When is a computed tomography (CT) scan indicated for a 3-month-old infant who has experienced a fall?

From the Guidelines

A CT scan is indicated for a 3-month-old infant who has experienced a fall when there are concerning signs of serious head injury or neurological compromise, such as altered mental status, loss of consciousness, seizures, persistent vomiting, bulging fontanelle, abnormal neurological examination, or visible skull fracture or significant scalp hematoma, as outlined in the PECARN criteria 1.

Key Considerations

• The decision to obtain imaging should follow a careful clinical assessment, considering that infants have open fontanelles which can accommodate some intracranial pressure changes.
• CT scans should be used selectively in infants due to radiation exposure concerns, with observation being preferred for minor falls without these concerning features.
• If imaging is necessary, rapid sequence MRI may be considered as an alternative when available to avoid radiation exposure.
• The threshold for imaging should be lower in cases of suspected non-accidental trauma, falls from significant heights (greater than 3 feet), or when the history provided is inconsistent with the observed injuries.

Imaging Recommendations

• Children with minor acute blunt head trauma (excluding suspected abusive head trauma) with very low risk for clinically important brain injury per PECARN criteria do not require imaging 1.
• Children with intermediate risk for clinically important brain injury per PECARN criteria may undergo careful clinical observation or CT head without IV contrast 1.
• Children with high risk for clinically important brain injury per PECARN criteria should undergo CT head without IV contrast 1.

Important Notes

• Any infant receiving a CT scan should be properly immobilized during the procedure to ensure diagnostic quality images while minimizing radiation dose.
• The PECARN criteria provide a framework for assessing the risk of clinically important traumatic brain injury in children, including those under 2 years of age 1.

From the Research

Indications for CT Scan in 3-Month-Old Infant with Fall

• The decision to perform a computed tomography (CT) scan on a 3-month-old infant who has experienced a fall depends on various factors, including the severity of the injury and the presence of specific clinical signs and symptoms 2, 3.
• According to the studies, CT scans are typically indicated in cases of moderate to severe traumatic brain injury (TBI), as they can help identify acute intracranial hemorrhage and other abnormalities that may require immediate medical attention 2, 4.
• In cases of mild TBI, the use of CT scans is more controversial, and other imaging modalities such as magnetic resonance imaging (MRI) may be preferred due to the lower radiation exposure and higher sensitivity for detecting certain types of injuries 3, 5.
• However, in infants and young children, CT scans may still be necessary due to the higher risk of severe injury and the potential for rapid deterioration 4, 6.
• The presence of certain clinical signs and symptoms, such as vomiting, lethargy, or seizures, may also indicate the need for a CT scan, regardless of the severity of the injury 2, 5.

Specific CT Features Associated with Adverse Outcomes

• Certain CT features, such as contusions, subarachnoid hemorrhage, and subdural hematoma, have been associated with adverse outcomes in patients with TBI, including impaired functional recovery and increased risk of mortality 2, 5.
• The presence of these features on a CT scan may indicate a higher risk of complications and the need for closer monitoring and more aggressive treatment 4, 6.
• However, the interpretation of CT scans in infants and young children requires careful consideration of the clinical context and the potential for rapid changes in the patient's condition 3, 5.

Limitations and Future Directions

• The use of CT scans in infants and young children with TBI is subject to certain limitations, including the risk of radiation exposure and the potential for underestimating the severity of the injury 3, 6.
• Further research is needed to develop more effective and safer imaging modalities for diagnosing and monitoring TBI in this population, as well as to improve our understanding of the clinical significance of specific CT features and their association with adverse outcomes 2, 4, 5, 6.