小児頭部外傷患者の画像検査施行基準と初期診療方針

Criteria for Applying Imaging Diagnosis and Initial Management for Pediatric Head Trauma

Ⅰ．はじめに

　頭部外傷患者の多くは軽症例であるが，初期診療における画像検査の必要性については議論が多く，一定の見解が得られていない^{4,6,10,12,13)}．特に小児の場合は成人と比べて訴えがわかりにくく，神経所見の把握も困難なことが多いため，画像検査を施行しておいたほうがよいと考えられるが¹⁵⁾，放射線被曝や体動などの問題で検査が困難なことが多いのも現状である．また，受傷直後に施行したCTで頭蓋内に異常がなくても，受傷後しばらく経過してから異常所見が出現することもあるため，受傷後数時間は経過観察を指示する場合が多い¹¹⁾．このような点を考慮すると，小児頭部外傷患者の初期診療では，画像検査よりも受傷後の経過観察のほうが重要とも考えられる．

　われわれは，小児頭部外傷患者の初期診療において画像検査施行基準を設定し，一定期間その基準に従って診療を行うことを試みた．画像検査が不要と判断した患者は，検査を行わずに自宅で経過観察する方針とし，数時間後に電話で状態の確認を行った．今回，画像検査施行基準と初期診療方針の妥当性について考察したので報告する．

　It may be difficult to perform CT for pediatric head trauma because of body movement and radiation exposure. Imaging application criteria were established, in which patients diagnosed as less likely to have an intracranial lesion meeting the criteria were not indicated for imaging and subjected to course observation at home, and this policy was explained to the parents. When consent was obtained, patients were followed up at home, and we checked on the condition by making a phone call 4-8 hours after injury. The patients were 103 infants aged 15 years or younger brought to the emergency medical care center of our hospital between May and August 2008. Imaging was basically indicated for cases of traffic accidents, falls from a high level, those brought in by ambulance, referred cases, and cases with disturbance of consciousness, neurologically abnormal findings, vomiting on examination, and trauma requiring X-ray examination in addition to that for the head. However, apart from these cases, imaging was not required. Imaging was not necessary for 94% of infant cases. The parents were convinced by the explanation and selected course observation at home in 94% of cases for which imaging was judged as unnecessary. None of the patients required re-examination based on the conditions reported in phone calls to homes. Imaging diagnosis for pediatric head trauma is not always necessary, and its application should be decided on after consultation. When no imaging is performed, this should be fully explained at the initial treatment before selecting course observation at home. Checking on the child's condition by making a phone call several hours after injury is useful for both patients and physicians.