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CATCH2 score accurate to identify children with minor head injury who need CT
Clinical Question
Which children with minor head injury can safely avoid computed tomography of the head?
Bottom line
Avoiding unnecessary head computed tomography (CT) is important, given the radiosensitivity of a child's brain. If we strictly follow the the Canadian Assessment of Tomography for Childhood Head injury (CATCH) score as a guide to ordering CT, though, approximately 55% of children with minor head injury would have a head CT, compared with only 35% when physicians use their clinical judgment. Rules like this should serve as a check on the decision-making of experienced clinicians, and as a guide for learners. 1a-
Reference
Study design: Cohort (prospective)
Funding: Government
Setting: Emergency department
Synopsis
These same investigators had previously developed the CATCH score to identify children with minor head injury who potentially benefitted from a head CT. It was a simple checklist of 7 items; if any of the first 4 were present, the child was at high risk for neurosurgical intervention, and if any of the final 3 were present, they were at medium risk for brain injury on CT. The 7 items are: (1) a Glasgow Coma Scale (GCS) score of less than 15 at 2 hours after injury; (2) suspected open or depressed skull fracture; (3) history of worsening headache; (4) irritability on examination; (5) any sign of basal skull fracture; (6) a large, boggy hematoma of the scalp; and (7) dangerous mechanism of injury including motor vehicle accident, a fall from 3 or more feet or down 5 or more stairs, or a bicyle injury without a helmet. (Personal aside: Wear your helmets, people!) The rule was originally developed in 3866 children with a GCS score of 13 to 15 accompanied by loss of consciousness, amnesia, disorientation, persistent vomiting, or irritability; the current study prospectively applied it to 4494 children (434 were subsequently lost to follow-up). The kids ranged in age from 1 month to 16 years, with only 11% younger than 2 years and 9% with a GCS score of 13 or 14. Physicians used their clinical judgment in ordering CT and were told not to use the CATCH score. Ultimately, 35% of patients underwent CT and the rest had 2 weeks of clinical follow-up to determine their outcome. Overall, 4.9% (n = 197) had brain injury on CT and 0.6% (n = 23 ) underwent a neurosurgical interention. The CATCH score correctly identified 21 of 23 children needing neurosurgical intervention, and 192 of 197 with brain injury on CT. Adding an eighth criterion (4 or more episodes of vomiting), which they now call the CATCH2 rule, identified all 23 children requiring neurosurgical interention and 196 of 197 with brain injury on CT. However, it hurt the specificity, decreasing it from approximately 58% to approximately 47%.
Reviewer
Mark H. Ebell, MD, MS
Professor
University of Georgia
Athens, GA
Comments
If we have open MRI we likely can do MRI on most of those children especially infant I have to ct of head on 6 months old against my own but by insistent very concern parents and recommendation of pediatric.
Some time child goes to ct even without being examined and other time there is no bed to keep child for observation those early negative ct,s can become positive if we have opportunity to observe pt for a day or that would be much better than following CATCH CATCH2 guideline.
when I was practicing for me observation was important some us even don,t see pts with out CT ibeleave that is wrong not only due to radiation also due to fact that at early without significant of intracranial problome ct may be negative and later on child may deteriorate and repeat ct may come positive I would recommend that every child with head injury to be kept for 24 hour observation and ct to be done as indicated and when indicated , fals assurance from ct may catastrophic outcome.
We do not need to CT scan to all children with minor head injury .It is important to know CATCH2 score accurately identify who need CT scan.
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Very helpful especially for doctors attached to sporting bodies where head injury is a possibility.