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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Alonso-Cadenas JA, Calderón Checa RM, Rivas García A, Durán Hidalgo I, Cabrero Hernández M, Ruiz González S, Pérez García MJ, 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. Evaluation of the PECARN rule for traumatic brain injury applied to infants younger than 3 months and creation of a modified, age-specific rule. Eur J Pediatr 2023; 182:191-200. [PMID: 36278996 DOI: 10.1007/s00431-022-04661-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 10/11/2022] [Accepted: 10/12/2022] [Indexed: 01/12/2023]
Abstract
UNLABELLED Infants < 3 months with minor head trauma (MHT) are a particularly vulnerable group, though few studies have focused specifically on these patients. We aimed to evaluate the application of the PECARN prediction rule, designed for clinically important traumatic brain injury (ciTBI) in children < 2 years in infants < 3 months, and create a specific prediction rule for this population. We conducted a prospective multicenter observational study in 13 pediatric emergency departments (PEDs) in Spain. The PECARN rule was applied to all patients. A new specific prediction rule for infants < 3 months of age was created. The main outcome measures were (1) ciTBI, (2) TBI evidenced on computed tomography (CT) scan, and (3) isolated skull fracture (ISF). Telephone follow-up was conducted for all patients over the 4 weeks after the initial PED visit. Of 21,981 children with MHT, 366 (1.7%) were < 3 months old and 195 (53.3%) underwent neuroimaging, including 37 (10.1%) with CT scan. The sensitivity and negative predictive value (NPV) of the PECARN prediction rule for ciTBI were 100% (95% CI, 20.7-100) and 99.7% (95% CI, 98.4-100%), respectively. Of the 230 infants (62.8%) who met the PECARN low-risk criteria, none had ciTBI, 1 (0.4% overall, 95% CI, 0-2.4) had TBI on CT, and 2 (0.9% overall; 95% CI, 0.1-3.1) had an ISF. Among the 136 infants (37.2%) who did not meet the PECARN low-risk criteria, 1 (0.3% overall; 95% CI, 0-1.5) had ciTBI, 11 (8.1% overall; 95% CI, 4.1-14.0) had TBI on CT, and 18 (13.2% overall; 95% CI, 8-20.1) had an ISF. The sensitivity and NPV of the Spanish prediction rule for ciTBI were 100% (95% CI, 20.7-100) and 100% (95% CI, 98.4-100%), respectively. No infants in the registry developed complications during follow-up. CONCLUSION The PECARN rule for infants < 2 years old accurately identified infants < 3 months old at low risk for ciTBI in our population, although the adapted Spanish rule presented here could be even more accurate. 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 • PECARN rule for infants < 2 years old is an adequate tool with which to identify infants < 3 months old at low risk for clinically important traumatic brain injury. • Spanish rule could identify even more low-risk infants without overlooking important outcomes but it should be validated to confirm its predictive capacity.
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Affiliation(s)
- José Antonio Alonso-Cadenas
- Pediatric Emergency Department, Hospital Infantil Universitario Niño Jesús, Spain Instituto de Investigación Sanitaria Hospital Universitario La Princesa, Avenida de Menedez Pelayo 65, 28009, Madrid, Spain. .,Instituto de Investigación Sanitaria, Hospital Universitario La Princesa, Madrid, Spain.
| | | | - Arístides Rivas García
- Pediatric Emergency Department, Hospital Universitario Gregorio Marañón, Spain Instituto de Investigación Sanitaria Hospital Universitario Gregorio Marañón, Madrid, Spain.,Instituto de Investigación Sanitaria, Hospital General Universitario Gregorio Marañón, 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 Universitario Sant Joan de Déu Barcelona, Esplugues de Llobregat, Spain
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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] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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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] [What about the content of this article? (0)] [Affiliation(s)] [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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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] [What about the content of this article? (0)] [Affiliation(s)] [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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Nozaki T, Fujimoto A, Ichikawa N, Baba S, Enoki H, Okanishi T. Higher intelligence may be a risk factor for postoperative transient disturbance of consciousness after corpus callosotomy. Epilepsy Behav 2021; 115:107617. [PMID: 33309425 DOI: 10.1016/j.yebeh.2020.107617] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Revised: 10/30/2020] [Accepted: 10/30/2020] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Corpus callosotomy (CC) is an established surgical option for palliative treatment of medically intractable epilepsy, especially for seizures with drop attacks. We postulated that specific risk factors for post-CC transient disturbance of consciousness (pCTDC) are associated with CC. The purpose of this study was to review patients with intractable epilepsy who underwent CC and to statistically analyze risk factors for pCTDC. METHODS Inclusion criteria for patients who underwent CC between January 2009 and November 2019 were: (1) ≥2 years old and (2) followed up for more than 8 months. The state of consciousness before and after CC was evaluated with the Glasgow coma scale. We statistically assessed predictors for pCTDC as the primary outcome. RESULTS Fifty-six patients (19 females, 37 males) were enrolled, and the age range was 2-57 years old. Thirty-seven (66.1%) patients developed pCTDC. The mean period from the beginning of the state of pCTDC to recovery to their baseline conscious level was 4.9 days (range: 2-25 days). All three (100%) normal intelligence level patients, 13 (81%) of 16 patients with a moderately impaired level of intelligence, and 21 (57%) of 37 patients with a severely impaired level of intelligence exhibited pCTDC. Univariate (p = 0.044) and multivariate (p = 0.006) logistic regression analyses for predictors of pCTDC showed that intellectual function was statistically significant. CONCLUSION Two-thirds of patients developed pCTDC. One risk factor for pCTDC may be higher intellectual function.
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Affiliation(s)
- Toshiki Nozaki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Ayataka Fujimoto
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan.
| | - Naoki Ichikawa
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Shimpei Baba
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Hideo Enoki
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
| | - Tohru Okanishi
- Comprehensive Epilepsy Center, Seirei Hamamatsu General Hospital, Shizuoka, Japan
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