Management Of Minor Head Injury Research Articles

The Role of Computed Tomography in Management of Minor Head Injury

Trauma is the main reason of death and various kinds of disability in pediatric population. Minor head injury has been described as a trauma that lead to physiological disorder of brain function and the symptoms may include altered in mental status that may be or may not be associated with loss of consciousness. furthermore, the expression (concussion) has been sometimes used to refer to the same cases. in general, minor head injury case is diagnosis of exclusion and may be possible to achieve final diagnosis after adequate observation and perform appropriate imaging studies [1].

Impact of guidelines for the management of minor head injury on the utilization and diagnostic yield of CT over two decades, using natural language processing in a large dataset

ObjectivesWe investigated the impact of clinical guidelines for the management of minor head injury on utilization and diagnostic yield of head CT over two decades.MethodsRetrospective before-after study using multiple electronic health record data sources. Natural language processing algorithms were developed to rapidly extract indication, Glasgow Coma Scale, and CT outcome from clinical records, creating two datasets: one based on all head injury CTs from 1997 to 2009 (n = 9109), for which diagnostic yield of intracranial traumatic findings was calculated. The second dataset (2009–2014) used both CT reports and clinical notes from the emergency department, enabling selection of minor head injury patients (n = 4554) and calculation of both CT utilization and diagnostic yield. Additionally, we tested for significant changes in utilization and yield after guideline implementation in 2011, using chi-square statistics and logistic regression.ResultsThe yield was initially nearly 60%, but in a decreasing trend dropped below 20% when CT became routinely used for head trauma. Between 2009 and 2014, of 4554 minor head injury patients overall, 85.4% underwent head CT. After guideline implementation in 2011, CT utilization significantly increased from 81.6 to 87.6% (p = 7 × 10−7), while yield significantly decreased from 12.2 to 9.6% (p = 0.029).ConclusionsThe number of CTs performed for head trauma gradually increased over two decades, while the yield decreased. In 2011, despite implementation of a guideline aiming to improve selective use of CT in minor head injury, utilization significantly increased.Key Points• Over two decades, the number of head CTs performed for minor, moderate, and severe head injury gradually increased, while the diagnostic yield for intracranial findings showed a decreasing trend.• Despite the implementation of a guideline in 2011, aiming to improve selective use of CT in minor head injury, utilization significantly increased, while diagnostic yield significantly decreased.• Natural language processing is a valuable tool to monitor the utilization and diagnostic yield of imaging as a potential quality-of-care indicator.

Economic evaluation of the NET intervention versus guideline dissemination for management of mild head injury in hospital emergency departments

BackgroundEvidence-based guidelines for the management of mild traumatic brain injury (mTBI) in the emergency department (ED) are now widely available, and yet, clinical practice remains inconsistent with the guidelines. The Neurotrauma Evidence Translation (NET) intervention was developed to increase the uptake of guideline recommendations and improve the management of minor head injury in Australian emergency departments (EDs). However, the adoption of this type of intervention typically entails an upfront investment that may or may not be fully offset by improvements in clinical practice, health outcomes and/or reductions in health service utilisation. The present study estimates the cost and cost-effectiveness of the NET intervention, as compared to the passive dissemination of the guideline, to evaluate whether any improvements in clinical practice or health outcomes due to the NET intervention can be obtained at an acceptable cost.Methods and findingsStudy setting: The NET cluster randomised controlled trial [ACTRN12612001286831]. Study sample: Seventeen EDs were randomised to the control condition and 14 to the intervention. One thousand nine hundred forty-three patients were included in the analysis of clinical practice outcomes (NET sample). A total of 343 patients from 14 control and 10 intervention EDs participated in follow-up interviews and were included in the analysis of patient-reported health outcomes (NET-Plus sample). Outcome measures: Appropriate post-traumatic amnesia (PTA) screening in the ED (primary outcome). Secondary clinical practice outcomes: provision of written information on discharge (INFO) and safe discharge (defined as CT scan appropriately provided plus PTA plus INFO). Secondary patient-reported, post-discharge health outcomes: anxiety (Hospital Anxiety and Depression Scale), post-concussive symptoms (Rivermead), and preference-based health-related quality of life (SF6D). Methods: Trial-based economic evaluations from a health sector perspective, with time horizons set to coincide with the final follow-up for the NET sample (2 months post-intervention) and to 1-month post-discharge for the NET-Plus sample. Results: Intervention and control groups were not significantly different in health service utilisation received in the ED/inpatient ward following the initial mTBI presentation (adjusted mean difference $23.86 per patient; 95%CI − $106, $153; p = 0.719) or over the longer follow-up in the NET-plus sample (adjusted mean difference $341.78 per patient; 95%CI − $58, $742; p = 0.094). Savings from lower health service utilisation are therefore unlikely to offset the significantly higher upfront cost of the intervention (mean difference $138.20 per patient; 95%CI $135, $141; p < 0.000). Estimates of the net effect of the intervention on total cost (intervention cost net of health service utilisation) suggest that the intervention entails significantly higher costs than the control condition (adjusted mean difference $169.89 per patient; 95%CI $43, $297, p = 0.009). This effect is larger in absolute magnitude over the longer follow-up in the NET-plus sample (adjusted mean difference $505.06; 95%CI $96, $915; p = 0.016), mostly due to additional health service utilisation. For the primary outcome, the NET intervention is more costly and more effective than passive dissemination; entailing an additional cost of $1246 per additional patient appropriately screened for PTA ($169.89/0.1363; Fieller’s 95%CI $525, $2055). For NET to be considered cost-effective with 95% confidence, decision-makers would need to be willing to trade one quality-adjusted life year (QALY) for 25 additional patients appropriately screened for PTA. While these results reflect our best estimate of cost-effectiveness given the data, it is possible that a NET intervention that has been scaled and streamlined ready for wider roll-out may be more or less cost-effective than the NET intervention as delivered in the trial.ConclusionsWhile the NET intervention does improve the management of mTBI in the ED, it also entails a significant increase in cost and—as delivered in the trial—is unlikely to be cost-effective at currently accepted funding thresholds. There may be a scope for a scaled-up and streamlined NET intervention to achieve a better balance between costs and outcomes.Trial registrationAustralian New Zealand Clinical Trials Registry ACTRN12612001286831, date registered 12 December 2012.

Adherence to guidelines for management of minor head injury in patients receiving anticoagulants or antiplatelets in an emergency department

La Société française de médecine d’urgence a émis en 2012 des recommandations formalisées d’experts (RFE) sur la prise en charge des traumatismes crâniens légers (TCL). L’objectif principal de notre étude était d’évaluer, chez les patients traumatisés crâniens légers définis par un score de Glasgow compris entre 13 et 15 et sous anticoagulants (AC) ou antiagrégants plaquettaires (AAP), l’adhésion à ces recommandations dans notre service et d’analyser les facteurs influençant une prise en charge conforme ou non conforme. L’objectif secondaire était de réaliser une description de la prise en charge et du devenir de cette population. Étude rétrospective monocentrique sur un an, incluant tous patients adultes sous AC ou AAP ayant présenté un TCL se présentant aux urgences. Ont été étudiés les caractéristiques des patients, leur devenir à J30 en termes de décès intra-hospitalier et de réhospitalisation et les facteurs associés à l’application ou la non-application des recommandations. Cent soixante-quinze patients inclus. Une tomodensitométrie cérébrale (TDMc) a été réalisée chez 97 % des patients en un temps conforme dans 60 % des cas, des anomalies ont été retrouvées chez 20 patients (11 %). Cent pour cent des patients sous antivitamine K (AVK) ont eu un dosage de l’international normalized ratio (INR). La durée de surveillance clinique a été conforme dans 47 % des cas. Deux patients (1 %) sont décédés et deux patients (1 %) ont été ré-hospitalisés à J30 pour cause neurologique. Les facteurs associés à une réalisation de TDMc hors délais étaient : un sexe masculin : OR=3,24 (IC 95 % : [1,07–10,83] ; p=0,04), un traitement par AVK : OR=76,3 (IC 95 % : [2,9–154,1], p=0,01) ou par anticoagulants oraux directs : OR=148,39 (IC 95 % : [7,1–266], p=0,003). Étaient associées à une durée de surveillance conforme : des anomalies à la TDMc : OR=0,08 (IC 95 % : [0,01–0,8], p=0,05) et une hospitalisation post-urgence : OR=0,02 (IC 95 % : [0,01–0,2], p=0,001). L’application stricte des RFE reste perfectible dans notre service. Cependant, le niveau de preuve des études sur ce thème est discuté. Une mise à jour des RFE nous paraît nécessaire pour préciser la prise en charge de cette population particulière de patients.

The use of CT in the management of minor head injuries in Queenstown.

AIM This study retrospectively reviewed the management of head injury at Lakes District Hospital in Queenstown, New Zealand. The aim is to describe the management of minor head injury with particular reference to the current Traumatic Brain Injury guidelines of the New Zealand Guidelines Group. METHODS We identified all patients with head injury as a primary diagnosis who were seen in the Emergency Department at Lakes District Hospital during 2013-2015. We recorded clinical criteria indicating need for computed tomography (CT) scanning according to current guidelines for management of minor head injury. RESULTS A total of 883 patients were seen with head injury as their primary diagnosis: 280 patients aged >15 years had a minor head injury that met current criteria for immediate CT scanning. Of these, 66 (23.6%) actually had a CT head scan. CONCLUSION The rate of CT head scanning for minor head injury in Queenstown does not comply with current New Zealand guidelines.

Minor head injury in anticoagulated patients: a 6-year retrospective analysis in an emergency department

The appropriate management of minor head injury (MHI) in patients receiving oral anticoagulant (OAC) is unclear. In this retrospective study, we focused on elderly patients (&gt;65 years) treated with OAC, presented to our emergency department with MHI between 2004 and 2010. Three hundred and six patients with MHI were taking OAC: we documented 7.19% hemorrhages at the first computed tomography (C); 18.19% deaths; 50.1% spontaneous reabsorptions; 22.73% deteriorations of intracranial bleeding without surgical intervention (for clinical comorbidity), and 4.55% neurosurgical interventions. We documented a second positive CT scan in 2 patients (1.51%) who had no symptoms and remained asymptomatic during observation. In both cases, intracranial bleeding resolved spontaneously. The mean international normalized ratio (INR) value was 2.26, higher in the group of patients with bleeding (2.74) than in the group without bleeding (2.19). We found a significant increased risk in patients with posttraumatic loss of consciousness [odds ratio (OR) 28.3], diffuse headache (OR 14.79), vomiting (OR 14.2) and neurological signs (OR 5.27). We did not reach significance in patients with post-traumatic amnesia. Our data confirm the need for a CT scan of any patients on OAC with MHI. None of our patients developed any symptoms or signs during observation, and only 2 patients developed an intracranial hemorrhage in the second CT scan with a favorable evolution. Our data need to be confirmed with an observational study, but we suggest that the second CT could be reserved for patients developing symptoms and signs during observation. We also underline the role of the INR in the stratification of risk.

Two Different Approaches in Obtaining Head Computerized Tomography Scan in Minor Head Injuries

Background: The management of minor head injury (GCS score of 15) especially in the use of computed tomography (CT) scan is still controversial. As a big and developing country, Indonesia faced some problems in the management of minor head injuries. Those problems were limited number of CT scan, big number of minor head injured patients assessed in emergency unit and far distance between small cities and referral centers. This study was aimed to provide different approaches in obtaining CT scan in this group of patients. Methods: This was a cohort prospective study involving 364 head injured patients with a GCS score of 15, aged over six years. All studied clinical data were recorded and CT scan was obtained. The relationship between the clinical risk factors and the presence of abnormal CT scan (the first end point of this study) and the need for surgery (the second end point) were tested by univariate analysis ((X 2 -test). Logistic regression analysis was then used to find the best combination of these clinical factors that were highly sensitive to detect abnormal CT scan and the need for surgery. Results: The incidence of abnormal CT scan and the need for surgery were 13.2% and 3.7% respectively. Loss of consciousness (LOC) ( R R 4 . 84, 95 % CI 1 . 29 - 18 . 13) , amnesia ( R R 4 . 45, 95% CI 1 . 86 - 10 . 68), cranial soft tissue injury ( R R 8 . 56, 95% CI 3 . 43 - 21 . 46), skull fracture ( R R 6 . 81, 95% CI 2 . 04 - 22 . 77), age > 60 years ( R R 5 . 56, 95% CI 2 . 09 - 14 . 77) were significant clinical factors of abnormal CT scan. While amnesia ( R R 0 . 068, 95% CI 0 . 007 - 0 . 626), cranial soft tissue injury ( RR 0 . 076, 95% CI 0 . 009 - 0 . 647) and skull fracture ( R R 0 . 145, 95% CI 0 . 035 - 0 . 607) were significant clinical factors of the need for surgery . Conclusion: Our recent study provided two different approaches in obtaining head CT scan in minor head injuries, which were dependent on the availability of CT scan and the aim of taking CT scan. doi: http://dx.doi.org/10.4021/jnr225w

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Implementation of Adapted PECARN Decision Rule for Children With Minor Head Injury in the Pediatric Emergency Department

Of the currently published clinical decision rules for the management of minor head injury (MHI) in children, the Pediatric Emergency Care Applied Research Network (PECARN) rule, derived and validated in a large multicenter prospective study cohort, with high methodologic standards, appears to be the best clinical decision rule to accurately identify children at very low risk of clinically important traumatic brain injuries (ciTBI) in the pediatric emergency department (PED). This study describes the implementation of an adapted version of the PECARN rule in a tertiary care academic PED in Italy and evaluates implementation success, in terms of medical staff adherence and satisfaction, as well as its effects on clinical practice. The adapted PECARN decision rule algorithms for children (one for those younger than 2 years and one for those older than 2 years) were actively implemented in the PED of Padova, Italy, for a 6-month testing period. Adherence and satisfaction of medical staff to the new rule were calculated. Data from 356 visits for MHI during PECARN rule implementation and those of 288 patients attending the PED for MHI in the previous 6 months were compared for changes in computed tomography (CT) scan rate, ciTBI rate (defined as death, neurosurgery, intubation for longer than 24 hours, or hospital admission at least for two nights associated with TBI) and return visits for symptoms or signs potentially related to MHI. The safety and efficacy of the adapted PECARN rule in clinical practice were also calculated. Adherence to the adapted PECARN rule was 93.5%. The percentage of medical staff satisfied with the new rule, in terms of usefulness and ease of use for rapid decision-making, was significantly higher (96% vs. 51%, p<0.0001) compared to the previous, more complex, internal guideline. CT scan was performed in 30 patients (8.4%, 95% confidence interval [CI]=6% to 11.8%) in the implementation period versus 21 patients (7.3%, 95% CI=4.8% to 10.9%) before implementation. A ciTBI occurred in three children (0.8%, 95% CI=0.3 to 2.5) during the implementation period and in two children (0.7%, 95% CI=0.2 to 2.5) in the prior 6 months. There were five return visits (1.4%) postimplementation and seven (2.4%) before implementation (p=0.506). The safety of use of the adapted PECARN rule in clinical practice was 100% (95% CI=36.8 to 100; three of three patients with ciTBI who received CT scan at first evaluation), while efficacy was 92.3% (95% CI=89 to 95; 326 of 353 patients without ciTBI who did not receive a CT scan). The adapted PECARN rule was successfully implemented in an Italian tertiary care academic PED, achieving high adherence and satisfaction of medical staff. Its use determined a low CT scan rate that was unchanged compared to previous clinical practice and showed an optimal safety and high efficacy profile. Strict monitoring is mandatory to evaluate the long-lasting benefit in patient care and/or resource utilization.

Continuing Professional Development: Diagnosis and management of minor head injury in the UK

Overview Head injury accounts for a large amount of emergency services work in the UK. This article summarizes the findings of studies undertaken for the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme examining the available evidence regarding the diagnostic management of minor head injuries. These studies included a review of current practice in the management of minor head injured patients (GCS 13–15) by way of a survey of UK emergency departments. We also performed a systematic review of the head injury literature to identify the most accurate clinical decision rule for adults (Canadian CT Head Rule) and children (Paediatric Emergency Care and Research Network) and commented on the applicability of these in the UK population. This review helped to identify the most significant clinical findings that increase the likelihood of intracranial and neurosurgical injury, following minor head injury in adults, children and infants. Finally, we have highlighted where these findings may be relevant to UK paramedic practice, in particular in influencing the decision to transfer patients to the emergency department. Learning Outcomes After completing this module you will: • Have an understanding of the significant clinical characteristics following head injury • Understand potential pathological problems following head injury • Be able to assess the relevant clinical features of all patients following head injury • Be familiar with key clinical decision rules for patients with head injury • Be able to provide the appropriate pre-hospital management for all head injured patients.

Management of Minor Head Injury in Patients Receiving Oral Anticoagulant Therapy: A Prospective Study of a 24-Hour Observation Protocol

Patients receiving warfarin who experience minor head injury are at risk of intracranial hemorrhage, and optimal management after a single head computed tomography (CT) scan is unclear. We evaluate a protocol of 24-hour observation followed by a second head CT scan. In this prospective case series, we enrolled consecutive patients receiving warfarin and showing no intracranial lesions on a first CT scan after minor head injury treated at a Level II trauma center. We implemented a structured clinical pathway, including 24-hour observation and a CT scan performed before discharge. We then evaluated the frequency of death, admission, neurosurgery, and delayed intracranial hemorrhage. We enrolled and observed 97 consecutive patients. Ten refused the second CT scan and were well during 30-day follow-up. Repeated CT scanning in the remaining 87 patients revealed a new hemorrhage lesion in 5 (6%), with 3 subsequently hospitalized and 1 receiving craniotomy. Two patients discharged after completing the study protocol with 2 negative CT scan results were admitted 2 and 8 days later with symptomatic subdural hematomas; neither received surgery. Two of the 5 patients with delayed bleeding at 24 hours had an initial international normalized ratio greater than 3.0, as did both patients with delayed bleeding beyond 24 hours. The relative risk of delayed hemorrhage with an initial international normalized ratio greater than 3.0 was 14 (95% confidence interval 4 to 49). For patients receiving warfarin who experience minor head injury and have a negative initial head CT scan result, a protocol of 24-hour observation followed by a second CT scan will identify most occurrences of delayed bleeding. An initial international normalized ratio greater than 3 suggests higher risk.

Diagnosis and management of minor head injury in the UK

Head injury accounts for a large amount of emergency services work in the UK. We performed a review of current practice in the management of minor head injured patients (GCS 13-15) by way of a survey of UK emergency departments. Nearly all departments (∼95%) reported unrestricted access to computer tomography (CT) scans. Admission rates for minor head injured patients were 18% for adults and 9% for children. From our systematic review, we identified the most accurate clinical decision rule for adults (Canadian CT Head Rule) and children (Pediatric Emergency Care and Research Network) and commented on the applicability of these in the UK population. We also identified the most significant clinical findings that increase the likelihood of intracranial and neurosurgical injury, following minor head injury in adults, children and infants. Finally, we have highlighted where these findings may be relevant to UK paramedic practice, in particular in influencing the decision to transfer patients to the emergency department. This article summarizes the findings of studies undertaken for the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme examining the available evidence regarding the diagnostic management of minor head injuries. It will be published in a number of articles and a full report for the HTA programme.

Emergency management of minor head injury in anticoagulated patients

Approximately 1% of the UK population receives anticoagulation with warfarin. Head injury accounts for some 1.4 million emergency department attendances in the country. Therefore, significant numbers of patients with head...

Management of minor head injury in adults

Head injury accounts for up to 20 per cent of emergency department (ED) attendances (Kay and Teasdale 2001), and approximately 800,000 patients attend U.K. EDs with head injuries every year (National Institute for Health and Clinical Excellence (NICE) 2007a, Scottish Intercollegiate Guidelines Network (SIGN) 2009). About 90 per cent of these patients have a mild or minor head injury and are managed in EDs before being discharged home (Swann and Teasdale 1999). NICE in England and Wales and SIGN in Scotland have issued guidelines for the early management of head injury in adults in an attempt to improve clinical practice. This article discusses the important role of emergency nurses, particularly with regard to discharge information and advice for patients, relatives and carers.

Management of isolated minor head injury in the UK

BackgroundRecent guidelines and service developments may have changed the management of isolated minor head injuries in the UK. The authors aimed to review current practice and national statistics, and determine...

Racial disparities in health care—emergency department management of minor head injury

Background/aimInternational research has demonstrated disparities in the Emergency Department care of patients of certain racial or ethnic backgrounds. The management of minor head injuries requires a careful clinical assessment to determine the requirement of a CT scan of the head. The aim of this study was to determine if there was any disparity, based on race, in the management of minor head injury.MethodsThis was a retrospective, structured, medical record review of patients presenting to The Townsville Hospital Emergency Department, between September 2004 and April 2007, with minor head injury. The main outcome measure was whether or not patients received a CT head scan when clinically indicated. The Canadian CT Head Rule was considered the standard for clinical indication for a CT head scan. Secondary outcome measures included triage category, waiting time, level of care provider, disposition and serum ethanol.ResultsA total of 270 patients (73 indigenous and 196 non-indigenous) were enrolled. There was no statistically significant difference in ordering CT head scans when clinically indicated between indigenous and non-indigenous patients. However, a trend indicating that indigenous patients were less likely to receive a CT head scan when clinically indicated (OR 0.35; 95% CI = 0.07 to 1.77) was noted. Indigenous patients had a mean waiting time of 44.6 min (SD 49.6) compared to non-indigenous with 31.1 min (SD 36.4; p = 0.02).ConclusionThis study concluded that there was no statistically significant disparity based upon race in the management of minor head injuries with regard to decision to perform a CT head scan. There is some evidence that indigenous patients waited longer to be seen. A multi-centre prospective study is necessary to confirm these findings.

Overview of management of minor head injuries

Head injuries are very common and paramedics will therefore see many patients with head injuries. Most of these patients will not require any specific treatment. The challenge for pre-hospital and hospital carers is to identify the small minority of patients in whom a computed tomography scan is required and to expedite safe transfer to a neurosurgical unit for those very few that require specialist intervention. The key to identifying these is a broad understanding of the anatomy and pathophysiology of head injuries and also learning the important features of assessment and examination.

Survey of the management of patients with minor head injuries in hospitals in Sweden.

Development of guidelines for quality assurance in head injury care has to be based on knowledge about how today's management is organized. To address the need for guidelines in minor head injury (MHI), the authors studied management practice in Sweden. We performed a cross-sectional mail survey including all 76 hospitals treating head-injured patients. The questionnaire outlined present management practice in MHI; including routines for clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up. The initial evaluation is frequently performed by inexperienced physicians. The level of consciousness is assessed according to the Swedish Reaction Level Scale or the Glasgow Coma Scale in 96% of the hospitals. Routine computerized tomography is used in 4%. Skull radiography is not routinely performed. Eighty percent of the hospitals discharge selected patients without in-hospital observation and most (93%) offer no routine follow-up. This survey shows a variation in the management of MHI in hospitals in Sweden. Routines for assessment of consciousness level are satisfactory, but CT scan for detection of skull fracture and early diagnoses of intracranial complications is usually not performed. Guidelines should be based on present routines including decision rules for CT scan.

Delayed life-threatening subdural hematoma after minor head injury in a patient with severe coagulopathy: a case report

Minor head injury is a frequent cause for neurologic consultation and imaging. Most patients with minor head injury will make an uneventful recovery, but in a very small proportion of these patients life threatening intracranial complications occur. We describe a patient on oral anticoagulation therapy, and severely impaired coagulation, with normal head computed tomography on admission, who developed a subdural hematoma requiring surgery 12 hours later. Current guidelines and literature for the management of minor head injury are discussed.

Clinical algorithm and resource use in the management of children with minor head trauma

Purpose There are no clear guidelines for the management of minor head injury, including the use of skull x-rays and computed tomography (CT) scans of the head. This is reflected in clinical practice by a wide variability in imaging study use and by the fact that some patients are discharged home from the emergency room (ER), whereas others are admitted to the hospital with or without a period of observation before admission. To address this issue, we proposed and applied a new protocol for minor head injury at our institution. Methods Between January 2004 and December 2005, 417 patients presented to the emergency department at our institution with minor head injury. All of them had fallen from less than 1 m. Every chart was retrospectively evaluated, and pertinent data were extracted. Results The mean age of the patients was 9.8 months (2 weeks to 32 months). One hundred fifty-three had a skull x-ray, and 13 had a CT scan of the head. Of the 153 patients who had a skull x-ray, only 15 had a skull fracture. Of these 15 patients, 3 also had a CT scan of the head that confirmed the diagnosis of skull fracture. Of the 13 CT scans that were done, only these 3 were positive. Eleven patients were kept in the ER for 6 hours for close observation, and 5 of these were eventually admitted. Overall, 8 patients were admitted to the hospital for observation. Of these 8 patients, 7 had a skull x-ray, from which 5 were positive. Only 2 of the admitted patients had a CT scan, and they were both positive for a skull fracture. One of the CT also demonstrated a subdural hematoma along with subarachnoid hemorrhage. These 2 patients also had a positive skull x-ray. None of the patients that were admitted had headaches or neurologic impairments. The mean age of the patients admitted was 3.8 months (2 weeks to 12 months). The mean hospital stay was 1.2 days (1-3 days). Conclusion Only 10% of the skull x-rays and CT scans were positive for a skull fracture, which led to an admission in half of these patients. The other half was mainly discharged from ER after being observed. Several patients underwent a skull x-ray that we feel was not necessary in the management of their minor head injury. For those who had a head CT scan, only one revealed additional information and none of them had an impact on the final management. Observation in the ER could have been reasonable for most cases.