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Proctor A, Lyttle M, Billing J, Shaw P, Simpson J, Voss S, Benger JR. Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis. BMJ Open 2024; 14:e078363. [PMID: 38355171 PMCID: PMC10868315 DOI: 10.1136/bmjopen-2023-078363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVE Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care. DESIGN Systematic mapping review and narrative synthesis. DATA SOURCES Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. ELIGIBILITY CRITERIA Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury. DATA EXTRACTION AND SYNTHESIS We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis. RESULTS Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories. CONCLUSION Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.
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Affiliation(s)
| | - Mark Lyttle
- Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | | | | | | | - Sarah Voss
- Health and Life Sciences, University of the West of England, Bristol, UK
| | - Jonathan Richard Benger
- Academic Department of Emergency Care, The University Hospitals NHS Foundation Trust, Bristol, UK
- Faculty of Health & Life Sciences, University of the West of England, Bristol, UK
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Peter C, Stranzinger E, Heverhagen JT, Keitel K, Romano F, Busch JD, Slavova N. Minor head trauma in infants - how accurate is cranial ultrasound performed by trained radiologists? Eur J Pediatr 2023:10.1007/s00431-023-04939-9. [PMID: 37093305 DOI: 10.1007/s00431-023-04939-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 03/08/2023] [Accepted: 03/15/2023] [Indexed: 04/25/2023]
Abstract
Correct management of infants after minor head trauma is crucial to minimize the risk to miss clinically important traumatic brain injury (ciTBI). Current practices typically involve CT or in-hospital surveillance. Cranial ultrasound (CUS) provides a radiation-free and fast alternative. This study examines the accuracy of radiologist-performed CUS to detect skull fracture (SF) and/or intracranial hemorrhage (ICH). An inconspicuous CUS followed by an uneventful clinical course would allow exclusion of ciTBI with a great certainty. This monocentric, retrospective, observational study analyzed CUS in infants (< 12 months) after minor head trauma at Bern University Children's Hospital, between 7/2013 and 8/2020. The primary outcome was the sensitivity and specificity of CUS in detecting SF and/or ICH by comparison to the clinical course and to additional neuroimaging. Out of a total of 325 patients, 73% (n = 241) had a normal CUS, 17% (n = 54) were found with SF, and ICH was diagnosed in 2.2% patients (n = 7). Two patients needed neurosurgery and three patients deteriorated clinically during surveillance. Additional imaging was performed in 35 patients. The sensitivity of CUS was 93% ([0.83, 0.97] 95% CI) and the specificity 98% ([0.95, 0.99] 95% CI). All false-negative cases originated in missed SF without clinical deterioration; no ICH was missed. Conclusion: This study shows high accuracy of CUS in exclusion of SF and ICH, which can cause ciTBI. Therefore, CUS offers a reliable method of neuroimaging in infants after minor head trauma and gives reassurance to reduce the duration of in-hospital surveillance. What is Known: • Minor head trauma can cause clinically important traumatic brain injury in infants, and the management of these cases is a challenge for the treating physician. • Cranial ultrasound (CUS) is regularly used in neonatology, but its accuracy after head trauma in infants is controversial. What is New: • CUS performed by a trained radiologist can exclude findings related to clinically important traumatic brain injury (ciTBI) with high sensitivity and specificity. It therefore offers reassurance in the management of infants after minor head trauma.
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Affiliation(s)
- Claudia Peter
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| | - Enno Stranzinger
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes T Heverhagen
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kristina Keitel
- Division of Paediatric Emergency Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Fabrizio Romano
- Division of Paediatric Emergency Medicine, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jasmin D Busch
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nedelina Slavova
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
- Pediatric Radiology, University Children's Hospital (UKBB) Basel and University of Basel, Basel, Switzerland
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Alonso-Cadenas JA, Calderón Checa RM, Ferrero García-Loygorri C, Durán Hidalgo I, Pérez García MJ, Delgado Gómez P, Jiménez García R. Variability in the management of infants under 3 months with minor head injury in paediatric emergency departments. An Pediatr (Barc) 2023; 98:83-91. [PMID: 36754719 DOI: 10.1016/j.anpede.2022.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 10/19/2022] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION In the assessment of infants younger than 3 months with minor traumatic head injury (MHI), it is essential to adapt the indication of imaging tests. The Pediatric Head Injury/Trauma Algorithm (PECARN) clinical prediction rule is the most widely used to guide clinical decision making. OBJECTIVES To analyse the variability in the performance of imaging tests in infants under 3 months with MHI in paediatric emergency departments (PEDs) and the adherence of each hospital to the recommendations of the PECARN rule. POPULATION AND METHODS We conducted a prospective multicentre observational study in 13 paediatric emergency departments in Spain between May 2017 and November 2020. RESULTS Of 21 981 children with MHI, 366 (1.7%) were aged less than 3 months; 195 (53.3%) underwent neuroimaging, with performance of CT scans in 37 (10.1%; interhospital range, 0%-40.0%), skull X-rays in 162 (44.3 %; range, 0%-100%) and transfontanellar ultrasound scans in 22 (6.0%; range, 0%-24.0%). The established recommendations were followed in 25.6% (10/39) of infants classified as high-risk based on PECARN criteria (range, 0%-100%); 37.1% (36/97) classified as intermediate-risk (range, 0%-100%) and 57.4% (132/230) classified as low-risk (range, 0%-100%). CONCLUSION We found substantial variability and low adherence to the PECARN recommendations in the performance of imaging tests in infants aged less than 3 months with MHI in Spanish PEDs, mainly due to an excessive use of skull X-rays.
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Affiliation(s)
| | | | | | - Isabel Durán Hidalgo
- Servicio de Urgencias, Hospital Universitario Materno-Infantil Málaga, Málaga, Spain
| | | | - Pablo Delgado Gómez
- Servicio de Urgencias, Hospital Universitario Materno-Infantil Virgen del Rocío, Sevilla, Spain
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4
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Şık N, Öztürk A, Yılmaz D, Duman M. The Role of Ultrasound in Pediatric Skull Fractures: Determination of Fracture and Optic Nerve Sheath Diameter Measurements. Pediatr Emerg Care 2023; 39:91-97. [PMID: 36719390 DOI: 10.1097/pec.0000000000002895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The aim of the present study was to determine the accuracy of point-of-care ultrasound (POCUS) for detecting skull fractures and to evaluate sonographic measurements of optic nerve sheath diameter (ONSD) and ONSD/eyeball vertical diameter (EVD) ratios in children with head trauma. METHODS Children who presented with local signs of head trauma and underwent cranial computed tomography (CT) were enrolled. The suspected area was examined by POCUS to identify a skull fracture, and then the ONSD at 3 mm posterior to the globe and the EVD were measured. Ratios of ONSD measurement at 3 mm/EVD were reported. All ONSD measurements and ratios were calculated from cranial CT images. RESULTS There were 112 children enrolled in the study. The sensitivity and specificity of POCUS for skull fractures was 93.7% (95% confidence interval [CI], 82.8-98.6) and 96.8% (95% CI, 89.1-99.6), whereas the positive predictive value was 95.7% (95% CI, 85.1-98.8), and the negative predictive value was 95.3% (95% CI, 87.3-98.4). There was high agreement between POCUS and CT for identifying skull fractures (κ, 0.90 [±0.04]). In the group without elevated intracranial pressure findings on CT, patients with space-occupying lesions (SOLs) had higher sonographic ONSD measurements and ratios (P < 0.001) compared with cases without SOLs. CONCLUSIONS When used with clinical decision rules to minimize the risk for clinically important traumatic brain injury, POCUS seems to be a promising tool to detect skull fractures and calculate ONSD measurements and rates to predict the risk for SOLs and perform further risk stratification of children with minor head trauma.
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Affiliation(s)
- Nihan Şık
- From the Division of Pediatric Emergency Care, Department of Pediatrics, Dokuz Eylul University, Faculty of Medicine, Izmir, Turkey
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5
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Alonso-Cadenas JA, Calderón Checa RM, Ferrero García-Loygorri C, Durán Hidalgo I, Pérez García MJ, Delgado Gómez P, Jiménez García R. Variabilidad en la atención en urgencias al lactante menor de 3 meses con un traumatismo craneoencefálico leve. An Pediatr (Barc) 2022. [DOI: 10.1016/j.anpedi.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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6
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Akın B, Coşkun A, Demirci B, Karaçam H, Çam B. Clinical and Imaging Consequences in Pediatric Head Trauma. BAGCILAR MEDICAL BULLETIN 2022. [DOI: 10.4274/bmb.galenos.2022.2022-03-030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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7
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Alonso-Cadenas JA, Ferrero García-Loygorri C, Calderón Checa RM, Durán Hidalgo I, Pérez García MJ, Ruiz González S, De Ceano-Vivas M, Delgado Gómez P, Antoñón Rodríguez M, Moreno Sánchez R, Martínez Hernando J, Muñoz López C, Ortiz Valentín I, Jiménez-García R. Epidemiology of minor blunt head trauma in infants younger than 3 months. Eur J Pediatr 2022; 181:2901-2908. [PMID: 35552807 DOI: 10.1007/s00431-022-04492-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/28/2022] [Accepted: 04/29/2022] [Indexed: 11/03/2022]
Abstract
UNLABELLED Specific knowledge of the features of minor head trauma in infants is necessary to develop appropriate preventive strategies and adjust clinical management in pediatric emergency departments (PEDs). The aim of this study is to describe the epidemiology of minor blunt head trauma in infants < 3 months who present to PEDs. We performed a prospective study of infants evaluated in any of 13 Spanish PEDs within 24 h of a minor head trauma (Glasgow Coma Scale scores of 14-15) between May 2017 and November 2020. Telephone follow-up was conducted for all patients over the 4 weeks after the initial PED visit. Of 1,150,255 visits recorded, 21,981 children (1.9%) sustained a head injury, 386 of whom (0.03%) were under 3 months old. Among the 369 patients who met the inclusion criteria (0.03%), 206 (56.3%) were male. The main causes of trauma were fall-related (298; 80.8%), either from furniture (138/298; 46.3%), strollers (92/298; 30.9%), or a caregiver's arms (61/298; 20.5%). Most infants were asymptomatic (317; 85.9%) and showed no signs of injury on physical exam (210; 56.9%). Imaging studies were performed in 195 patients (52.8%): 37 (10.0%) underwent computed tomography (CT) scan, 162 (43.9%) X-ray, and 22 (6.0%) ultrasound. A clinically important traumatic brain injury (ciTBI) occurred in 1 infant (0.3% overall; 95% CI, 0-1.5), TBI was evidenced on CT scan in 12 (3.3% overall; 95% CI, 1.7-5.7), and 20 infants had an isolated skull fracture (5.5% overall; 95% CI, 3.4-8.3). All outcomes were caused by falls onto hard surfaces. CONCLUSION Most head injuries in infants younger than 3 months are benign, and the rate of ciTBI is low. Prevention strategies should focus on falls onto hard surfaces from furniture, strollers, and caregivers' arms. Optimizing imaging studies should be a priority in this population. WHAT IS KNOWN • Infants younger than 3 months are vulnerable to minor blunt head trauma due to their age and to difficulties in assessing the subtle symptoms and minimal physical findings detected on examination. • A low threshold for CT scan is recommended in this population. WHAT IS NEW • Most cases of blunt head trauma in infants younger than 3 months have good outcomes, and the rate of clinically important traumatic brain injury is low. • Optimizing imaging studies should be a priority in this population, avoiding X-ray examinations and reducing unnecessary CT scans.
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Affiliation(s)
- José Antonio Alonso-Cadenas
- Pediatric Emergency Department, Hospital Infantil Universitario Niño Jesús, Avenida de Menedez Pelayo 65, 28009, Madrid, Spain.
| | | | | | - Isabel Durán Hidalgo
- Pediatric Emergency Department, Hospital Materno-Infantil Universitario Málaga, Málaga, Spain
| | | | - Sara Ruiz González
- Pediatrics Department, Hospital Universitario Severo Ochoa, Leganés, Spain
| | | | - Pablo Delgado Gómez
- Pediatric Emergency Department, Hospital Universitario Virgen del Rocío, Seville, Spain
| | | | | | - José Martínez Hernando
- Pediatric Emergency Department, Hospital UniversitarioSant Joan de Déu Barcelona, Esplugues de Llobregat, Spain
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8
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Chong S. Head Injury during Childbirth. J Korean Neurosurg Soc 2022; 65:342-347. [PMID: 35468705 PMCID: PMC9082121 DOI: 10.3340/jkns.2022.0045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 03/14/2022] [Indexed: 11/27/2022] Open
Abstract
Head injuries are the most common type of birth injuries. Among them, most of the injuries is limited to the scalp. and the prognosis is good enough to be unnoticed in some cases. Intracranial injuries caused by excessive forces during delivery are rare. However, since some of them can be fatal, it is necessary to suspect it at an early stage and evaluate thoroughly if there are abnormal findings in the patient.
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Affiliation(s)
- Sangjoon Chong
- Department of Neurosurgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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9
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Lynham R, Boxall S, Warren J, Lynham A. Paediatric trauma imaging in a regional Queensland hospital: Do we need clearer guidance? Emerg Med Australas 2022; 34:704-710. [PMID: 35243766 DOI: 10.1111/1742-6723.13954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/08/2022] [Accepted: 02/11/2022] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Rohan Lynham
- Anaesthesia Department, Whangarei Hospital, Whangarei, New Zealand
| | - Sarah Boxall
- Emergency Department, Mackay Hospital and Health Service, Mackay, Queensland, Australia
| | - Jacelle Warren
- Jamieson Trauma Institute, Metro North Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Anthony Lynham
- Jamieson Trauma Institute, Metro North Health, The University of Queensland, Brisbane, Queensland, Australia
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Kriss S, Morris J, Martich V. Cranial Suture Evaluation in Pediatric Head Trauma: Importance in Differentiating Abusive From Accidental Injury. Pediatr Emerg Care 2022; 38:e703-e708. [PMID: 34034336 DOI: 10.1097/pec.0000000000002461] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Pediatric skull fracture association with the cranial sutures (crossing, widening, or contacting 2 or more cranial sutures) is suggestive of abusive injury. We studied the efficacy of head computed tomography (CT) versus skull radiographs in identifying pediatric skull fracture association with cranial sutures and reviewed head CT literature recommendations for pediatric head trauma. METHODS Retrospective review was performed of skull radiographs and head CT at a tertiary care, free-standing children's hospital (2012-2019). Statistical 2-proportion Z test determined efficacy of head CT versus skull radiographs in assessing cranial suture involvement with fractures. RESULTS Forty-seven children with 56 abusive skull fractures and 47 children with 54 accidental skull fractures were evaluated, ages 1 to 36 months. Of the 110 total skull fractures evaluated, 51 abusive and 41 accidental skull fractures had terminal ends contacting cranial sutures for a total of 92 (84%). Twelve abusive fractures (24%) crossed sutures; no accidental fractures crossed sutures (P < 0.01). Of the 12 abusive cases with skull fractures that crossed sutures, 7 were definitively identified only on CT (P < 0.01). Widened sutures were documented in 4 (8%) of the abusive cases with skull fracture; none in the accidental cases. All 4 of these cases were equally identified on both skull radiography and CT imaging. In 21 of 47 abusive versus 5 of 47 accidental cases, CT identified skull fractures lines that extended to cranial sutures that were not definitive on skull radiography (P = 0.00022). CONCLUSIONS Cranial suture involvement with pediatric skull fractures is common. Head CT significantly aided in the identification of skull fractures contacting and crossing cranial sutures in abusive cases, supporting eliminating concurrent skull radiographs.
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Affiliation(s)
- Spencer Kriss
- From the Department of Radiology, Norton Children's Hospital, Louisville KY
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Cho S, Hwang S, Jung JY, Kwak YH, Kim DK, Lee JH, Jung JH, Park JW, Kwon H, Suh D. Validation of Pediatric Emergency Care Applied Research Network (PECARN) rule in children with minor head trauma. PLoS One 2022; 17:e0262102. [PMID: 35041677 PMCID: PMC8765658 DOI: 10.1371/journal.pone.0262102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 12/18/2021] [Indexed: 11/25/2022] Open
Abstract
The Pediatric Emergency Care Applied Research Network (PECARN) rule is commonly used for predicting the need for computed tomography (CT) scans in children with mild head trauma. The objective of this study was to validate the PECARN rule in Korean children presenting to the pediatric emergency department (PED) with head trauma. This study was a multicenter, retrospective, observational cohort study in two teaching PEDs in Korea between August 2015 and August 2016. In this observational study, 448 patients who visited PEDs were included in the final analysis. Risk stratification was performed with clinical decision support software based on the PECARN rule, and decisions to perform CT scans were subsequently made. Patients were followed-up by phone call between 7 days and 90 days after discharge from the PED. The sensitivity and specificity were analyzed. The sensitivity was 100% for all age groups, and no cases of clinically important traumatic brain injury (ciTBI) were identified in the very-low-risk group. CT scans were performed for 14.7% of patients in this study and for 33.8% in the original PECARN study. The PECARN rule successfully identified low-risk patients, and no cases of ciTBI were missed despite the reduced proportion of patients undergoing CT scans.
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Affiliation(s)
- Sooje Cho
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Soyun Hwang
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- * E-mail:
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Do Kyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Hee Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jin Hee Jung
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - Joong Wan Park
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyuksool Kwon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dongbum Suh
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Tsao J, Hook M, Shah P, Bingham PM. Implementation of Pediatric Emergency Care Applied Research Network Guidelines for Traumatic Brain Injury in a Rural Tertiary Care Center. Pediatr Emerg Care 2021; 37:513-518. [PMID: 32541400 DOI: 10.1097/pec.0000000000002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate changes in imaging practices for pediatric head trauma after publication of the Pediatric Emergency Care Applied Research Network (PECARN) guidelines, explore areas for quality improvement regarding neuroradiology referrals. We also sought to determine the prevalence of incidental findings discovered on computed tomographies (CTs) attained for minor head trauma and ascertain disposition in these cases. METHODS This retrospective study was conducted at a rural academic center and included 156 children who received CTs for head trauma between 2005 and 2015. Subjects were divided into 2 groups: pre-PECARN publication and post-PECARN publication. Electronic medical records were reviewed to determine whether or not head CTs were obtained according to PECARN guidelines. The proportion of scanned cases and incidental findings in each group was then compared. RESULTS Significantly more subjects met PECARN criteria for head CT during the pre-PECARN period (67.1% vs 50.6%, P = 0.04). Among those who met PECARN criteria, severe mechanism of injury was the most common criterion met in both groups (43.8% pre-PECARN and 26.5% post-PECARN). Nine (5.7%) subjects had incidental findings (similar for both study periods), of which 3 prompted additional diagnostic testing or invasive intervention. Among those who did not meet PECARN criteria, the most common mechanism of injury was fall (<3 ft). CONCLUSIONS Implementation of PECARN guidelines at our center remained limited in the 5 years after publication of this practice guide. Clinically insignificant incidental findings were often detected and may heighten patient anxiety.
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Affiliation(s)
- Jackie Tsao
- From the Department of Neurosciences, Robert Larner, MD, School of Medicine
| | | | - Purvi Shah
- From the Department of Neurosciences, Robert Larner, MD, School of Medicine
| | - Peter M Bingham
- Division of Pediatric Neurology, the University of Vermont Medical Center, Burlington, VT
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Abid Z, Kuppermann N, Tancredi DJ, Dayan PS. Risk of Traumatic Brain Injuries in Infants Younger than 3 Months With Minor Blunt Head Trauma. Ann Emerg Med 2021; 78:321-330.e1. [PMID: 34148662 DOI: 10.1016/j.annemergmed.2021.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Indexed: 01/21/2023]
Abstract
STUDY OBJECTIVE Infants with head trauma often have subtle findings suggestive of traumatic brain injury. Prediction rules for traumatic brain injury among children with minor head trauma have not been specifically evaluated in infants younger than 3 months old. We aimed to determine the risk of clinically important traumatic brain injuries, traumatic brain injuries on computed tomography (CT) images, and skull fractures in infants younger than 3 months of age who did and did not meet the age-specific Pediatric Emergency Care Applied Research Network (PECARN) low-risk criteria for children with minor blunt head trauma. METHODS We conducted a secondary analysis of infants <3 months old in the public use data set from PECARN's prospective observational study of children with minor blunt head trauma. Main outcomes included (1) clinically important traumatic brain injury, (2) traumatic brain injury on CT, and (3) skull fracture on CT. RESULTS Of 10,904 patients <2 years old, 1,081 (9.9%) with complete data were <3 months old; most (750/1081, 69.6%) sustained falls, and 633/1081 (58.6%) underwent CT scans. Of the 514/1081 (47.5%) infants who met the PECARN low-risk criteria, 1/514 (0.2%, 95% confidence interval [CI] 0.005% to 1.1%), 10/197 (5.1%, 2.5% to 9.1%), and 9/197 (4.6%, 2.1% to 8.5%) had clinically important traumatic brain injuries, traumatic brain injuries on CT, and skull fractures, respectively. Of 567 infants who did not meet the low-risk PECARN criteria, 24/567 (4.2%, 95% CI 2.7% to 6.2%), 94/436 (21.3%, 95% CI 17.6% to 25.5%), and 122/436 (28.0%, 95% CI 23.8% to 32.5%) had clinically important traumatic brain injuries, traumatic brain injuries, and skull fractures, respectively. CONCLUSION The PECARN traumatic brain injury low-risk criteria accurately identified infants <3 months old at low risk of clinically important traumatic brain injuries. However, infants at low risk for clinically important traumatic brain injuries remained at risk for traumatic brain injuries on CT, suggesting the need for a cautious approach in these infants.
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Affiliation(s)
- Zaynah Abid
- Department of Pediatrics, Columbia University Irving Medical Center, New York, NY.
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, Davis School of Medicine, University of California, Sacramento, CA
| | - Daniel J Tancredi
- Departments of Emergency Medicine and Pediatrics, Davis School of Medicine, University of California, Sacramento, CA
| | - Peter S Dayan
- Department of Emergency Medicine, Columbia University Irving Medical Center, New York, NY
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Aldinc H, Gun C, Yaylaci S, Barbur E. Pediatric Minor Head Trauma: Factors Affecting the Anxiety of Parents. Clin Pediatr (Phila) 2021; 60:273-278. [PMID: 33884910 DOI: 10.1177/00099228211009678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Managing the anxiety of the parents of pediatric patients with head trauma is challenging. This study aimed to examine the factors that affect anxiety levels of parents whose children were admitted to the emergency department with minor head trauma. In this prospective study, the parents of 663 consecutive pediatric patients were invited to answer a questionnaire. Parents of 600 children participated in the study. The parents who believed they were provided sufficient information and who were satisfied with the service received had significantly more improvement in anxiety-related questions. Cranial X-ray assessment had a significantly positive impact on the anxiety of the parents, whereas cranial computed tomography and neurosurgery consultation did not. In assessing pediatric minor head trauma, cranial computed tomography imaging and neurosurgery consultation should not be expected to relieve the anxiety of the parents. However, adequately informing them and providing satisfaction are the factors that could lead to improvement.
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Affiliation(s)
- Hasan Aldinc
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Department of Emergency Medicine, Istanbul, Turkey
| | - Cem Gun
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Department of Emergency Medicine, Istanbul, Turkey
| | - Serpil Yaylaci
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Department of Emergency Medicine, Istanbul, Turkey
| | - Erol Barbur
- Acibadem Mehmet Ali Aydinlar University, School of Medicine, Istanbul, Turkey
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Velasco R, Moore CM, Deiratany S, D'Elia F, Tourteau LB, Zuiani C, Bognar Z, Erdelyi K, Fadgyas B, Fejes M, Teksam O, Mirzeyev Y, Esmeray P, Fernández SM, Ricondo A, Da Dalt L, Bressan S, Priante E, Snoeck E, Broers M, Castman-Berrevoets CE, Fernandes RM, Borges J, Obieta A, Alcalde M, Piñol S, González J, Azzali A, Gioè D, La Spina L, Bianconi M, Arribas M, Parri N. Variability in the management and imaging use in paediatric minor head trauma in European emergency departments. A Research in European Pediatric Emergency Medicine study. Eur J Emerg Med 2021; 28:196-201. [PMID: 33079737 DOI: 10.1097/mej.0000000000000763] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of the study was to assess the variability in the management of paediatric MHT in European emergency departments (EDs). METHODS This was a multicentre retrospective study of children ≤18 years old with minor head trauma (MHT) (Glasgow Coma Scale ≥14) who presented to 15 European EDs between 1 January 2013 and 31 December 31. Data on clinical characteristics, imaging tests, and disposition of included patients were collected at each hospital over a 3-year period. RESULTS We included 11 212 patients. Skull radiography was performed in 3416 (30.5%) patients, range 0.4-92.3%. A computed tomography (CT) was obtained in 696 (6.2%) patients, range 1.6-42.8%. The rate of admission varied from 0 to 48.2%. CONCLUSION We found great variability in terms of the type of imaging and rate of CT scan obtained. Our study suggests opportunity for improvement in the area of paediatric head injury and the need for targeted individualised ED interventions to improve management of MHT.
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Cheng CY, Pan HY, Li CJ, Chen YC, Chen CC, Huang YS, Cheng FJ. Physicians' Risk Tolerance and Head Computed Tomography Use for Pediatric Patients With Minor Head Injury. Pediatr Emerg Care 2021; 37:e129-e135. [PMID: 29847541 PMCID: PMC7938907 DOI: 10.1097/pec.0000000000001540] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
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.
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Affiliation(s)
- Chi-Yung Cheng
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Hsiu-Yung Pan
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Chao-Jui Li
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Yi-Chuan Chen
- Department of Emergency Medicine, Chang Gung Memorial Hospital
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan
| | - Chien-Chih Chen
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Yi-Syun Huang
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
| | - Fu-Jen Cheng
- From the Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Kaohsiung
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17
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Alexandridis G, Verschuuren EW, Rosendaal AV, Kanhai DA. Evidence base for point-of-care ultrasound (POCUS) for diagnosis of skull fractures in children: a systematic review and meta-analysis. Emerg Med J 2020; 39:30-36. [PMID: 33273039 PMCID: PMC8717482 DOI: 10.1136/emermed-2020-209887] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Blunt head trauma is a common presentation to emergency departments (EDs). Identifying skull fractures in children is important as they are known factor of risk for traumatic brain injury (TBI). Currently, CT is the reference standard for diagnosing skull fractures and TBIs in children. Identifying skull fractures with point-of-care ultrasound (POCUS) may help risk-stratify children for TBI following blunt trauma. The purpose of this study is to evaluate the sensitivity, specificity, positive predictive value and negative predictive value of POCUS in identifying skull fractures in children. METHODS A systematic search was performed on 17 July 2020 in Ovid Medline, Cochrane Library, Google Scholar, Web of Science and Embase. Prospective studies reporting skull fractures diagnosed with ultrasound in children younger than 18 years due to blunt head injury were included. Studies that did not confirm the fracture with CT were excluded. The quality of studies was evaluated using the QUADAS-2 tool. Data were extracted from the eligible studies to calculate outcomes such as sensitivity and specificity; when possible overall outcomes were calculated. RESULTS Seven studies were included. All eligible studies included patients for whom the decision to perform a CT scan was made in advance. Overall, the included studies demonstrated low risk of bias or had minor concerns regarding risk of bias. The pooled data (n=925) demonstrated a sensitivity of 91%, specificity of 96%, positive predictive value of 88% and negative predictive value of 97%. CONCLUSION The included studies demonstrate minor methodological limitations. Overall, the evidence suggests that POCUS is a valid option for diagnosing skull fractures in children visiting the ED after blunt head injury.
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Affiliation(s)
- Georgios Alexandridis
- Emergency Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands .,Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Eva W Verschuuren
- Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Arthur V Rosendaal
- Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Danny A Kanhai
- Pediatrics, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
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18
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Kim JS, Kim JC, Sung WY. 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. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920975371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
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.
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Affiliation(s)
- Jon Soo Kim
- Department of Pediatrics, Chungbuk National University Hospital, Cheongju, Republic of Korea
| | - Jin Cheol Kim
- Department of Emergency Medicine, Eulji University Hospital, Daejeon, Republic of Korea
| | - Won Young Sung
- Department of Emergency Medicine, Eulji University Hospital, Daejeon, Republic of Korea
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19
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Shah J, Dubb S, Agar S, Shah P, Mirza T. Computed tomographic indications for occult skull fractures in paediatric head trauma diagnosed at the time of wound closure under general anaesthesia. Br J Oral Maxillofac Surg 2020; 59:35-38. [PMID: 32747033 DOI: 10.1016/j.bjoms.2020.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2020] [Accepted: 07/02/2020] [Indexed: 11/18/2022]
Abstract
Children with head injuries commonly present to the emergency department with forehead lacerations, and are frequently referred to the oral and maxillofacial team. Assessing the Glasgow coma scale (GCS) and neurological status of these patients is particularly challenging and there remains marked ambiguity regarding the use of computed tomographic (CT) imaging in children who have no obvious signs of traumatic brain injury. We present a case series of three patients who presented to our unit with forehead lacerations following a fall. All had a normal GCS, no obvious neurological signs, and all were listed for wound closure under general anaesthesia. Intraoperatively they were found to have underlying skull fractures that necessitated emergency CT whilst under general anaesthesia. Retrospective analysis was performed. Current guidelines and the literature were reviewed to identify factors that may help to identify occult skull fractures in the context of paediatric head trauma. Despite the subsequent discovery of skull fractures under general anaesthesia, none of our patients would have satisfied the present absolute indications for CT in the current guidelines. A number of helpful factors are not common in the UK guidelines but are present in others, including the presence of an appreciable haematoma and lacerations greater than 5 cm, amongst others. The assessment of paediatric patients with head trauma often remains a challenge when assessing for features such as headache, focal neurology, and amnesia. A high index of suspicion, formal examination under anaesthesia, and communication with the radiology department, are imperative if we are to avoid missing an occult injury that could potentially result in brain injury.
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Affiliation(s)
- J Shah
- Luton and Dunstable University Hospital.
| | - S Dubb
- Luton and Dunstable University Hospital
| | - S Agar
- Luton and Dunstable University Hospital
| | - P Shah
- Luton and Dunstable University Hospital
| | - T Mirza
- Luton and Dunstable University Hospital
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20
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Gizli G, Durak VA, Koksal O. The comparison of PECARN, CATCH, AND CHALICE criteria in children under the age of 18 years with minor head trauma in emergency department. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920930510] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction: Minor head traumas constitute a significant part of childhood injuries. The incidence of intracranial pathologies in children with minor head trauma varies in the range of 3%–5%, but it is higher among younger infants. The criteria of the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events are the most frequently accepted clinical decision-making criteria that were developed for selective computerized tomography requests. This study was conducted to assess the diagnostic performances of the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria in Turkish society, determine their validity, and find the most suitable algorithm for cranial imaging in children with minor head trauma. Methods: This study retrospectively examined the data of patients under the age of 18 years who were admitted to the Emergency Medicine Department of Uludağ University Medical Faculty due to minor head trauma; 530 patients were included as they complied with the criteria. The exclusion criteria were being any trauma patients above the age of 18 years, Glasgow Coma Scale <13, pregnant patients, hemorrhagic diathesis, using anticoagulants, patients with penetrant trauma, patients with priorly known brain tumor, and patients with neurological diseases. The patients were divided into group based on the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events Criteria. Results: Among all patients, 37.40% were female and 62.60% were male. Abnormal computed tomography findings such as epidural bleeding, subdural bleeding, and skull fractures were detected in 44 of the patients. The sensitivity of the Pediatric Emergency Care Applied Research Network criteria was 72.4%, the specificity was 54.5%, the sensitivity of the Canadian Assessment of Tomography for Childhood Head Injury criteria was 57.8%, the specificity was 50%, the sensitivity of the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria was 87.7%, and the specificity was 20%. Conclusion: Given the populations to which the rules apply, it is understood that the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria is more determinative in detecting pathological computed tomography outcomes compared to Pediatric Emergency Care Applied Research Network and Canadian Assessment of Tomography for Childhood Head Injury.
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Affiliation(s)
- Gizem Gizli
- Department of Emergency Medicine, Van Yüzüncü Yıl University, Van, Turkey
| | - Vahide Aslihan Durak
- Department of Emergency Medicine, Faculty of Medicine, School of Medicine, Uludağ University, Bursa, Turkey
| | - Ozlem Koksal
- Department of Emergency Medicine, Faculty of Medicine, School of Medicine, Uludağ University, Bursa, Turkey
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21
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Characteristics of vomiting as a predictor of intracranial injury in pediatric minor head injury. CAN J EMERG MED 2020; 22:793-801. [PMID: 32513343 DOI: 10.1017/cem.2020.378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Vomiting is common in children after minor head injury. In previous research, isolated vomiting was not a significant predictor of intracranial injury after minor head injury; however, the significance of recurrent vomiting is unclear. This study aimed to determine the value of recurrent vomiting in predicting intracranial injury after pediatric minor head injury. METHODS This secondary analysis of the CATCH2 prospective multicenter cohort study included participants (0-16 years) who presented to a pediatric emergency department (ED) within 24 hours of a minor head injury. ED physicians completed standardized clinical assessments. Recurrent vomiting was defined as ≥ four episodes. Intracranial injury was defined as acute intracranial injury on computed tomography scan. Predictors were examined using chi-squared tests and logistic regression models. RESULTS A total of 855 (21.1%) of the 4,054 CATCH2 participants had recurrent vomiting, 197 (4.9%) had intracranial injury, and 23 (0.6%) required neurosurgical intervention. Children with recurrent vomiting were significantly more likely to have intracranial injury (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.7-3.1), and require neurosurgical intervention (OR, 3.5; 95% CI, 1.5-7.9). Recurrent vomiting remained a significant predictor of intracranial injury (OR, 2.8; 95% CI, 1.9-3.9) when controlling for other CATCH2 criteria. The probability of intracranial injury increased with number of vomiting episodes, especially when accompanied by other high-risk factors, including signs of a skull fracture, or irritability and Glasgow Coma Scale score < 15 at 2 hours postinjury. Timing of first vomiting episode, and age were not significant predictors. CONCLUSIONS Recurrent vomiting (≥ four episodes) was a significant risk factor for intracranial injury in children after minor head injury. The probability of intracranial injury increased with the number of vomiting episodes and if accompanied by other high-risk factors, such as signs of a skull fracture or altered level of consciousness.
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22
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Accuracy of Bedside Ultrasound for the Diagnosis of Skull Fractures in Children Aged 0 to 4 Years. Pediatr Emerg Care 2020; 36:e268-e273. [PMID: 29698348 DOI: 10.1097/pec.0000000000001485] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The aim of this study was to investigate the accuracy of bedside ultrasound (US) performed by emergency physicians for diagnosing skull fractures in children 0 to 4 years old compared with the accuracy of head computed tomography (CT). We also sought to investigate characteristics and precautions associated with US. METHODS This single-center prospective study involved children 0 to 4 years old who had a history of head trauma. Bedside US was performed by emergency medicine physicians, and the results were compared with CT scan interpretations provided by attending radiologists. The accuracy of US for the diagnosis of skull fractures was calculated, and the errors were reviewed. RESULTS A total of 87 patients were enrolled. Skull fracture was present in 13 patients (14.9%), according to CT. Bedside US had a sensitivity and specificity of 76.9% (95% confidence interval [CI], 46.0%-93.8%) and 100% (95% CI, 93.9%-100%), respectively. Overall positive predictive value was 100% (95% CI, 65.5%-100%), and negative predictive value was 96.1% (95% CI, 88.3%-99.0%). Three false-negative cases were observed. CONCLUSIONS Bedside US performed by emergency medicine physicians with short focused US training is a useful tool for diagnosing skull fractures in children 0 to 4 years of age. However, there were 3 false-negative cases. A meticulous examination is needed in the area adjacent to the orbital wall and skull base.
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Sönnerqvist C, Brus O, Olivecrona M. Validation of the scandinavian guidelines for initial management of minor and moderate head trauma in children. Eur J Trauma Emerg Surg 2020; 47:1163-1173. [PMID: 31907552 PMCID: PMC8321988 DOI: 10.1007/s00068-019-01288-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Accepted: 12/17/2019] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
| | - Ole Brus
- Clinical Epidemiology and Biostatics, School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Magnus Olivecrona
- Department of Medical Sciences, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
- Department of Anaesthesiology and Intensive Care, Section for Neurosurgery, Örebro University Hospital, Örebro, Sweden.
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Osmond MH, Klassen TP, Wells GA, Davidson J, Correll R, Boutis K, Joubert G, Gouin S, Khangura S, Turner T, Belanger F, Silver N, Taylor B, Curran J, Stiell IG. Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department. CMAJ 2019; 190:E816-E822. [PMID: 29986857 DOI: 10.1503/cmaj.170406] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/13/2018] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND There is uncertainty about which children with minor head injury need to undergo computed tomography (CT). We sought to prospectively validate the accuracy and potential for refinement of a previously derived decision rule, Canadian Assessment of Tomography for Childhood Head injury (CATCH), to guide CT use in children with minor head injury. METHODS This multicentre cohort study in 9 Canadian pediatric emergency departments prospectively enrolled children with blunt head trauma presenting with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. Phys icians completed standardized assessment forms before CT, including clinical predictors of the rule. The primary outcome was neurosurgical intervention and the secondary outcome was brain injury on CT. We calculated test characteristics of the rule and used recursive partitioning to further refine the rule. RESULTS Of 4060 enrolled patients, 23 (0.6%) underwent neurosurgical intervention, and 197 (4.9%) had brain injury on CT. The original 7-item rule (CATCH) had sensitivities of 91.3% (95% confidence interval [CI] 72.0%-98.9%) for neurosurgical intervention and 97.5% (95% CI 94.2%-99.2%) for predicting brain injury. Adding "≥ 4 episodes of vomiting" resulted in a refined 8-item rule (CATCH2) with 100% (95% CI 85.2%-100%) sensitivity for neurosurgical intervention and 99.5% (95% CI 97.2%-100%) sensitivity for brain injury. INTERPRETATION Among children presenting to the emergency department with minor head injury, the CATCH2 rule was highly sensitive for identifying those children requiring neurosurgical intervention and those with any brain injury on CT. The CATCH2 rule should be further validated in an implementation study designed to assess its clinical impact.
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Affiliation(s)
- Martin H Osmond
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont.
| | - Terry P Klassen
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - George A Wells
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Jennifer Davidson
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Rhonda Correll
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Kathy Boutis
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Gary Joubert
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Serge Gouin
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Simi Khangura
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Troy Turner
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Francois Belanger
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Norm Silver
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Brett Taylor
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Janet Curran
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
| | - Ian G Stiell
- Department of Pediatrics and Children's Hospital of Eastern Ontario Research Institute (Osmond), University of Ottawa, Ottawa, Ont.; Department of Pediatrics and Child Health (Klassen, Silver), University of Manitoba, Winnipeg, Man.; School of Epidemiology and Public Health (Wells), University of Ottawa, Ottawa, Ont.; Department of Pediatrics (Davidson, Belanger), University of Calgary, Calgary, Alta.; Clinical Research Unit (Correll), Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; Department of Pediatrics, and Child Health Evaluative Sciences Research Institute, Hospital for Sick Children (Boutis), University of Toronto, Toronto, Ont.; Department of Paediatrics (Joubert), Western University, London, Ont.; Paediatric Department (Gouin), CHU Sainte-Justine, Montréal, Que.; Department of Pediatrics (Khangura), University of British Columbia, Vancouver, BC; Department of Pediatrics (Turner), University of Alberta, Edmonton, Alta.; Department of Pediatrics (Taylor, Curran), Dalhousie University, Halifax, NS; Department of Emergency Medicine and Ottawa Hospital Research Institute (Stiell), University of Ottawa, Ottawa, Ont
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25
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Bressan S, Kochar A, Oakley E, Borland M, Phillips N, Dalton S, Lyttle MD, Hearps S, Cheek JA, Furyk J, Neutze J, Dalziel S, Babl FE. Traumatic brain injury in young children with isolated scalp haematoma. Arch Dis Child 2019; 104:664-669. [PMID: 30833284 DOI: 10.1136/archdischild-2018-316066] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 12/06/2018] [Accepted: 01/21/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Despite high-quality paediatric head trauma clinical prediction rules, the management of otherwise asymptomatic young children with scalp haematomas (SH) can be difficult. We determined the risk of intracranial injury when SH is the only predictor variable using definitions from the Pediatric Emergency Care Applied Research Network (PECARN) and Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) head trauma rules. DESIGN Planned secondary analysis of a multicentre prospective observational study. SETTING Ten emergency departments in Australia and New Zealand. PATIENTS Children <2 years with head trauma (n=5237). INTERVENTIONS We used the PECARN (any non-frontal haematoma) and CHALICE (>5 cm haematoma in any region of the head) rule-based definition of isolated SH in both children <1 year and <2 years. MAIN OUTCOME MEASURES Clinically important traumatic brain injury (ciTBI; ie, death, neurosurgery, intubation >24 hours or positive CT scan in association with hospitalisation ≥2 nights for traumatic brain injury). RESULTS In children <1 year with isolated SH as per PECARN rule, the risk of ciTBI was 0.0% (0/109; 95% CI 0.0% to 3.3%); in those with isolated SH as defined by the CHALICE, it was 20.0% (7/35; 95% CI 8.4% to 36.9%) with one patient requiring neurosurgery. Results for children <2 years and when using rule specific outcomes were similar. CONCLUSIONS In young children with SH as an isolated finding after head trauma, use of the definitions of both rules will aid clinicians in determining the level of risk of ciTBI and therefore in deciding whether to do a CT scan. TRIAL REGISTRATION NUMBER ACTRN12614000463673.
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Affiliation(s)
- Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Amit Kochar
- Pediatric Emergency, Women's and Children's Hospital Adelaide Women's and Babies Division, North Adelaide, South Australia, Australia
| | - Ed Oakley
- Departmentof Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - Meredith Borland
- Emergency Medicine, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, South Brisbane, Queensland, Australia
| | - Sarah Dalton
- Emergency Department, Children's Hospital at Westmead, Westmead, New South Wales, Australia
| | - Mark D Lyttle
- Emergency Department, Bristol Royal Hospital for Children, Bristol, UK.,Academic Department of Emergency Care, University of the West of England, Bristol, Avon, UK
| | - Stephen Hearps
- Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
| | - John Alexander Cheek
- Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Jeremy Furyk
- Emergency Department, University Hospital Geelong, Victoria, Australia
| | - Jocelyn Neutze
- Emergency Medicine, Kidzfirst Middlemore Hospital, Otahuhu, New Zealand
| | - Stuart Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand
| | - Franz E Babl
- Departmentof Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.,Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia.,Clinical Sciences, Murdoch Childrens Research Institute, Melbourne, Victoria, Australia
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26
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Khalifa M, Gallego B. Grading and assessment of clinical predictive tools for paediatric head injury: a new evidence-based approach. BMC Emerg Med 2019; 19:35. [PMID: 31200643 PMCID: PMC6570950 DOI: 10.1186/s12873-019-0249-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/03/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many clinical predictive tools have been developed to diagnose traumatic brain injury among children and guide the use of computed tomography in the emergency department. It is not always feasible to compare tools due to the diversity of their development methodologies, clinical variables, target populations, and predictive performances. The objectives of this study are to grade and assess paediatric head injury predictive tools, using a new evidence-based approach, and to provide emergency clinicians with standardised objective information on predictive tools to support their search for and selection of effective tools. METHODS Paediatric head injury predictive tools were identified through a focused review of literature. Based on the critical appraisal of published evidence about predictive performance, usability, potential effect, and post-implementation impact, tools were evaluated using a new framework for grading and assessment of predictive tools (GRASP). A comprehensive analysis was conducted to explain why certain tools were more successful. RESULTS Fourteen tools were identified and evaluated. The highest-grade tool is PECARN; the only tool evaluated in post-implementation impact studies. PECARN and CHALICE were evaluated for their potential effect on healthcare, while the remaining 12 tools were only evaluated for predictive performance. Three tools; CATCH, NEXUS II, and Palchak, were externally validated. Three tools; Haydel, Atabaki, and Buchanich, were only internally validated. The remaining six tools; Da Dalt, Greenes, Klemetti, Quayle, Dietrich, and Güzel did not show sufficient internal validity for use in clinical practice. CONCLUSIONS The GRASP framework provides clinicians with a high-level, evidence-based, comprehensive, yet simple and feasible approach to grade, compare, and select effective predictive tools. Comparing the three main tools which were assigned the highest grades; PECARN, CHALICE and CATCH, to the remaining 11, we find that the quality of tools' development studies, the experience and credibility of their authors, and the support by well-funded research programs were correlated with the tools' evidence-based assigned grades, and were more influential, than the sole high predictive performance, on the wide acceptance and successful implementation of the tools. Tools' simplicity and feasibility, in terms of resources needed, technical requirements, and training, are also crucial factors for their success.
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Affiliation(s)
- Mohamed Khalifa
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Road, North Ryde, Sydney, NSW, 2113, Australia.
| | - Blanca Gallego
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Lowy Cancer Research Centre, Level 4, Cnr High &, Botany St, Kensington, Sydney, NSW, 2052, Australia
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27
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Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O'Connor RE, Timmons SD. Centers for Disease Control and Prevention Guideline on the Diagnosis and Management of Mild Traumatic Brain Injury Among Children. JAMA Pediatr 2018; 172:e182853. [PMID: 30193284 PMCID: PMC7006878 DOI: 10.1001/jamapediatrics.2018.2853] [Citation(s) in RCA: 285] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Importance Mild traumatic brain injury (mTBI), or concussion, in children is a rapidly growing public health concern because epidemiologic data indicate a marked increase in the number of emergency department visits for mTBI over the past decade. However, no evidence-based clinical guidelines have been developed to date for diagnosing and managing pediatric mTBI in the United States. Objective To provide a guideline based on a previous systematic review of the literature to obtain and assess evidence toward developing clinical recommendations for health care professionals related to the diagnosis, prognosis, and management/treatment of pediatric mTBI. Evidence Review The Centers for Disease Control and Prevention (CDC) National Center for Injury Prevention and Control Board of Scientific Counselors, a federal advisory committee, established the Pediatric Mild Traumatic Brain Injury Guideline Workgroup. The workgroup drafted recommendations based on the evidence that was obtained and assessed within the systematic review, as well as related evidence, scientific principles, and expert inference. This information includes selected studies published since the evidence review was conducted that were deemed by the workgroup to be relevant to the recommendations. The dates of the initial literature search were January 1, 1990, to November 30, 2012, and the dates of the updated literature search were December 1, 2012, to July 31, 2015. Findings The CDC guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI that were assigned a level of obligation (ie, must, should, or may) based on confidence in the evidence. Recommendations address imaging, symptom scales, cognitive testing, and standardized assessment for diagnosis; history and risk factor assessment, monitoring, and counseling for prognosis; and patient/family education, rest, support, return to school, and symptom management for treatment. Conclusions and Relevance This guideline identifies the best practices for mTBI based on the current evidence; updates should be made as the body of evidence grows. In addition to the development of the guideline, CDC has created user-friendly guideline implementation materials that are concise and actionable. Evaluation of the guideline and implementation materials is crucial in understanding the influence of the recommendations.
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Affiliation(s)
| | | | - Kelly Sarmiento
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Matthew J Breiding
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Tamara M Haegerich
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention (CDC), Atlanta, Georgia
| | - Gerard A Gioia
- Children's National Health System, George Washington University School of Medicine, Washington, DC
| | | | | | - Stacy J Suskauer
- Kennedy Krieger Institute, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher C Giza
- The University of California, Los Angeles (UCLA) Steve Tisch BrainSPORT Program, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles
| | | | - Catherine Broomand
- Center for Neuropsychological Services, Kaiser Permanente, Roseville, California
| | | | - Wayne Gordon
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Karen McAvoy
- Rocky Mountain Hospital for Children, Denver, Colorado
| | - Linda Ewing-Cobbs
- Children's Learning Institute, Department of Pediatrics, University of Texas (UT) Health Science Center at Houston
| | | | - Margot Putukian
- University Health Services, Princeton University, Princeton, New Jersey
| | | | | | - Shari L Wade
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Meeryo Choe
- The University of California, Los Angeles (UCLA) Steve Tisch BrainSPORT Program, UCLA Mattel Children's Hospital, David Geffen School of Medicine at UCLA, Los Angeles
| | - Cindy W Christian
- Children's Hospital of Philadelphia, Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | | | - P B Raksin
- John H. Stroger, Jr Hospital of Cook County (formerly Cook County Hospital), Chicago, Illinois
| | - Andrew Gregory
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Anne Mucha
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | - H Gerry Taylor
- Nationwide Children's Hospital Research Institute, Columbus, Ohio
| | - James M Callahan
- Children's Hospital of Philadelphia, Raymond and Ruth Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - John DeWitt
- Jameson Crane Sports Medicine Institute, School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus
| | - Michael W Collins
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | | | - John Ragheb
- Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | | | - Theodore J Spinks
- Department of Pediatric Neurosurgery, St Joseph's Children's Hospital, Tampa, Florida
| | | | | | | | | | - Tom Getchius
- American Academy of Neurology, Minneapolis, Minnesota
| | | | - Zoe Donnell
- Social Marketing Group, ICF, Rockville, Maryland
| | | | - Shelly D Timmons
- Penn State University Milton S. Hershey Medical Center, Hershey, Pennsylvania
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28
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Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskauer SJ, Giza CC, Joseph M, Broomand C, Weissman B, Gordon W, Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duhaime AC, Putukian M, Holshouser B, Paulk D, Wade SL, Herring SA, Halstead M, Keenan HT, Choe M, Christian CW, Guskiewicz K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWitt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman R, Getchius T, Gronseth G, Donnell Z, O'Connor RE, Timmons SD. Diagnosis and Management of Mild Traumatic Brain Injury in Children: A Systematic Review. JAMA Pediatr 2018; 172:e182847. [PMID: 30193325 DOI: 10.1001/jamapediatrics.2018.2847] [Citation(s) in RCA: 91] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE In recent years, there has been an exponential increase in the research guiding pediatric mild traumatic brain injury (mTBI) clinical management, in large part because of heightened concerns about the consequences of mTBI, also known as concussion, in children. The CDC National Center for Injury Prevention and Control's (NCIPC) Board of Scientific Counselors (BSC), a federal advisory committee, established the Pediatric Mild TBI Guideline workgroup to complete this systematic review summarizing the first 25 years of literature in this field of study. OBJECTIVE To conduct a systematic review of the pediatric mTBI literature to serve as the foundation for an evidence-based guideline with clinical recommendations associated with the diagnosis and management of pediatric mTBI. EVIDENCE REVIEW Using a modified Delphi process, the authors selected 6 clinical questions on diagnosis, prognosis, and management or treatment of pediatric mTBI. Two consecutive searches were conducted on PubMed, Embase, ERIC, CINAHL, and SportDiscus. The first included the dates January 1, 1990, to November 30, 2012, and an updated search included December 1, 2012, to July 31, 2015. The initial search was completed from December 2012 to January 2013; the updated search, from July 2015 to August 2015. Two authors worked in pairs to abstract study characteristics independently for each article selected for inclusion. A third author adjudicated disagreements. The risk of bias in each study was determined using the American Academy of Neurology Classification of Evidence Scheme. Conclusion statements were developed regarding the evidence within each clinical question, and a level of confidence in the evidence was assigned to each conclusion using a modified GRADE methodology. Data analysis was completed from October 2014 to May 2015 for the initial search and from November 2015 to April 2016 for the updated search. FINDINGS Validated tools are available to assist clinicians in the diagnosis and management of pediatric mTBI. A significant body of research exists to identify features that are associated with more serious TBI-associated intracranial injury, delayed recovery from mTBI, and long-term sequelae. However, high-quality studies of treatments meant to improve mTBI outcomes are currently lacking. CONCLUSIONS AND RELEVANCE This systematic review was used to develop an evidence-based clinical guideline for the diagnosis and management of pediatric mTBI. While an increasing amount of research provides clinically useful information, this systematic review identified key gaps in diagnosis, prognosis, and management.
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Affiliation(s)
| | | | - Kelly Sarmiento
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew J Breiding
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Tamara M Haegerich
- Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Gerard A Gioia
- Children's National Health System, George Washington University School of Medicine, Washington, DC
| | | | | | - Stacy J Suskauer
- Kennedy Krieger Institute, Johns Hopkins University , Baltimore, Maryland.,Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher C Giza
- UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Mattel Children's Hospital, Los Angeles.,David Geffen School of Medicine at University of California, Los Angeles
| | | | - Catherine Broomand
- Kaiser Permanente, Center for Neuropsychological Services, Roseville, California
| | | | - Wayne Gordon
- Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Karen McAvoy
- Rocky Mountain Hospital for Children, Denver, Colorado
| | - Linda Ewing-Cobbs
- Children's Learning Institute and Department of Pediatrics, University of Texas Health Science Center at Houston
| | | | - Margot Putukian
- Princeton University, University Health Service, Princeton, New Jersey
| | | | - David Paulk
- Kaiser Permanente, Center for Neuropsychological Services, Roseville, California
| | - Shari L Wade
- Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | | | | | - Meeryo Choe
- UCLA Steve Tisch BrainSPORT Program, University of California, Los Angeles, Mattel Children's Hospital, Los Angeles.,David Geffen School of Medicine at University of California, Los Angeles
| | - Cindy W Christian
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | | | - P B Raksin
- John H. Stroger Jr. Hospital of Cook County, Chicago, Illinois
| | - Andrew Gregory
- Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Anne Mucha
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | - H Gerry Taylor
- Nationwide Children's Hospital Research Institute, Columbus, Ohio
| | - James M Callahan
- Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Raymond and Ruth Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - John DeWitt
- Jameson Crane Sports Medicine Institute and School of Health and Rehabilitation Sciences, The Ohio State University Wexner Medical Center, Columbus
| | - Michael W Collins
- University of Pittsburgh Medical Center Sports Medicine Concussion Program, Pittsburgh, Pennsylvania
| | | | - John Ragheb
- Nicklaus Children's Hospital, University of Miami Miller School of Medicine, Miami, Florida
| | | | - T J Spinks
- St. Joseph's Children's Hospital, Department of Pediatric Neurosurgery, Tampa, Florida
| | | | | | | | | | - Tom Getchius
- American Academy of Neurology, Minneapolis, Minnesota
| | | | - Zoe Donnell
- ICF, Social Marketing Group, Rockville, Maryland
| | | | - Shelly D Timmons
- Penn State University, Milton S. Hershey Medical Center, Hershey
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Umerani MS, Abbas A, Aziz F, Shahid R, Ali F, Rizvi RK. Pediatric Extradural Hematoma: Clinical Assessment Using King's Outcome Scale for Childhood Head Injury. Asian J Neurosurg 2018; 13:681-684. [PMID: 30283526 PMCID: PMC6159040 DOI: 10.4103/ajns.ajns_164_16] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Introduction: Epidural hematoma (EDH) is a traumatic accumulation of blood between the inner table of the skull and the stripped off dural membrane and predominantly consists of venous blood in infants. The study aims to assess the outcome of pediatric EDH using King's Outcome Scale for Childhood Head Injury (KOSCHI). Materials and Methods: A total of 72 patients’ files were reviewed retrospectively with a diagnosis of EDH from January 2012 to December 2014. Predesigned proforma was filled using data from patient records. In addition, KOSCHI was calculated using recent telephone interviews. Results: Among 72 patients, 65.3% were male and 34.7% were female. Overall, road traffic accident was the most common cause (52.8%) followed by fall, assault, and sports injury. The most common symptom was more than two episodes of vomiting which was present in 51.4% of patients followed by loss of consciousness in 37.5%, ENT bleed in 33.3%, headache in 16.7%, and fits in 11.1% of patients. The median follow-up of our patients was 19 (6–40) months. Most of our patients made good recovery with 76.4% of our patients scoring 5b on KOSCHI. Conclusion: EDH is not uncommon among children with head injury. It should be suspected in every child with posttraumatic skull fracture or scalp hematoma. Prompt surgical intervention can give good long-term outcome.
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Affiliation(s)
- Muhammad Sohail Umerani
- Department of Neurosurgery, King Fahd Military Medical Complex, Dammam, Saudi Arabia.,Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan
| | - Asad Abbas
- Department of Neurosurgery, Liaquat National Hospital and Medical College, Karachi, Pakistan.,Department of Neurosurgery, Jinnah Post Graduate Medical Center, Karachi, Pakistan
| | - Fatima Aziz
- Department of Neurosurgery, Jinnah Post Graduate Medical Center, Karachi, Pakistan
| | - Rafiya Shahid
- Department of Neurosurgery, Jinnah Post Graduate Medical Center, Karachi, Pakistan
| | - Faiza Ali
- Department of Neurosurgery, Jinnah Post Graduate Medical Center, Karachi, Pakistan
| | - Raza Khairat Rizvi
- Department of Neurosurgery, Jinnah Post Graduate Medical Center, Karachi, Pakistan
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A Systematic Review and Meta-Analysis of the Management and Outcomes of Isolated Skull Fractures in Children. Ann Emerg Med 2018; 71:714-724.e2. [PMID: 29174834 PMCID: PMC10052777 DOI: 10.1016/j.annemergmed.2017.10.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Revised: 09/13/2017] [Accepted: 10/16/2017] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE Most studies of children with isolated skull fractures have been relatively small, and rare adverse outcomes may have been missed. Our aim is to quantify the frequency of short-term adverse outcomes of children with isolated skull fractures. METHODS PubMed, EMBASE, the Cochrane Library, Scopus, Web of Science, and gray literature were systematically searched to identify studies reporting on short-term adverse outcomes of children aged 18 years or younger with linear, nondisplaced, isolated skull fractures (ie, without traumatic intracranial injury on neuroimaging). Two investigators independently reviewed identified articles for inclusion, assessed quality, and extracted relevant data. Our primary outcome was emergency neurosurgery or death. Secondary outcomes were hospitalization and new intracranial hemorrhage on repeated neuroimaging. Meta-analyses of pooled estimate of each outcome were conducted with random-effects models, and heterogeneity across studies was assessed. RESULTS Of the 587 studies screened, the 21 that met our inclusion criteria included 6,646 children with isolated skull fractures. One child needed emergency neurosurgery and no children died (pooled estimate 0.0%; 95% confidence interval [CI] 0.0% to 0.0%; I2=0%). Of the 6,280 children with known emergency department disposition, 4,914 (83%; 95% CI 71% to 92%; I2=99%) were hospitalized. Of the 569 children who underwent repeated neuroimaging, 6 had new evidence of intracranial hemorrhage (0.0%; 95% CI 0.0% to 9.0%; I2=77%); none required operative intervention. CONCLUSION Children with isolated skull fractures were at extremely low risk for emergency neurosurgery or death, but were frequently hospitalized. Clinically stable children with an isolated skull fracture may be considered for outpatient management in the absence of other clinical concerns.
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Parri N, Crosby BJ, Mills L, Soucy Z, Musolino AM, Da Dalt L, Cirilli A, Grisotto L, Kuppermann N. Point-of-Care Ultrasound for the Diagnosis of Skull Fractures in Children Younger Than Two Years of Age. J Pediatr 2018; 196:230-236.e2. [PMID: 29499992 DOI: 10.1016/j.jpeds.2017.12.057] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/30/2017] [Accepted: 12/19/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To determine the accuracy of skull point-of-care ultrasound (POCUS) for identifying fractures in children younger than 2 years of age with signs of head trauma, and the ability of POCUS to identify the type and depth of fracture depression. STUDY DESIGN This was a multicenter, prospective, observational study of children younger than 2 years of age with nontrivial mechanisms of injury and signs of scalp/skull trauma. Patients were enrolled if they underwent computed tomography (CT). Patients underwent clinical evaluation, in addition to a cranial POCUS in the emergency department (ED). From the POCUS examinations, we documented whether fractures were present or absent, their location, characteristics, and depth. POCUS and CT findings were compared to calculate the diagnostic accuracy. RESULTS We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures. Agreement between POCUS and CT to identify the type of fracture as linear, depressed, or complex was 84.4% (97 of 115) with a kappa of 0.75 (95% CI 0.70-0.84). CONCLUSIONS POCUS performed by emergency physicians may identify the type and depth of fractures in infants with local physical signs of head trauma with substantial accuracy. Emergency physicians should consider POCUS as an adjunct to clinical evaluation and prediction rules for traumatic brain injuries in children younger than 2 years of age.
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Affiliation(s)
- Niccolò Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer Children's Hospital, Firenze, Italy.
| | - Bradley J Crosby
- Emergency Department, Dixie Regional Medical Center, St. George, UT
| | - Lisa Mills
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Zachary Soucy
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Anna Maria Musolino
- Emergency Department, Bambino Gesù Children's Hospital, IRCCS Rome, Rome, Italy
| | - Liviana Da Dalt
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Angela Cirilli
- Department of Emergency Medicine, Long Island Jewish Medical Center & Cohen Children's Medical Center, New Hyde Park, NY
| | - Laura Grisotto
- Department of Statistics G. Parenti, University of Florence and ISPO Cancer Prevention and Research Institute, Florence, Italy
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA; Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA
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Reliability of Triage Nurses and Emergency Physicians for the Interpretation of the C-3PO Rule for Head Trauma in Children. J Emerg Nurs 2018; 44:164-168. [DOI: 10.1016/j.jen.2017.06.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Revised: 05/22/2017] [Accepted: 06/16/2017] [Indexed: 11/18/2022]
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Abstract
OBJECTIVE The objective of this study was to evaluate the sensitivity and specificity of cranial ultrasound (CUS) for detection of intracranial hemorrhage (ICH) in infants with open fontanels. METHODS This was a retrospective study of infants younger than 2 years who had a CUS performed for the evaluation of potential ICH. We excluded patient with CUSs that were done for reasons related to prematurity, transplant or oncologic evaluations, routine follow-up or preoperative screen, or congenital and known perinatal anomalies. Two clinicians independently classified each of the patients with ICH into significant or insignificant based on the radiology reports. RESULTS Of 4948 CUS studies performed during the 5-year study period, 283 studies fit the inclusion criteria. Patient age ranged from 0 to 458 days, with a median of 33 days. There were 39 total cases of ICH detected, with 27 significant bleeds and 12 insignificant bleeds. Using computed tomography, magnetic resonance imaging, or clinical outcome as criterion standard, the overall ultrasound sensitivity and specificity for bleed were 67% (confidence interval [CI], 50%-81%) and 99% (CI, 97%-100%), respectively. For those with significant bleeds, the overall sensitivity was 81% (CI, 62%-94%), and for those with insignificant bleeds, it was 33% (CI, 1%-65%). CONCLUSIONS The sensitivity of CUS is inadequate to justify its use as a screening tool for detection of ICH in young infants.
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Da Dalt L, Parri N, Amigoni A, Nocerino A, Selmin F, Manara R, Perretta P, Vardeu MP, Bressan S. Italian guidelines on the assessment and management of pediatric head injury in the emergency department. Ital J Pediatr 2018; 44:7. [PMID: 29334996 PMCID: PMC5769508 DOI: 10.1186/s13052-017-0442-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/18/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury. METHODS These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text. CONCLUSIONS Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.
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Affiliation(s)
- Liviana Da Dalt
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Niccolo' Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Angela Amigoni
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Agostino Nocerino
- Department of Pediatrics, S. Maria della Misericordia University Hospital, University of Udine, Udine, Italy
| | - Francesca Selmin
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Renzo Manara
- Department of Radiology, Neuroradiology Unit, University of Salerno, Salerno, Italy
| | - Paola Perretta
- Neurosurgery Unit, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Maria Paola Vardeu
- Pediatric Emergency Department, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Silvia Bressan
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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Cho SM, Kim HG, Yoon SH, Chang KH, Park MS, Park YH, Choi MS. Reappraisal of Neonatal Greenstick Skull Fractures Caused by Birth Injuries: Comparison of 3-Dimensional Reconstructed Computed Tomography and Simple Skull Radiographs. World Neurosurg 2018; 109:e305-e312. [DOI: 10.1016/j.wneu.2017.09.168] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2017] [Revised: 09/24/2017] [Accepted: 09/25/2017] [Indexed: 11/29/2022]
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Sim SY, Kim HG, Yoon SH, Choi JW, Cho SM, Choi MS. Reappraisal of Pediatric Diastatic Skull Fractures in the 3-Dimensional CT Era: Clinical Characteristics and Comparison of Diagnostic Accuracy of Simple Skull X-Ray, 2-Dimensional CT, and 3-Dimensional CT. World Neurosurg 2017; 108:399-406. [DOI: 10.1016/j.wneu.2017.08.107] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2017] [Revised: 08/14/2017] [Accepted: 08/16/2017] [Indexed: 11/16/2022]
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Bozan Ö, Aksel G, Kahraman HA, Giritli Ö, Eroğlu SE. Comparison of PECARN and CATCH clinical decision rules in children with minor blunt head trauma. Eur J Trauma Emerg Surg 2017; 45:849-855. [DOI: 10.1007/s00068-017-0865-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 10/16/2017] [Indexed: 11/30/2022]
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Yang T. Traumatic nondisplaced coronal suture fracture causing delayed intracranial hemorrhage in a pediatric patient. J Neurosurg Pediatr 2017; 20:77-80. [PMID: 28452656 DOI: 10.3171/2017.3.peds1722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Skull fracture after a head injury is relatively common in children younger than 2 years of age. The author reports the case of a 14-month-old girl who sustained a unilateral nondisplaced coronal suture fracture from a fall. She developed delayed intracranial hemorrhage from an underlying dural tear and cortical vein injury. Although an isolated skull fracture in a pediatric trauma patient typically portends a benign clinical course and may not require that the patient be hospitalized, a nondisplaced fracture across the coronal suture can lead to dural tear and intracranial injuries. High vigilance is warranted when evaluating CT images around the suture lines and treating pediatric patients with fractures across the coronal suture.
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Affiliation(s)
- Tong Yang
- Sanford Brain and Spine Center, Sanford Children's Hospital, Fargo, North Dakota
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Quality Improvement in Pediatric Head Trauma with PECARN Rules Implementation as Computerized Decision Support. Pediatr Qual Saf 2017; 2:e019. [PMID: 30229157 PMCID: PMC6132459 DOI: 10.1097/pq9.0000000000000019] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Accepted: 02/28/2017] [Indexed: 01/30/2023] Open
Abstract
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.
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Badawy MK, Dayan PS, Tunik MG, Nadel FM, Lillis KA, Miskin M, Borgialli DA, Bachman MC, Atabaki SM, Hoyle JD, Holmes JF, Kuppermann N. Prevalence of Brain Injuries and Recurrence of Seizures in Children With Posttraumatic Seizures. Acad Emerg Med 2017; 24:595-605. [PMID: 28170143 DOI: 10.1111/acem.13168] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 01/09/2017] [Accepted: 01/31/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Computed tomography (CT) is often used in the emergency department (ED) evaluation of children with posttraumatic seizures (PTS); however, the frequency of traumatic brain injuries (TBIs) and short-term seizure recurrence is lacking. Our main objective was to evaluate the frequency of TBIs on CT and short-term seizure recurrence in children with PTS. We also aimed to determine the associations between the likelihood of TBI on CT with the timing of onset of PTS after the traumatic event and duration of PTS. Finally, we aimed to determine whether patients with normal CT scans and normal neurological examinations are safe for discharge from the ED. METHODS This was a planned secondary analysis from a prospective observational cohort study to derive and validate a neuroimaging decision rule for children after blunt head trauma at 25 EDs in the Pediatric Emergency Care Applied Research Network. We evaluated children < 18 years with head trauma and PTS between June 2004 and September 2006. We assessed TBI on CT, neurosurgical interventions, and recurrent seizures within 1 week. Patients discharged from the ED were contacted by telephone 1 week to 3 months later. RESULTS Of 42,424 children enrolled, 536 (1.3%, 95% confidence interval [CI] = 1.2%-1.4%) had PTS. A total of 466 of 536 (86.9%, 95% CI = 83.8%-89.7%) underwent CT in the ED. TBIs on CT were identified in 72 (15.5%, 95% CI = 12.3%-19.1%), of whom 20 (27.8%, 95% CI = 17.9%-39.6%) underwent neurosurgical intervention and 15 (20.8%, 95% CI = 12.2%-32.0%) had recurrent seizures. Of the 464 without TBIs on CT (or no CTs performed), 457 had recurrent seizure status known, and five (1.1%, 95 CI = 0.4%-2.5%) had recurrent seizures; four of five presented with Glasgow Coma Scale scores < 15. None of the 464 underwent neurosurgical intervention. We found significant associations between likelihood of TBI on CT with longer time until the PTS after the traumatic event (p = 0.006) and longer duration of PTS (p < 0.001). CONCLUSIONS Children with PTS have a high likelihood of TBI on CT, and those with TBI on CT frequently require neurosurgical interventions and frequently have recurrent seizures. Those without TBIs on CT, however, are at low risk of short-term recurrent seizures, and none required neurosurgical interventions. Therefore, if CT-negative and neurologically normal, patients with PTS may be safely considered for discharge from the ED.
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Affiliation(s)
- Mohamed K. Badawy
- Department of Pediatrics; University of Texas Southwestern Medical School; Dallas TX
| | - Peter S. Dayan
- Department of Pediatrics; Columbia University College of Physicians and Surgeons; New York NY
| | - Michael G. Tunik
- Departments of Emergency Medicine and Pediatrics; NYU School of Medicine; New York NY
| | - Frances M. Nadel
- Department of Pediatrics; University of Pennsylvania; School of Medicine; Philadelphia PA
| | - Kathleen A. Lillis
- Departments of Pediatrics and Emergency Medicine; State University of New York at Buffalo School of Medicine and Biomedical Sciences; Buffalo NY
| | - Michelle Miskin
- Department of Pediatrics; University of Utah and PECARN Data Coordinating Center; Salt Lake City UT
| | - Dominic A. Borgialli
- Department of Emergency Medicine; University of Michigan School of Medicine and Hurley Medical Center; Flint MI
| | - Michael C. Bachman
- Departments of Emergency Medicine and Pediatrics; Newark Beth Israel Medical Center; Newark NJ
| | - Shireen M. Atabaki
- Departments of Pediatrics and Emergency Medicine; George Washington University School of Medicine; Washington DC
| | - John D. Hoyle
- Division of Emergency Medicine; Michigan State University School of Medicine/Helen Devos Children's Hospital; Grand Rapids MI
| | - James F. Holmes
- Department of Emergency Medicine; University of California; Davis School of Medicine; Sacramento CA
| | - Nathan Kuppermann
- Department of Emergency Medicine; University of California; Davis School of Medicine; Sacramento CA
- Department of Pediatrics; University of California; Davis School of Medicine; Sacramento CA
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Wootton-Gorges SL, Soares BP, Alazraki AL, Anupindi SA, Blount JP, Booth TN, Dempsey ME, Falcone RA, Hayes LL, Kulkarni AV, Partap S, Rigsby CK, Ryan ME, Safdar NM, Trout AT, Widmann RF, Karmazyn BK, Palasis S. ACR Appropriateness Criteria ® Suspected Physical Abuse—Child. J Am Coll Radiol 2017; 14:S338-S349. [DOI: 10.1016/j.jacr.2017.01.036] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/19/2017] [Accepted: 01/23/2017] [Indexed: 10/19/2022]
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Children presenting in delayed fashion after minor head trauma with scalp swelling: do they require further workup? Childs Nerv Syst 2017; 33:647-652. [PMID: 28050641 DOI: 10.1007/s00381-016-3332-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2016] [Accepted: 12/20/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE It is common to evaluate children who have sustained minor head trauma with computed tomography (CT) of the head. Scalp swelling, in particular, has been associated with intracranial injury. A subset of patients, however, present in delayed fashion, often days after the head trauma, as soft tissue edema progresses and their caregiver notices scalp swelling. We explore the value of further workup in this setting. METHODS We conducted a retrospective review of a prospectively collected cohort of children ≤24 months of age presenting to the Texas Children's Hospital with scalp swelling more than 24 h following a head trauma. Cases were collected over a 2-year study period from June 1, 2014 to May 31, 2016. RESULTS Seventy-six patients comprising 78 patient encounters were included in our study. The mean age at presentation was 8.8 months (range 3 days-24 months). All patients had noncontrast CT of the head as part of their evaluation by emergency medicine, as well as screening for nonaccidental trauma (NAT) by the Child Protection Team. The most common finding on CT head was a linear/nondisplaced skull fracture (SF) with associated extra-axial hemorrhage (epidural or subdural hematoma), which was found in 31/78 patient encounters (40%). Of all 78 patient encounters, 43 patients (55%) were discharged from the emergency room (ER), 17 patients (22%) were admitted for neurologic monitoring, and 18 patients (23%) were admitted solely to allow further NAT evaluation. Of those patients admitted, none experienced a neurologic decline and all had nonfocal neurologic exams on discharge. No patient returned to the ER in delayed fashion for a neurologic decline. Of all the patient encounters, no patient required surgery. CONCLUSIONS Pediatric patients ≤24 months of age presenting to the ER in delayed fashion with scalp swelling after minor head trauma-who were otherwise nonfocal on examination-did not require surgical intervention and did not experience any neurologic decline. Further radiographic investigation did not alter neurosurgical management in these patients; however, it should be noted that workup for child abuse and social care may have been influenced by CT findings, suggesting the need for the future development of a clinical decision-making tool to help safely avoid CT imaging in this setting.
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Araki T, Yokota H, Morita A. Pediatric Traumatic Brain Injury: Characteristic Features, Diagnosis, and Management. Neurol Med Chir (Tokyo) 2017; 57:82-93. [PMID: 28111406 PMCID: PMC5341344 DOI: 10.2176/nmc.ra.2016-0191] [Citation(s) in RCA: 146] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in children. Pediatric TBI is associated with several distinctive characteristics that differ from adults and are attributable to age-related anatomical and physiological differences, pattern of injuries based on the physical ability of the child, and difficulty in neurological evaluation in children. Evidence suggests that children exhibit a specific pathological response to TBI with distinct accompanying neurological symptoms, and considerable efforts have been made to elucidate their pathophysiology. In addition, recent technical advances in diagnostic imaging of pediatric TBI has facilitated accurate diagnosis, appropriate treatment, prevention of complications, and helped predict long-term outcomes. Here a review of recent studies relevant to important issues in pediatric TBI is presented, and recent specific topics are also discussed. This review provides important updates on the pathophysiology, diagnosis, and age-appropriate acute management of pediatric TBI.
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Affiliation(s)
- Takashi Araki
- Department of Emergency and Critical Care Medicine, Nippon Medical School Hospital
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Point-of-Care Ultrasound for the Detection of Traumatic Intracranial Hemorrhage in Infants: A Pilot Study. Pediatr Emerg Care 2017; 33:18-20. [PMID: 26308609 DOI: 10.1097/pec.0000000000000518] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Computed tomography is the criterion standard imaging modality to detect intracranial hemorrhage (ICH) in children and infants after closed head injury, but its use can be limited by patient instability, need for sedation, and risk of ionizing radiation exposure. Cranial ultrasound is used routinely to detect intraventricular hemorrhage in neonates. We sought to determine if point-of-care (POC) cranial ultrasound performed by emergency physicians can detect traumatic ICH in infants. METHODS Infants with ICH diagnosed by computed tomography were identified. For every infant with an ICH, 2 controls with symptoms and diagnoses unrelated to head trauma were identified. Point-of-care cranial ultrasound was performed by an emergency physician on all patients, and video clips were recorded. Two ultrasound fellowship-trained emergency physicians, blinded to the patients' diagnosis and clinical status, independently reviewed the ultrasound clips and determined the presence or absence of ICH. RESULTS Twelve patients were included in the study, 4 with ICH and 8 controls. Observer 1 identified ICH with 100% sensitivity (95% confidence interval [CI], 40%-100%) and 100% specificity (95% CI, 60%-100%). Observer 2 identified ICH with 50% sensitivity (95% CI, 9%-98%) and 87.5% specificity (95% CI, 47%-99%). Agreement between observers was 75%, κ = 0.4 (P = 0.079; 95% CI, 0-0.95). CONCLUSIONS Traumatic ICH can be identified with POC cranial ultrasound by ultrasound fellowship-trained emergency physicians. Although variations between observers and wide confidence intervals preclude drawing meaningful conclusions about sensitivity and specificity from this sample, these results support the need for further investigation into the role of POC cranial ultrasound.
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Arneitz C, Sinzig M, Fasching G. Diagnostic and Clinical Management of Skull Fractures in Children. J Clin Imaging Sci 2016; 6:47. [PMID: 28028451 PMCID: PMC5157005 DOI: 10.4103/2156-7514.194261] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2016] [Accepted: 10/05/2016] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE The indications of routine skull X-rays after mild head trauma are still in discussion, and the clinical management of a child with a skull fracture remains controversial. The aim of our retrospective study was to evaluate our diagnostic and clinical management of children with skull fractures following minor head trauma. METHODS We worked up the medical history of all consecutive patients with a skull fracture treated in our hospital from January 2009 to October 2014 and investigated all skull X-rays in our hospital during this period. RESULTS In 5217 skull radiographies, 66 skull fractures (1.3%) were detected. The mean age of all our patients was 5.9 years (median age: 4.0 years); the mean age of patients with a diagnosed skull fracture was 2.3 years (median age: 0.8 years). A total of 1658 children (32%) were <2 years old. A typical boggy swelling was present in 61% of all skull fractures. The majority of injuries were caused by falls (77%). Nine patients (14%) required a computed tomography (CT) scan during their hospital stay due to neurological symptoms, and four patients had a brain magnetic resonance imaging. Nine patients (14%) showed an intracranial hemorrhage (ICH; mean age: 7.3 years); one patient had a neurosurgery because of a depressed skull fracture. Nine patients (14%) were observed at our pediatric intensive care unit for a mean time of 2.9 days. The mean hospital stay was 4.2 days. CONCLUSIONS Our findings support previous evidence against the routine use of skull X-rays for evaluation of children with minor head injury. The rate of diagnosed skull fractures in radiographs following minor head trauma is low, and additional CT scans are not indicated in asymptomatic patient with a linear skull fracture. All detected ICHs could be treated conservatively. Children under the age of 2 years have the highest risk of skull fractures after minor head trauma, but do not have a higher incidence of intracranial bleeding. Neuroobservation without initial CT scans is safe in infants and children following minor head trauma and CT scans should be reserved for patients with neurological symptoms.
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Affiliation(s)
- Christoph Arneitz
- Department of Paediatric and Adolescent Surgery, Clinical Centre Klagenfurt, Klagenfurt, Austria
| | - Maria Sinzig
- Department of Radiology, Section of Paediatric Radiology, Clinical Centre Klagenfurt, Klagenfurt, Austria
| | - Günter Fasching
- Department of Paediatric and Adolescent Surgery, Clinical Centre Klagenfurt, Klagenfurt, Austria
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Electrophysiological correlates of emotional face processing after mild traumatic brain injury in preschool children. COGNITIVE AFFECTIVE & BEHAVIORAL NEUROSCIENCE 2016; 17:124-142. [DOI: 10.3758/s13415-016-0467-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
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47
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Andrade FP, Montoro R, Oliveira R, Loures G, Flessak L, Gross R, Donnabella C, Puchnick A, Suzuki L, Regacini R. Pediatric minor head trauma: do cranial CT scans change the therapeutic approach? Clinics (Sao Paulo) 2016; 71:606-610. [PMID: 27759850 PMCID: PMC5054767 DOI: 10.6061/clinics/2016(10)09] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 08/04/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES: 1) To verify clinical signs correlated with appropriate cranial computed tomography scan indications and changes in the therapeutic approach in pediatric minor head trauma scenarios. 2) To estimate the radiation exposure of computed tomography scans with low dose protocols in the context of trauma and the additional associated risk. METHODS: Investigators reviewed the medical records of all children with minor head trauma, which was defined as a Glasgow coma scale ≥13 at the time of admission to the emergency room, who underwent computed tomography scans during the years of 2013 and 2014. A change in the therapeutic approach was defined as a neurosurgical intervention performed within 30 days, hospitalization, >12 hours of observation, or neuro-specialist evaluation. RESULTS: Of the 1006 children evaluated, 101 showed some abnormality on head computed tomography scans, including 49 who were hospitalized, 16 who remained under observation and 36 who were dismissed. No patient underwent neurosurgery. No statistically significant relationship was observed between patient age, time between trauma and admission, or signs/symptoms related to trauma and abnormal imaging results. A statistically significant relationship between abnormal image results and a fall higher than 1.0 meter was observed (p=0.044). The mean effective dose was 2.0 mSv (0.1 to 6.8 mSv), corresponding to an estimated additional cancer risk of 0.05%. CONCLUSION: A computed tomography scan after minor head injury in pediatric patients did not show clinically relevant abnormalities that could lead to neurosurgical indications. Patients who fell more than 1.0 m were more likely to have changes in imaging tests, although these changes did not require neurosurgical intervention; therefore, the use of computed tomography scans may be questioned in this group. The results support the trend of more careful indications for cranial computed tomography scans for children with minor head trauma.
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Affiliation(s)
- Felipe P Andrade
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
- E-mail:
| | - Roberto Montoro
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Renan Oliveira
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Gabriela Loures
- Hospital Infantil Sabará, Departamento de Diagnóstico por Imagem, São Paulo/SP, Brazil
| | - Luana Flessak
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Roberta Gross
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Camille Donnabella
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Andrea Puchnick
- Universidade Federal de São Paulo (UNIFESP), Departamento de Diagnóstico por Imagem, São Paulo/SP, Brazil
| | - Lisa Suzuki
- Hospital Infantil Sabará, Departamento de Diagnóstico por Imagem, São Paulo/SP, Brazil
| | - Rodrigo Regacini
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
- Hospital Infantil Sabará, Departamento de Diagnóstico por Imagem, São Paulo/SP, Brazil
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48
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The role of computed tomography in following up pediatric skull fractures. Am J Surg 2016; 214:483-488. [PMID: 27614418 DOI: 10.1016/j.amjsurg.2016.07.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 06/07/2016] [Accepted: 07/18/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite the added radiation exposure and costs, the role of computed tomography (CT) in following pediatric skull fractures has not been fully evaluated. METHODS We reviewed the radiology reports and images of the initial and follow-up head CT examinations of children with skull fractures to determine whether any interval changes in the fracture morphology and associated complications necessitate a change in clinical management. RESULTS A total of 316 pediatric cases of skull fractures were identified, including 172 patients with and 144 without follow-up scans. At follow-up, 7% of skull fractures were unchanged, 65% healing, and 28% healed. No patient showed findings to cause a change in clinical management or a need for further medical or surgical intervention regardless of the number and patterns of the fractures or the initial intracranial complications such as intracranial hemorrhage, pneumocephalus, and traumatic brain injuries. CONCLUSIONS Head CT may be unnecessary in following pediatric skull fractures in asymptomatic patients to avoid added radiation exposure and cost.
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Merhar SL, Kline-Fath BM, Nathan AT, Melton KR, Bierbrauer KS. Identification and management of neonatal skull fractures. J Perinatol 2016; 36:640-2. [PMID: 27054839 DOI: 10.1038/jp.2016.53] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 12/17/2015] [Accepted: 02/01/2016] [Indexed: 11/10/2022]
Abstract
OBJECTIVE Suspected skull fractures in the neonate are uncommon and present a management dilemma. We hypothesized that skull fractures are more common than reported in the literature and that few infants require any intervention. STUDY DESIGN We retrospectively reviewed the charts of 21 infants referred to our level IV Neonatal Intensive Care Unit for possible skull fracture over a 3-year period after birth trauma, suspicious findings on clinical exam, or accidental falls in the birth hospital. RESULTS Skull films at the birth hospital were unreliable for fracture in 23% of cases. Seven of nine infants with accidental falls had fracture on computed tomography scan. Only three infants required neurosurgical intervention, all after severe birth trauma associated with instrumentation. CONCLUSION Skull fractures are more common than previously reported in neonates after accidental falls, but few infants with skull fractures require neurosurgical intervention.
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Affiliation(s)
- S L Merhar
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - B M Kline-Fath
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - A T Nathan
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K R Melton
- Perinatal Institute, Division of Neonatology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - K S Bierbrauer
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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Lyons TW, Stack AM, Monuteaux MC, Parver SL, Gordon CR, Gordon CD, Proctor MR, Nigrovic LE. A QI Initiative to Reduce Hospitalization for Children With Isolated Skull Fractures. Pediatrics 2016; 137:peds.2015-3370. [PMID: 27244848 PMCID: PMC4894255 DOI: 10.1542/peds.2015-3370] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/04/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVE Although children with isolated skull fractures rarely require acute interventions, most are hospitalized. Our aim was to safely decrease the hospitalization rate for children with isolated skull fractures. METHODS We designed and executed this multifaceted quality improvement (QI) initiative between January 2008 and July 2015 to reduce hospitalization rates for children ≤21 years old with isolated skull fractures at a single tertiary care pediatric institution. We defined an isolated skull fracture as a skull fracture without intracranial injury. The QI intervention consisted of 2 steps: (1) development and implementation of an evidence-based guideline, and (2) dissemination of a provider survey designed to reinforce guideline awareness and adherence. Our primary outcome was hospitalization rate and our balancing measure was hospital readmission within 72 hours. We used standard statistical process control methodology to assess change over time. To assess for secular trends, we examined admission rates for children with an isolated skull fracture in the Pediatric Health Information System administrative database. RESULTS We identified 321 children with an isolated skull fracture with a median age of 11 months (interquartile range 5-16 months). The baseline admission rate was 71% (179/249, 95% confidence interval, 66%-77%) and decreased to 46% (34/72, 95% confidence interval, 35%-60%) after implementation of our QI initiative. No child was readmitted after discharge. The admission rate in our secular trend control group remained unchanged at 78%. CONCLUSIONS We safely reduced the hospitalization rate for children with isolated skull fractures without an increase in the readmissions.
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Affiliation(s)
| | | | | | | | | | | | - Mark R. Proctor
- Department of Neurosurgery, Boston Children’s Hospital and Harvard Medical School, Boston, Massachusetts
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