. 2014;64(2):153-62.
- 4. Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Jou-bert G, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010;182(4):341-8.
- 5. Mathews JD, Forsythe AV, Brady Z, Butler MW, Goergen SK, Byrnes GB, et al. Cancer risk in 680,000 people exposed to computed tomography scans in childhood or adolescence: data linkage study of 11 million Australians. BMJ. 2013;346:f2360.
- 6. Miglioretti DL, Johnson E, Williams A, Greenlee RT, Wein-mann S, Solberg LI, et al. The use of computed tomography in pediatrics and the associated radiation exposure and es-timated cancer risk. JAMA Pediatr. 2013;167(8):700-7.
- 7. Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukemia and brain tumors: a retrospecti-ve cohort study. Lancet. 2012;380(9840):499-505.
- 8. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, et al. Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-70.
- 9. Atabaki SM, Stiell IG, Bazarian JJ, Sadow KE, Vu TT. A clinical decision rule for cranial computed tomography in minor pe-diatric head trauma. Arch Pediatr Adolesc Med. 2008;162(5):439-45.
- 10. Babl FE, Borland ML, Phillips N, Cheek JA, Dalziel SR, Oakley E, et al. Accuracy of PECARN, CATCH, and CHALICE head in-jury decision rules in children: a prospective cohort study. Lancet. 2017;389(10087):2393-2402.
- 11. Jennings RM, Burtner JJ, Pellicer JF, Nair DK, Bradford MC, Shaffer M, et al. Reducing head CT use for children with mi-nor head injuries in the emergency department. Pediatrics. 2020;145(6):e20193632.
- 12. Nigrovic LE, Stack AM, Mannix RC, Lyons TW, Samnaliev M, Bachur RG. Quality improvement effort to reduce cranial CT for minor blunt head trauma in children. Pediatrics. 2015;136(2):e474-82.
- 13. Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Pediatrics. 2018;141(5):e20173104.
- 14. Quayle KS, Powell EC, Mahajan P, Hoyle JD Jr, Nadel FM, Badawy MK, et al. Epidemiology of blunt head trauma in children in U.S. emergency departments. N Engl J Med. 2014;371(20):1945-7.
- 15. Borland ML, Dalziel SR, Phillips N, Cheek JA, Neutze J, Babl FE, et al. Vomiting as a predictor of intracranial injury in children with minor blunt head trauma. Pediatrics. 2018;142(4):e20183028.
- 16. Atabaki SM, Hoyle JD Jr, Schunk JE, Monroe DJ, Alpern ER, Quayle KS, et al. Comparison of prediction rules and clini-cian suspicion for identifying children with clinically impor-tant brain injuries after blunt head trauma. Acad Emerg Med. 2016;23(5):566-75.
- 17. Cicogna A, Minca G, Posocco F, Corno F, Basile C, Da Dalt L, et al. Non-ionizing imaging for the emergency department assessment of pediatric minor head trauma. Front Pediatr. 2022;10:881461.
- 18. Trenchs V, Curcoy AI, Castillo M, Badosa J, Luaces C, Pou J, et al. Minor head trauma and linear skull fracture in infants: cranial ultrasound or computed tomography? Eur J Emerg Med. 2009;16(3):150-2.
- 19. Cohen AR, Caruso PA, Duhaime AC, Klig JE. Feasibility and safety of rapid-sequence brain MRI in the evaluation of children with head trauma. J Neurosurg Pediatr. 2015;16(4):440-6.
- 20. Mehta H, Acharya J, Mohan AL, Tobias JD, Leach JL. Minimi-zing radiation exposure in evaluation of pediatric head tra-uma: use of rapid-sequence MRI. J Pediatr. 2019;205:213-7.
- 21. Lindberg DM, Stence NV, Grubenhoff JA, Lewis T, Mirsky DM, Miller AL, et al. Feasibility and accuracy of fast MRI versus CT for traumatic brain injury in young children. Pediatrics. 2019;144(4):e20190419.
- 22. Nigrovic LE, Schunk JE, Foerster A, Cooper A, Miskin M, Atabaki SM, et al. The effect of observation on cranial com-puted tomography utilization for children after blunt head trauma. Pediatrics. 2011;127(6):1067-73.
Ayrıntılar
| Birincil Dil | İngilizce |
|---|---|
| Konular | Acil Tıp |
| Bölüm | Araştırma Makalesi |
| Yazarlar | |
| Erken Görünüm Tarihi | 25 Haziran 2025 |
| Yayımlanma Tarihi | 27 Haziran 2025 |
| Gönderilme Tarihi | 12 Mart 2025 |
| Kabul Tarihi | 24 Haziran 2025 |
| Yayımlandığı Sayı | Yıl 2025 Cilt: 22 Sayı: 2 |
Harran Üniversitesi Tıp Fakültesi Dergisi / Journal of Harran University Medical Faculty