A national sample of pediatricians, family physicians, and emergency physicians was surveyed by questionnaire regarding initial and subsequent management of minor head injury, and responses were analyzed at the University of Washington, Seattle; the American Academy of Pediatrics; the American Academy of Family Physicians; University of California; and Children's Hospital, Boston. Surveys were returned by 765 (51%) of 1500 physicians. Pediatricians were the most frequent reponders (40%), while family practitioners and emergency physicians accounted for 35% and 25% responses, respectively. For minor head trauma without complications, the majority (72%) of physicians chose observation at home as the initial management, while 11% chose observation in office or hospital. CT scan or skull X-ray was obtained by only 1% and 3%, respectively, but 80% ordered a CT scan if clinical deterioration occurred. With loss of consciousness, 18% chose CT, 21% inpatient observation, and 19% chose CT and observation. Seizures were of most concern, 27% choosing CT, 9% inpatient observation, 45% a combination of CT and observation, and 6% neurology consultation. Younger children received more X-rays, neurologic consultations, and hospital admissions than older children. [1]

COMMENT. Variations in clinical management of minor head trauma among physicians suggests a need for the development of practice guidelines. Hopefully, pediatric neurologists and neurosurgeons will be included in these deliberations and recommendations. A persisting cognitive deficit and subsequent reading disability reported in 78 preschool children sustaining mild head injury, not sufficient to require admission for observation, points to the serious nature of the problem and the need for expert attention in management protocols (see Progress in Pediatric Neurology III. PNB Publ, 1997;pp476-478). Hyperactive behavior noted after mild head injury warrants careful follow-up.

Head injury in a pediatric emergency department is reviewed, comparing treatment methods before and after implementation of treatment protocols, at the Children's Hospital of Philadelphia [2]. Trauma management protocols resulted in significant increases of laboratory and radiologic services, without improving outcome: CT scans, cervical spine radiographs, and hepatic enzymes were ordered 14, 11, and 23 times more frequently, respectively. Management cost administrators who advocate treatment protocols should take note! (Dr DeAngelis, editorial comment).