PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study

BACKGROUND

The intra-abdominal injury and traumatic brain injury prediction rules derived by the Pediatric Emergency Care Applied Research Network (PECARN) were designed to reduce inappropriate use of CT in children with abdominal and head trauma, respectively. We aimed to validate these prediction rules for children presenting to emergency departments with blunt abdominal or minor head trauma.

METHODS

For this prospective validation study, we enrolled children and adolescents younger than 18 years presenting to six emergency departments in Sacramento (CA), Dallas (TX), Houston (TX), San Diego (CA), Los Angeles (CA), and Oakland (CA), USA between Dec 27, 2016, and Sept 1, 2021. We excluded patients who were pregnant or had pre-existing neurological disorders preventing examination, penetrating trauma, injuries more than 24 h before arrival, CT or MRI before transfer, or high suspicion of non-accidental trauma. Children presenting with blunt abdominal trauma were enrolled into an abdominal trauma cohort, and children with minor head trauma were enrolled into one of two age-segregated minor head trauma cohorts (younger than 2 years vs aged 2 years and older). Enrolled children were clinically examined in the emergency department, and CT scans were obtained at the attending clinician's discretion. All enrolled children were evaluated against the variables of the pertinent PECARN prediction rule before CT results were seen. The primary outcome of interest in the abdominal trauma cohort was intra-abdominal injury undergoing acute intervention (therapeutic laparotomy, angiographic embolisation, blood transfusion, intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries, or death from intra-abdominal injury). In the age-segregated minor head trauma cohorts, the primary outcome of interest was clinically important traumatic brain injury (neurosurgery, intubation for >24 h for traumatic brain injury, or hospital admission ≥2 nights for ongoing symptoms and CT-confirmed traumatic brain injury; or death from traumatic brain injury).

FINDINGS

7542 children with blunt abdominal trauma and 19 999 children with minor head trauma were enrolled. The intra-abdominal injury rule had a sensitivity of 100·0% (95% CI 98·0-100·0; correct test for 145 of 145 patients with intra-abdominal injury undergoing acute intervention) and a negative predictive value (NPV) of 100·0% (95% CI 99·9-100·0; correct test for 3488 of 3488 patients without intra-abdominal injuries undergoing acute intervention). The traumatic brain injury rule for children younger than 2 years had a sensitivity of 100·0% (93·1-100·0; 42 of 42) for clinically important traumatic brain injuries and an NPV of 100·0%; 99·9-100·0; 2940 of 2940), whereas the traumatic brain injury rule for children aged 2 years and older had a sensitivity of 98·8% (95·8-99·9; 168 of 170) and an NPV of 100·0% (99·9-100·0; 6015 of 6017). The two children who were misclassified by the traumatic brain injury rule were admitted to hospital for observation but did not need neurosurgery.

INTERPRETATION

The PECARN intra-abdominal injury and traumatic brain injury rules were validated with a high degree of accuracy. Their implementation in paediatric emergency departments can therefore be considered a safe strategy to minimise inappropriate CT use in children needing high-quality care for abdominal or head trauma.

FUNDING

The Eunice Kennedy Shriver National Institute of Child Health and Human Development.

The role of resilience in the development of depression, anxiety, and post-traumatic stress disorder after trauma in children and adolescents

This investigation, conducted within the Texas Childhood Trauma Research Network, investigated the prospective relationships between resiliency and emergent internalizing symptoms among trauma-exposed youth. The cohort encompassed 1262 youth, aged 8-20, from twelve health-related institutions across Texas, who completed assessments at baseline and one- and six-month follow-ups for resiliency, symptoms of depression, generalized anxiety, posttraumatic stress disorder (PTSD), and other demographic and clinical characteristics. At baseline, greater resilience was positively associated with older age, male (vs female) sex assigned at birth, and history of mental health treatment. Unadjusted for covariates, higher baseline resilience was associated with greater prospective depression and PTSD symptoms but not anxiety symptoms. Upon adjusting for demographic and clinical factors, higher baseline resilience was no longer associated with depression, PTSD, or anxiety symptoms. Our analyses demonstrate that the predictive value of resilience on psychopathology is relatively small compared to more readily observable clinical and demographic factors. These data suggest a relatively minor prospective role of resilience in protecting against internalizing symptoms among trauma-exposed youth and highlight the importance of controlling for relevant youth characteristics when investigating a protective effect of resilience on internalizing symptoms.

Risk Factors for Blunt Cerebrovascular Injury in a Cohort of Pediatric Patients With Cervical Seat Belt Sign

BACKGROUND

Three-point seat belt restraints have been attributed to blunt cerebrovascular injury (BVCI), injury to the carotid or vertebral arteries. Although previous studies have not found a seat belt sign to be a significant predictor for BCVI, it is still used to screen patients for BCVI.

OBJECTIVE

This study aims to determine risk factors for BCVI within a cohort of patients with seat belt signs.

METHODS

We conducted a retrospective cohort study using our institutional trauma registry and included patients younger than 18 years with blunt trauma who both had a computed tomography angiography (CTA) of the neck performed and had evidence of a seat belt sign per the medical record. We reported frequencies, proportions, and measures of central tendency and conducted univariate analysis to evaluate factors associated with BCVI. We estimated the magnitude of the effect of each variable associated with the study outcome by conducting logistic regression and reporting odds ratios and 95% confidence intervals.

RESULTS

Among all study patients, BCVI injuries were associated with Injury Severity Score higher than 15 (P = 0.04), cervical spinal fractures (P = 0.007), or basilar skull fractures (P = 0.01). We observed higher proportions of children with BCVI when other motorized and other blunt mechanisms were reported as the mechanisms of injury (P = 0.002) versus motor vehicle collision.

CONCLUSIONS

Significant risk factors for BCVI in the presence of seat belt sign are: Injury severity score greater than 15, cervical spinal fracture, basilar skull fracture, and the other motorized mechanism of injury, similar to those in all children at risk of BCVI.

National community disparities in prehospital penetrating trauma adjusted for income, 2020-2021

INTRODUCTION

While Black individuals experienced disproportionately increased firearm violence and deaths during the COVID-19 pandemic, less is known about community level disparities. We sought to evaluate national community race and ethnicity differences in 2020 and 2021 rates of penetrating trauma.

METHODS

We linked the 2018-2021 National Emergency Medical Services Information System databases to ZIP Code demographics. We stratified encounters into majority race/ethnicity communities (>50% White, Black, or Hispanic/Latino). We used logistic regression to compare penetrating trauma for each community in 2020 and 2021 to a combined 2018-2019 historical baseline. Majority Black and majority Hispanic/Latino communities were compared to majority White communities for each year. Analyses were adjusted for household income.

RESULTS

We included 87,504,097 encounters (259,449 penetrating traumas). All communities had increased odds of trauma in 2020 when compared to 2018-2019, but this increase was largest for Black communities (aOR 1.4, [1.3-1.4]; White communities - aOR 1.2, [1.2-1.3]; Hispanic/Latino communities - aOR 1.1. [1.1-1.2]). There was a similar trend of increased penetrating trauma in 2021 for Black (aOR 1.2, [1.2-1.3]); White (aOR 1.2, [1.1-1.2]); Hispanic/Latino (aOR 1.1, [1.1-1.1]). Comparing penetrating trauma in each year to White communities, Black communities had higher odds of trauma in all years (2018/2019 - aOR 3.0, [3.0-3.1]; 2020 - aOR 3.3, [3.3-3.4]; 2021 - aOR 3.3, [3.2-3.2]). Hispanic/Latino also had more trauma each year but to a lesser degree (2018/2019 - aOR 2.0, [2.0-2.0]; 2020 - aOR 1.8, [1.8-1.9]; 2021 - aOR 1.9, [1.8-1.9]).

CONCLUSION

Black communities were most impacted by increased penetrating trauma rates in 2020 and 2021 even after adjusting for income.

A Novel Risk Score to Guide the Evaluation of Acute Hematogenous Osteomyelitis in Children

OBJECTIVES

To identify independent predictors of and derive a risk score for acute hematogenous osteomyelitis (AHO) in children.

METHODS

We conducted a retrospective matched case-control study of children >90 days to <18 years of age undergoing evaluation for a suspected musculoskeletal (MSK) infection from 2017 to 2019 at 23 pediatric emergency departments (EDs) affiliated with the Pediatric Emergency Medicine Collaborative Research Committee. Cases were identified by diagnosis codes and confirmed by chart review to meet accepted diagnostic criteria for AHO. Controls included patients who underwent laboratory and imaging tests to evaluate for a suspected MSK infection and received an alternate final diagnosis.

RESULTS

We identified 1135 cases of AHO matched to 2270 controls. Multivariable logistic regression identified 10 clinical and laboratory factors independently associated with AHO. We derived a 4-point risk score for AHO using (1) duration of illness >3 days, (2) history of fever or highest ED temperature ≥38°C, (3) C-reactive protein >2.0 mg/dL, and (4) erythrocyte sedimentation rate >25 mm per hour (area under the curve: 0.892, 95% confidence interval [CI]: 0.881 to 0.901). Choosing to pursue definitive diagnostics for AHO when 3 or more factors are present maximizes diagnostic accuracy at 84% (95% CI: 82% to 85%), whereas children with 0 factors present are highly unlikely to have AHO (sensitivity: 0.99, 95% CI: 0.98 to 1.00).

CONCLUSIONS

We identified 10 predictors for AHO in children undergoing evaluation for a suspected MSK infection in the pediatric ED and derived a novel 4-point risk score to guide clinical decision-making.

Pediatric firearm injury epidemiology at a level 1 trauma center from 2019 to 2021: including time of the COVID-19 pandemic

BACKGROUND

Firearms are a leading cause of death in children. The demand for firearms increased following COVID-19 "stay-at home orders" in March 2020, resulting in record-breaking firearm sales and background checks. We aim to describe the changes in pediatric firearm-related injuries, demographics, and associated risk factors at a Level 1 trauma center in Houston before and during the COVID 19 pandemic.

RESULTS

The total number of pediatric firearm-related injury cases increased during March 15th to December 31st, 2020 and 2021 compared to the same time period in 2019 (104 verses 89 verses 78). The demographic group most affected across years were males (87% in 2019 vs 82% in 2020 and 87% in 2021) between 14 and 17 years old (83% in 2019 vs 81% in 2020 and 76% in 2021). There was an increase in firearm injuries among black youth across all years (28% in 2019 vs 41% in 2020 vs 49% in 2021). Injuries in those with mental illness (10% in 2019 vs 24% in 2020 vs 17% in 2021), and injuries where the shooter was a known family member or friend (14% in 2019 vs 18% in 2020 vs. 15% in 2021), increased from 2019 to 2020.

CONCLUSION

The total number of pediatric firearm-related injuries increased during the COVID-19 pandemic compared to the previous year despite a decline in overall pediatric emergency department visits. Increases in pediatric firearm-related injuries in already vulnerable populations should prompt further hospital initiatives including counseling on safe firearm storage, implementation of processes to identify children at risk for firearm injuries, and continued research to mitigate the risk of injury and death associated with firearms in our community.

Establishing a training plan and estimating inter-rater reliability across the multi-site Texas childhood trauma research network

OBJECTIVE

Minimal guidance is available in the literature to develop protocols for training non-clinician raters to administer semi-structured psychiatric interviews in large, multi-site studies. Previous work has not produced standardized methods for maintaining rater quality control or estimating interrater reliability (IRR) in such studies. Our objective is to describe the multi-site Texas Childhood Trauma Research Network (TX-CTRN) rater training protocol and activities used to maintain rater calibration and evaluate protocol effectiveness.

METHODS

Rater training utilized synchronous and asynchronous didactic learning modules, and certification involved critique of videotaped mock scale administration. Certified raters attended monthly review meetings and completed ongoing scoring exercises for quality assurance purposes. Training protocol effectiveness was evaluated using individual measure and pooled estimated IRRs for three key study measures (TESI-C, CAPS-CA-5, MINI-KID [Major Depressive Episodes - MDE & Posttraumatic Stress Disorder - PTSD modules]). A random selection of video-recorded administrations of these measures was evaluated by three certified raters to estimate agreement statistics, with jackknife (on the videos) used for confidence interval estimation. Kappa, weighted kappa and intraclass correlations were calculated for study measure ratings.

RESULTS

IRR agreement across all measures was strong (TESI-C median kappa 0.79, lower 95% CB 0.66; CAPS-CA-5 median weighted kappa 0.71 (0.62), MINI-MDE median kappa 0.71 (0.62), MINI-PTSD median kappa 0.91 (0.9). The combined estimated ICC was ≥0.86 (lower CBs ≥0.69).

CONCLUSIONS

The protocol developed by TX-CTRN may serve as a model for other multi-site studies that require comprehensive non-clinician rater training, quality assurance guidelines, and a system for assessing and estimating IRR.

Multi-Center Validation of the McGovern Pediatric Blunt Cerebrovascular Injury Screening Score

Blunt cerebrovascular injury (BCVI) is defined as blunt trauma to the head and neck leading to damage to the vertebral and/or carotid arteries; debate exists regarding which children are considered at high risk for BCVI and in need of angiographic/vessel imaging. We previously proposed a screening tool, the McGovern score, to identify pediatric trauma patients at high risk for BCVI, and we aim to validate the McGovern score by pooling data from multiple pediatric trauma centers. This is a multi-center, hospital-based, cohort study from all prospectively registered pediatric (<16 years of age) trauma patients who presented to the emergency department (ED) between 2003 and 2017 at six Level 1 pediatric trauma centers. The registry was retrospectively queried for patients who received a computed tomography angiogram (CTA) as a screening method for BCVI. Age, length of follow-up, mechanism of injury (MOI), arrival Glasgow Coma Scale (GCS) score, and focal neurological deficit were recorded. Radiological variables queried were the presence of a carotid canal fracture, petrous temporal bone fracture, and CT presence of infarction. Patients with BCVI were queried for mode of treatment, type of intracranial injury, artery damaged, and BCVI injury grade. The McGovern score was calculated for all patients who underwent CTA across all data groups. A total of 1012 patients underwent CTA; 72 of these patients were found to have BCVI, 51 of which were in the validation cohort. Across all data groups, the McGovern score has a >80% sensitivity (SN) and >98% negative predictive value (NPV). The McGovern score for pediatric BCVI is an effective, generalizable screening tool.

Validation of Prediction Rules for Computed Tomography Use in Children With Blunt Abdominal or Blunt Head Trauma: Protocol for a Prospective Multicenter Observational Cohort Study

BACKGROUND

Traumatic brain injuries (TBIs) and intra-abdominal injuries (IAIs) are 2 leading causes of traumatic death and disability in children. To avoid missed or delayed diagnoses leading to increased morbidity, computed tomography (CT) is used liberally. However, the overuse of CT leads to inefficient care and radiation-induced malignancies. Therefore, to maximize precision and minimize the overuse of CT, the Pediatric Emergency Care Applied Research Network (PECARN) previously derived clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma in large cohorts of children who are injured.

OBJECTIVE

This study aimed to validate the IAI and age-based TBI clinical prediction rules for identifying children at high risk and very low risk for IAIs undergoing acute intervention and clinically important TBIs after blunt trauma.

METHODS

This was a prospective 6-center observational study of children aged <18 years with blunt torso or head trauma. Consistent with the original derivation studies, enrolled children underwent routine history and physical examinations, and the treating clinicians completed case report forms prior to knowledge of CT results (if performed). Medical records were reviewed to determine clinical courses and outcomes for all patients, and for those who were discharged from the emergency department, a follow-up survey via a telephone call or SMS text message was performed to identify any patients with missed IAIs or TBIs. The primary outcomes were IAI undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries) and clinically important TBI (death from TBI, neurosurgical procedure, intubation for >24 hours for TBI, or hospital admission of ≥2 nights due to a TBI on CT). Prediction rule accuracy was assessed by measuring rule classification performance, using standard point and 95% CI estimates of the operational characteristics of each prediction rule (sensitivity, specificity, positive and negative predictive values, and diagnostic likelihood ratios).

RESULTS

The project was funded in 2016, and enrollment was completed on September 1, 2021. Data analyses are expected to be completed by December 2022, and the primary study results are expected to be submitted for publication in 2023.

CONCLUSIONS

This study will attempt to validate previously derived clinical prediction rules to accurately identify children at high and very low risk for clinically important IAIs and TBIs. Assuming successful validation, widespread implementation is then indicated, which will optimize the care of children who are injured by better aligning CT use with need.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/43027.

Does attention-deficit/hyperactivity disorder increase the risk of minor blunt head trauma in children?

PROBLEM

It is unclear if attention-deficit hyperactivity disorder (ADHD) increases the risk of head trauma in children.

METHODS

We conducted a multicenter prospective observational study of children with minor blunt head trauma. Guardians were queried, and medical records were reviewed as to whether the patient had previously been diagnosed with ADHD. Enrolled patients were categorized based on their mechanism of injury, with a comparison of those with motor vehicle collision (MVC) versus non-MVC mechanisms.

FINDINGS

A total of 3410 (84%) enrolled children had ADHD status available, and 274 (8.0%; 95% confidence interval, CI: 7.1, 9.0%) had been diagnosed with ADHD. The mean age was 9.2 ± 3.5 years and 64% were males. Rates of ADHD for specific mechanisms of injury were: assaults: 23/131 (17.6%; 95% CI 11.5, 25.2%), automobile versus pedestrian 23/173 (13.3%; 95% CI: 8.6, 19.3%), bicycle crashes 26/148 (17.6%; 95% CI: 11.8, 24.7%), falls 107/1651 (6.5%; 95% 5.3, 7.8%), object struck head 31/421 (7.4%; 5.1, 10.3%), motorized vehicle crashes (e.g., motorcycle, motor scooter) 11/148 (7.4%; 3.8, 12.9%), and MVCs 46/704 (6.5%; 95% CI: 4.8, 8.6%).

CONCLUSION

Children with ADHD appear to be at increased risk of head trauma from certain mechanisms of injury including assaults, auto versus pedestrian, and bicycle crashes but are not at an increased risk for falls.

The Impact of Pediatric Opioid-Related Visits on U.S. Emergency Departments

Background: While there is significant research exploring adults’ use of opioids, there has been minimal focus on the opioid impact within emergency departments for the pediatric population. Methods: We examined data from the Agency for Healthcare Research, the National Emergency Department Sample (NEDS), and death data from the Centers for Disease Control and Prevention. Sociodemographic and financial variables were analyzed for encounters during 2014–2017 for patients under age 18, matching diagnoses codes for opioid-related overdose or opioid use disorder. Results: During this period, 59,658 children presented to an ED for any diagnoses involving opioids. The majority (68.5%) of visits were related to overdoses (poisoning), with a mean age of 11.3 years and a majority female (53%). There was a curvilinear relationship between age and encounters, with teens representing the majority of visits, followed by infants. The highest volume was seen in the Southern U.S., with over 58% more opioid visits than the next highest region (Midwest). Charges exceeded USD 157 million, representing 2% of total ED costs, with Medicaid responsible for 54% of the total. Conclusions: With increases in substance use among children, there is a growing need for pediatric emergency physicians to recognize, refer, and initiate treatments.

Focused assessment with sonography for trauma in predicting early surgical intervention in hemodynamically unstable children with blunt abdominal trauma

OBJECTIVES

The predictive accuracy and clinical role of the focused assessment with sonography for trauma (FAST) exam in pediatric blunt abdominal trauma are uncertain. This study investigates the performance of the emergency department (ED) FAST exam to predict early surgical intervention and subsequent free fluid (FF) in pediatric trauma patients.

METHODS

Pediatric level 1 trauma patients ages 0 to 15 years with blunt torso trauma at a single trauma center were retrospectively reviewed. After stratification by initial hemodynamic (HD) instability, the association of a positive FAST with (1) early surgical intervention, defined as operative management (laparotomy or open pericardial window) or angiography within 4 hours of ED arrival and (2) presence of FF during early surgical intervention was determined.

RESULTS

Among 508 salvageable pediatric trauma patients with an interpreted FAST exam, 35 (6.9%) had HD instability and 98 (19.3%) were FAST positive. A total of 42 of 508 (8.3%) patients required early surgical intervention, and the sensitivity and specificity of FAST predicting early surgical intervention were 59.5% and 84.3%, respectively. The specificity and positive predictive value of FF during early surgical intervention in FAST-positive HD unstable patients increased from 50% and 90.9% at 4 hours after ED arrival to 100% and 100% at 2 hours after ED arrival, respectively.

CONCLUSIONS

In this large series of injured children, a positive FAST exam improves the ability to predict the need for early surgical intervention, and accuracy is greater for FF in HD unstable patients 2 hours after arrival to the ED.

Prehospital airway management in the pediatric patient: A systematic review

BACKGROUND

Critically ill children may require airway management to optimize delivery of oxygen and ventilation during resuscitation. We performed a systematic review of studies comparing the use of bag-valve-mask ventilation (BVM), supraglottic airway devices (SGA), and endotracheal intubation (ETI) in pediatric patients requiring prehospital airway management.

METHODS

We searched Ovid MEDLINE, EMBASE, and Cochrane databases for papers that compared SGA or ETI to BVM use in children, including studies that reported survival outcomes. We followed the Preferred Reporting Items in Systematic Reviews and Meta-Analyses (PRISMA) guidelines and assessed study quality using the Newcastle-Ottawa Scale. We compared key characteristics of the candidate papers, including inclusion criteria, definitions of airway interventions, and association with outcomes.

RESULTS

Of 773 studies, eight met criteria for inclusion. Only one study was a randomized controlled trial; the other seven studies were observational. Four studies compared ETI to BVM, two studies compared SGA to BVM, one study compared ETI to SGA, and two studies compared advanced airway management (AAM) to BVM. Primary outcomes varied, ranging from overall mortality and 24-h mortality to 1-month survival, hospital survival, and neurologically favorable survival. Four of the studies found no difference in survival with the use of ETI, and four found increased mortality with the use of ETI. Associations with outcomes could not be assessed by meta-analysis due to limited number of studies and the wide variation in the design, population, interventions, and outcome measures of the included studies.

CONCLUSIONS

In this systematic review, studies of prehospital pediatric airway management varied in scope, design, and conclusions. There was insufficient evidence to evaluate efficacy of pediatric prehospital airway management; however, the current research suggests that there are equal or worse outcomes with the use of ETI compared to other airway techniques. Additional clinical trials are needed to assess the merits of this practice.

Chest x-ray vs. computed tomography of the chest in pediatric blunt trauma

INTRODUCTION

Chest x-ray (CXR) has been shown to be an effective detection tool for clinically significant trauma. We evaluated differences in findings between CXR and computed tomography of the chest (CCT), their impact on clinical management and the performance of the CXR.

METHODS

This retrospective study examined children (less than 18 years) who received a CXR and CCT between 2009 and 2015. We compared characteristics of children by conducting univariate analysis, reporting the proportion of additional diagnoses captured by CCT, and using it to evaluate the sensitivity and specificity of the CXR. Outcome variables were diagnoses made by CCT as well as the ensuing changes in the clinical management attributable to the diagnoses reported by the CCT and not observed by the CXR.

RESULTS

In 1235 children, CCT was associated with diagnosing higher proportions of contusion or atelectasis (60% vs 31%; p < .0001), pneumothorax (23% vs 9%; p < .0001), rib fracture (18% vs 7%; p < .0001), other fracture (20% vs 10%; p < .0001), diaphragm rupture (0.2% vs 0.1%; p = .002), and incidental findings (7% vs 2%; p < .0001) as compared to CXR. CCT findings changed the management of 107 children (8.7%) with 32 (2.6%) of the changes being surgical procedures. The overall sensitivity and specificity of the CXR were 57.9% (95% CI: 54.5-61.2) and 90.2% (95% CI: 86.8-93.1), respectively. The positive predictive value and negative predictive value were 93.1% and 48.6%, respectively.

CONCLUSION

CXR is a useful initial screening tool to evaluate pediatric trauma patients along with clinical presentation in the Emergency Department in children.

LEVEL OF EVIDENCE

Level III, diagnostic test.

Case Series of Adolescents With Stroke-Like Symptoms Following Head Trauma

BACKGROUND

Studies cite the incidence of pediatric blunt cerebrovascular injuries (BCVI) ranges from 0.03% to 1.3%. While motor vehicle incidents are a known high-risk mechanism, we are the first to report on football injuries resulting in BCVI.

CASE REPORT

Case 1 is a 14-year-old male football player who presented with slurred speech and facial droop 16 h after injury that had resulted in unilateral stinger on the field. The patient had a negative brain computed tomography (CT) at the onset of symptoms. Given progression of symptoms over the next 24 h, re-evaluation with CT angiography (CTA) of brain and neck showed left internal carotid artery (ICA) dissection, and magnetic resonance imaging of the brain showed left middle cerebral artery infarct. Case 2 is a 16-year-old male football player who presented with headache and right hemiparesis immediately following a tackle injury. CT brain and neck were negative at an outside hospital, but he was transferred to us for progressive symptoms, and then CTA showed a left ICA dissection with distal emboli, including occlusive involvement of the intracranial left ICA. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The diagnosis of BCVI requires a high level of suspicion. Focal neurologic deficits are consistently a risk factor across all screening criteria, including the Denver, Utah, Memphis, and Eastern Association for the Surgery of Trauma. These current screening criteria, however, may not be sufficient to diagnosis BCVI in children. The addition of the mechanism of injury and attention to the patient's clinical presentation and examination are important to prevent missed diagnosis and poor neurologic outcomes.

Risk Factors in Pediatric Blunt Cervical Vascular Injury and Significance of Seatbelt Sign

Introduction

Computed tomography angiography (CTA) is used to screen patients for cerebrovascular injury after blunt trauma, but risk factors are not clearly defined in children. This modality has inherent radiation exposure. We set out to better delineate the risk factors associated with blunt cervical vascular injury (BCVI) in children with attention to the predictive value of seatbelt sign of the neck.

Methods

We collected demographic, clinical and radiographic data from the electronic medical record and a trauma registry for patients less than age 18 years who underwent CTA of the neck in their evaluation at a Level I trauma center from November 2002 to December 2014 (12 years). The primary outcome was BCVI.

Results

We identified 11,446 pediatric blunt trauma patients of whom 375 (2.7%) underwent CTA imaging. Fifty-three patients (0.4%) were diagnosed with cerebrovascular injuries. The average age of patients was 12.6 years and included 66% males. Nearly half of the population was white (52%). Of those patients who received CTA, 53 (14%) were diagnosed with arterial injury of various grades (I-V). We created models to evaluate factors independently associated with BCVI. The independent predictors associated with BCVI were Injury Severity Score >/= 16 (odds ratio [OR] [2.35]; 95% confidence interval [CI] [1.11-4.99%]), infarct on head imaging (OR [3.85]; 95% CI [1.49-9.93%]), hanging mechanism (OR [8.71]; 95% CI [1.52-49.89%]), cervical spine fracture (OR [3.84]; 95% CI [1.94-7.61%]) and basilar skull fracture (OR [2.21]; 95% CI [1.13-4.36%]). The same independent predictors remained associated with BCVI when excluding hanging mechanism from the multivariate regression analysis. Seatbelt sign of the neck was not associated with BCVI (p=0.68).

Conclusion

We have found independent predictors of BCVI in pediatric patients. These may help in identifying children that may benefit from screening with CTA of the neck.

Pediatric blunt cerebrovascular injury: the McGovern screening score

OBJECTIVE The objective of this study was to assess the incidence, diagnosis, and treatment of pediatric blunt cerebrovascular injury (BCVI) at a busy Level 1 trauma center and to develop a tool for accurately predicting pediatric BCVI and the need for diagnostic testing. METHODS This is a retrospective cohort study of a prospectively collected database of pediatric patients who had sustained blunt trauma (patient age range 0-15 years) and were treated at a Level 1 trauma center between 2005 and 2015. Digital subtraction angiography, MR angiography, or CT angiography was used to confirm BCVI. Recently, the Utah score has emerged as a screening tool specifically targeted toward evaluating BCVI risk in the pediatric population. Using logistical regression and adding mechanism of injury as a logit, the McGovern score was able to use the Utah score as a starting point to create a more sensitive screening tool to identify which pediatric trauma patients should receive angiographic imaging due to a high risk for BCVI. RESULTS A total of 12,614 patients (mean age 6.6 years) were admitted with blunt trauma and prospectively registered in the trauma database. Of these, 460 (3.6%) patients underwent angiography after blunt trauma: 295 (64.1%), 107 (23.3%), 6 (1.3%), and 52 (11.3%) patients underwent CT angiography, MR angiography, digital subtraction angiography, and a combination of imaging modalities, respectively. The BCVI incidence (n = 21; 0.17%) was lower than that in a comparable adult group (p < 0.05). The mean patient was age 10.4 years with a mean follow-up of 7.5 months. Eleven patients (52.4%) were involved in a motor vehicle collision, with a mean Glasgow Coma Scale score of 8.6. There were 8 patients (38.1%) with carotid canal fracture, 6 patients (28.6%) with petrous bone fracture, and 2 patients (9.5%) with infarction on initial presentation. Eight patients (38.1%) were managed with observation alone. The Denver, modified Memphis, Eastern Association for the Surgery of Trauma (EAST), and Utah scores, which are the currently used screening tools for BCVI, misclassified 6 (28.6%), 6 (28.6%), 7 (33.3%), and 10 (47.6%) patients with BCVI, respectively, as "low risk" and not in need of subsequent angiographic imaging. By incorporating the mechanism of injury into the score, the McGovern score only misclassified 4 (19.0%) children, all of whom were managed conservatively with no treatment or aspirin. CONCLUSIONS With a low incidence of pediatric BCVI and a nonsurgical treatment paradigm, a more conservative approach than the Biffl scale should be adopted. The Denver, modified Memphis, EAST, and Utah scores did not accurately predict BCVI in our equally large cohort. The McGovern score is the first BCVI screening tool to incorporate the mechanism of injury into its screening criteria, thereby potentially allowing physicians to minimize unnecessary radiation and determine which high-risk patients are truly in need of angiographic imaging.