Necessity of hospital admission for pediatric minor head injury

A Child Presenting with a Glasgow Coma Scale Score of 13: Mild or Moderate Traumatic Brain Injury? A Narrative Review

OBJECTIVE

The objective of this article was to compare children with traumatic brain injury (TBI) and Glasgow Coma Scale score (GCS) 13 with children presenting with GCS 14 and 15 and GCS 9 to 12.

DATA SOURCE

We searched PubMed for clinical studies of children of 0 to 18 years of age with mild TBI (mTBI) and moderate TBI, published in English language in the period of 2000 to 2020.

STUDY SELECTION

We selected studies sub-classifying children with GCS 13 in comparison with GCS 14 and 15 and 9 to 12. We excluded reviews, meta-analyses, non-U.S./European population studies, studies of abusive head trauma, and severe TBI.

DATA SYNTHESIS

Most children (>85%) with an mTBI present at the emergency department with an initial GCS 15. A minority of only 5% present with GCS 13, 40% of which sustain a high-energy trauma. Compared with GCS 15, they present with a longer duration of unconsciousness and of post-traumatic amnesia. More often head computerized tomography scans show abnormalities (in 9-16%), leading to neurosurgical intervention in 3 to 8%. Also, higher rates of severe extracranial injury are reported. Admission is indicated in more than 90%, with a median length of hospitalization of more than 4 days and 28% requiring intensive care unit level care. These data are more consistent with children with GCS 9 to 12. In children with GCS 15, all these numbers are much lower.

CONCLUSION

We advocate classifying children with GCS 13 as moderate TBI and treat them accordingly.

Investigating the Variability in Mild Traumatic Brain Injury Definitions: A Prospective Cohort Study

OBJECTIVE

To prospectively compare the proportion of traumatic brain injuries (TBIs) that would be classified as mild by applying different published definitions of mild TBI to a large prospectively collected dataset, and to examine the variability in the proportions included by various definitions.

DESIGN

Prospective observational study.

SETTING

Hospital emergency departments.

PARTICIPANTS

Children (N=11,907) aged 3 to 16 years (mean age, 8.2±3.9y). Of the participants, 3868 (32.5%) were girls, and 7374 (61.9%) of the TBIs were the result of a fall. Median Glasgow Coma Scale score was 15.

MAIN OUTCOME MEASURES

We applied 17 different definitions of mild TBI, identified through a published systematic review, to children aged 3 to 16 years. Adjustments and clarifications were made to some definitions. The number and percentage identified for each definition is presented.

RESULTS

Adjustments had to be made to the 17 definitions to apply to the dataset: none in 7, minor to substantial in 10. The percentage classified as mild TBI across definitions varied from 7.1% (n=841) to 98.7% (n=11,756) and varied by age group.

CONCLUSIONS

When applying the 17 definitions of mild TBI to a large prospective multicenter dataset of TBI, there was wide variability in the number of cases classified. Clinicians and researchers need to be aware of this variability when examining literature concerning children with mild TBI.

The Relationship between Risk Factors of Head Trauma with CT Scan Findings in Children with Minor Head Trauma Admitted to Hospital

BACKGROUND:

In emergency medicine for determining the intracranial injury (ICI) in children with head trauma, usually brain CT scan is performed. Since brain CT scan, especially in children, has some disadvantages, it is better to find a procedure which could help to choose only the children with real head trauma injury for brain CT scan.

AIMS:

The aim of this study is to find such procedure. This study was descriptive, analytic and non-interventional.

METHODS:

We reviewed the archived files of children with head trauma injuries referred to the emergency department of Imam Hossein Hospital within two years. Patient’s CT scan findings and head trauma risk factors were evaluated in this study.

RESULTS:

Out of 368 patients, 326 patients had normal brain CT scan. 28 of them showed symptoms of ICI consisting intraventricular haemorrhage (IVH), contusion, subarachnoid haemorrhage (SAH), subdural haemorrhage (SDH), epidural hematoma (EDH), and pneumocephalus. Twenty-seven patients showed skull FX, which 14 of them had an Isolated fracture, and 13 of them also showed symptoms of ICI. Since patients with isolated FX usually discharge quickly from Emergency Department; their data did not include in results of the study. The patients have been divided into two groups: 1- ICI, 2- without ICI. RR (relative risk), CI (Confidence interval) and sensitivity, positive predictive value (PPV), negative predictive value (NPV) and association of these risk factors with ICI were assessed with the Chi-2 test. In the end to determine the indications of CT scan, the presence of one of these five risk factors is important including abnormal mental status, clinical symptoms of skull FX, history of vomiting, craniofacial soft tissue injury (including subgaleal hematomas or laceration) and headache.

CONCLUSIONS:

For all other patients without these risk factors, observation and Follow Up can be used which has more advantages and less cost.

Management of skull fractures in children less than 1 year of age

BACKGROUND

Management of skull fracture (SF) in pediatric patients varies from observation in the emergency department (ED) to floor admission. Since 2010, a protocol for admitting children with SF specifically to the trauma service was implemented at our institution. The purpose of our study was to review the management of children with SF younger than 1 year of age.

METHODS

Retrospective chart review of all patients between 0 and 1year of age seen in our ED for a SF was done from 2010 to 2013.

RESULTS

A total of 180 patients with a mean age of 4.5months (1day-12months) were identified. Of these, 131 patients (73%) were admitted. Mean length of stay was 1.6days. Admitted patients had more depressed (21 vs. 8%) and diastatic (43 vs. 14%) fractures. Fifty-seven children had intracranial hemorrhages (32%) but only 8 patients required non-emergent surgery for depressed fractures. Admission to the trauma service increased from none to 76% with phone follow-ups increasing from 12% to 91%.

CONCLUSIONS

Instituting a protocol allowed a safer management of patients with SF. Moreover, we argue that asymptomatic infants with isolated SF can be safely discharged home after brief observation in the ED.

Observation for isolated traumatic skull fractures in the pediatric population: unnecessary and costly

BACKGROUND

Blunt head trauma accounts for a majority of pediatric trauma admissions. There is a growing subset of these patients with isolated skull fractures, but little evidence guiding their management. We hypothesized that inpatient neurological observation for pediatric patients with isolated skull fractures and normal neurological examinations is unnecessary and costly.

METHODS

We performed a single center 10year retrospective review of all head traumas with isolated traumatic skull fractures and normal neurological examination. Exclusion criteria included: penetrating head trauma, depressed fractures, intracranial hemorrhage, skull base fracture, pneumocephalus, and poly-trauma. In each patient, we analyzed: age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention.

RESULTS

Seventy-one patients presented to our ED with acute isolated skull fractures, 56% were male and 44% were female. Their ages ranged from 1week to 12.4years old. The minority (22.5%) of patients were discharged from the ED following evaluation, whereas 77.5% were admitted for neurological observation. None of the patients required neurosurgical intervention. Age was not associated with repeat imaging or inpatient observation (p=0.7474, p=0.9670). No patients underwent repeat head imaging during their index admission. Repeat imaging was obtained in three previously admitted patients who returned to the ED. Cost analysis revealed a significant difference in total hospital costs between the groups, with an average increase in charges of $4,291.50 for admitted patients (p<0.0001).

CONCLUSION

Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Further studies are necessary to change clinical practice, but our research indicates that these patients can be discharged safely from the ED without inpatient observation. This change in practice, additionally, would allow for huge health care dollar savings.

Scandinavian guidelines for initial management of minor and moderate head trauma in children

BACKGROUND

The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim.

METHODS

General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders.

RESULTS

The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children.

CONCLUSIONS

We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma.

Acute evaluation of pediatric patients with minor traumatic brain injury

PURPOSE OF REVIEW

This review focuses on minor traumatic brain injury (TBI), evaluates the most recent literature regarding clinical prediction rules for the use of cranial computed tomography (CT) in children presenting with minor TBI, reviews the evidence on the need for hospitalization in children with minor TBI, and evaluates the role of S100B testing.

RECENT FINDINGS

The majority of children presenting to an emergency department (ED) after TBI have a Glasgow Coma Scale (GCS) of 14-15, and the rate of clinically significant intracranial injury is exceedingly rare. Nevertheless, the number of cranial CTs performed in the US has increased dramatically over the past two decades. Several clinical prediction rules have been developed to aid the clinician in identifying children with low-risk TBI, but only the Pediatric Emergency Care Applied Research Network (PECARN) rules have been sufficiently validated to warrant clinical application. Two recent studies provide evidence that children with low-risk TBI can be safely discharged from the ED and do not require prolonged hospitalization for neurologic observation. Lastly, studies evaluating the diagnostic utility of S100B in patients with TBI have shown that it may be a useful adjunct to the clinical evaluation and aid in minimizing neuroimaging.

SUMMARY

Clinical prediction rules, most notably the PECARN rules, can be applied to determine children with low-risk TBI and help decrease unnecessary CT use and hospitalizations. S100B testing requires further investigation, but may serve as an adjunct in determining children with low-risk TBI.

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.

Pediatric minor closed head injury

Many studies have found conflicting evidence over the use of clinical indicators to predict intracranial injury in pediatric mild head injury. Although altered mental status, loss of consciousness, and abnormal neurologic examination have all been found to be more prevalent among head-injured children, studies have observed inconsistent results over their specificity and predictive value. Children older than 2 years have been evaluated, managed, and studied differently than those less than 2 years old. Evidence strongly supports a lower threshold to perform a CT scan in younger children because they have a higher risk of significant brain injury after blunt head trauma.

Analysis of Head Injury Admission Trends in an Urban American Pediatric Trauma Center

BACKGROUND

Head injury is the leading cause of death in children. Child safety legislation and risk-specific intervention programs have flourished to mitigate the incidence of injury to children. This analysis documents the trend in head injury to children in a specific institution.

METHODS

Analysis of 5,003 head injury admissions to a pediatric trauma center over thirteen years was performed. Admission rates were calculated using the appropriate population denominator from census data. Poisson regression analysis was applied to estimate the relative risk of head injury admission by year in different age, sex, mechanism of injury and severity group.

RESULTS

There has been a 70% decline in the head injury admission rate since 1989, consistent with regional and national data. The decline was present in all mechanisms of injury and age groups except for less than 1 year of age. The decline in total trauma admissions over the same time period was 50% and the decline in total hospital admission was 10%.

CONCLUSION

Pediatric head injury has significantly declined in the last 13 years at a Level I pediatric trauma center.