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Northam W, Chandran A, Quinsey C, Abumoussa A, Flores A, Elton S. Pediatric nonoperative skull fractures: delayed complications and factors associated with clinic and imaging utilization. J Neurosurg Pediatr 2019; 24:489-497. [PMID: 31470399 DOI: 10.3171/2019.5.peds18739] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Skull fractures represent a common source of morbidity in the pediatric trauma population. This study characterizes the type of follow-up that these patients receive and discusses predictive factors for follow-up. METHODS The authors reviewed cases of nonoperative pediatric skull fractures at a single academic hospital between 2007 and 2017. Clinical patient and radiological fractures were recorded. Recommended neurosurgical follow-up, follow-up appointments, imaging studies, and fracture-related complications were recorded. Statistical analyses were performed to identify predictors for outpatient follow-up and imaging. RESULTS The study included 414 patients, whose mean age was 5.2 years; 37.2% were female, and the median length of stay was 1 day (IQR 0.9-4 days). During 438 clinic visits and a median follow-up period of 8 weeks (IQR 4-12, range 1-144 weeks), 231 imaging studies were obtained, mostly head CT scans (55%). A total of 283 patients were given recommendations to attend follow-up in the clinic, and 86% were seen. Only 12 complications were detected, including 7 growing skull fractures, 2 traumatic encephaloceles, and 3 cases of hearing loss. Primary care physician (PCP) status and insurance status were associated with a recommendation of follow-up, actual follow-up compliance, and the decision to order outpatient imaging in patients both with and without intracranial hemorrhage. PCP status remained an independent predictor in each of these analyses. Follow-up compliance was not associated with a patient's distance from home. Among patients without intracranial hemorrhage, a follow-up recommendation and actual follow-up compliance were associated with pneumocephalus and other polytraumatic injuries, and outpatient imaging was associated with a bilateral fracture. No complications were found in patients with linear fractures above the skull base in those without an intracranial hemorrhage. CONCLUSIONS Pediatric nonoperative skull fractures drive a large expenditure of clinic and imaging resources to detect a relatively small profile of complications. Understanding the factors underlying the decision for clinic follow-up and additional imaging can decrease future costs, resource utilization, and radiation exposure. Factors related to injury severity and socioeconomic indicators were associated with outpatient imaging, the decision to follow up patients in the clinic, and patients' subsequent attendance. Socioeconomic status (PCP and insurance) may affect access to appropriate neurosurgical follow-up and deserves future research attention. Patients with no intracranial hemorrhage and with a linear fracture above the skull base do not appear to be at risk for delayed complications and could be candidates for reduced follow-up and imaging.
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Affiliation(s)
| | - Avinash Chandran
- 2Matthew Gfeller Sport-Related TBI Research Center, Department of Exercise and Sport Science; and
| | | | | | - Alex Flores
- 3School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Singh N, Singhal A. Challenges in minor TBI and indications for head CT in pediatric TBI-an update. Childs Nerv Syst 2017; 33:1677-1681. [PMID: 29149393 DOI: 10.1007/s00381-017-3535-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/06/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pediatric head trauma is one of the commonest presentations to emergency departments. Over 90% of such head injuries are considered mild, but still present risk acute clinical deterioration and longer term morbidity. Identifying which children are at risk of clinically important brain injuries remains challenging and much of the data on minor head injuries is based on the adult population. CHALLENGES IN PEDIATRICS Children, however, are different, both anatomically and in terms of mechanism of injury, to adults and, even within the pediatric group, there are differences with age and stage of development. IMAGING CT scans have added to the repertoire of clinicians in the assessment of pediatric head injury population, but judicious use is required given radiation exposure, malignancy risk, and resource constraints. Guidelines and head injury rules have been developed, for adults and children, to support decision-making in the emergency department though whether their use is applicable to all population groups is debatable. Further challenges in mild pediatric head trauma also include appropriate recommendations for school attendance and physical activity after discharge. FURTHER DEVELOPMENTS Concern remains for second-impact syndrome and, in the longer term, for post-concussive syndrome and further research in both is still needed. Furthermore, the development of clinical decision rules raises further questions on the purpose of admitting children with minor head injuries and answering this question may aid the evolution of clinical decision guidelines. CONCLUSIONS The next generation of catheter with homogeneous flow patterns based on parametric designs may represent a step forward for the treatment of hydrocephalus, by possibly broadening their lifespan.
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Affiliation(s)
- Navneet Singh
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada
| | - Ash Singhal
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada.
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Stovitz SD, Weseman JD, Hooks MC, Schmidt RJ, Koffel JB, Patricios JS. What Definition Is Used to Describe Second Impact Syndrome in Sports? A Systematic and Critical Review. Curr Sports Med Rep 2017; 16:50-55. [PMID: 28067742 DOI: 10.1249/jsr.0000000000000326] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Concern about what has been termed, "second impact syndrome" (SIS) is a major factor determining return-to-play decisions after concussion. However, definitions of SIS vary. We used Scopus to conduct a systematic review and categorize the definitions used to describe SIS. Of the 91 sources identified, 79 (87%) clearly specified that SIS involved either cerebral edema or death after a concussion when a prior concussion had not resolved. Twelve articles (13%) could be interpreted as merely the events of two consecutive concussions. Among the articles that listed mortality rates, nearly all (33/35, 94%) said the rate of death was "high" (e.g., 50% to 100%). Our review found that most articles define SIS as a syndrome requiring catastrophic brain injury after consecutive concussive episodes. Given that it is unclear how common it is to have a second concussion while not fully recovered from a first concussion, the actual mortality rate of SIS is unknown.
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Affiliation(s)
- Steven D Stovitz
- 1Department of Family Medicine and Community Health, University of Minnesota, Minneapolis, MN; 2University of Minnesota Medical School, Minneapolis, MN; 3Bio-Medical Library, University of Minnesota, Minneapolis, MN; 4Section of Sports Medicine, Faculty of Health Sciences, University of Pretoria, Pretoria, South Africa; and 5Department of Emergency Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Trauma. HANDBOOK OF CLINICAL NEUROLOGY 2016. [PMID: 27430465 DOI: 10.1016/b978-0-444-53486-6.00062-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
Traumatic brain and spine injury (TBI/TSI) is a leading cause of death and lifelong disability in children. The biomechanical properties of the child's brain, skull, and spine, the size of the child, the age-specific activity pattern, and variance in trauma mechanisms result in a wide range of age-specific traumas and patterns of brain and spine injuries. A detailed knowledge about the various types of primary and secondary pediatric head and spine injuries is essential to better identify and understand pediatric TBI/TSI, which enhances sensitivity and specificity of diagnosis, will guide therapy, and may give important information about the prognosis. The purposes of this chapter are to: (1) discuss the unique epidemiology, mechanisms, and characteristics of TBI/TSI in children; (2) review the anatomic and functional imaging techniques that can be used to study common and rare pediatric TBI/TSI and their complications; (3) comprehensively review frequent primary and secondary brain injuries; and (4) to give a short overview of two special types of pediatric TBI/TSI: birth-related and nonaccidental injuries.
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Ismail S, McIntosh M, Kalynych C, Joseph M, Wylie T, Butterfield R, Smotherman C, Kraemer DF, Osian SR. Impact of Video Discharge Instructions for Pediatric Fever and Closed Head Injury from the Emergency Department. J Emerg Med 2016; 50:e177-83. [DOI: 10.1016/j.jemermed.2015.10.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2015] [Revised: 09/17/2015] [Accepted: 10/05/2015] [Indexed: 11/28/2022]
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Arrey EN, Kerr ML, Fletcher S, Cox CS, Sandberg DI. Linear nondisplaced skull fractures in children: who should be observed or admitted? J Neurosurg Pediatr 2015; 16:703-8. [PMID: 26339955 DOI: 10.3171/2015.4.peds1545] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In this study the authors reviewed clinical management and outcomes in a large series of children with isolated linear nondisplaced skull fractures (NDSFs). Factors associated with hospitalization of these patients and costs of management were also reviewed. METHODS After institutional review board approval, the authors retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for NDSFs at a single children's hospital between January 2009 and December 2013. Patients were excluded if the fracture was open or comminuted. Additional exclusion criteria included intracranial hemorrhage, more than 1 skull fracture, or pneumocephalus. RESULTS Three hundred twenty-six patients met inclusion criteria. The median patient age was 19 months (range 2 weeks to 15 years). One hundred ninety-three patients (59%) were male and 133 (41%) were female. One hundred eighty-four patients (56%) were placed under 23-hour observation, 87 (27%) were admitted to the hospital, and 55 patients (17%) were discharged from the emergency department. Two hundred seventy-eight patients (85%) arrived by ambulance, 36 (11%) arrived by car, and 12 (4%) were airlifted by helicopter. Two hundred fifty-seven patients (79%) were transferred from another institution. The mean hospital stay for patients admitted to the hospital was 46 hours (range 7-395 hours). The mean hospital stay for patients placed under 23-hour observation status was 18 hours (range 2-43 hours). The reasons for hospitalization longer than 1 day included Child Protective Services involvement in 24 patients and other injuries in 11 patients. Thirteen percent (n = 45) had altered mental status or loss of consciousness by history. No patient had any neurological deficits on examination, and none required neurosurgical intervention. Less than 16% (n = 50) had subsequent outpatient follow-up. These patients were all neurologically intact at the follow-up visit. CONCLUSIONS Hospitalization is not necessary for many children with NDSFs. Patients with mental status changes, additional injuries, or possible nonaccidental injury may require observation.
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Affiliation(s)
- Eliel N Arrey
- Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas
| | - Marcia L Kerr
- Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas
| | - Stephen Fletcher
- Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas
| | - Charles S Cox
- Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas
| | - David I Sandberg
- Departments of Pediatric Surgery and Neurosurgery, The University of Texas Health Science Center at Houston Medical School, and Children's Memorial Hermann Hospital, Houston, Texas
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Nath PC, Mishra SS, Deo RC, Jena SP. Spectrum of pediatric head injury with management and outcome – A single tertiary care centre study. INDIAN JOURNAL OF NEUROTRAUMA 2015. [DOI: 10.1016/j.ijnt.2014.12.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Serinken M, Kocyigit A, Karcioglu O, Sengül C, Hatipoğlu C, Elicabuk H. Parental anxiety and affecting factors in acute paediatric blunt head injury. Emerg Med J 2014; 31:637-640. [PMID: 23686732 DOI: 10.1136/emermed-2013-202492] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE This study is designed to investigate the factors affecting parental anxiety regarding their children with head injury in the emergency department (ED). MATERIALS AND METHODS This prospective observational study enrolled all consecutive paediatric patients admitted to the university-based ED with the presenting chief complaint of paediatric blunt head injury (PBHI). The parents were asked to respond to the 10-item questionnaire during both presentation and discharge. Anxiety and persuasion scores of the parents were calculated and magnitudes of the decreases in anxiety and persuasion scores were analysed with respect to sociodemographic and clinical variables. RESULTS The study sample included 341 patients admitted to the ED. The anxiety and persuasion scores of mothers and fathers were not significantly different from each other on presentation while the extent of decrease in anxiety scores of mothers were significantly smaller than that of the fathers (p=0.003). The parents' education levels had significant impact on anxiety and persuasion scores recorded on presentation. The anxiety and persuasion scores were inversely related to education levels of the parents on presentation (p=0.002 and p=0.000, respectively). In addition, lower education levels were found to be associated with a greater decrease in anxiety and persuasion scores. Neurosurgical consultation also affected the magnitude of the decrease in anxiety and persuasion scores of the parents. The changes in the scores were affected negatively by the parents' age. CONCLUSIONS Radiological investigations had no significant impact on the decrease in anxiety and persuasion scores of the parents by themselves, while neurosurgical consultation had significant impact on them. Emergency physicians should tailor their strategy to institute effective communication with the parents of children to cut down unnecessary investigations in PBHI.
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Affiliation(s)
- M Serinken
- Department of Emergency Medicine, Pamukkale University Medical Faculty, Turkey
| | - A Kocyigit
- Department of Radiology, Pamukkale University Medical Faculty, Turkey
| | - O Karcioglu
- Department of Emergency Medicine, Acibadem University School of Medicine, Turkey
| | - C Sengül
- Department of Psychiatry, Pamukkale University Medical Faculty, Turkey
| | - C Hatipoğlu
- Department of Public Health, Pamukkale University Medical Faculty, Turkey
| | - H Elicabuk
- Department of Emergency Medicine, Pamukkale University Medical Faculty, Turkey
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Amaranath JE, Ramanan M, Reagh J, Saekang E, Prasad N, Chaseling R, Soundappan S. Epidemiology of traumatic head injury from a major paediatric trauma centre in New South Wales, Australia. ANZ J Surg 2014; 84:424-8. [DOI: 10.1111/ans.12445] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/07/2013] [Indexed: 11/30/2022]
Affiliation(s)
- Jeevaka E. Amaranath
- Douglas Cohen Department of Paediatric Surgery; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Mahesh Ramanan
- Department of Neurosurgery; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Jessica Reagh
- Douglas Cohen Department of Paediatric Surgery; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Eilen Saekang
- Douglas Cohen Department of Paediatric Surgery; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Narayan Prasad
- Douglas Cohen Department of Paediatric Surgery; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Raymond Chaseling
- Department of Neurosurgery; The Children's Hospital at Westmead; Sydney New South Wales Australia
| | - Sannappa Soundappan
- Douglas Cohen Department of Paediatric Surgery and Trauma; The Children's Hospital at Westmead; Sydney New South Wales Australia
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Farrell CA. La prise en charge du patient d’âge pédiatrique victime d’un traumatisme crânien aigu. Paediatr Child Health 2013. [DOI: 10.1093/pch/18.5.259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Pinto PS, Meoded A, Poretti A, Tekes A, Huisman TAGM. The unique features of traumatic brain injury in children. review of the characteristics of the pediatric skull and brain, mechanisms of trauma, patterns of injury, complications, and their imaging findings--part 2. J Neuroimaging 2012; 22:e18-41. [PMID: 22303964 DOI: 10.1111/j.1552-6569.2011.00690.x] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Traumatic brain injury (TBI) is a major cause of morbidity and mortality in children. The unique biomechanical, hemodynamical, and functional characteristics of the developing brain and the age-dependent variance in trauma mechanisms result in a wide range of age specific traumas and patterns of brain injuries. Detailed knowledge of the main primary and secondary pediatric injuries, which enhance sensitivity and specificity of diagnosis, will guide therapy and may give important information about the prognosis. In recent years, anatomical but also functional imaging methods have revolutionized neuroimaging of pediatric TBI. The purpose of this article is (1) to comprehensively review frequent primary and secondary brain injuries and (2) to give a short overview of two special types of pediatric TBI: birth related and nonaccidental injuries.
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Affiliation(s)
- Pedro S Pinto
- Division of Pediatric Radiology, Russell H. Morgan Department of Radiology and Radiological Science, The Johns Hopkins Hospital, Baltimore, MD, USA
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Scherwath A, Sommerfeldt DW, Bindt C, Nolte A, Boiger A, Koch U, Petersen-Ewert C. Identifying children and adolescents with cognitive dysfunction following mild traumatic brain injury—Preliminary findings on abbreviated neuropsychological testing. Brain Inj 2011; 25:401-8. [DOI: 10.3109/02699052.2011.557351] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
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Gordon KE, Dooley JM, Fitzpatrick EA, Wren P, Wood EP. Concussion or mild traumatic brain injury: parents appreciate the nuances of nosology. Pediatr Neurol 2010; 43:253-7. [PMID: 20837303 DOI: 10.1016/j.pediatrneurol.2010.05.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2010] [Revised: 04/15/2010] [Accepted: 05/15/2010] [Indexed: 11/25/2022]
Abstract
We explored whether parents of our pediatric patients valued the diagnostic terms "concussion," "minor traumatic brain injury," and "mild traumatic brain injury" as equivalent or nonequivalent. 1734 of 2304 parents attending a regional pediatric emergency department completed a brief questionnaire assessing the equivalence or nonequivalence of the diagnostic terms "concussion," "minor traumatic brain injury," and "mild traumatic brain injury" in a pairwise fashion. Many parents viewed these diagnostic terms as equivalent, when assessed side by side. For those who considered these diagnostic terms nonequivalent, concussion was regarded as considerably "better" (or less "worse") than minor traumatic brain injury (P < 0.001, χ(2) test) or mild traumatic brain injury (P < 0.001, χ(2) test). A moderate degree of variability was evident in parent/guardian responses. As a group, parents reported that concussion or mild/minor traumatic brain injuries are valued equivalently. However, many parents considered them different, with concussion reflecting a "better" (or less "worse") outcome.
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Affiliation(s)
- Kevin E Gordon
- Division of Pediatric Neurology, Department of Pediatrics, Dalhousie University, Halifax, Nova Scotia, Canada.
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Mild traumatic brain injury in the pediatric population: the role of the pediatrician in routine follow-up. ACTA ACUST UNITED AC 2010; 68:1396-400. [PMID: 20539184 DOI: 10.1097/ta.0b013e3181cf7d1b] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic brain injury is common in children. Fortunately, most patients suffer mild traumatic brain injury (MTBI). Appropriate guidelines for follow-up care are not well established. We sought to determine practice experience and preferences of general pediatricians related to follow-up care of MTBI. METHODS Members of the American Academy of Pediatrics Council of Community Pediatrics and general pediatricians in the Pennsylvania Chapter of the American Academy of Pediatrics participated in a web-based survey regarding practice setting, level of comfort caring for patients with MTBI, and referral patterns for such patients. RESULTS A total of 298 pediatricians responded. An urban or suburban practice setting was reported by 83.3% with a wide distribution in practice experience (0-10 years 40.5%, 11-20 years 24.5%, >21 years 35%). Most respondents (54.5%) had cared for at least 2 to 5 patients with MTBI in the past 6 months but only 8% had seen >10 patients. Fifty-nine percent had not participated in continuing medical education activities related to MTBI and 62.2% did not use neurocognitive tests. The majority (89%) thought that they were the appropriate provider for follow-up; this declined to 61.2% for patients with loss of consciousness and only 5.4% if patients had persistent symptoms. Neurologists (75%) were the consultant of choice for referral. Increased practice experience was associated with an increased comfort in determining return to play status. CONCLUSION In this survey, pediatricians thought that they were the most appropriate clinicians to follow-up patients with MTBI. However, most accepted this responsibility without the benefit of specific continuing medical education or using neurocognitive tests. Ensuring the availability of appropriate resources for pediatricians to care for these patients is important.
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Hamilton M, Mrazik M, Johnson DW. Incidence of delayed intracranial hemorrhage in children after uncomplicated minor head injuries. Pediatrics 2010; 126:e33-9. [PMID: 20566618 DOI: 10.1542/peds.2009-0692] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES This study sought to determine the incidence of delayed diagnosis of intracranial hemorrhage in the general population and the proportion of children who presented to emergency departments (EDs) with uncomplicated minor head injuries who received delayed diagnoses of intracranial hemorrhage. METHODS This was an 8-year, retrospective, cohort study of children <14 years of age who presented to EDs in the Calgary Health Region between April 1992 and March 2000. Cases of uncomplicated minor head injuries and delayed diagnosis of intracranial hemorrhage (intracranial hemorrhage not apparent until > or =6 hours after injury) were identified. RESULTS An estimated 17,962 children (95% confidence interval [CI]: 17,412-18,511 children) with uncomplicated minor head injuries were evaluated at Calgary Health Region EDs. Two and 8 children were identified as having delayed diagnoses of intracranial hemorrhage with and without delayed deterioration in level of consciousness (Glasgow Coma Scale scores of <15), respectively. The proportions of children with uncomplicated minor head injuries with delayed diagnoses of intracranial hemorrhage with and without deterioration in level of consciousness were approximately 0.00% (0 of 17,962 children [upper limit of 95% CI: 0.02%]) and 0.03% (5 of 17,962 children [95% CI: 0.01%-0.07%]), respectively. On the basis of population data for the Calgary Health Region, the incidences of delayed diagnosis of intracranial hemorrhage with and without deterioration in level of consciousness were 0.14 and 0.57 cases per 100,000 children per year, respectively. CONCLUSIONS The occurrence of delayed diagnosis of intracranial hemorrhage among children who present with uncomplicated minor head injuries is rare.
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Affiliation(s)
- Mark Hamilton
- Department of Pediatrics, Faculty of Medicine, University of Calgary, Calgary, Alberta, Canada
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Katz JS, Oluigbo CO, Wilkinson CC, McNatt S, Handler MH. Prevalence of cervical spine injury in infants with head trauma. J Neurosurg Pediatr 2010; 5:470-3. [PMID: 20433260 DOI: 10.3171/2009.11.peds09291] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The incidence, type, and severity of pediatric cervical spine injuries (CSIs) are related to age and mechanism of injury. In this study, the authors assessed the prevalence of CSIs in infants with head trauma treated in their institution. METHODS The authors reviewed the medical records of children younger than 1 year of age who presented to The Children's Hospital with head injuries between January 1993 and December 2007. They excluded infants with head injuries resulting from motor vehicle accidents and known falls from heights greater than 10 ft. For each patient, collected data included age, cause of injury, diagnosis, discharge disposition, and outcome. Relevant imaging data were reviewed, and when appropriate, autopsy reports were also reviewed. RESULTS Nine hundred five infants with head trauma and without a major mechanism/cause were identified. Their mean age was 4.3 months. Of the 905 patients, only 2 cases of CSI were detected, giving a prevalence of 0.2%. The mechanism of injury in these 2 patients was nonaccidental trauma (NAT). CONCLUSIONS The study revealed a very low prevalence of CSIs in infants with head trauma (0.2%). Routine cervical spine imaging in these infants, therefore, appears to have low diagnostic yield. The mechanism of head injury was NAT in the 2 patients who sustained an associated CSI. This supports the need for more stringent cervical spine imaging criteria for the infant with suspected NAT.
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Affiliation(s)
- Joel S Katz
- Department of Pediatric Neurosurgery, The Children's Hospital, University of Colorado, Aurora, Colorado 80045, USA
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Ruan S, Noyes K, Bazarian JJ. The economic impact of S-100B as a pre-head CT screening test on emergency department management of adult patients with mild traumatic brain injury. J Neurotrauma 2010; 26:1655-64. [PMID: 19413465 DOI: 10.1089/neu.2009.0928] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Recent research suggests that serum S-100B may serve as a good pre-head computed tomography (CT) screening test because of its high sensitivity for abnormal head CT scans. The potential economic impact of using S-100B in the emergency department setting for management of adult patients with isolated mild traumatic brain injury (mTBI) has not been evaluated despite its clinical implementation in Europe. Using evidence from the literature, we constructed a decision tree to compare the average cost per patient of using S-100B as a pre-head CT screening test to the current practice of ordering CT scans based on patients' presenting symptoms without the aid of S-100B. When compared to scanning 45-77% of isolated mTBI patients based upon their presenting symptoms, using S-100B as a pre-head CT screen does not lower hospital costs ($281 versus $160), primarily due to its low specificity for abnormal head CT scans. Sensitivity analyses showed, however, that S-100B becomes cost-lowering when the proportion of mTBI patients being scanned exceeds 78%, or when final CT scan results require 96 min or more than the wait for blood test results. Generally speaking, if blood test results require less time than imaging, and if head CT scan rates for patients with isolated mTBI are relatively high, using S-100B will lower costs. Recommendations for using S-100B as a screening tool should account for setting-specific characteristics and their consequent economic impacts. Despite its high sensitivity and excellent negative predictive value, serum S-100B has low specificity and low positive predictive value, limiting its ability to reduce numbers of CT scans and hospital costs.
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Affiliation(s)
- Shuolun Ruan
- Department of Community and Preventive Medicine, University of Rochester School of Medicine and Dentistry, Rochester, New York 14642, USA.
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Kirkwood MW, Yeates KO, Taylor HG, Randolph C, McCrea M, Anderson VA. Management of pediatric mild traumatic brain injury: a neuropsychological review from injury through recovery. Clin Neuropsychol 2008; 22:769-800. [PMID: 17896204 PMCID: PMC2847840 DOI: 10.1080/13854040701543700] [Citation(s) in RCA: 135] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Little scientific attention has been aimed at the non-acute clinical care of pediatric mild TBI. We propose a clinical management model focused on both evaluation and intervention from the time of injury through recovery. Intervention strategies are outlined using a framework encompassing four relevant domains: the individual youth, family, school, and athletics. Clinical management has primary value in its potential to speed recovery, minimize distress during the recovery process, and reduce the number of individuals who subjectively experience longer lasting postconcussive problems. With proper management, most children and adolescents sustaining an uncomplicated mild TBI can be expected to recover fully.
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Affiliation(s)
- Michael W Kirkwood
- Department of Physical Medicine, University of Colorado at Denver and Health Sciences Center and The Children's Hospital, Denver, CO, USA.
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Kim PD, Jennings JS, Fisher M, Siddiqui AH. Risk of cervical spine injury and other complications seen with skull fractures in the setting of mild closed head injury in young children: a retrospective study. Pediatr Neurosurg 2008; 44:124-7. [PMID: 18230926 DOI: 10.1159/000113114] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2007] [Accepted: 09/18/2007] [Indexed: 01/15/2023]
Abstract
We have reviewed records for patients under 2 years of age who presented at our hospital with mild closed head injuries and nondisplaced skull fractures, specifically to examine methods utilized for spine clearance, associated cervical injuries, involvement and findings of child protective services and delayed complications. Of 42 patients included in the series, none were found to have cervical spine injuries. Child protective services were involved in 12 cases with confirmatory findings and subsequent placement occurring in 2 cases. There were no serious delayed complications in this series of patients. AP and lateral plain films of the cervical spine are nonetheless recommended until larger prospective studies suggest otherwise.
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Affiliation(s)
- Peter D Kim
- Department of Neurosurgery, State University of New York, Upstate Medical University, Syracuse, NY 13210, USA
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Avarello JT, Cantor RM. Pediatric major trauma: an approach to evaluation and management. Emerg Med Clin North Am 2007; 25:803-36, x. [PMID: 17826219 DOI: 10.1016/j.emc.2007.06.013] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Trauma is the leading cause of death in children nationwide. Proper management of the pediatric trauma patient involves many of the components contained within standard trauma protocols. By paying strict attention to the anatomical and physiological differences in the pediatric population, clinicians will be assured the best possible outcomes. This article outlines the fundamentals of proper management of pediatric trauma patients.
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Affiliation(s)
- Jahn T Avarello
- Department of Emergency Medicine, SUNY Upstate Medical University, 750 East Adams Street, Syracuse, NY 13210, USA.
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Mack KA, Gilchrist J, Ballesteros MF. Bunk bed-related injuries sustained by young children treated in emergency departments in the United States, 2001-2004, National Electronic Injury Surveillance System - All Injury Program. Inj Prev 2007; 13:137-40. [PMID: 17446257 PMCID: PMC2610585 DOI: 10.1136/ip.2006.013193] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To characterize children's bunk bed-related injuries. METHODS Data are from the 2001-2004 National Electronic Injury Surveillance System - All Injury Program. Cases were defined as children aged 0-9 years treated for a non-fatal, unintentional injury related to a bunk bed. RESULTS An estimated 23 000 children aged 0-9 years were treated annually in emergency departments for bunk bed fall-related injuries, including 14 600 children aged <6 years. Overall, 3.2% were hospitalized. The injuries sustained were largely fractures, lacerations, contusions and abrasions, and internal injuries, with 25.2% injured in a fall from the top bunk. The most commonly injured body region was the head and neck. CONCLUSIONS Strategies are needed to reduce the most serious injuries. Bunk beds should meet CPSC standards, and the youngest children should not sleep or play in the upper bunk or on ladders. Making care givers aware of the risks, and modifying the living environment are essential.
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Affiliation(s)
- Karin A Mack
- National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, GA 30341, USA.
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Abstract
Despite improved education and prevention initiatives, trauma remains the leading cause of death in children. A variety of preventative measures have been developed to decrease the morbidity and mortality, and the financial burden on the health care system. This article discusses injury prevention strategies, issues in prehospital care, and key points of initial resuscitation. In addition, the major injury patterns are described with attention paid to the diagnosis and management of patients with multiple traumatic injuries.
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Affiliation(s)
- Kim G Mendelson
- Division of Pediatric Surgery, Department of Surgery, University of Louisville, 233 East Gray Street, Suite 708, Louisville, KY 40202, USA
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Barnes PD, Krasnokutsky M. Imaging of the central nervous system in suspected or alleged nonaccidental injury, including the mimics. Top Magn Reson Imaging 2007; 18:53-74. [PMID: 17607143 DOI: 10.1097/rmr.0b013e3180d0a455] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
Because of the widely acknowledged controversy in nonaccidental injury, the radiologist involved in such cases must be thoroughly familiar with the imaging, clinical, surgical, pathological, biomechanical, and forensic literature from all perspectives and with the principles of evidence-based medicine. Children with suspected nonaccidental injury versus accidental injury must not only receive protective evaluation but also require a timely and complete clinical and imaging workup to evaluate pattern of injury and timing issues and to consider the mimics of abuse. All imaging findings must be correlated with clinical findings (including current and past medical record) and with laboratory and pathological findings (eg, surgical, autopsy). The medical and imaging evidence, particularly when there is only central nervous system injury, cannot reliably diagnose intentional injury. Only the child protection investigation may provide the basis for inflicted injury in the context of supportive medical, imaging, biomechanical, or pathological findings.
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