Technical report: minor head injury in children

Serum S100B Level in the Management of Pediatric Minor Head Trauma: A Randomized Clinical Trial

Importance

Minor head trauma (HT) is one of the most common causes of hospitalization in children. A diagnostic test could prevent unnecessary hospitalizations and cranial computed tomographic (CCT) scans.

Objective

To evaluate the effectiveness of serum S100B values in reducing exposure to CCT scans and in-hospital observation in children with minor HT.

Design, Setting, and Participants

This multicenter, unblinded, prospective, interventional randomized clinical trial used a stepped-wedge cluster design to compare S100B biomonitoring and control groups at 11 centers in France. Participants included children and adolescents 16 years or younger (hereinafter referred to as children) admitted to the emergency department with minor HT. The enrollment period was November 1, 2016, to October 31, 2021, with a follow-up period of 1 month for each patient. Data were analyzed from March 7 to May 29, 2023, based on the modified intention-to-treat and per protocol populations.

Interventions

Children in the control group had CCT scans or were hospitalized according to current recommendations. In the S100B biomonitoring group, blood sampling took place within 3 hours after minor HT, and management depended on serum S100B protein levels. If the S100B level was within the reference range according to age, the children were discharged from the emergency department. Otherwise, children were treated as in the control group.

Main Outcomes and Measures

Proportion of CCT scans performed (absence or presence of CCT scan for each patient) in the 48 hours following minor HT.

Results

A total of 2078 children were included: 926 in the control group and 1152 in the S100B biomonitoring group (1235 [59.4%] boys; median age, 3.2 [IQR, 1.0-8.5] years). Cranial CT scans were performed in 299 children (32.3%) in the control group and 112 (9.7%) in the S100B biomonitoring group. This difference of 23% (95% CI, 19%-26%) was not statistically significant (P = .44) due to an intraclass correlation coefficient of 0.32. A statistically significant 50% reduction in hospitalizations (95% CI, 47%-53%) was observed in the S100B biomonitoring group (479 [41.6%] vs 849 [91.7%]; P < .001).

Conclusions and Relevance

In this randomized clinical trial of effectiveness of the serum S100B level in the management of pediatric minor HT, S100B biomonitoring yielded a reduction in the number of CCT scans and in-hospital observation when measured in accordance with the conditions defined by a clinical decision algorithm.

Trial Registration

ClinicalTrials.gov Identifier: NCT02819778.

Identification of practically important traumatic brain injury using Pediatric Emergency Care Applied Research Network rule in children younger than 2 years with minor head trauma

Background:

Minor head trauma is frequently presented to the pediatric emergency department. Despite the burden this injury poses on public health, evidence-based clinical guidelines on the assessment and management of pediatric minor head trauma remain unestablished, particularly in children below 2 years. We aimed to assess the diagnostic accuracy of a clinical decision rule (Pediatric Emergency Care Applied Research Network rule) and physician discretion in the recognition of practically important traumatic brain injury in children below 2 years of age presenting with minor head trauma to the emergency department.

Methods:

The medical records of children younger than 2 years presenting with head trauma to the emergency department were reviewed with Glasgow Coma Scale scores of 14–15. Practically important traumatic brain injury is a clinically essential traumatic brain injury including all cranial abnormalities (e.g. skull fracture) detected by computed tomography. All predictor variables of the Pediatric Emergency Care Applied Research Network rule and practically important traumatic brain injury outcomes were validated.

Results:

We enrolled and analyzed 433 children below 2 years. The most frequently observed mechanisms of injury in decreasing order were as follows: falls > 90 cm, head struck by high-impact objects, slip down, and automobile traffic accident. Of 224 children, positive findings were observed in 35 and 144 had one or more predictors of Pediatric Emergency Care Applied Research Network rule. The sensitivity, specificity, and negative likelihood ratio of the Pediatric Emergency Care Applied Research Network rule for practically important traumatic brain injury were 94.3%, 41.3%, and 0.14, respectively.

Conclusion:

The Pediatric Emergency Care Applied Research Network rule would assist in clinical decision-making to appropriately detect potential head injuries in children below 2 years, thereby reducing unnecessary performance of computed tomography scan.

Trauma center variation of head computed tomography utilization in children presenting with mild traumatic brain injury

BACKGROUND

Although published clinical decision rules have identified indications for the use of head CT in children with mild traumatic brain injury, practices vary.

OBJECTIVE

This study seeks to evaluate whether the utilization of head CT in pediatric trauma patients presenting with mTBI varies between American College of Surgeons verified pediatric trauma centers (ACS-PTC) and adult-only trauma centers (ACS-AOTC).

MATERIAL AND METHODS

A retrospective cohort study of 24,104 trauma patients, ≤17, who presented to the emergency department at 337 ACS verified level I/II trauma centers with isolated mTBI was conducted using National Trauma Data Bank records (2011-2015). Multivariable logistic regression was used to compare the odds of a patient receiving a head CT when treated at an ACS-PTC vs. an ACS-AOTC, controlling for demographic, injury, and hospital-level confounders. Effect modification by loss of consciousness was assessed and adjusted head CT odds were recalculated in patients stratified by LOC status.

RESULTS

There was no significant difference in the adjusted odds of receiving a head CT at an ACS-PTC vs. an ACS-AOTC (odds ratio: 0.98, 95% confidence interval: 0.92-1.04). However, in patients who had a LOC, the adjusted OR of receiving a head CT at an ACS-PTC vs ACS-AOTC was 0.71 (95% confidence interval: 0.65-0.78).

CONCLUSION

Children presenting to the emergency department of an ACS-verified level I or II trauma center with mTBI who had a loss of consciousness are less likely to receive a head CT at an ACS verified pediatric trauma center than at an ACS verified adult-only trauma center.

Statistical and machine learning approaches to predict the necessity for computed tomography in children with mild traumatic brain injury

BACKGROUND

Minor head trauma in children is a common reason for emergency department visits, but the risk of traumatic brain injury (TBI) in those children is very low. Therefore, physicians should consider the indication for computed tomography (CT) to avoid unnecessary radiation exposure to children. The purpose of this study was to statistically assess the differences between control and mild TBI (mTBI). In addition, we also investigate the feasibility of machine learning (ML) to predict the necessity of CT scans in children with mTBI.

METHODS AND FINDINGS

The study enrolled 1100 children under the age of 2 years to assess pre-verbal children. Other inclusion and exclusion criteria were per the PECARN study. Data such as demographics, injury details, medical history, and neurological assessment were used for statistical evaluation and creation of the ML algorithm. The number of children with clinically important TBI (ciTBI), mTBI on CT, and controls was 28, 30, and 1042, respectively. Statistical significance between the control group and clinically significant TBI requiring hospitalization (csTBI: ciTBI+mTBI on CT) was demonstrated for all nonparametric predictors except severity of the injury mechanism. The comparison between the three groups also showed significance for all predictors (p<0.05). This study showed that supervised ML for predicting the need for CT scan can be generated with 95% accuracy. It also revealed the significance of each predictor in the decision tree, especially the "days of life."

CONCLUSIONS

These results confirm the role and importance of each of the predictors mentioned in the PECARN study and show that ML could discriminate between children with csTBI and the control group.

Physicians' Risk Tolerance and Head Computed Tomography Use for Pediatric Patients With Minor Head Injury

OBJECTIVES

Traumatic brain injury is the leading cause of death and disability in children worldwide. The objective of this study was to determine the association between physician risk tolerance and head computed tomography (CT) use in patients with minor head injury (MHI) in the emergency department (ED).

METHODS

We retrospectively analyzed pediatric patients (<17 years old) with MHI in the ED and then administered 2 questionnaires (a risk-taking subscale [RTS] of the Jackson Personality Inventory and a malpractice fear scale [MFS]) to attending physicians who had evaluated these patients and made decisions regarding head CT use. The primary outcome was head CT use during ED evaluation; the secondary outcome was ED length of stay and final diagnosis of intracranial injury (ICI).

RESULTS

Of 523 patients with MHI, 233 (44.6%) underwent brain CT, and 16 (3.1%) received a final diagnosis of ICI. Among the 16 emergency physicians (EPs), the median scores of the MFS and RTS were 22 (interquartile range, 17-26) and 23 (interquartile range, 19-25), respectively. Emergency physicians who were most risk averse tended to order more head CT scans compared with the more risk-tolerant EPs (56.96% vs 37.37%; odds ratio, 8.463; confidence interval, 2.783-25.736). The ED length of stay (P = 0.442 and P = 0.889) and final diagnosis (P = 0.155 and P = 0.835) of ICI were not significantly associated with the RTS and MFS scores.

CONCLUSIONS

Individual EP risk tolerance, as measured by RTS, was predictive of CT use in pediatric patients with MHI.

Injuries from alleged accidental minor head trauma in a prospective cohort of children aged 0-3 years in an emergency department

INTRODUCTION

Minor head trauma in the child, whether accidental or inflicted, is a frequent reason for seeking medical attention. Our aim is to describe the characteristics of minor head trauma in children aged 0-3 years and the resulting injuries. This in order to help the clinician to suspect and thelegal expert to confirm intentional abuse.

STUDY DESIGN

Children aged from 0 to 3 years with minor head trauma and attending the pediatric emergency department were included in the study between January 2013 and June 2014. The correlation between the characteristics of trauma and the resulting injuries was analyzed using a prospective data collection questionnaire completed by the physicians who cared for the child.

RESULTS

A total of 709 children with minor head trauma were included in the study. In nearly 90% of cases, fall height was less than 1 m. Only one-third of children aged less than 6 months had external head injury. Low-intensity trauma, such as a low-velocity fall from a height of less than 1.5 m does not cause intracranial injury. External injuries were more frequent in children who had a fall with an anterior impact, while internal injuries were found only in posterior and lateral impacts.

CONCLUSION

In the context of minor head trauma, the physician must be vigilant and must ask for a full and clear description of the trauma, its mechanisms and other characteristics, when external or internal head injuries are observed in children aged less than 6 months.

Blood biomarkers of mild traumatic brain injury: State of art

BACKGROUND

Mild traumatic brain injury (mTBI) is one of the most common causes of emergency department visits around the world. Up to 90% of injuries are classified as mTBI. Cranial computed tomography (CCT) is a standard diagnosis tool to identify intracranial complications in adults with mTBI. Alternatively, children can be admitted for inpatient observation with CCT scans performed only on those with clinical deterioration. The use of blood biomarkers is a supplementary tool for identifying patients at risk of intracerebral lesions who may need imaging.

METHOD

We realised a bibliographic state of art providing a contemporary clinical and laboratory framework for blood biomarker testing in mTBI management.

RESULTS

The S100B protein is the only biomarker that can be used today in the clinical routine for management of mTBI with appropriate evidence-based medicine. Due to its excellent negative predictive value, S100B protein is an alternative choice to CCT scanning for mTBI management with considered, consensual and pragmatic use. In this state of art, we propose points to help clinicians and clinical pathologists use serum S100B protein in the clinical routine. A state of art on the different biomarkers (GFAP, UCH-L1, NF [H or L], tau, H-FABP, SNTF, NSE, miRNAs, MBP) is also conducted. Some of these other biomarkers, used alone (GFAP, UCH-L1) or in combination (GFAP+H-FABP±S100B±IL10) can improve the specificity of S100B.

CONCLUSION

Using a bibliographic state of art, we highlighted the added values of the blood biomarkers for the clinical management of mTBI.

Interest of blood biomarkers to predict lesions in medical imaging in the context of mild traumatic brain injury

Mild traumatic brain injury (mTBI) is one of the common causes of emergency department visits around the world. Up to 90% of injuries are classified as mTBI. Cranial computed tomography (CCT) is a standard diagnostic tool for adults with mTBI. Alternatively, children can be admitted for inpatient observation with CCT scans performed only on those with clinical deterioration. The use of blood biomarkers is a supplementary tool for identifying patients at risk of intracerebral lesions who may need imaging. This review provides a contemporary clinical and laboratory framework for blood biomarker testing in mTBI management. The S100B protein is used routinely in the management of mTBI in Europe together with clinical guidelines. Due to its excellent negative predictive value, S100B protein is an alternative choice to CCT scanning for mTBI management under considered, consensual and pragmatic use. In this review, we propose points to help clinicians and clinical pathologists use serum S100B protein in the clinical routine. A review of the literature on the different biomarkers (GFAP, UCH-L1, NF [H or L], tau, H-FABP, SNTF, NSE, miRNAs, MBP, β trace protein) is also conducted. Some of these other blood biomarkers, used alone (GFAP, UCH-L1) or in combination (GFAP + H-FABP ± S100B ± IL10) can improve the specificity of S100B.

Validation of the scandinavian guidelines for initial management of minor and moderate head trauma in children

Background

Head trauma in children is common, with a low rate of clinically important traumatic brain injury. CT scan is the reference standard for diagnosis of traumatic brain injury, of which the increasing use is alarming because of the risk of induction of lethal malignancies. Recently, the Scandinavian Neurotrauma Committee derived new guidelines for the initial management of minor and moderate head trauma. Our aim was to validate these guidelines.

Methods

We applied the guidelines to a population consisting of children with mild and moderate head trauma, enrolled in the study: “Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study” by Kuppermann et al. (Lancet 374(9696):1160–1170, https://doi.org/10.1016/S0140-6736(09)61558-0, 2009). We calculated the negative predictive values of the guidelines to assess their ability to distinguish children without clinically-important traumatic brain injuries and traumatic brain injuries on CT scans, for whom CT could be omitted.

Results

We analysed a population of 43,025 children. For clinically-important brain injuries among children with minimal head injuries, the negative predictive value was 99.8% and the rate was 0.15%. For traumatic findings on CT, the negative predictive value was 96.9%. Traumatic finding on CT was detected in 3.1% of children with minimal head injuries who underwent a CT examination, which accounts for 0.45% of all children in this group.

Conclusion

Children with minimal head injuries can be safely discharged with oral and written instructions. Use of the SNC-G will potentially reduce the use of CT.

New Zealand Caregiver Knowledge of Paediatric Traumatic Brain Injury

Background:

Traumatic brain injury (TBI) is common among children. However, their caregivers’ knowledge and understanding of symptoms may influence how the injury is managed.

Primary objective:

To investigate the knowledge of New Zealand (NZ) parents about TBI and concussion.

Method and procedures:

Parents (n = 205) of children aged 5–13 years completed a pen-and-paper or online survey containing questions examining their knowledge of TBI terminology, TBI symptoms and knowledge about concussion management.

Main outcomes and results:

A high proportion (61%) of parents did not think that a concussion was the same as a brain injury. Loss of consciousness (LOC) was the most endorsed symptom of TBI. However, 69% of participants were aware that TBI could occur without LOC. On average, parents correctly identified 19.5 (67.3%) of the 29 symptoms of TBI, but also identified 2.0 (11.9%) of the 17 distractor symptoms as being TBI related. Demographic factors and experience of TBI/concussion were associated with TBI symptom identification accuracy and concussion knowledge.

Conclusions:

Further education of parents is needed to ensure they recognise the signs and symptoms of concussion/mild TBI so that they can make informed decisions on how best to manage their child’s injury.

Assessment of the advantage of the serum S100B protein biomonitoring in the management of paediatric mild traumatic brain injury-PROS100B: protocol of a multicentre unblinded stepped wedge cluster randomised trial

INTRODUCTION

S100B serum analysis in clinical routine could reduce the number of cranial CT (CCT) scans performed on children with mild traumatic brain injury (mTBI). Sampling should take place within 3 hours of trauma and cut-off levels should be based on paediatric reference ranges. The aim of this study is to evaluate the utility of measuring serum S100B in the management of paediatric mTBI by demonstrating a decrease in the number of CCT scans prescribed in an S100B biomonitoring group compared with a 'conventional management' control group, with the assumption of a 30% relative decrease of the number of CCT scans between the two groups.

METHODS AND ANALYSIS

The protocol is a randomised, multicentre, unblinded, prospective, interventional study (nine centres) using a stepped wedge cluster design, comparing two groups (S100B biomonitoring and control). Children in the control group will have CCT scans or be hospitalised according to the current recommendations of the French Society of Paediatrics (SFP). In the S100B biomonitoring group, blood sampling to determine serum S100B protein levels will take place within 3 hours after mTBI and subsequent management will depend on the assay. If S100B is in the normal range according to age, the children will be discharged from the emergency department after 6 hours' observation. If the result is abnormal, CCT scans or hospitalisation will be prescribed in accordance with current SFP recommendations. The primary outcome measure will be the proportion of CCT scans performed (absence/presence of CCT scan for each patient) in the 48 hours following mTBI.

ETHICS AND DISSEMINATION

The protocol presented (Version 5, 03 November 2017) has been approved by the ethics committee Comité de Protection des Personnes sud-est 6 (first approval 08 June 2016, IRB: 00008526). Participation in the study is voluntary and anonymous. The study findings will be disseminated in international peer-reviewed journals and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

NCT02819778.

The Biomarker S100B and Mild Traumatic Brain Injury: A Meta-analysis

CONTEXT

The usefulness of S100B has been noted as a biomarker in the management of mild traumatic brain injury (mTBI) in adults. However, S100B efficacy as a biomarker in children has previously been relatively unclear.

OBJECTIVE

A meta-analysis is conducted to assess the prognostic value of S100B in predicting intracerebral lesions in children after mTBI.

DATA SOURCES

Medline, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science, Scopus, and Google Scholar.

STUDY SELECTION

Studies including children suffering mTBI who underwent S100B measurement and computed tomography (CT) scans were included.

DATA EXTRACTION

Of 1030 articles screened, 8 studies met the inclusion criteria.

RESULTS

The overall pooled sensitivity and specificity were 100% (95% confidence interval [CI]: 98%-100%) and 34% (95% CI: 30%-38%), respectively. A second analysis was based on the collection of 373 individual data points from 4 studies. Sensitivity and specificity results, obtained from reference ranges in children with a sampling time <3 hours posttrauma, were 97% (95% CI: 84.2%-99.9%) and 37.5% (95% CI: 28.8%-46.8%), respectively. Only 1 child had a low S100B level and a positive CT scan result without clinically important traumatic brain injury.

LIMITATIONS

Only patients undergoing both a CT scan and S100B testing were selected for evaluation.

CONCLUSIONS

S100B serum analysis as a part of the clinical routine could significantly reduce the number of CT scans performed on children with mTBI. Sampling should take place within 3 hours of trauma. Cutoff levels should be based on pediatric reference ranges.

The Necessity of Follow-Up Brain Computed-Tomography Scans: Is It the Pathology Itself Or Our Fear that We Should Overcome?

AIM:

This study aimed to make a retrospective analysis of pediatric patients with head traumas that were admitted to one hospital setting and to make an analysis of the patients for whom follow-up CT scans were obtained.

METHODS:

Pediatric head trauma cases were retrospectively retrieved from the hospital’s electronic database. Patients’ charts, CT scans and surgical notes were evaluated by one of the authors. Repeat CT scans for operated patients were excluded from the total number of repeat CT scans.

RESULTS:

One thousand one hundred and thirty-eight pediatric patients were admitted to the clinic due to head traumas. Brain CT scan was requested in 863 patients (76%) in the cohort. Follow-up brain CT scans were obtained in 102 patients. Additional abnormal finding requiring surgical intervention was observed in only one patient (isolated 4th ventricle hematoma) on the control CTs (1% of repeat CT scans), who developed obstructive hydrocephalus. None of the patients with no more than 1 cm epidural hematoma in its widest dimension and repeat CT scans obtained 1.5 hours after the trauma necessitated surgery.

CONCLUSION:

Follow-up CT scans changed clinical approach in only one patient in the present series. When ordering CT scan in the follow-up of pediatric traumas, benefits and harms should be weighted based upon time interval from trauma onset to initial CT scan and underlying pathology.

Quality Improvement in Pediatric Head Trauma with PECARN Rules Implementation as Computerized Decision Support

Supplemental Digital Content is available in the text.

Background:

For the 1.4 million emergency department (ED) visits for traumatic brain injury (TBI) annually in the United States, computed tomography (CT) may be over utilized. The Pediatric Emergency Care Applied Research Network developed 2 prediction rules to identify children at very low risk of clinically important TBI. We implemented these prediction rules as decision support within our electronic health record (EHR) to reduce CT.

Objective:

To test EHR decision support implementation in reducing CT rates for head trauma at 2 pediatric EDs.

Methods:

We compared monthly CT rates 1 year before [preimplementation (PRE)] and 1 year after [postimplementation (POST)] decision support implementation. The primary outcome was change in CT use rate over time, measured using statistical process control charts. Secondary analyses included multivariate comparisons of PRE to POST. Balancing measures included ED length of stay and returns within 7 days after ED release.

Results:

There were 2,878 patients with head trauma (1,329 PRE and 1,549 POST) included. Statistical process control charts confirmed decreased CT rates over time POST that was not present PRE. Secondary statistical analyses confirmed that CT scan utilization rates decreased from 26.8% to 18.9% (unadjusted Odds Ratio [OR], 0.64; 95% Confidence Interval [CI], 0.53 -0.76; adjusted OR, 0.71; 95% CI, 0.58 -0.86). Length of stay was unchanged. There was no increase in returns within 7 days and no significant missed diagnoses.

Conclusions:

Implementation of EHR-integrated decision support for children with head trauma presenting to the ED is associated with a decrease in CT utilization and no increase in significant safety events.

Validation of the PECARN clinical decision rule for children with minor head trauma: a French multicenter prospective study

BACKGROUND

To date, the Pediatric Emergency Care Applied Research Network (PECARN) rule for identifying children who are at very low risk of clinically-important traumatic brain injuries after minor head trauma has not been validated prospectively in an independent population. Our goal was to evaluate the diagnostic performance of the PECARN clinical decision rule in a French pediatric population in multiple clinical settings.

METHODS

We conducted a multicenter, prospective, non-interventional cohort study of patients with minor head trauma who presented to three emergency departments in France. We enrolled patients younger than 16 years of age seeking a consultation within 24 h of head trauma with Glasgow Coma Scale scores of 14-15.

RESULTS

During the study period, we included 1499 children of which 421 (28 %) were under 2 years of age, and 955 (64 %) were male. A cranial computed tomography (CT) scan was performed on 76 patients (5.1 %). Of the 1499 included patients, 9 children (0.6 %) had a clinically-important traumatic brain injury, and none were classified as very low risk by the PECARN rule. In our study, the sensitivity of this clinical decision rule was 100 % (95 % CI 66.4 to 100 %), the specificity was 69.9 % (95 % CI 67.5 to 72.2 %) and the negative predictive value was 100 % (95 % CI 99.7 to 100 %).

DISCUSSION

Our study confirmed the good predictive performances of the PECARN clinical decision rule for minor head trauma in children. The PECARN rule performed similarly to our study and to its internal validation study.

CONCLUSIONS

We conducted an external validation study of the PECARN clinical decision rule for the detection of clinically-important traumatic brain injuries in children with minor head trauma, according to the methodological standards. The PECARN rule successfully identified all patients with clinically-important traumatic brain injuries, with a limited use of CT scans. Conducting a broad validation study with a large cohort is a prerequisite to provide sufficient statistical power before authorizing its implementation and generalization.

TRIAL REGISTRATION

This study has been registered in ClinicalTrials.gov with identifier number: NCT02752711 on April 27, 2016.

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.

Clinical Practice Experiences in Diagnosis and Treatment of Traumatic Brain Injury in Children: A Survey among Clinicians at 9 Large Hospitals in China

Proper diagnosis and treatment of traumatic brain injury (TBI) in children is becoming an increasingly problematic issue in China. This study investigated Chinese clinicians to provide information about their knowledge and experiences in diagnosis and treatment of pediatric TBI. We conducted a questionnaire survey among clinicians in the emergency departments and neurosurgery departments at 9 major hospitals in China. The questionnaire included demographic information, and knowledge and experiences regarding the diagnosis and treatment of pediatric TBI. A total of 235 clinicians completed questionnaires. 43.8% of the surveyed clinicians reported children with only scalp hematoma without any other signs and symptoms of concussion as TBI cases. Most clinicians (85.1%) reported no existing uniform diagnostic criteria for children with TBI in China. The majority of clinicians (91.9%) reported that CT scans were performed in all patients with suspected head injury as a routine procedure in their hospitals. Only 20.9% of clinicians believed that radiation from CT scanning may increase cancer risk in children. About 33.6% of the clinicians reported that they ordered CT scans to investigate suspected head injury due to the poor doctor-patient relationship in China, and to protect themselves against any medical lawsuits in the future. About 80% of the clinicians reported that there are no existing pediatric TBI treatment guidelines in China. Instead a senior doctor’s advice is the most reported guidelines regarding treating pediatric TBI (66.0%). All of the surveyed clinicians reported that the lack of diagnosis and/or treatment standard is the biggest problem in effectively diagnosing and treating pediatric TBI in China. Developing guidelines for the diagnosis and treatment of children with TBI is a high priority in China. The extremely high usage of CT for pediatric TBI in China suggests that it is important to establish evidence-based clinical decision rules to help Chinese clinicians make diagnostic and therapeutic decisions during their practice in order to identify children unlikely to have a clinically-important TBI who can be safely discharged without a CT scan.

Minor and repetitive head injury

Traumatic brain injury (TBI) is the leading cause of death and disability in the young, active population and expected to be the third leading cause of death in the whole world until 2020. The disease is frequently referred to as the silent epidemic, and many authors highlight the "unmet medical need" associated with TBI.The term traumatically evoked brain injury covers a heterogeneous group ranging from mild/minor/minimal to severe/non-salvageable damages. Severe TBI has long been recognized to be a major socioeconomical health-care issue as saving young lives and sometimes entirely restituting health with a timely intervention can indeed be extremely cost efficient.Recently it has been recognized that mild or minor TBI should be considered similarly important because of the magnitude of the patient population affected. Other reasons behind this recognition are the association of mild head injury with transient cognitive disturbances as well as long-term sequelae primarily linked to repeat (sport-related) injuries.The incidence of TBI in developed countries can be as high as 2-300/100,000 inhabitants; however, if we consider the injury pyramid, it turns out that severe and moderate TBI represents only 25-30 % of all cases, while the overwhelming majority of TBI cases consists of mild head injury. On top of that, or at the base of the pyramid, are the cases that never show up at the ER - the unreported injuries.Special attention is turned to mild TBI as in recent military conflicts it is recognized as "signature injury."This chapter aims to summarize the most important features of mild and repetitive traumatic brain injury providing definitions, stratifications, and triage options while also focusing on contemporary knowledge gathered by imaging and biomarker research.Mild traumatic brain injury is an enigmatic lesion; the classification, significance, and its consequences are all far less defined and explored than in more severe forms of brain injury.Understanding the pathobiology and pathomechanisms may aid a more targeted approach in triage as well as selection of cases with possible late complications while also identifying the target patient population where preventive measures and therapeutic tools should be applied in an attempt to avoid secondary brain injury and late complications.

[Compliance with the PECARN and AEP guidelines in diagnostic approach of mild head trauma in patients younger than 24 months old]

INTRODUCTION

Mild head trauma is a frequent complaint in Pediatric Emergency Departments. Several guidelines have been published in the last few years. However, significant variability can be appreciated in terms of the demand for image tests. The aim of this study is to determine the level of compliance with PECARN and AEP guidelines in the management of patients younger than 24 months old in four different hospitals.

PATIENTS AND METHODS

A multicenter retrospective study was conducted on patients presenting with mild head trauma between October 1st, 2011 and March 31st, 2013 in the Emergency Departments of four hospitals.

RESULTS

In the analysis of the results obtained, only one of the four hospitals complied with the AEP guidelines in more than 50% of the patients. The other three hospitals had a level of compliance lower than 50%. Management was more suitable according to PECARN guidelines, with 3 of the 4 hospitals having a level of compliance greater than 50%. However, the best compliance achieved by a hospital was only of 70%.

CONCLUSIONS

The study shows that the level of compliance with guidelines for management of mild head trauma in patients younger than 24 months old is low.

Variation in emergency department head computed tomography use for pediatric head trauma

OBJECTIVES

The objectives were to evaluate general emergency department (ED) variation in head computed tomography (CT) use for pediatric head trauma, hospital factors associated with CT use, and recent secular trends in CT utilization for pediatric head trauma.

METHODS

This was a cross-sectional study of a sample of general EDs in the Nationwide Emergency Department Sample (NEDS; 2006-2010). The authors included visits by patients <19 years of age with International Classification of Diseases, 9th Revision, Clinical Modification, diagnosis codes for head trauma and determined head CT use via Current Procedural Terminology (CPT), Fourth Edition, codes. Crude and risk-adjusted proportions of visits with CT for each hospital were calculated using multilevel mixed effects logistic regression. The association between hospital-level characteristics and head CT were evaluated by constructing multivariable negative binomial regression models.

RESULTS

There were 324,435 pediatric head trauma visits to 848 EDs in the sample. Median patient age was 8 years (interquartile range [IQR] = 2 to 15 years) and 62% of visits were by males. A minority of patients (0.7%) were severely injured, and only 4.2% were admitted to the hospital. Most EDs (79%) were nonteaching institutions, and 84% were nontrauma centers. Risk-adjusted median CT use was 56.0% (IQR = 46.4% to 64.7%). In multivariate analysis, nontrauma centers were 9% (95% confidence interval [CI] = 4% to 15%) less likely to use head CT for pediatric head trauma patients and among discharged patients, EDs within nonteaching hospitals were 8% more likely to perform CT imaging (95% CI = 2% to 14%). There was no change in CT use from 2006 through 2010 (p = 0.31).

CONCLUSIONS

There is significant variability among general EDs in CT use for pediatric head trauma, indicating the need for strategies to reduce variation and improve ED imaging practices for this population.

[New recommendations for the management of children after minor head trauma]

Minor head trauma is a common cause for pediatric emergency department visits. In 2009, the Pediatric Emergency Care Applied Research Network (PECARN) published a clinical prediction rule for identifying children at very low risk of clinically important traumatic brain injuries (ciTBI) and for reducing CT use because of malignancy induced by ionizing radiation. The prediction rule for ciTBI was derived and validated on 42,412 children in a prospective cohort study. The Société Française de Médecine d'Urgence (French Emergency Medicine Society) and the Groupe Francophone de Réanimation et Urgences Pédiatriques (French-Language Pediatric Emergency Care Group) recommend this algorithm for the management of children after minor head trauma. Based on clinical variables (history, symptoms, and physical examination findings), the algorithm assists in medical decision-making: CT scan, hospitalization for observation or discharge, according to three levels of ciTBI risk (high, intermediate, or low risk). The prediction rule sensitivity for children younger than 2 years is 100 % [86.3-100] and for those aged 2 years and older it is 96.8 % [89-99.6]. Our aim is to present these new recommendations for the management of children after minor head trauma.

Indications of brain computed tomography scan in children younger than 3 years of age with minor head trauma

Objective. To investigate the indications to receive brain computed tomography (CT) scan and to define the pathological findings in children younger than three years of age with minor head trauma in emergency departments. Methods. In this study, hospital case notes of 1350 children attending the emergency department of Bitlis State Hospital between January 2011 and June 2013 were retrospectively reviewed. 508 children under 3 years of age with minor head trauma were included in this study. We also asked 37 physicians about the indications for requiring CT in these children. Results. This study included 508 children, 233 (45,9%) of whom were female and 275 were male. In 476 (93,7%) children, the brain CT was completely normal. 89,2% of physicians asked in the emergency department during that time interval reported that they requested CT scan to protect themselves against malpractice litigation. Conclusion. In infants and children with minor head trauma, most CT scans were unnecessary and the fear of malpractice litigation of physicians was the most common reason for requesting a CT.

Emergency physicians' knowledge and attitudes of clinical decision support in the electronic health record: a survey-based study

OBJECTIVES

The objective was to investigate clinician knowledge of and attitudes toward clinical decision support (CDS) and its incorporation into the electronic health record (EHR).

METHODS

This was an electronic survey of emergency physicians (EPs) within an integrated health care delivery system that uses a complete EHR. Randomly assigned respondents completed one of two questionnaires, both including a hypothetical vignette and self-reported knowledge of and attitudes about CDS. One vignette version included CDS, and the other did not (NCDS). The vignette described a scenario in which a cranial computed tomography (CCT) is not recommended by validated prediction rules (the Pediatric Emergency Care Applied Research Network [PECARN] rules). In both survey versions, subjects responded first with their likely approach to evaluation and then again after receiving either CDS (the PECARN prediction rules) or no additional support. Descriptive statistics were used for self-reported responses and multivariate logistic regression was used to identify predictors of self-reported knowledge and use of the PECARN rules, as well as use of vignette responses.

RESULTS

There were 339 respondents (68% response rate), with 172 of 339 (51%) randomized to the CDS version. Initially, 25% of respondents to each version indicated they would order CCTs. After CDS, 30 of 43 (70%) of respondents who initially would order CCTs changed their management decisions to no CCT versus two of 41 (5%) with the NCDS version (chi-square, p = 0.003). In response to self-report questions, 81 of 338 respondents (24%) reported having never heard of the PECARN prediction rules, 122 of 338 (36%) were aware of the rules but not their specifics, and 135 of 338 (40%) reported knowing the rules and their specifics. Respondents agreed with favorable statements about CDS (75% to 96% agreement across seven statements) and approaches to its implementation into the EHR (60% to 93% agreement across seven statements). In multivariable analyses, EPs with tenure of 5 to 14 years (odds ratio [AOR] = 0.51, 95% confidence interval [CI] = 0.30 to 0.86) and for 15 years or more (AOR = 0.37, 95% CI = 0.20 to 0.70) were significantly less likely to report knowing the specifics of the PECARN prediction rules compared with EPs who practiced for fewer than 5 years. In addition, in the initial vignette responses (across both versions), physicians with ≥15 years of ED tenure compared to those with fewer than 5 years of experience (AOR = 0.30, 95% CI = 0.13 to 0.69), and those reporting knowing the specifics of the PECARN prediction rules were less likely to order CCTs (AOR = 0.53, 95% CI = 0.30 to 0.92).

CONCLUSIONS

EPs incorporated pediatric head trauma CDS via the EHR into their clinical judgment in a hypothetical scenario and reported favorable opinions of CDS in general and their inclusion into the EHR.

Variation in specialists' reported hospitalization practices of children sustaining blunt head trauma

Introduction

Questions surround the appropriate emergency department (ED) disposition of children who have sustained blunt head trauma (BHT). Our objective was to identify physician disposition preferences of children with blunt head trauma (BHT) and varying computed tomography (CT) findings.

Methods:

We surveyed pediatric and general emergency physicians (EP), pediatric neurosurgeons (PNSurg), general neurosurgeons (GNSurg), pediatric surgeons (PSurg) and trauma surgeons regarding care of two hypothetical patients: Case 1: a 9-year-old who fell 10 feet and Case 2: an 11-month-old who fell 5 feet. We presented various CT findings and asked physicians about disposition preferences. We evaluated predictors of patient discharge using multivariable regression analysis adjusting for hospital and ED characteristics and clinician experience. Pediatric EPs served as the reference group.

Results:

Of 2,341 eligible surveyed, 715 (31%) responded. Most would discharge children with linear skull fractures (Case 1, 71%; Case 2, 62%). Neurosurgeons were more likely to discharge children with small subarachnoid hemorrhages (Case 1 PNSurg OR 6.87, 95% CI 3.60, 13.10; GNSurg OR 6.54, 95% CI 2.38, 17.98; Case 2 PNSurg OR 5.38, 95% CI 2.64, 10.99; GNSurg OR 6.07, 95% CI 2.08, 17.76). PSurg were least likely to discharge children with any CT finding, even linear skull fractures (Case 1 OR 0.14, 95% CI 0.08, 0.23; Case 2 OR 0.18, 95% CI 0.11, 0.30). Few respondents (<6%) would discharge children with small intraventricular, subdural, or epidural bleeds.

Conclusion:

Substantial variation exists between specialties in reported hospitalization practices of neurologically-normal children with BHT and traumatic CT findings.

Pediatric traumatic brain injury and radiation risks: a clinical decision analysis

OBJECTIVE

To determine the optimal imaging strategy for young children with minor head injury considering health-related quality of life and radiation risk. In children with minor head trauma, the risk of missing a clinically important traumatic brain injury (ciTBI) must be weighed against the risk of radiation-induced malignancy from computed tomography (CT) to assess impact on public health.

STUDY DESIGN

We included children <2 years old with minor blunt head trauma defined by a Glasgow Coma Scale score of 14-15. We used decision analysis to model a CT-all versus no-CT strategy and assigned values to clinical outcomes based on a validated health-related quality of life scale: (1) baseline health; (2) non-ciTBI; (3) ciTBI without neurosurgery, death, or intubation; and (4) ciTBI with neurosurgery, death, or intubation >24 hours with probabilities from a prospective study of 10000 children. Sensitivity analysis determined the optimal management strategy over a range of ciTBI risk.

RESULTS

The no-CT strategy resulted in less risk with the expected probability of a ciTBI of 0.9%. Sensitivity analysis for the probability of ciTBI identified 4.8% as the threshold above which CT all becomes the preferred strategy and shows that the threshold decreases with less radiation. The CT all strategy represents the preferred approach for children identified as high-risk.

CONCLUSION

Among children <2 years old with minor head trauma, the no-CT strategy is preferable for those at low risk, reserving CT for children at higher risk.

Blunt head trauma in children in a community health care setting: outcomes and variables associated with the use of computed tomography

OBJECTIVE

To evaluate the incidence of clinically important traumatic brain injury (ciTBI) in children presenting to a community hospital setting and identified factors associated with computed tomography (CT) use.

STUDY DESIGN

Retrospective cohort study of consecutive children presenting with blunt head trauma to a community emergency department or clinic over 12 months. Logistic regression models were used to compare differences in characteristics between patients who received and did not receive CT scans.

RESULTS

Of 1007 patients, 62% male, age 14 days-18 years (270 <2 years, 737 ≥2 years), 189 (18%) had CT scans, 2 (0.2%) showed evidence of ciTBI on CT, 13 (1.3%) hospitalized, and none required neurosurgical intervention or died. Factors associated with CT use in patients ≥2 years: history of vomiting (OR 4.08, 95% CI 2.08-7.99, P < .001), change in behavior (OR 2.83, 95% CI 1.63-4.91, P < .001), headache (OR 3.4, 95% CI 1.87-6.16, P < .001), loss of consciousness (OR 2.83, 95% CI 1.38-5.8, P = .004), and abnormal neurologic examination (OR 26.18, 95% CI 2.26-303.05, P = .009). Patients were more likely to receive CT scans in community emergency departments than clinics (OR 7.04, 95% CI 2.40-20.65, P = .002).

CONCLUSION

Patients in our community hospital setting are at low risk of ciTBI. The clinical indicators used to determine the need for CT in patients with more significant mechanisms of injury to pediatric or academic centers may not apply to this group. Future studies are required to determine which clinical indications are significant in this setting.

Serum S100B Determination in the Management of Pediatric Mild Traumatic Brain Injury

BACKGROUND

The place of serum S100B measurement in mild traumatic brain injury (mTBI) management is still controversial. Our prospective study aimed to evaluate its utility in the largest child cohort described to date.

METHODS

Children younger than 16 years presenting at a pediatric emergency department within 3 h after TBI were enrolled prospectively for blood sampling to determine serum S100B concentrations. The following information was collected: TBI severity determined by using the Masters classification [1: minimal or Glasgow Coma Scale (GCS) 15, 2: mild or GCS 13–15, and 3: severe or GCS &lt;13]; whether hospitalized or not; good or bad clinical evolution (CE); whether cranial computed tomography (CCT) was prescribed; and related presence (CCT+) or absence (CCT−) of lesions.

RESULTS

For the 446 children enrolled, the median concentrations of S100B were 0.21, 0.31, and 0.44 μg/L in Masters groups 1, 2, and 3, respectively, with a statistically significant difference between these groups (P &lt; 0.05). In Masters group 2, 65 CCT scans were carried out. Measurement of S100B identified patients as CCT+ with 100% (95% CI 85–100) sensitivity and 33% (95% CI 20–50) specificity. Of the 424 children scored Masters 1 or 2, 21 presented “bad CE.” S100B identified bad CE patients with 100% (95% CI 84–100) sensitivity and 36% (95% CI 31–41) specificity. Of the 242 children hospitalized, 81 presented an S100B concentration within the reference interval.

CONCLUSIONS

Serum S100B determination during the first 3 h of management of children with mTBI has the potential to reduce the number of CCT scans, thereby avoiding unnecessary irradiation, and to save hospitalization costs.

Minimal and mild paediatric brain injury: a 3-year cohort of consecutive presentations

OBJECTIVE

To determine the number of children with minimal and mild traumatic brain injury (TBI) and their demographic factors, causes, associated signs/symptoms and management.

METHODS

A cross-sectional analysis of consecutive presentations to a tertiary paediatric centre.

RESULTS

There were 2043 presentations of minimal and mild TBI over 3 years (minimal TBI = 79.7% [n = 1628]; mild TBI = 20.3% [n = 415]). Mean age was 5.12 years (SD = 5.14) with children ≤3 years comprising 53.2% (n = 1086). There was a bimodal distribution in mild TBI with peaks at 0-2 and 13-15 years. The male-to-female ratio was 1.6:1. Only 34.6% of GCS scores were documented. Falls caused most injury. Overall, 6.3% (n = 129) required hospital admission and 29.1% (n = 594) were reviewed clinically.

CONCLUSION

Minimal and mild TBI is common, representing a significant burden on individuals, families and healthcare providers. High rates of follow-up impact on the healthcare system and warrant further investigation.

Role of Neuroprotein S-100B in the Diagnostic of Pediatric Mild Brain Injury

Traumatic brain injury is one of the leading causes of death and disability in children and adolescents. Patients with moderate or severe lesions can be readily recognized clinically, require immediate radiologic diagnostics by computed tomography (CT) or magnetic resonance imaging (MRI), admission to intensive care units, and, in some cases, will go on to require neurosurgical intervention. Patients with mild traumatic brain injuries (MTBIs) are diagnostically challenging. Often, the event is unobserved and head injury can only be suspected. Clinical symptoms are unreliable and clinical findings from neurological examination have to be interpreted with care. As a small percentage of MTBI patients progress to have a life-threatening intracranial hemorrhage, the recognition of this group of patients and their judicious and timely management is, therefore, an important goal. Subjecting every MTBI patient to a cranial CT scanning results in high costs and unnecessary exposure to ionizing radiation. Admitting all MTBI patients for observation and performing CTs only in case of clinical deterioration is costly and a substantial drain on resources, not to mention the radiation exposure and a source of stress for the majority of patients. Current European guidelines for diagnostics and therapy in MTBI patients are only partially applicable to the pediatric population. This article reviews the clinical problem, treatment options and guidelines, as well as diagnostic tools, with special focus on neuroprotein S-100B in pediatric and adolescent patients with MTBIs.

Postconcussive symptoms and neurocognitive function after mild traumatic brain injury in children

OBJECTIVES

We describe children's postconcussive symptoms (PCSs), neurocognitive function, and recovery during 4 to 5 weeks after mild traumatic brain injury (MTBI) and compare performance and recovery with those of injured control group participants without MTBIs.

METHODS

A prospective, longitudinal, observational study was performed with a convenience sample from a tertiary care, pediatric emergency department. Participants were children 10 to 17 years of age who were treated in the emergency department and discharged. The MTBI group included patients with blunt head trauma, Glasgow Coma Scale scores of 13 to 15, loss of consciousness for < or = 30 minutes, posttraumatic amnesia of < or = 24 hours, altered mental status, or focal neurologic deficits, and no intracranial abnormalities. The control group included patients with injuries excluding the head. The Post-Concussion Symptom Questionnaire and domain-specific neurocognitive tests were completed at baseline and at 1 and 4 to 5 weeks after injury.

RESULTS

Twenty-eight MTBI group participants and 45 control group participants were compared. There were no significant differences in demographic features. Control group participants reported some PCSs; however, MTBI group participants reported significantly more PCSs at all times. Among MTBI group participants, PCSs persisted for 5 weeks after injury, decreasing significantly between 1 and 4 to 5 weeks. Patterns of recovery on the Trail-Making Test Part B differed significantly between groups; performance on other neurocognitive measures did not differ.

CONCLUSIONS

In children 10 to 17 years of age, self-reported PCSs were not exclusive to patients with MTBIs. However, PCSs and recovery patterns for the Trail-Making Test Part B differed significantly between the groups.

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study

BACKGROUND

CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.

METHODS

We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights).

FINDINGS

We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.

INTERPRETATION

These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.

FUNDING

The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

Relationship of serum S100B levels and intracranial injury in children with closed head trauma

OBJECTIVE

To determine if serum levels of S100B are higher in children with CHT and ICI as detected by cranial CT and if long bone fractures affect the level of S100B in children with CHT and skeletal injury.

METHODS

Children <18 years of age who presented to an urban pediatric emergency department or were transferred from a referral hospital within 6 hours after accidental closed head trauma and who underwent cranial computed tomography were enrolled prospectively. Mean serum S100B levels for children with or without intracranial injury (ICI) and long-bone fractures were evaluated through analysis of covariance.

RESULTS

One hundred fifty-two children, 24 with ICI and 128 without ICI, were enrolled prospectively. Twenty-five children had long-bone fractures. Children with ICI were significantly younger than those without ICI (6.9 vs 9.8 years; P = .01). The time of venipuncture after injury was significantly later in children with ICI (P = .03). Mean S100B levels were significantly greater for children with ICI (212.9 vs 84.4 ng/L; P = .001), children with long-bone fractures (P = .008), and nonwhite children (P = .03). After controlling for time of venipuncture, long-bone fractures, and race, mean S100B levels were still greater for children with ICI (409 vs 118 ng/L; P = .001). The ability of serum S100B measurements to detect ICI, determined as the area under the curve, was 0.67.

CONCLUSIONS

After controlling for time of venipuncture, long-bone fractures, and race, S100B levels were still higher in children with ICI than in those without ICI. However, the ability of serum S100B measurements to detect ICI was poor.

Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules

CONTEXT

Given radiation- and sedation-associated risks, there is uncertainty about which children with head trauma should receive cranial computed tomography (CT) scanning. A high-quality and high-performing clinical prediction rule may reduce this uncertainty.

OBJECTIVE

To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury.

METHODS

Medline and Embase were searched in December 2008. Studies were selected if they included clinical prediction rules involving children aged 0 to 18 years with a history of head injury. Prediction-rule quality was assessed by using 14 previously published items. Prediction-rule performance was evaluated by rule sensitivity and the predicted frequency of CT scanning if the rule was used.

RESULTS

A total of 3357 titles and abstracts were assessed, and 8 clinical prediction rules were identified. For all studies, the rule derivations were reported; no study validated a rule in a separate population or assessed its impact in actual practice. The rules differed considerably in population, predictors, outcomes, methodologic quality, and performance. Five of the rules were applicable to children of all ages and severities of trauma. Two of these were high quality (>or=11 of 14 quality items) and had high performance (lower confidence limits for sensitivity >0.95 and required <or=56% to undergo CT). Four of the 8 rules were applicable to children with minor head injury (Glasgow coma score >or=13). One of these had high quality (11 of 14 quality items) and high performance (lower confidence limit for sensitivity = 0.94 and required 13% to undergo CT). Four of the 8 rules were applicable to young children, but none exhibited adequate quality or performance.

CONCLUSIONS

Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodologic quality, and performance. Future efforts should be directed toward validating rules with high quality and performance in other populations and deriving a high-quality, high-performance rule for young children.

Management of pediatric trauma

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Children's Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.

Skull radiographs and computed tomography scans in children and adolescents with mild head trauma

OBJECTIVE: To identify which pediatric patients with mild head trauma are candidates for skull radiographs or cranial computed tomography (CCT) scans. METHOD: Patients with mild head trauma aged from 0 to 19 years presenting to the Emergency Department of a trauma centre from Salvador City, Brazil, between May 2007 and May 2008. RESULTS: A total of 1888 mild head trauma patients were admitted; mean age was 7.4 (±5.5) years. A total of 1956 skull radiographs and 734 CCT scans were performed. About 44.4% patients with Glasgow coma score (GCS) 13 and 55.4% with GCS 14 had abnormal CCT scans. In patients with multiple traumas, 16% had abnormal findings on CCT scans. CONCLUSION: We strongly recommend routine CCT studies to patients with GCS of 13 and 14 or to multiple trauma victims, independently of score. Routine screening skull radiographs were not useful in the evaluation of mild head trauma patients in this study.

Controversies in the evaluation and management of minor blunt head trauma in children

PURPOSE OF REVIEW

We present data from recently conducted research regarding controversial aspects of the evaluation and management of children with minor blunt head trauma.

RECENT FINDINGS

Clinicians frequently but at times indiscriminately perform computed tomography scans for children with minor blunt head trauma resulting in potentially harmful radiation exposure. Recent guidelines recognize the limited but increasing data available to make strong recommendations regarding appropriate neuroimaging decisions. Investigators have derived and validated clinical prediction models to accurately identify patients with substantial traumatic brain injury, though no clear definitive rule exists. Children younger than 2 years appear to have a higher risk of intracranial injury following minor head trauma. These patients can be difficult to assess, with the evidence suggesting the need for a more conservative approach to diagnostic imaging. We present current and accepted definitions of concussion along with risk factors and treatment for postconcussion syndrome. Current return-to-play guidelines suggest that athletes who have sustained concussion should not resume play until symptoms have resolved because of the possibility, though rare, of second impact syndrome.

SUMMARY

Research in the management of children with minor head trauma is actively evolving. We present a review of recent developments that can influence current clinical practice.

Characteristics of children with vomiting after minor head trauma: a case-control study

OBJECTIVE

To study selected factors associated with vomiting after minor head trauma in children.

STUDY DESIGN

During a 1-year study, 1097 children with a minor head injury were consecutively discharged from the pediatric emergency department; 162 had associated vomiting. A case-control study was conducted, with each subject matched with 2 children of the same age group with a minor head injury who did not have associated vomiting. Final analysis was conducted in 148 case subjects and 296 matched control subjects.

RESULTS

With univariate analysis, a personal history of recurrent headache (6.1% versus 2.4%), motion sickness (27% versus 11.8%), and recurrent vomiting (6.1% versus 0.7%) were significantly more common in the vomiting group, as was a family history of recurrent headache in parents (45.9% versus 27%) or motion sickness in parents (26.4% versus 15.2%) or siblings (14.2% versus 3.7%). The strongest predictors of vomiting were a personal history of recurrent vomiting (odds ratio, 5.90; 95% CI, 1.18-29.47), motion sickness (odds ratio, 2.34; 95% CI, 1.32-4.10), headache at the time of the injury (odds ratio, 4.37; 95% CI, 2.23-8.57), and a strong family history of the same recurrent problems (odds ratio, 1.66; 95% CI, 1.29-2.13).

CONCLUSIONS

Post-traumatic vomiting is significantly related to personal or familial predisposition to vomit rather than to the presence of intracranial lesions.

Pediatric Head Trauma: Changes in Use of Computed Tomography in Emergency Departments in the United States Over Time

STUDY OBJECTIVE

Head trauma is common in children. In the absence of evidence-based recommendations, variations exist in the initial emergency department (ED) evaluation and treatment of children with head trauma. We sought to describe the use of computed tomography (CT) over time in the treatment of children with acute closed head trauma in US EDs.

METHODS

This was a cross-sectional analysis of data from the National Hospital Ambulatory Care Survey database from 1995 to 2003. We identified patients aged 0 to 18 years, with head trauma by chief complaint or discharge diagnosis. We collected the following data: chief complaint, patient demographics, patient disposition, discharge diagnosis, and use of CT. Frequency and characteristics of the use of CT scan for evaluation of children with head trauma. We used descriptive statistics with appropriate weighting to account for the survey methodology. We determined the frequency and the characteristics of the use of CT scans for evaluation of children with head trauma. We used descriptive statistics with appropriate weighting to account for the survey methodology.

RESULTS

We identified 2,747 patient encounters, representing 10,536,717 pediatric head trauma visits during the 9-year period. The use of CT increased from 12.8% to 22.4% from 1995 to 2003, with a peak of 28.6% in 2000. CT was used more frequently in the older age groups: 13% (<1 year), 11% (1 to 4 years), 20% (5 to 9 years), and 32% (10 to 18 years). CT was also used more frequently in general EDs (22%) than in pediatric-specific EDs (13%). There were no differences in CT use between teaching and nonteaching facilities (21% in each). Overall, 6.4% of children were either admitted to the hospital or transferred, and this rate remained stable over time.

CONCLUSION

The use of CT has increased substantially in the evaluation of children with head trauma from 1995 to 2003. Further study is needed to identify objective criteria for cranial CT in head-injured children and to evaluate the impact of increased CT use on patient outcomes.

Pediatric minor traumatic brain injury

The literature surrounding minor traumatic brain injury is complex, methodologically challenging, and controversial. Although we lack a consistent standardized definition, the annual rate is likely in excess of 200 per 100,000 children. The proportion of children with minor traumatic brain injury who will require neurosurgery is certainly <1%. Several studies are underway that have the potential to significantly advance our understanding of the specific risk factors for intracranial injury and more specifically neurosurgical injury. The mortality within children is very low, with estimates of 0% to 0.25%. Virtually all studies of the prognosis of minor brain injury in children have reported no long-term behavioral or cognitive sequelae as a specific result of the brain injury. Symptoms fall in 4 domains: somatic, cognitive, sleep/fatigue, and affective. Limited pediatric studies are available to assist clinicians in the prognosis or in optimizing recovery. Until further studies are available, a conservative approach is recommended. Children with suspected concussions should be removed from activity and observed. Children with symptomatic concussions must be limited to no physical activity. Adolescents and families need to self-monitor symptoms and limit environments or circumstances that exacerbate any symptoms. When symptoms resolve, a gradual progressive return to play is currently recommended. The recurrence risk for subsequent concussions is elevated, but there is limited documentation of the effectiveness of preventative efforts. Much remains to be learned.

Derivation of the children's head injury algorithm for the prediction of important clinical events decision rule for head injury in children

BACKGROUND

A quarter of all patients presenting to emergency departments are children. Although there are several large, well-conducted studies on adults enabling accurate selection of patients with head injury at high risk for computed tomography scanning, no such study has derived a rule for children.

AIM

To conduct a prospective multicentre diagnostic cohort study to provide a rule for selection of high-risk children with head injury for computed tomography scanning.

DESIGN

All children presenting to the emergency departments of 10 hospitals in the northwest of England with any severity of head injury were recruited. A tailor-made proforma was used to collect data on around 40 clinical variables for each child. These variables were defined from a literature review, and a pilot study was conducted before the children's head injury algorithm for the prediction of important clinical events (CHALICE) study. All children who had a clinically significant head injury (death, need for neurosurgical intervention or abnormality on a computed tomography scan) were identified. Recursive partitioning was used to create a highly sensitive rule for the prediction of significant intracranial pathology.

RESULTS

22,772 children were recruited over 2 1/2 years. 65% of these were boys and 56% were <5 years old. 281 children showed an abnormality on the computed tomography scan, 137 had a neurosurgical operation and 15 died. The CHALICE rule was derived with a sensitivity of 98% (95% confidence interval (CI) 96% to 100%) and a specificity of 87% (95% CI 86% to 87%) for the prediction of clinically significant head injury, and requires a computed tomography scan rate of 14%.

CONCLUSION

A highly sensitive clinical decision rule is derived for the identification of children who should undergo computed tomography scanning after head injury. This rule has the potential to improve and standardise the care of children presenting with head injuries. Validation of this rule in new cohorts of patients should now be undertaken.

Predictors of intracranial injuries in children after blunt head trauma

This study was conducted to determine if clinical features can predict the risk of intracranial injury (ICI) in pediatric closed head trauma. We enrolled 3,806 children under 16 years consecutively referred for acute closed head trauma to the paediatric emergency room of five Italian children's hospitals. Relevant outcomes were death and diagnosis of ICI. Clinical symptoms and signs were evaluated as possible outcome predictors. Children were also classified into five groups according to their clinical presentation. The association of ICI with signs and symptoms and the appropriateness of the five-group classification in predicting the likelihood of ICI were evaluated by logistic regression analyses. ICI was diagnosed in 22 children; 2 of them died. The risk of fatal and nonfatal ICI was 0.5 and 5.2 per 1,000 children with closed head trauma respectively. Significant associations were found between ICI and loss of consciousness, prolonged headache, persistent drowsiness, abnormal mental status, focal neurological signs, signs of skull fracture in non-frontal areas and signs of basal skull fracture. The five-group classification of children allowed an excellent prediction in terms of likelihood of ICI (ROC area 0.972).

CONCLUSIONS

Selection of children with closed head trauma based on different combinations of signs and symptoms allows for early identification of subjects at different risk for ICI. In patients with minor head injuries, the absence of loss of consciousness, drowsiness, amnesia, prolonged headache, clinical evidence of basal or non-frontal skull fracture identified 100% of children without lesions. Validation of our results with a larger sample of patients with ICI would be highly desirable.

Evaluation of mild head injury in a pediatric population

Approximately 5 million children present to emergency departments, seeking care for head injuries, each year, and 80% of these children are classified as cases of mild head injury. Due to the huge number of patients and low frequency of intracranial lesions in this group, obtaining a computed tomography scan for each and every patient is a significant economic problem. This study was conducted to identify the clinical parameters and the radiographic findings that may be associated with intracranial lesions in children with mild head injury. 421 patients, with a Glasgow Coma Scale score of 15 and without any focal neurological deficit, were studied. Intracranial lesion was noted in 37 cases (8.8%). Sensitivity of a plain radiogram was 43.2%, and specificity was 93%. An intracranial pathology was demonstrated in 28.9% of the patients with a linear skull fracture. The only clinical parameters associated with an increase in the frequency of detection of intracranial lesions were posttraumatic seizures and loss of consciousness. Age, sex, headache, vomiting and scalp lacerations were not associated with a higher frequency. Even when patients with a history of loss of consciousness or posttraumatic seizure were subtracted from the study group, intracranial lesions were noted in 4.1% of the cases, and in 1.8% neurosurgical intervention was required. Computed tomography is the gold standard in the evaluation of pediatric patients with mild head trauma, and every child who has experienced a head injury should undergo a cranial computed tomography evaluation, even if he or she appears in perfect health.