Identification of Ethanol-intoxicated Patients with Minor Head TVauma Requiring Computed Tomography Scans

Objective: To determine whether clinical parameters and neurologic scores can be used to guide the decision to obtain computed tomography (CT) head scans for ethanol-intoxicated patients with presumed-minor head injuries.
Methods: In a prospective cohort analysis, 107 consecutive adult patients who presented to a county emergency department (ED) with serum ethanol levels >80 mg/dL and minor head trauma were studied. Commonly used clinical variables were determined for each patient. Each patient also underwent an abbreviated neurologic scoring examination and a Glasgow coma scale (GCS) score evaluation at the time of presentation and one hour later, after which a cranial CT scan was done. For purposes of analysis, patients with and patients without intracerebral injuries visible on CT scans of the head were compared.
Results: Nine of 107 patients (8.4%; 95% confidence interval [CI] = 3.9–15.4%) had CT scans that were positive for intracerebral injury. Two patients (1.9%; 95% CI = 0.2–6.6%) needed craniotomy. Five patients had hemotympanum and two patients had bilateral periorbital ecchy-mosis, but CT scans were negative for intracerebral injury in these patients. There was no statistically significant difference between the patients with and without CT scan abnormalities, based on the clinical variables, the GCS scores, or the abbreviated neurologic scoring examinations at presentation or at one hour.
Conclusion: The prevalence of intracerebral injury in CT scans of ethanol-intoxicated patients with minor head injuries was 8.4%. Commonly used clinical parameters and neurologic scores at presentation and one hour later were unable to predict which patients would have intracerebral injuries as evidenced by CT scans. Our low (1.9%) neurosurgical intervention rate supports the need to develop a selective approach to CT scanning in this population.     

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.     

Clinical decision instruments for CT scan in minor head trauma

Previous studies have presented conflicting results regarding the predictive value of various clinical symptoms and signs for performing computed tomography (CT) scan in minor head injury. Moreover, despite the presence in the literature of several similar publications regarding whether or not CT should be employed at the time of presentation of minor head injured patients, data regarding delayed CT are limited. The objective of this study was to determine whether high-risk criteria represent a significant indication for initial CT scan in patients with minor head trauma, and whether or not analysis using delayed CT scan is necessary in patients with high-risk criteria before being discharged. Patients presenting to the Emergency Department with minor head trauma between September 1, 2003 and September 1, 2004 were evaluated prospectively. After being divided into two main groups, low- and high-risk, four separate sub-groups based on age were established. Initial spiral CT examination was done within 3 h of trauma on all patients in addition to a delayed control CT scan in those with high-risk criteria between 16 and 24 h after trauma. The difference between the high- and low-risk groups in terms of abnormal CT findings was statistically significant (p < 0.0005). Among high-risk patients there was a significant difference between patients with a Glasgow Coma Scale (GCS) score of 13 or 14 and those with a GCS score of 15 (p < 0.0005). The relationship between vomiting and abnormal CT scan was significant (odds ratio 4.61, 95% confidence interval 2.20-9.64, p = 0.0001), and the relationship between abnormal CT scan and suspected skull fracture was also significant (odds ratio 3.46, 95% confidence interval 1.52-7.91, p = 0.0032). No significant correlations between other high-risk criteria and abnormal CT scan were determined. The difference between initial and delayed CT scans in patients with high-risk criteria was not significant (p = 0.161). Low-risk patients with a GCS score of 15 may be discharged without initial CT scan being performed. Initial CT scan absolutely must be performed, however, on patients with GCS < or = 15 in the event of vomiting or suspected skull fracture, even if isolated. Even though the difference between initial and delayed CT scans in patients with high-risk criteria is not significant, it is our opinion that it is still prudent for delayed CT scan to be performed, particularly on patients whose GCS score does not rise to 15, or decreases.     

Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients

Our study objective was to determine whether simple clinical criteria can be used to safely reduce the number of patients who require cranial computed tomography (CT) scan after sustaining minor head trauma. Awake patients (Glascow Coma Scale = 15) who presented to the emergency department with acute head injury associated with a loss of consciousness were evaluated for clinical predictors of head injury prior to CT scan. The studied risk factors included severe headache, nausea, vomiting, and depressed skull fracture on physical examination. Patients with no risk factors present were compared with patients with one or more risk factors with respect to abnormal CT rate and rate of operative intervention for head injury. Of the 2143 patients entered into the study, 1302 (61%) had no risk factor for head injury, whereas 841 (39%) had one or more risk factors present. A total of 138 (6.4%) of those studied had an abnormal CT scan. This number included 3.7% of those patients with no risk factors vs. 11% in patients with one or more risk factors. The CT scan abnormalities in the no-risk-factor group were not clinically significant. All 5 patients who required operative intervention had at least one of the risk factors present. The use of four simple clinical criteria in minor head trauma patients would allow a 61% reduction in the number of head CT scans performed and still identify all patients who require neurosurgical intervention and the majority of patients with an abnormal CT scan. This method could lead to a large savings in patient charges nationwide. Further studies may be helpful in confirming these findings.     

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.     

The application of North American CT scan criteria to an Australian population with minor head injury

Objective: To determine potential changes in the number of CT head scans performed if the New Orleans Criteria (NOC) or Canadian CT Head Rule (CCTR) was applied to an Australian emergency department population of minor head injured (MHI) patients. Methods: A retrospective chart review was conducted in an adult metropolitan teaching hospital in Brisbane. All patients presenting over a 3‐month period with a GCS Score of 15 following an MHI and had a CT head scan performed were selected for analysis. Using clinically significant CT abnormalities and neurological intervention as the outcome measures, the NOC and CCTR were applied to determine if CT scanning was considered necessary. Results: Of the 240 patients reviewed, 230 had a normal CT scan and 10 had clinically significant CT abnormalities. One patient with CT abnormality required neurosurgical intervention. Application of the NOC would have resulted in a 3.8% (95% CI 1.7–7.0%) reduction in CT scans performed without missing any patients with CT abnormalities or requiring neurological intervention. Application of the CCTR using both high and low risk factors would have resulted in a 46.7% (95% CI 40.2–53.2%) reduction in CT scans performed without missing the patient requiring neurological intervention, but would not have detected two patients with clinically significant CT abnormalities. Conclusion: Neither the NOC nor the CCRT appear suitable for significantly reducing the number of normal CT head scans performed without missing clinically significant CT abnormalities when applied to our current clinical practice.     

Use of a complete neurological examination to screen for significant intracranial abnormalities in minor head injury

Indications for head computed tomography (CT) scans are unclear in patients with nonpenetrating head injury and Glasgow Coma Scale (GCS) scores of 15. We performed a prospective study to determine if significant intracranial injury could be excluded in patients with GCS-15 and a normal complete neurological examination. A prospective trial of clinically sober adult patients with GCS = 15 on emergency department (ED) presentation after closed head injury with loss of consciousness or amnesia was conducted from May 1996 through April 1997. All subjects underwent a standardized neurological examination including mental status evaluation, and assessment of motor, sensory, cerebellar and reflex function before CT scan. During the study period, 58 patients met inclusion criteria. Fifty-five patients (95%) had normal CT scans and 23 (42%) had focal neurological abnormalities. Three patients (5%) had CT scan findings of acute intracranial injury, two of whom had normal neurological examinations. One patient had an acute subdural hematoma requiring emergent surgical decompression; the other had both an epidural hematoma and pneumocephalus that did not require surgery. Significant brain injury and need for CT scanning cannot be excluded in patients with minor head injury despite a GCS = 15 and normal complete neurological examination on presentation.     

Repeat computed tomographic scan within 24-48 hours of admission in children with moderate and severe head trauma

OBJECTIVE: To asses the yield and contribution of a routine predetermined repeat head computed tomographic (CT) scan within 24-36 hrs in pediatric patients with moderate to severe head trauma. DESIGN: Records review. SETTING: Five pediatric intensive care units. PATIENTS: We reviewed the charts of 173 consecutive pediatric patients with moderate to severe head trauma (Glasgow Coma Scale score of < or = 11) that survived the first 24 hrs after being admitted to five Israeli trauma centers. Clinical data collected included status at admission, at the time between the first and second CT scans, and after the second scan. Head details of the first, second, and, if performed, third CT scan were collected. Treatment strategy during each period was recorded, including any change in treatment after each CT scan. MEASUREMENTS AND MAIN RESULTS: A total of 47 (27%) of the second CT scans showed new lesions including six intracranial hemorrhages, 17 cases of worsening brain edema, and 18 newly diagnosed brain contusions. However, none of these findings necessitated surgical intervention or any change in therapy. Of the 67 patients who underwent a third CT scan, two cases required surgical intervention because of new findings in the third CT. CONCLUSIONS: A second routine prescheduled head CT scan within 24-36 hrs after admission in pediatric patients with moderate to severe head trauma is unlikely to yield any change in therapy. Clinically and intracranial pressure-oriented CT scan may better select and diagnose patients who require changes in therapy, including surgery. Studies aimed to determine the ideal timing for the second are warranted.     

The use of head computed tomography in elderly patients sustaining minor head trauma

The study objectives were to ascertain historical and clinical criteria differentiating intracranial injury (ICI) in elderly patients with minor head trauma (MHT), and determine applicability of current head computed tomography (CT) scan indications in this population. A 12-month retrospective chart review was performed at a community teaching hospital with 34,000 annual Emergency Department (ED) visits. Included were patients > or = 65 years old sustaining MHT with a Glasgow Coma Scale (GCS) score of 13-15 who had a CT scan performed during their hospital stay. Data included: injury mechanism, symptoms, signs, GCS, anticoagulation use or studies, presence of alcohol or drug, CT scan result, diagnosis, and outcome and intervention(s). There were 133 patients, with 19 (14.3%) suffering ICI. Four ICI patients required neurosurgical intervention. The mean age was 80.4 years and 66% were female. Four of 19 ICI patients (21%) had a GCS of 15, no neurologic symptoms, alcohol use or anticoagulation. Only 1 of 13 signs and symptoms correlated with ICI. In this study, no useful clinical predictors of intracranial injury in elderly patients with MHT were found. Current protocols based on clinical findings may miss 30% of elderly ICI patients. Head CT scan is recommended on all elderly patients with MHT.     

Evaluation of the impact of the Canadian CT head rule on British practice

Background: The Canadian CT head rule has been developed to identify which adults with minor head injuries require computed tomography (CT). This is hoped will reduce the number of CT scans performed for minor head injury in North America. It was unclear whether applying the rule would reduce or even increase the number of CT scans requested in UK emergency departments.

Methods: A retrospective evaluation was conducted of all adults who presented after minor head injuries to Addenbrooke's emergency department. Clinical information about patients with head injuries is collected on standardised forms. A dataset was constructed to predict how many patients would require head CT scans if the Canadian CT rule was applied.

Results: 1489 adults presented after minor head injury over a seven month period. Seventy four of these had CT scans for head injury, applying the Canadian CT head rule would have resulted in 132 CT scans being requested. This is significantly more (p>0.001). This would have resulted in a 68% increase in costs.

Interpretation: The Canadian CT head rule would result in an increase in the number of CT scans requested for minor head injuries. This increased cost must be considered against the 488 skull radiographs that were requested during the study period.

     

Sensitivity of New-generation Computed Tomography in Subarachnoid Hemorrhage

Objective: To determine the sensitivity of the initial new-generation CT (NGCT) scan interpretation for detection of acute nontraumatic subarachnoid hemorrhage (SAH) and to decide whether lumbar puncture (LP) should follow a "normal" NGCT scan.
Methods: A retrospective chart review was performed of patients admitted between March 1988 and July 1994 with proven SAH. Exclusion criteria were age <2 years, diagnosis other than acute SAH, history of head trauma within 24 hours before symptom onset, NGCT scan not done before diagnosis, and records not available. Patients were placed into two groups: symptom duration <24 hours (group 1) and >24 hours (group 2) prior to CT scan. The resolution of each NGCT scanner was recorded. An NGCT sceinner was defined as a third-generation scanner or more recent.
Results: Of 349 SAH patients, 181 met inclusion criteria. The sensitivity of NGCT scans for SAH was 93.1% for the group 1 patients ( n = 144) and 83.8% for the group 2 patients ( n = 37). The overall sensitivity was 91.2%. All the patients who had SAH not detected by NGCT scans were diagnosed by LP. There was no significant relationship between NGCT scanner resolution and sensitivity for SAH.
Conclusion: Initial interpretation of NGCT scans to detect SAH does not approach 100% sensitivity. A "normal" NGCT scan does not reliably exclude the need for LP in patients who have symptoms suggestive of SAH.     

Emergent intubation and CT scan pathology of blunt trauma patients with Glasgow Coma Scale scores of 3-13

INTRODUCTION: Widely accepted guidelines for use of pharmacologic agents for prehospital intubation have not been fully developed. Toward the goal of formulating specific guidelines, this study sought to determine how well the Glasgow Coma Scale (GCS) score stratifies the need for emergent intubation (within 30 minutes of emergency department arrival or in the prehospital setting). METHODS: A one-year, retrospective review of the charts of blunt trauma patients with presumed head injury who presented to the emergency department of a Level 1 trauma center with a GCS score of less than or equal to 13 was performed. A total of 120 patients met the inclusion and exclusion criteria. RESULTS: A significant number of patients presenting with a GCS score of less than or equal to 9 required emergent intubation. A significant minority of patients presenting with a GCS score of 10-13 required emergent intubation (20%) or had intracranial pathology on head CT scan (23%), and the majority of patients from this subgroup did not require subsequent intubation. Alcohol or substance intoxication and communication barriers such as deafness and language difficulties limited the clinical examination. CONCLUSIONS: Patients with a presenting GCS score of less than or equal to 9 represent candidates for the use of pharmacologic agents to facilitate aggressive airway control by well-trained and supervised emergency medical technicians (EMTs). Emergent intubation of patients with a GCS score of 10-13 is problematic. Patients with a presenting GCS score of 10-13 must be evaluated individually and closely monitored.(ABSTRACT TRUNCATED AT 250 WORDS)     

Minimal craniocerebral trauma

The patient with mild head injury is the most frequently hospitalised trauma patient. The costs for this treatment are enormous. Guidelines for managing the patients are changing for the last 20 years. Haematoma rates of 10% have been shown with CT scans in prospective studies for patients with GCS 14/15 and normal neurological examination. One out of ten of these patients had to undergo craniotomy. CT scans have shown to reduce costs if done on all patients with mild head injury and discharged with normal findings. Patients with skull fractures and age over 65 years are at higher risk, but not patients with loss of consciousness and post traumatic amnesia. We suggest CT scans on all patients. If a CT scan is not available we recommend to observe the patient for 24 hours in the hospital. If a patient with GCS 15 is to be discharged, an information leaflet with instructions for surveillance at home should be given to the patients and to the care taker.     

Elderly patients with closed head trauma after a fall: mechanisms and outcomes

Falls in the elderly leading to closed head trauma represent a significant cause of morbidity and mortality in that population, but are not well-characterized. The purpose of this study was to determine the mechanism of fall, outcome, and additional risk factors in elderly patients who require cranial computed tomography (CT) scan after a fall. We conducted a retrospective case series of patients age 60 years and older with closed head trauma secondary to falling who underwent CT scan in the emergency department (ED). Data were gathered from ED and hospital records. The setting was an urban Level I trauma center. Our series consisted of 189 patients, of whom 31 (16%) had an abnormal head CT scan and four (2%) required neurosurgery. Cerebral contusions (38%) and subdural hematomas (33%) were the most common lesions seen on CT scan. Falls from standing (76%) were more common than falls on stairs (19%) or from height (5%), but the latter two were more likely to result in an abnormal CT scan (stairs 42%, height 40%). An abnormal neurologic examination was associated with a higher risk of the need for neurosurgery (risk ratio 11.5). We conclude that among elderly patients who fall and present to an ED with evidence of closed head trauma, a significant percentage will have abnormal CT scans but only a small minority will require neurosurgery. While falls from standing are more common, falls on stairs or from height are associated with a higher risk of having an abnormal CT scan. A focal neurologic examination is a strong predictor of the need for neurosurgical intervention.     

Isolated LOC in head trauma associated with significant injury on brain CT scan

Background

A report of loss of consciousness (LOC) is frequently considered reason enough to obtain a computed tomography (CT) scan in the evaluation of head trauma. We conducted this study to reduce exposure to radiation from CT, while still not overlooking clinically significant injuries.

Objective

The objective of the study is to determine the correlation between LOC status and brain CT scan results in patients with blunt head trauma and to determine whether there is a subset of patients for whom CT scan need not be performed, without missing clinically significant intracranial injuries.

Methods

This is a retrospective study conducted in the emergency department of an inner-city hospital. The patient population included patients ranging between 13 and 35 years of age, with blunt head trauma, who presented to the emergency department (ED) between January 2010 and December 2013. Patients were divided into two groups: “LOC” group and “no LOC” group. The results of brain CT scans from each group were compared with LOC status. For study purposes, “clinically significant” were those that required interventions or ICU hospitalization of at least 24 h or extended hospitalization. The results were analyzed using chi-square calculations.

Results

During the study period, 494 patients were identified as having suffered head trauma. Of these, 185 (37.5%) reported LOC and 309 (62.5%) did not lose consciousness. In the LOC group, 15 (8.1%) had significant CT findings compared to 1.3% (4/309) of those without LOC (p < .001). Of the 4 who had no LOC and had significant brain CT findings, all 4 patients had positive physical findings of head, neck, or facial trauma. In the LOC group, only 1/15 (6.7%) had significant CT findings with a normal GCS of 15 and no physical signs of the head, neck, or facial trauma.

Conclusions

A small proportion of patients with LOC had CT finding requiring intervention. Head trauma patients with no physical injuries to the head, neck, or face and a normal GCS had no significant brain CT findings. This raises the question of whether a routine brain CT scan should be obtained in patients with LOC, no physical findings, and a normal GCS after blunt head trauma.

     

Should transient loss of consciousness in blunt head trauma be a pre-hospital trauma triage criterion?

The objective of this study was to evaluate pre-hospital triage of patients with an isolated brief loss of consciousness (LOC) to a regional trauma center (RTC). Data from a 6-month period were retrospectively reviewed from an existing pre-hospital data collection set. Patients were included if either they or a witness claimed a LOC, but they had regained consciousness to at least a Glasgow Coma Score (GCS) > 13 by the time the paramedics arrived. Endpoints for need for trauma center services included positive head computed tomography (CT) scan, the occurrence of emergency non-orthopedic surgery in < 6 h, admission to a surgical intensive care unit (ICU), or a length of stay (LOS) greater than 3 days for surgical evaluation. There were 655 complete records available for 275 cases of vehicular trauma and 380 cases of non-vehicular trauma. There were 170 (62%) patients in the vehicular group, and 287 (76%) in the non-vehicular group evaluated in the emergency department and discharged. In the vehicular group, only one (0.4%) patient required operative intervention in less than 6 h, three (1.1%) had a positive head CT scan, 10 (3.6%) were admitted to a surgical ICU, and four (1.5%) had a LOS > 3 days. In the non-vehicular trauma group, only one (0.3%) had surgery in < 6 h, eight (2.1%) had a positive CT scan, six (1.6%) were admitted to a surgical ICU or had a LOS > 3 days. Overall, 19 (2.9%, CI 0.018–0.045) patients met any one of the end-point criteria for trauma center utilization; however, only one patient (0.2% CI < 0.0001–0.008) required immediate neurosurgical intervention. Transient LOC, in the absence of any other American College of Surgeons (ACS) trauma triage criteria, triaged 97% of patients to a trauma center, who did not require trauma center services based on our criteria.     

Low Yield of Paired Head and Cervical Spine Computed Tomography in Blunt Trauma Evaluation

Background

With increased computed tomography (CT) utilization, clinicians may simultaneously order head and neck CT scans, even when injury is suspected only in one region.

Validation of the PECARN head trauma prediction rules in Japan: A multicenter prospective study

BackgroundHead trauma in children is one of the most common causes for emergency department visits. Although most trauma cases are minor, identifying those patients who have clinically important traumatic brain injury (ciTBI) is challenging. The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules identifying children who do not require cranial computed tomography (CT) were validated and are used all over the world. However, these rules have not been validated with large cohort multicenter studies in Asia.ObjectivesTo investigate whether the PECARN rules can be safely applied to Japanese children.MethodsWe conducted a multicenter, prospective, observational cohort study. We included children younger than 16 with minor head trauma (Glasgow Coma Scale ≥14) who presented to the six participating centers within 24 h of their injuries between June 2016 and September 2017.The primary analysis was set to calculate the negative predictive value of the patients with very low risk by the PECARN rules, compared with a preset threshold of 99.85%.ResultsWe included 6585 children of which 463 (7.0%) had head CT scans performed and 23 (0.35%) had ciTBI. There were two patients with ciTBI who were classified as very low risk. The negative predictive value, calculated as 99.96% (95%CI: 99.86–100.00; P = .019), was significantly superior compared with the preset threshold of 99.85%.ConclusionsThe PECARN head trauma prediction rules seemed to be safely applicable to Japanese children. Further studies are needed to determine safety in hospitals where physicians do not have expertise in managing children.     

Performance of the Pediatric Glasgow Coma Scale in Children with Blunt Head Trauma

Objectives: To compare the accuracy of a pediatric Glasgow Coma Scale (GCS) score in preverbal children with blunt head trauma with the standard GCS score in older children. Methods: The authors prospectively enrolled children younger than 18 years with blunt head trauma. Patients were divided into cohorts of those 2 years and younger and those older than 2 years. The authors assigned a pediatric GCS score to the younger cohort and the standard GCS score to the older cohort. Outcomes were 1) traumatic brain injury (TBI) on computed tomography (CT) scan or 2) TBI in need of acute intervention. The authors created and compared receiver operating characteristic (ROC) curves between the age cohorts for the association of GCS scores and TBI. Results: The authors enrolled 2,043 children, and 327 were 2 years and younger. Among these 327, 15 (7.7%; 95% confidence interval [CI] = 4.4% to 12.4%) of 194 who underwent imaging with CT had TBI visible and nine (2.8%; 95% CI = 1.3% to 5.2%) had TBI needing acute intervention. In children older than 2 years, 83 (7.7%; 95% CI = 6.2% to 9.5%) of the 1,077 who underwent imaging with CT had TBI visible and 96 (5.6%; 95% CI = 4.6% to 6.8%) had TBI needing acute intervention. For the pediatric GCS in children 2 years and younger, the area under the ROC curve was 0.72 (95% CI = 0.56 to 0.87) for TBI on CT scan and 0.97 (95% CI = 0.94 to 1.00) for TBI needing acute intervention. For the standard GCS in older children, the area under the ROC curve was 0.82 (95% CI = 0.76 to 0.87) for TBI on CT scan and 0.87 (95% CI = 0.83 to 0.92) for TBI needing acute intervention. Conclusions: This pediatric GCS for children 2 years and younger compares favorably with the standard GCS in the evaluation of children with blunt head trauma. The pediatric GCS is particularly accurate in evaluating preverbal children with blunt head trauma with regard to the need for acute intervention.