CATCH Rule in Pediatric Head Trauma

ID: 10y/o boy; referred to EM from a walk-in clinic following a fall while playing with a friend in his PE class. 

HPI: Was dragged from behind while playing, fell on the ground, and  hit his head. 15min witnessed LOC. He remembers being assessed in the office at school. Mom was notified, and took him to a walk in clinic. After vomiting once in the walk-in clinic, was referred to the ER. Was seen in the ER approximately 4h after the incident. Vomited once again in triage. Generalized head ache(HA) which was getting better, no N/V, anterograde amnesia of about 15min. 

PMH: Previously healthy. 

Meds: Non

Allergies: NKDA

E/P: Drowsy, Oriented ✗ 3, Not in acute distress (NAD), 

VSSA

HEENT: 3 ✗ 3cm bruise on the Rt temple. No racoon or Battle's signs, No otorrhea/rhinorrhea/hemotympanum. Palpation of facial bones showed no #.

Neuro:  GCS 15

Pupils symmetric, reactive; No RAPD

CN II-XII normal; Motor/Sensory normal; Gail normal

MSK: Able to move limbs ✗ 4 w/o pain.

I/P: 11y/o boy with a minor head injury, does not meet CATCH criteria for CT head. Admit for a short period of observation. D/C with f/u precautions. F/U with GP in 1wk if residual sx. 

Discussion:

The length of observation in the ER probably depends on the reliability of the caregiver, and distance of their residence from the ER. 

The CT head rule does not apply to children. Instead the CATCH rule can be used for the paediatric population with mild head injury. You can also use PECARN algorithms(3) to decide whether or not a CT head is necessary.

Canadian Assessment of Tomography for Childhood Head injury: the CATCH rule

CT of the head is required only for children with minor head injury* and any one of the following findings(1):

High risk (need for neurologic intervention)

1. Glasgow Coma Scale score < 15 at two hours after injury 

2. Suspected open or depressed skull fracture

3. History of worsening headache

4. Irritability on examination

Medium risk (brain injury on CT scan)

5. Any sign of basal skull fracture(e.g.,hemotympanum, “raccoon” eyes, otorrhea or rhinorrhea of the cerebrospinal fluid, Battle’s sign)

6. Large,boggy hematoma of the scalp

7. Dangerous mechanism of injury(e.g.,motorvehiclecrash,

fall from elevation ≥ 3 ft [≥ 91 cm] or 5 stairs, fall from bicycle with no helmet)

*Minor head injury is defined as injury within the past 24 hours associated with witnessed loss of consciousness, definite amnesia, witnessed disorientation, persistent vomiting (more than one episode) or persistent irritability (in a child under two years of age) in a patient with a Glasgow Coma Scale score of 13–15.

Below is the Canadian CT Head rule for comparison. Keep in mind that CT Head Rule dose not apply in the following situations:

- Non-trauma cases

- GCS < 13

- Age < 16 years

- Coumadin or bleeding disorder

- Obvious open skull fracture

Canadian CT Head Rule(2): 

CT Head Rule: CT Head is only required for patients with minor head injuries

with any one of the following:

High risk (for neurological intervention)

● GCS score <15 at 2 h after injury

● Suspected open or depressed skull fracture

● Any sign of basal skull fracture (haemotympanum, ‘racoon’ eyes,

cerebrospinal fluid otorrhoea/rhinorrhoea, Battle’s sign)

● Vomiting two episodes

● Age 65 years

Medium risk (for brain injury on CT)

● Amnesia before impact >30 min

● Dangerous mechanism (pedestrian struck by motor vehicle,

occupant ejected from motor vehicle, fall from height >3 feet or five stairs)

Minor head injury is defined as witnessed loss of consciousness, definite amnesia, or witnessed disorientation in a patients with a GCS score of 13–15.

References:

1. Osmond, M., for the Pediatric Emergency Research Canada (PERC) Head Injury Study Group, Pediat Emergency Res Canada PERC H, & Pediatric Emergency Research Canada (PERC) Head Injury Study Group. (2010). CATCH: A clinical decision rule for the use of computed tomography in children with minor head injury. Cmaj, 182(4), 341-348. doi:10.1503/cmaj.091421

2. Stiell, I. G., Cass, D., Eisenhauer, M. E., Greenberg, G., Worthington, J., Wells, G. A., . . . CCC Study Grp. (2001). The canadian CT head rule for patients with minor head injury. Lancet, 357(9266), 1391-1396. doi:10.1016/S0140-6736(00)04561-X


3. Kuppermann, N., Borgialli, D. A., Badawy, M. K., Schunk, J. E., Quayle, K. S., Mahajan, P., . . . PECARN. (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet, 374(9696), 1160-1170. doi:10.1016/S0140-6736(09)61558-0