Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children

Appraisal of Australian and New Zealand paediatric sepsis guidelines

OBJECTIVE

Clinical practice guidelines (CPGs) are an important tool for the management of children with sepsis. The quality, consistency and concordance of Australian and New Zealand (ANZ) childhood sepsis CPGs with the Australian Commission on Safety and Quality in Healthcare (ACSQHC) sepsis clinical care standards and international sepsis guidelines is unclear.

METHODS

We accessed childhood sepsis CPGs for all ANZ states and territories through Paediatric Research in Emergency Departments International Collaborative members. The guidelines were assessed for quality using the AGREE-II instrument. Consistency between CPG treatment recommendations was assessed, as was concordance with the ACSQHC sepsis clinical care standards and international sepsis guidelines.

RESULTS

Overall, eight CPGs were identified and assessed. CPGs used a narrative and pathway format, with those using both having the highest quality overall. CPG quality was highest for description of scope and clarity of presentation, and lowest for editorial independence. Consistency between guidelines for initial treatment recommendations was poor, with substantial variation in the choice and urgency of empiric antimicrobial administration; the choice, volume and urgency of fluid resuscitation; and the choice of first-line vasoactive agent. Most CPGs were concordant with time-critical components of the ACSQHC sepsis clinical care standard, although few addressed post-acute care. Concordance with international sepsis guidelines was poor.

CONCLUSION

Childhood sepsis CPGs in current use in ANZ are of variable quality and lack consistency with key treatment recommendations. CPGs are concordant with the ACSQHC care standard, but not with international sepsis guidelines. A bi-national sepsis CPG may reduce unnecessary variation in care.

Validation of the Scandinavian guidelines for minor and moderate head trauma in children: protocol for a pragmatic, prospective, observational, multicentre cohort study

INTRODUCTION

Mild traumatic brain injury is common in children and it can be challenging to accurately identify those in need of urgent medical intervention. The Scandinavian guidelines for management of minor and moderate head trauma in children, the Scandinavian Neurotrauma Committee guideline 2016 (SNC16), were developed to aid in risk stratification and decision-making in Scandinavian emergency departments (EDs). This guideline has been validated externally with encouraging results, but internal validation in the intended healthcare system is warranted prior to broad clinical implementation.

OBJECTIVE

We aim to validate the diagnostic accuracy of the SNC16 to predict clinically important intracranial injuries (CIII) in paediatric patients suffering from blunt head trauma, assessed in EDs in Sweden and Norway.

METHODS AND ANALYSIS

This is a prospective, pragmatic, observational cohort study. Children (aged 0-17 years) with blunt head trauma, presenting with a Glasgow Coma Scale of 9-15 within 24 hours postinjury at an ED in 1 of the 16 participating hospitals, are eligible for inclusion. Included patients are assessed and managed according to the clinical management routines of each hospital. Data elements for risk stratification are collected in an electronic case report form by the examining doctor. The primary outcome is defined as CIII within 1 week of injury. Secondary outcomes of importance include traumatic CT findings, neurosurgery and 3-month outcome. Diagnostic accuracy of the SNC16 to predict endpoints will be assessed by point estimate and 95% CIs for sensitivity, specificity, likelihood ratio, negative predictive value and positive predictive value.

ETHICS AND DISSEMINATION

The study is approved by the ethical board in both Sweden and Norway. Results from this validation will be published in scientific journals, and a tailored development and implementation process will follow if the SNC16 is found safe and effective.

TRIAL REGISTRATION NUMBER

NCT05964764.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review

STUDY OBJECTIVE

Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations.

METHODS

We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework.

RESULTS

We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses.

CONCLUSIONS

We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

A retrospective analysis of concussion and post-concussional syndrome diagnoses in Western Australian emergency departments

OBJECTIVE(S)

To determine the rate of concussion diagnoses per capita recorded in hospital emergency departments in Western Australia (WA) from 2002-2018 for ICD-10-AM concussion diagnoses S06.00-S06.05, and post-concussional syndrome (PCS) (F07.2).

DESIGN, SETTING AND ANALYSIS

Retrospective analysis of hospital Emergency Department (ED) presentations and hospital admissions from all WA hospitals for all patients with an ICD-10-AM diagnosis code for concussion and post-concussional syndrome (PCS) over the period 2002-2018. Data pertaining to concussion and PCS presentations were extracted from the WA Department of Health Emergency Department Data Collection (EDDC). Total case numbers were aggregated by year (2002-2018) and regions of WA.

MAIN OUTCOME MEASURES

The rates of diagnoses were calculated based on the population in the specific region and expressed as incidence rate per 100,000 person-years. The overall trends of diagnoses across the regions were analysed using negative binomial regression models and expressed as incidence rate ratio (IRR) with the corresponding 95 % CI, whilst adjusting for region. Tests for linearity were also performed.

RESULTS

The rate of concussion diagnosis had significantly increased linearly over the years (p for trend: p < 0.001) whilst the rate of PCS diagnosis had significantly declined linearly over the same period (p for trend: p < 0.001).

CONCLUSION

There was significant increase in all-cause ICD-10-AM concussion diagnoses in WA emergency departments. To further clarify the incidence and prevalence of all-cause concussion in Australia, investigation must focus on truly reflective S06.0 codes and include data linkage to primary care data. Conversely PCS ED presentations reduced; whether this relates to a change in where presentations occur for management of such a diagnosis, improved early intervention or an alternative explanation warrants further investigation.

Pediatric Sport-Related Concussion: Recommendations From the Amsterdam Consensus Statement 2023

The 6th International Consensus Conference on Concussion in Sport, Amsterdam 2022, addressed sport-related concussion (SRC) in adults, adolescents, and children. We highlight the updated evidence-base and recommendations regarding SRC in children (5-12 years) and adolescents (13-18 years). Prevention strategies demonstrate lower SRC rates with mouthguard use, policy disallowing bodychecking in ice hockey, and neuromuscular training in adolescent rugby. The Sport Concussion Assessment Tools (SCAT) demonstrate robustness with the parent and child symptom scales, with the best diagnostic discrimination within the first 72 hours postinjury. Subacute evaluation (>72 hours) requires a multimodal tool incorporating symptom scales, balance measures, cognitive, oculomotor and vestibular, mental health, and sleep assessment, to which end the Sport Concussion Office Assessment Tools (SCOAT6 [13+] and Child SCOAT6 [8-12]) were developed. Rather than strict rest, early return to light physical activity and reduced screen time facilitate recovery. Cervicovestibular rehabilitation is recommended for adolescents with dizziness, neck pain, and/or headaches for greater than 10 days. Active rehabilitation and collaborative care for adolescents with persisting symptoms for more than 30 days may decrease symptoms. No tests and measures other than standardized and validated symptom rating scales are valid for diagnosing persisting symptoms after concussion. Fluid and imaging biomarkers currently have limited clinical utility in diagnosing or assessing recovery from SRC. Improved paradigms for return to school were developed. The variable nature of disability and differences in evaluating para athletes and those of diverse ethnicity, sex, and gender are discussed, as are ethical considerations and future directions in pediatric SRC research.

Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline Recommendations

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.

Fluid biomarkers and neuroimaging in mild traumatic brain injury: current uses and potential future directions for clinical use in emergency medicine

Mild traumatic brain injury is a common presentation to the emergency department, with current management often focusing on determining whether a patient requires a CT head scan and/or neurosurgical intervention. There is a growing appreciation that approximately 20%-40% of patients, including those with a negative (normal) CT, will develop ongoing symptoms for months to years, often termed post-concussion syndrome. Owing to the requirement for improved diagnostic and prognostic mechanisms, there has been increasing evidence concerning the utility of both imaging and blood biomarkers.Blood biomarkers offer the potential to better risk stratify patients for requirement of neuroimaging than current clinical decisions rules. However, improved assessment of the clinical utility is required prior to wide adoption. MRI, using clinical sequences and advanced quantitative methods, can detect lesions not visible on CT in up to 30% of patients that may explain, at least in part, some of the ongoing problems. The ability of an acute biomarker (be it imaging, blood or other) to highlight those patients at greater risk of ongoing deficits would allow for greater personalisation of follow-up care and resource allocation.We discuss here both the current evidence and the future potential clinical usage of blood biomarkers and advanced MRI to improve diagnostic pathways and outcome prediction following mild traumatic brain injury.

2022 Systematic Review of Evidence-Based Guidelines for Prehospital Care

INTRODUCTION

Multiple national organizations and federal agencies have promoted the development, implementation, and evaluation of evidence-based guidelines (EBGs) for prehospital care. Previous efforts have identified opportunities to improve the quality of prehospital guidelines and highlighted the value of high-quality EBGs to inform initial certification and continued competency activities for EMS personnel.

OBJECTIVES

We aimed to perform a systematic review of prehospital guidelines published from January 2018 to April 2021, evaluate guideline quality, and identify top-scoring guidelines to facilitate dissemination and educational activities for EMS personnel.

METHODS

We searched the literature in Ovid Medline and EMBASE from January 2018 to April 2021, excluding guidelines identified in a prior systematic review. Publications were retained if they were relevant to prehospital care, based on organized reviews of the literature, and focused on providing recommendations for clinical care or operations. Included guidelines were appraised to identify if they met the National Academy of Medicine (NAM) criteria for high-quality guidelines and scored across the six domains of the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool.

RESULTS

We identified 75 guidelines addressing a variety of clinical and operational aspects of EMS medicine. About half (n = 39, 52%) addressed time/life-critical conditions and 33 (44%) contained recommendations relevant to non-clinical/operational topics. Fewer than half (n = 35, 47%) were based on systematic reviews of the literature. Nearly one-third (n = 24, 32%) met all NAM criteria for clinical practice guidelines. Only 27 (38%) guidelines scored an average of >75% across AGREE II domains, with content relevant to guideline implementation most commonly missing.

CONCLUSIONS

This interval systematic review of prehospital EBGs identified many new guidelines relevant to prehospital care; more than all guidelines reported in a prior systematic review. Our review reveals important gaps in the quality of guideline development and the content in their publications, evidenced by the low proportion of guidelines meeting NAM criteria and the scores across AGREE II domains. Efforts to increase guideline dissemination, implementation, and related education may be best focused around the highest quality guidelines identified in this review.

Research and Implementation of Distributed Computing Management System for College Students' Sports Health Based on Integrated Regional Collaborative Medical Care

This paper constructs and applies a university student sports health management system through the theory of integrated regional collaborative medical care and distributed computing technology. Firstly, it analyzes the current situation and problems of cross-regional medical care, the root causes, and the corresponding business scenarios, reflecting the development trend of cross-regional medical care, in the light of the current practical needs of cross-regional medical care. In response to the strong demand for cross-regional medical care, this paper gives the overall design of the distributed computing system, for the deployment and architecture of the cross-regional platform; the registration of cross-regional patients, regional platforms, and health events and documents; and data exchange, service integration, and process integration, etc. The corresponding design is given. The research was conducted on several medical institutions to refine the functional requirements for the construction of the regional collaborative medical platform, and the requirements were analyzed to present the research results of the collaborative medical project. Based on this, requirements were made for the preparation of the project construction data center and medical institutions, and the remote consultation and two-way referral modules of the distributed collaborative medical platform were designed, which are processed and analyzed through a system composed of multiple servers. The results are returned to the user, and the design results were tested for functionality, compatibility, security, and other usability tests. The necessity and feasibility of the college physical health test data platform were analyzed. Students have various needs for physical test data management, the necessity of designing the college physical health test data platform, and the feasibility of the college physical health test data platform in terms of technical means, theoretical basis, and social environment.

Non-ionizing Imaging for the Emergency Department Assessment of Pediatric Minor Head Trauma

Minor blunt head trauma (MHT) represents a common reason for presentation to the pediatric emergency department (ED). Despite the low incidence of clinically important traumatic brain injuries (ciTBIs) following MHT, many children undergo computed tomography (CT), exposing them to the risk associated with ionizing radiation. The clinical predictions rules developed by the Pediatric Emergency Care Applied Research Network (PECARN) for MHT are validated accurate tools to support decision-making about neuroimaging for these children to safely reduce CT scans. However, a few non-ionizing imaging modalities have the potential to contribute to further decrease CT use. This narrative review provides an overview of the evidence on the available non-ionizing imaging modalities that could be used in the management of children with MHT, including point of care ultrasound (POCUS) of the skull, near-infrared spectroscopy (NIRS) technology and rapid magnetic resonance imaging (MRI). Skull ultrasound has proven an accurate bedside tool to identify the presence and characteristics of skull fractures. Portable handheld NIRS devices seem to be accurate screening tools to identify intracranial hematomas also in pediatric MHT, in selected scenarios. Both imaging modalities may have a role as adjuncts to the PECARN rule to help refine clinicians' decision making for children at high or intermediate PECARN risk of ciTBI. Lastly, rapid MRI is emerging as a feasible and accurate alternative to CT scan both in the ED setting and when repeat imaging is needed. Advantages and downsides of each modality are discussed in detail in the review.

Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review

INTRODUCTION

Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality.

METHODS AND ANALYSIS

We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix.

ETHICS AND DISSEMINATION

Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers.

PROSPERO REGISTRATION NUMBER

International Prospective Register of Systematic Reviews (CRD42021226934).

Paediatric trauma imaging in a regional Queensland hospital: Do we need clearer guidance?

OBJECTIVE

Paediatric trauma is a major cause of morbidity and mortality in those aged 0-14. Anatomical and physiological differences require a specialised approach to paediatric trauma care. Medical imaging, particularly computed tomography (CT) scans, requires specific consideration because of the consequences of radiation exposure in the paediatric population. The present study compares current practice of CT scan ordering in paediatric trauma patients at a regional Australian hospital against consensus guidelines published in the UK.

METHODS

A retrospective audit of paediatric trauma CT scans referred from the ED from May 2017 to May 2018 was completed. Details relating to CT scan ordering were reviewed and compliance with the Royal College of Radiologists Paediatric trauma protocols, was determined. Descriptive statistics and χ² tests comparing those that met and did not meet guidelines were performed.

RESULTS

A total of 71 CT scans were included with an overall compliance rate of 56.3%. Specific regional compliance was lowest with CT neck at 14%. Patients where a trauma call was initiated were more likely to receive a full body (pan) scan rather than region specific imaging. Compliance improved when paediatric team involvement was documented.

CONCLUSIONS

Evidence-based guidelines for CT imaging in paediatric trauma are essential to reduce unnecessary radiation exposure for children. The present study has demonstrated that current practice has the potential to be improved and that decisions should involve a multidisciplinary team.

An audit of computed tomography request practices for suspected cervical spine injury post‐guideline change in a tertiary referral paediatric hospital

BACKGROUND

Paediatric neck injuries are a common presenting complaint to emergency departments (EDs). Medical imaging can assist diagnosis, however previous research suggests computed tomography (CT) scan results do not alter management in this patient group and therefore expose children to unnecessary radiation. Following an audit by the hospital Trauma Service that identified unnecessary cervical spine CTs in patients at Women's and Children's Hospital (WCH), Adelaide, the Clinical Procedure for imaging and clearance of the cervical spine in conscious patients was modified to include CT scan only at the request of the orthopaedic service. The aim of this study was to evaluate whether a change in hospital guideline resulted in a change in practice and radiation exposure.

METHODS

A retrospective review was performed for patients that presented to the WCH ED with a suspected cervical spine injury during two defined time periods pre- and post-guideline change. Mechanism of injury, imaging requested, radiation exposure and final diagnosis were compared.

RESULTS

Three hundred seventy-nine patients were included, with 164 (43.3%) post-guideline changes. Radiograph use was similar between groups, 132/215 (61.4%) versus 101/164 (61.6%) (p = 0.97). CT scan use was lower post-guideline modification 19/215 (8.8%) versus 12/164 (7.3%), however was not statistically significant (p = 0.59), with an absolute reduction of 17%.

CONCLUSION

Guideline modification at our hospital did not significantly reduce CT scan use or eliminate unnecessary CTs. Unnecessary CT scans followed lack of knowledge of and therefore compliance with guidelines. Individual hospitals should consider strategies to reduce unnecessary CTs, given the association with cancer risk in children.

Review article: Developing the Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children: An adoption/adaption approach

The Paediatric Research in Emergency Departments International Collaborative (PREDICT) released the Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children in 2021. We describe innovative and practical methods used to develop this guideline. Informed by GRADE-ADOLOPMENT and ADAPTE frameworks, we adopted or adapted recommendations from multiple high-quality guidelines or developed de novo recommendations. A Guideline Steering Committee and a multidisciplinary Guideline Working Group of 25 key stakeholder representatives formulated the guideline scope and developed 33 clinical questions. We identified four relevant high-quality source guidelines; their recommendations were mapped to clinical questions. The choice of guideline recommendation, if more than one guideline addressed a question, was based on its appropriateness, currency of the literature, access to evidence, and relevance. Updated literature searches identified 440 new studies and key new evidence identified. The decision to develop adopted, adapted or de novo recommendations was based on the supporting evidence-base and its transferability to the local setting. The guideline underwent a 12-week consultation period. The final guideline consisted of 35 evidence-informed and 17 consensus-based recommendations and 19 practice points. An algorithm to inform imaging and observation decision-making was also developed. The resulting process was an efficient and rigorous way to develop a guideline based on existing high-quality guidelines from different settings.