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Parker LA, Villamor LL, Groszman L, Xiang L, Koganti D, Smith R, Sola R. Understanding Head CT Scan Usage Amongst Adolescent Blunt Trauma Patients Treated at a Level 1 Adult Trauma Center. Am Surg 2023:31348231157806. [PMID: 36803093 DOI: 10.1177/00031348231157806] [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: 02/20/2023]
Abstract
BACKGROUND Guidelines developed by the Pediatric Emergency Care Applied Research Network (PECARN) exist to reserve the use of head CT for pediatric patients with a high risk of head injury. However, CTs are still being overutilized especially at adult trauma centers. The aim of our study was to review our use of head CTs in adolescent blunt trauma patients. MATERIALS AND METHODS Patients aged 11-18 who underwent head CT scans from 2016 to 2019 at our urban level 1 adult trauma center were included. Data was collected via electronic medical record and analyzed through retrospective chart review. RESULTS Of the 285 patients requiring a head CT, 205 had a negative head CT (NHCT) and 80 patients had a positive head CT (PHCT). There was no difference in age, gender, race, and trauma mechanism between the groups. The PHCT group was found to be with a statistically significant higher likelihood of the Glasgow Coma Scale (GCS) < 15 (65% vs 23%; P < .01), abnormal head exam (70% vs 25%; P < .01), and loss of consciousness (85% vs 54%; P < .01) compared to the NHCT group. There were 44 patients who had low risk of head injury, based on the PECARN guidelines, and received a head CT. None of the patients had a positive head CT. CONCLUSION Our study suggests that reinforcement of the PECARN guidelines should occur for ordering head CTs in adolescent blunt trauma patients. Future prospective studies are needed to validate the use of PECARN head CT guidelines in this patient population.
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Affiliation(s)
- Laurel A Parker
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
| | - Laurie L Villamor
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
| | - Lilly Groszman
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
| | - Laurel Xiang
- Center for Data Science, 5894New York University, New York, NY, USA
| | - Deepika Koganti
- Department of Surgery, 1371Emory University, Atlanta, GA, USA
| | - Randi Smith
- Department of Surgery, 1371Emory University, Atlanta, GA, USA
| | - Richard Sola
- Department of Surgery, 1374Morehouse School of Medicine, Atlanta, GA, USA
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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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103
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Gerber N, Munnangi S, Vengalasetti Y, Gupta S. Trauma center variation of head computed tomography utilization in children presenting with mild traumatic brain injury. Clin Imaging 2023; 94:125-131. [PMID: 36529077 DOI: 10.1016/j.clinimag.2022.11.024] [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: 04/28/2022] [Revised: 10/16/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND Although published clinical decision rules have identified indications for the use of head CT in children with mild traumatic brain injury, practices vary. OBJECTIVE This study seeks to evaluate whether the utilization of head CT in pediatric trauma patients presenting with mTBI varies between American College of Surgeons verified pediatric trauma centers (ACS-PTC) and adult-only trauma centers (ACS-AOTC). MATERIAL AND METHODS A retrospective cohort study of 24,104 trauma patients, ≤17, who presented to the emergency department at 337 ACS verified level I/II trauma centers with isolated mTBI was conducted using National Trauma Data Bank records (2011-2015). Multivariable logistic regression was used to compare the odds of a patient receiving a head CT when treated at an ACS-PTC vs. an ACS-AOTC, controlling for demographic, injury, and hospital-level confounders. Effect modification by loss of consciousness was assessed and adjusted head CT odds were recalculated in patients stratified by LOC status. RESULTS There was no significant difference in the adjusted odds of receiving a head CT at an ACS-PTC vs. an ACS-AOTC (odds ratio: 0.98, 95% confidence interval: 0.92-1.04). However, in patients who had a LOC, the adjusted OR of receiving a head CT at an ACS-PTC vs ACS-AOTC was 0.71 (95% confidence interval: 0.65-0.78). CONCLUSION Children presenting to the emergency department of an ACS-verified level I or II trauma center with mTBI who had a loss of consciousness are less likely to receive a head CT at an ACS verified pediatric trauma center than at an ACS verified adult-only trauma center.
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Affiliation(s)
- Noam Gerber
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States of America.
| | - Swapna Munnangi
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States of America
| | - Yasaswi Vengalasetti
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, CA, United States of America
| | - Sameer Gupta
- Department of Surgery, Nassau University Medical Center, East Meadow, NY, United States of America
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104
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Shannon MM, Burris HH, Graham DA. Variation in NICU Head CT Utilization Among U.S. Children's Hospitals. Hosp Pediatr 2023; 13:106-141. [PMID: 36617983 DOI: 10.1542/hpeds.2021-006322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
OBJECTIVES Evaluate nationwide 12-year trend and hospital-level variation in head computed tomography (CT) utilization among infants admitted to pediatric hospital NICUs. We hypothesized there was significant variation in utilization. METHODS We conducted a retrospective cohort study examining head CT utilization for infants admitted to the NICU within 31 United States children's hospitals within the Pediatric Health Information System database between 2010 and 2021. Mixed effects logistic regression was used to estimate head CT, head MRI, and head ultrasound utilization (% of admissions) by year. Risk-adjusted hospital head CT rates were examined within the 2021 cohort. RESULTS Between 2010 and 2021, there were 338 644 NICU admissions, of which 10 052 included head CT (3.0%). Overall, head CT utilization decreased (4.9% in 2010 to 2.6% in 2021, P < .0001), with a concomitant increase in head MRI (12.1% to 18.7%, P < .0001) and head ultrasound (41.3% to 43.4%, P < .0001) utilization. In 2021, significant variation in risk-adjusted head CT utilization was noted across centers, with hospital head CT rates ranging from 0% to 10% of admissions. Greatest hospital-level variation was noted for patients with codes for seizure or encephalopathy (hospital head CT rate interquartile range [IQR] = 11.6%; 50th percentile = 12.0%), ventriculoperitoneal shunt (IQR = 10.8%; 50th percentile = 15.4%), and infection (IQR = 10.1%; 50th percentile = 7.5%). CONCLUSIONS Head CT utilization within pediatric hospital NICUs has declined over the past 12-years, but substantial hospital-level variation remains. Development of CT stewardship guidelines may help decrease variation and reduce infant radiation exposure.
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Affiliation(s)
- Megan M Shannon
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania.,Children's Hospital of Philadelphia
| | - Heather H Burris
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Dionne A Graham
- Program for Patient Safety and Quality, Boston Children's Hospital, Boston, Massachusetts.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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105
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Kuitunen I, Ponkilainen VT, Iverson GL, Isokuortti H, Luoto TM, Mattila VM. Increasing incidence of pediatric mild traumatic brain injury in Finland - a nationwide register study from 1998 to 2018. Injury 2023; 54:540-546. [PMID: 36564327 DOI: 10.1016/j.injury.2022.12.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/15/2022] [Accepted: 12/18/2022] [Indexed: 12/23/2022]
Abstract
AIM The purpose of this study is to document the annual incidence and incidence trends of pediatric traumatic brain injury (pTBI) in Finland over the course of 21 years. METHODS We conducted a retrospective nationwide register-based cohort study and used the Finnish Care Register and Population information statistics from 1998 to 2018. The patient group includes all patients aged <18 at the time of injury. We included all emergency department (ED) visits and subsequent inpatient admissions (meaning at least one night in the hospital) with International Classification of Diseases diagnostic code S06*. We calculated pTBI incidences per 100,000 person-years with 95% confidence intervals and the incidences were compared by incidence rate ratios (IRR), including age, diagnosis, and gender stratified analyses. RESULTS A total of 71,972 patients were included with 76,785 ED visits or hospitalizations for pTBI diagnoses. The annual incidence of diagnosed pTBI was 251 (CI: 241-260) per 100,000 in 1998 and 547 (CI: 533-561) per 100,000 in 2018, indicating a 118% increase in the incidence (IRR 2.18 CI: 2.09-2.28). Boys had 32% higher incidence (IRR 1.32 CI: 1.30-1.34) than girls. The highest cumulative incidence was observed among boys aged <1 years, 525 (CI: 507-543) per 100,000, and boys had higher incidences in all age groups. The most used diagnostic code was concussion, which included 92.1% of the diagnoses followed by diffuse brain injury, which included 2.3% of the diagnoses. The increase in the incidence of diagnosed pTBI was notably high after 2010. Concussion diagnoses and pTBI cases that were discharged directly from the ED had more than a two-fold increase from 2010 to 2018, whereas the incidence of inpatient admissions for pTBI increased by 53%. CONCLUSIONS The overall incidence of diagnosed pTBI has increased in Finland especially since 2010. Boys have higher incidence of diagnosed pTBI in all age groups. Most of the increase was due to increase in the concussion diagnoses, which may be due to the centralization of EDs into bigger units and increased diagnostic awareness of mild pTBI.
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Affiliation(s)
- Ilari Kuitunen
- University of Eastern Finland, Institute of Clinical Medicine, Kuopio, Finland; Department of Pediatrics, Mikkeli Central Hospital, Mikkeli, Finland.
| | | | - Grant L Iverson
- Department of Physical Medicine & Rehabilitation, Harvard Medical School, Boston, MA, United States of America; Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital and Spaulding Research Institute, Charlestown, Massachusetts, United States of America
| | - Harri Isokuortti
- Department of Neurosurgery, Helsinki University Hospital, Helsinki, Finland
| | - Teemu M Luoto
- Department of Neurosurgery, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland
| | - Ville M Mattila
- Faculty of Medicine and Life Sciences, Tampere University, Tampere, Finland; Department of Orthopedics and Traumatology, Tampere University Hospital, Tampere, Finland
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106
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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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107
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Granda E, Urbano M, Andrés P, Corchete M, Cano A, Velasco R. Comparison of severity scales for acute bronchiolitis in real clinical practice. Eur J Pediatr 2023; 182:1619-1626. [PMID: 36702906 DOI: 10.1007/s00431-023-04840-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 01/09/2023] [Accepted: 01/21/2023] [Indexed: 01/28/2023]
Abstract
Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing in-hospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, M-WCAS, Respiratory Severity Score, Respiratory Clinical Score, Respiratory Score and Bronchiolitis risk of admission score) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) and the odds ratio (OR) for a relevant outcome were calculated in each scale. Also, the best cut-off point was estimated according to the Youden index, and its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P25-P75 2.6-7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. A score ≤ 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7-96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV). Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. However, the PERN scale might be more useful to select patients at low risk of a severe outcome. What is Known: • Several clinical scales are used to assess the severity of bronchiolitis. Nevertheless, none of them seems to be better than others. What is New: • This is the first study comparing different bronchiolitis scales in a real clinical scenario. None of the nine scales compared performed better than the other. However, the PERN scale might be more useful to select patients at low risk of relevant outcomes.
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Affiliation(s)
- Elena Granda
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain.
| | - Mario Urbano
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Pilar Andrés
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Marina Corchete
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Alfredo Cano
- Pediatrics Department, Hospital Universitario Río Hortega, Valladolid, Spain
| | - Roberto Velasco
- Pediatric Emergency Department, Hospital Universitario Río Hortega, Valladolid, Spain
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Mahdi E, Toscano N, Pierson L, Ndikumana E, Ayers B, Chacon A, Brayer A, Chess M, Davis C, Dorman R, Livingston M, Arca M, Wakeman D. Sustaining the gains: Reducing unnecessary computed tomography scans in pediatric trauma patients. J Pediatr Surg 2023; 58:111-117. [PMID: 36272813 DOI: 10.1016/j.jpedsurg.2022.09.027] [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: 09/12/2022] [Accepted: 09/16/2022] [Indexed: 01/12/2023]
Abstract
BACKGROUND/PURPOSE "Pan-scanning" pediatric blunt trauma patients leads to exposure to harmful radiation and increased healthcare costs without improving outcomes. We aimed to reduce computed tomography (CT) scans that are not indicated (NI) by imaging guidelines for injured children. METHODS In July 2017, our Pediatric Trauma Center prospectively implemented validated imaging guidelines to direct CT imaging for trauma activations and consultations for children younger than 16 years old with blunt traumatic injuries. Patients with suspected physical abuse, CT imaging prior to arrival, penetrating mechanism, and instability precluding CT imaging were excluded. We compared CT scanning rates for pre-implementation (01/2016-06/2017) and post-implementation (07/2017-08/2021) time periods. Guideline compliance was evaluated by chart review and sustained through iterative process improvement cycles. RESULTS During the pre-implementation era, 61 patients underwent 171 CT scans of which 87 (51%) scans were not indicated by guidelines. Post-implementation, 363 patients had 531 scans and only 134 (25%) CTs were not indicated. Total CTs performed declined after initiation of guidelines (2.80 vs 1.46 scans/patient, p<0.0001). Total NI CTs declined (1.41 vs 0.37 NI scans/patient, p<0.0001) reflected in significant reductions in all anatomic regions: head, cervical spine, chest, and abdomen/pelvis. Charges related to NI scans decreased from $1,490.31/patient to $408.21/patient, saving $218,000 in charges. Based on prior utilization, 146 children were spared excessive radiation with no clinically significant missed injuries since guideline implementation. CONCLUSIONS Quality improvement and implementation science methodologies to enhance compliance with imaging guidelines for children with blunt injuries can significantly reduce unnecessary CT scanning without compromising care. This practice reduces harmful radiation exposure in a sensitive patient population and may save healthcare systems money and resources.
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Affiliation(s)
- Elaa Mahdi
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Nicole Toscano
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Lauren Pierson
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Eric Ndikumana
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Brian Ayers
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Alexander Chacon
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Anne Brayer
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Mitchell Chess
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Colleen Davis
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Robert Dorman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Michael Livingston
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Marjorie Arca
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States
| | - Derek Wakeman
- Department of Surgery, University of Rochester Medical Center, Rochester, NY, 14642, United States.
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109
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Miyagawa T, Saga M, Sasaki M, Shimizu M, Yamaura A. Statistical and machine learning approaches to predict the necessity for computed tomography in children with mild traumatic brain injury. PLoS One 2023; 18:e0278562. [PMID: 36595496 PMCID: PMC9810188 DOI: 10.1371/journal.pone.0278562] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2021] [Accepted: 11/18/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Minor head trauma in children is a common reason for emergency department visits, but the risk of traumatic brain injury (TBI) in those children is very low. Therefore, physicians should consider the indication for computed tomography (CT) to avoid unnecessary radiation exposure to children. The purpose of this study was to statistically assess the differences between control and mild TBI (mTBI). In addition, we also investigate the feasibility of machine learning (ML) to predict the necessity of CT scans in children with mTBI. METHODS AND FINDINGS The study enrolled 1100 children under the age of 2 years to assess pre-verbal children. Other inclusion and exclusion criteria were per the PECARN study. Data such as demographics, injury details, medical history, and neurological assessment were used for statistical evaluation and creation of the ML algorithm. The number of children with clinically important TBI (ciTBI), mTBI on CT, and controls was 28, 30, and 1042, respectively. Statistical significance between the control group and clinically significant TBI requiring hospitalization (csTBI: ciTBI+mTBI on CT) was demonstrated for all nonparametric predictors except severity of the injury mechanism. The comparison between the three groups also showed significance for all predictors (p<0.05). This study showed that supervised ML for predicting the need for CT scan can be generated with 95% accuracy. It also revealed the significance of each predictor in the decision tree, especially the "days of life." CONCLUSIONS These results confirm the role and importance of each of the predictors mentioned in the PECARN study and show that ML could discriminate between children with csTBI and the control group.
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Affiliation(s)
- Tadashi Miyagawa
- Department of Pediatric Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
- * E-mail:
| | - Marina Saga
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
| | - Minami Sasaki
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
| | - Miyuki Shimizu
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
| | - Akira Yamaura
- Department of Neurosurgery, Matsudo City General Hospital, Matsudo, Japan
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Underreporting of Traumatic Brain Injuries in Pediatric Craniomaxillofacial Trauma: A 20-Year Retrospective Cohort Study. Plast Reconstr Surg 2023; 151:105e-114e. [PMID: 36251865 DOI: 10.1097/prs.0000000000009783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Despite clinical concerns associated with pediatric traumatic brain injuries (TBIs), they remain grossly underreported. This is the first retrospective study to characterize concomitant pediatric TBIs and craniomaxillofacial (CMF) trauma patients, including frequency, presentation, documentation, and outcomes. METHODS An institutional review board-approved retrospective cohort study was performed to identify all pediatric patients presenting with CMF fractures at a high-volume, tertiary trauma center between the years 1990 and 2010. Patient charts were reviewed for demographic information, presentation, operative management, length of stay, mortality at 2 years, dentition, CMF fracture patterns, and concomitant TBIs. Data were analyzed using two-tailed t tests and chi-square analysis. A value of P≤ 0.05 was considered statistically significant. RESULTS Of the 2966 pediatric CMF trauma patients identified and included for analysis [mean age, 7 ± 4.7 years; predominantly White (59.8%), and predominantly male (64.0%)], 809 had concomitant TBI (frequency, 27.3%). Only 1.6% of the TBI cases were documented in charts. Mortality at 2 years, length of stay in the hospital, and time to follow-up increased significantly from mild to severe TBIs. Concomitant TBIs were more common with skull and upper third fractures than CMF trauma without TBIs (81.8% versus 61.1%; P < 0.05). CONCLUSIONS Concomitant TBIs were present in a significant number of pediatric CMF trauma cases but were not documented for most cases. CMF surgeons should survey all pediatric CMF trauma patients for TBI and manage with neurology and/or neurosurgery teams. Future prospective studies are necessary to characterize and generate practice-guiding recommendations. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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111
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Ramgopal S, Sanchez-Pinto LN, Horvat CM, Carroll MS, Luo Y, Florin TA. Artificial intelligence-based clinical decision support in pediatrics. Pediatr Res 2023; 93:334-341. [PMID: 35906317 PMCID: PMC9668209 DOI: 10.1038/s41390-022-02226-1] [Citation(s) in RCA: 33] [Impact Index Per Article: 33.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 06/29/2022] [Accepted: 07/18/2022] [Indexed: 11/24/2022]
Abstract
Machine learning models may be integrated into clinical decision support (CDS) systems to identify children at risk of specific diagnoses or clinical deterioration to provide evidence-based recommendations. This use of artificial intelligence models in clinical decision support (AI-CDS) may have several advantages over traditional "rule-based" CDS models in pediatric care through increased model accuracy, with fewer false alerts and missed patients. AI-CDS tools must be appropriately developed, provide insight into the rationale behind decisions, be seamlessly integrated into care pathways, be intuitive to use, answer clinically relevant questions, respect the content expertise of the healthcare provider, and be scientifically sound. While numerous machine learning models have been reported in pediatric care, their integration into AI-CDS remains incompletely realized to date. Important challenges in the application of AI models in pediatric care include the relatively lower rates of clinically significant outcomes compared to adults, and the lack of sufficiently large datasets available necessary for the development of machine learning models. In this review article, we summarize key concepts related to AI-CDS, its current application to pediatric care, and its potential benefits and risks. IMPACT: The performance of clinical decision support may be enhanced by the utilization of machine learning-based algorithms to improve the predictive performance of underlying models. Artificial intelligence-based clinical decision support (AI-CDS) uses models that are experientially improved through training and are particularly well suited toward high-dimensional data. The application of AI-CDS toward pediatric care remains limited currently but represents an important area of future research.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - L. Nelson Sanchez-Pinto
- grid.16753.360000 0001 2299 3507Division of Critical Care Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA ,grid.16753.360000 0001 2299 3507Department of Preventive Medicine (Health and Biomedical Informatics), Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Christopher M. Horvat
- grid.21925.3d0000 0004 1936 9000Department of Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, PA USA
| | - Michael S. Carroll
- grid.16753.360000 0001 2299 3507Data Analytics and Reporting, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
| | - Yuan Luo
- grid.16753.360000 0001 2299 3507Department of Preventive Medicine (Health and Biomedical Informatics), Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Todd A. Florin
- grid.16753.360000 0001 2299 3507Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL USA
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112
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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] [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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113
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Al Mukhtar A, Bergenfeldt H, Edelhamre M, Vedin T, Larsson PA, Öberg S. The epidemiology of and management of pediatric patients with head trauma: a hospital-based study from Southern Sweden. Scand J Trauma Resusc Emerg Med 2022; 30:67. [PMID: 36494828 PMCID: PMC9733190 DOI: 10.1186/s13049-022-01055-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 11/30/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is a common cause of morbidity and mortality in children worldwide. In Scandinavia, the epidemiology of pediatric head trauma is poorly documented. This study aimed to investigate and compare the epidemiology and management of pediatric patients with isolated head trauma (IHT) and head trauma in connection with multitrauma (MHT). METHODS We conducted a retrospective review of medical records of patients < 18 years of age who attended any of the five emergency departments (ED) in Scania County in Sweden in 2016 due to head trauma. Clinical data of patients with IHT were analyzed and compared with those of patients with MHT. RESULTS We identified 5046 pediatric patients with head trauma, 4874 with IHT and 186 with MHT, yielding an incidence of ED visits due to head trauma of 1815/100,000 children/year. There was male predominance, and the median age was four years. Falls were the dominating trauma mechanism in IHT patients, while motor vehicle accidents dominated in MHT patients. The frequencies of CT head-scans, ward admissions and intracranial injuries (ICI) were 5.4%, 11.1% and 0.7%, respectively. Four patients (0.08%) required neurosurgical intervention. The relative risks for CT-scans and admissions to a hospital ward and ICI were 10, 4.5 and 19 times higher for MHT compared with IHT patients. CONCLUSION Head trauma is a common cause of ED visits in our study. Head-CTs and ICIs were less frequent than in previous studies. MHT patients had higher rates of CT-scans, admissions, and ICIs than IHT patients, suggesting that they are separate entities that should ideally be managed using different guidelines to optimize the use of CT-scans of the head.
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Affiliation(s)
- Ali Al Mukhtar
- grid.411843.b0000 0004 0623 9987Departments of Surgery, Skåne’s University Hospital, Carl-Bertil Laurells Gata 9, 214 28 Malmö, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Henrik Bergenfeldt
- grid.413823.f0000 0004 0624 046XHelsingborg Hospital, Helsingborg, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Marcus Edelhamre
- grid.413823.f0000 0004 0624 046XHelsingborg Hospital, Helsingborg, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Tomas Vedin
- grid.411843.b0000 0004 0623 9987Departments of Surgery, Skåne’s University Hospital, Carl-Bertil Laurells Gata 9, 214 28 Malmö, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Per-Anders Larsson
- grid.416029.80000 0004 0624 0275Skaraborg Hospital, Skövde, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Stefan Öberg
- grid.413823.f0000 0004 0624 046XHelsingborg Hospital, Helsingborg, Sweden ,grid.4514.40000 0001 0930 2361Department of Clinical Sciences, Lund University, Lund, Sweden
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114
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No Difference in Mortality and Outcomes After Addition of a Nearby Pediatric Trauma Center. Pediatr Emerg Care 2022; 38:654-658. [PMID: 36252047 DOI: 10.1097/pec.0000000000002665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Previous studies demonstrate that higher volume pediatric trauma centers (PTCs) offer improved outcomes. This study evaluated pediatric trauma volume and outcomes at an existing level I (L-I) adult and level II (L-II) PTC after the addition of a new children's hospital L-II PTC within a 2-mile radius, hypothesizing no difference in mortality and complications. METHODS A retrospective review of patients aged 14 years or younger presenting to a single adult L-I and L-II PTC was performed. Patients from 2015-2016 (PRE) were compared with patients from 2018-2019 (POST) for mortality and complications using bivariate analyses. RESULTS Compared with the PRE cohort, there were less patients in the POST cohort (277 vs 373). Patients in the POST cohort had higher rates of insurance coverage (91.3% vs 78.8%, P < 0.001), self-transportation (7.2% vs 2.7%, P < 0.01), and hospital admission (72.6% and 46.1%, P < 0.001). There was no difference in all complications and mortality (all P > 0.05) between the 2 cohorts. CONCLUSIONS After opening a second L-II PTC within a 2-mile radius, there was an increase in the rate of admissions and self-transportation to the preexisting L-II PTC. Despite a nearly 26% decrease in pediatric trauma volume, there was no difference in length of stay, hospital complications, or mortality.
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115
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Ugalde IT, Chaudhari PP, Badawy M, Ishimine P, McCarten-Gibbs KA, Yen K, Atigapramoj NS, Sage A, Nielsen D, Adelson PD, Upperman J, Tancredi D, Kuppermann N, Holmes JF. 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. JMIR Res Protoc 2022; 11:e43027. [PMID: 36422920 PMCID: PMC9732756 DOI: 10.2196/43027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Revised: 11/09/2022] [Accepted: 11/12/2022] [Indexed: 11/25/2022] Open
Abstract
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.
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Affiliation(s)
- Irma T Ugalde
- Department of Emergency Medicine, Children's Memorial Hermann Hospital, McGovern Medical School at UTHealth Houston, Houston, TX, United States
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine of the University of Southern California, Los Angeles, CA, United States
| | - Mohamed Badawy
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States
| | - Paul Ishimine
- Department of Emergency Medicine and Pediatrics, University of California San Diego School of Medicine, Rady Children's Hospital, San Diego, CA, United States
| | - Kevan A McCarten-Gibbs
- Department of Emergency Medicine, University of California San Francisco Benioff Children's Hospital, Oakland, CA, United States
| | - Kenneth Yen
- Department of Pediatrics, University of Texas Southwestern, Dallas, TX, United States
| | - Nisa S Atigapramoj
- Department of Emergency Medicine, University of California San Francisco Benioff Children's Hospital, Oakland, CA, United States
| | - Allyson Sage
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Donovan Nielsen
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - P David Adelson
- Barrow Neurological Institute of Phoenix Children's Hospital, Department of Child Health, Division of Pediatric Neurosurgery, University of Arizona College of Medicine, Phoenix, AZ, United States
| | - Jeffrey Upperman
- Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital, Vanderbilt University School of Medicine, Nashville, TN, United States
| | - Daniel Tancredi
- Department of Pediatrics, University of California Davis School of Medicine, Sacramento, CA, United States
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
| | - James F Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, CA, United States
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116
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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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117
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Pakyurek M, Badawy M, Ugalde IT, Ishimine P, Chaudhari PP, McCarten-Gibbs K, Nobari O, Kuppermann N, Holmes JF. Does attention-deficit/hyperactivity disorder increase the risk of minor blunt head trauma in children? JOURNAL OF CHILD AND ADOLESCENT PSYCHIATRIC NURSING 2022; 35:356-361. [PMID: 35962779 PMCID: PMC9637762 DOI: 10.1111/jcap.12390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2022] [Revised: 06/07/2022] [Accepted: 07/28/2022] [Indexed: 11/27/2022]
Abstract
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.
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Affiliation(s)
- Murat Pakyurek
- Department of Psychiatry and Behavioral Sciences, School of Medicine, UC Davis, Sacramento, California, USA
| | - Mohamed Badawy
- Department of Pediatrics, UT Southwestern, Dallas, Texas, USA
| | - Irma T Ugalde
- Department of Emergency Medicine, McGovern Medical School at UTHealth Houston, Houston, Texas, USA
| | - Paul Ishimine
- Department of Emergency Medicine and Pediatrics, School of Medicine, University of California, San Diego, La Jolla, California, USA
| | - Pradip P Chaudhari
- Division of Emergency and Transport Medicine, Children's Hospital Los Angeles, Keck School of Medicine of USC, Los Angeles, California, USA
| | - Kevan McCarten-Gibbs
- Department of Emergency Medicine, UCSF Benioff Children's Hospital, Oakland, California, USA
| | - Ozra Nobari
- Department of Psychiatry and Behavioral Sciences, School of Medicine, UC Davis, Sacramento, California, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine and Pediatrics, School of Medicine, UC Davis, Sacramento, California, USA
| | - James F Holmes
- Department of Emergency Medicine, School of Medicine, UC Davis, Sacramento, California, USA
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118
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Pearls and Pitfalls of Trauma Management. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2022.08.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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119
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Wazir A, Tamim H, Wakil C, Sawaya RD. Misdiagnosis of Pediatric Concussions in the Emergency Department: A Retrospective Study. Pediatr Emerg Care 2022; 38:e1641-e1645. [PMID: 35477571 DOI: 10.1097/pec.0000000000002714] [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: 11/26/2022]
Abstract
OBJECTIVE We aimed to determine the rate and predictors of correctly diagnosed concussions in the pediatric emergency department and to describe the characteristics, presentation, and management of concussions in children presenting for minor head injury. METHODS We included 186 patients aged 5 to 18 years presenting within 24 hours of minor head injuries and met our diagnostic criteria for concussion. We compared patients correctly diagnosed with a concussion with those who were not. Our main outcome was the rate and predictors of misdiagnoses. RESULTS Of the patients, 5.4% were correctly diagnosed. Amnesia was the only variable associated with correct diagnoses (40.0% vs 10.2%, P = 0.02). The most common mechanism of injury was fall (8.4%); the most frequent symptoms were nausea/vomiting (42.5%), and 48.4% had a brain computed tomography scan done. CONCLUSIONS The high rate of concussion misdiagnosis puts into question the usability of current concussion guidelines, their accuracy, and barriers to translation into clinical practice.
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Affiliation(s)
| | - Hani Tamim
- Clinical Research Institute, American University of Beirut Medical Center, Beirut, Lebanon
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120
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Raikot SR, Polites SF. Current management of pediatric traumatic brain injury. Semin Pediatr Surg 2022; 31:151215. [PMID: 36399949 DOI: 10.1016/j.sempedsurg.2022.151215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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121
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Knighton AJ, Wolfe D, Hunt A, Neeley A, Shrestha N, Hess S, Hellewell J, Snow G, Srivastava R, Nelson D, Schunk JE. Improving Head CT Scan Decisions for Pediatric Minor Head Trauma in General Emergency Departments: A Pragmatic Implementation Study. Ann Emerg Med 2022; 80:332-343. [PMID: 35752519 PMCID: PMC9509420 DOI: 10.1016/j.annemergmed.2022.04.030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 04/13/2022] [Accepted: 04/22/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE To measure the effectiveness of a multimodal strategy, including simultaneous implementation of a clinical decision support system, to sustain adherence to a clinical pathway for care of children with minor head trauma treated in general emergency departments (EDs). METHODS Prospective, type III hybrid effectiveness-implementation cohort study with a nonrandomized stepped-wedge design and monthly repeated site measures. The study population included pediatric minor head trauma encounters from July 2018 to December 2020 at 21 urban and rural general ED sites in an integrated health care system. Sites received the intervention in 1 of 2 steps, with each site providing control and intervention observations. Measures included guideline adherence, the computed tomography (CT) scan rate, and 72-hour readmissions with clinically important traumatic brain injury. Analysis was performed using multilevel hierarchical modeling with random intercepts for the site and physician. RESULTS During the study, 12,670 pediatric minor head trauma encounters were cared for by 339 clinicians. The implementation of the clinical pathway resulted in higher odds of guideline adherence (adjusted odds ratio 1.12 [95% confidence interval 1.03 to 1.22]) and lower odds of a CT scan (adjusted odds ratio 0.96 [95% confidence interval 0.93 to 0.98]) in intervention versus control months. Absolute risk difference was observed in both guideline adherence (site median: +2.3% improvement) and the CT scan rate (site median: -6.6% reduction). No 72-hour readmissions with confirmed clinically important traumatic brain injury were identified. CONCLUSION Implementation of a minor head trauma clinical pathway using a multimodal approach, including a clinical decision support system, led to sustained improvements in adherence and a modest, yet safe, reduction in CT scans among generally low-risk patients in diverse general EDs.
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Affiliation(s)
| | - Doug Wolfe
- Intermountain Healthcare, Salt Lake City, UT
| | | | | | | | - Steven Hess
- Intermountain Healthcare, Salt Lake City, UT
| | | | | | - Rajendu Srivastava
- Intermountain Healthcare, Salt Lake City, UT; University of Utah School of Medicine, Salt Lake City, UT
| | - Douglas Nelson
- Intermountain Healthcare, Salt Lake City, UT; University of Utah School of Medicine, Salt Lake City, UT
| | - Jeff E Schunk
- University of Utah School of Medicine, Salt Lake City, UT
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122
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Bressan S, Heidt R, Wang C, Tancredi D, Kuppermann N. Isolated Altered Mental Status in Children With Minor Blunt Head Trauma. Pediatrics 2022; 150:189493. [PMID: 36102119 DOI: 10.1542/peds.2022-057138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/21/2022] [Indexed: 11/24/2022] Open
Abstract
Traumatic brain injuries are uncommon in children with isolated Glasgow Coma Scale scores of 14 or other isolated minor signs of altered mental status (AMS).
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Affiliation(s)
- Silvia Bressan
- Department of Women's and Children's Health, University of Padova, Padua, Italy
| | - Rachel Heidt
- Now at the Permanente Medical Group, Oakland, California.,Departments of Pediatrics
| | - Caroline Wang
- Department of Pediatrics, Section of Emergency Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas.,Departments of Pediatrics
| | - Daniel Tancredi
- Departments of Pediatrics.,Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
| | - Nathan Kuppermann
- Departments of Pediatrics.,Emergency Medicine, University of California Davis School of Medicine, Sacramento, California
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123
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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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124
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Bryant P, Yengo-Kahn A, Smith C, Smith M, Guillamondegui O. Decision Support Tool to Judiciously Assign High-Frequency Neurologic Examinations in Traumatic Brain Injury. J Surg Res 2022; 280:557-566. [PMID: 36096021 DOI: 10.1016/j.jss.2022.07.045] [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: 02/25/2022] [Revised: 07/11/2022] [Accepted: 07/14/2022] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Traumatic brain injury (TBI) management includes serial neurologic examinations to assess for changes dictating neurosurgical interventions. We hypothesized hourly examinations are overassigned. We conducted a decision tree analysis to determine an algorithm to judiciously assign hourly examinations. METHODS A retrospective cohort study of 1022 patients with TBI admitted to a Level 1 trauma center from January 1, 2019, to December 31, 2019, was conducted. Patients with penetrating TBI or immediate or planned interventions and those with nonsurvivable injuries were excluded. Patients were stratified by whether they underwent an unplanned intervention (e.g., craniotomy or invasive intracranial monitoring). Univariate analysis identified factors for inclusion in chi-square automatic interaction detection technique, classifying those at risk for unplanned procedures. RESULTS A total of 830 patients were included, 287 (35%) were assigned hourly (Q1) examinations, and 17 (2%) had unplanned procedures, with 16 of 17 (94%) on Q1 examinations. Patients requiring unplanned procedures were more likely to have mixed intracranial hemorrhage pattern (82% versus 39%; P = 0.001), midline shift (35% versus 14%; P = 0.023), an initial poor neurologic examination (Glasgow Comas Scale ≤8, 77% versus 14%; P < 0.001), and be intubated (88% versus 17%; P < 0.001). Using chi-square automatic interaction detection, the decision tree demonstrated low-risk (2% misclassification) and excellent discrimination (area under the curve = 0.915, 95% confidence interval 0.844-0.986; P < 0.001) of patients at risk of an unplanned procedure. By following the algorithm, 167 fewer patients could have been assigned Q1 examinations, resulting in an estimated 6012 fewer examinations. CONCLUSIONS Using a 4-factor algorithm can optimize the assignment of neuro examinations and substantially reduce neuro examination burden without sacrificing patient safety.
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Affiliation(s)
- Peter Bryant
- Division of Trauma And Surgical Critical Care, Vanderbilt University Medical Center Nashville, Tennessee.
| | - Aaron Yengo-Kahn
- Department of Neurosurgery, Vanderbilt University Medical Center Nashville, Tennessee
| | - Candice Smith
- Division of Trauma And Surgical Critical Care, Vanderbilt University Medical Center Nashville, Tennessee
| | - Melissa Smith
- Division of Trauma And Surgical Critical Care, Vanderbilt University Medical Center Nashville, Tennessee
| | - Oscar Guillamondegui
- Division of Trauma And Surgical Critical Care, Vanderbilt University Medical Center Nashville, Tennessee
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125
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Hanalioglu S, Hanalioglu D, Elbir C, Gulmez A, Sahin OS, Sahin B, Turkoglu ME, Kertmen HH. A Novel Decision-Support Tool (IniCT Score) for Repeat Head Computed Tomography in Pediatric Mild Traumatic Brain Injury. World Neurosurg 2022; 165:e102-e109. [PMID: 35654329 DOI: 10.1016/j.wneu.2022.05.103] [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: 01/22/2022] [Revised: 05/22/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND The necessity of computed tomography (CT) has been questioned in pediatric mild traumatic brain injury (mTBI) because of concerns related to radiation exposure. Distinguishing patients with lower and higher risk of clinically important TBI (ciTBI) is paramount to the optimal management of these patients. OBJECTIVE This study aimed to analyze the imaging predictors of ciTBI and develop an algorithm to identify patients at low and high risk for ciTBI to inform clinical decision making using a large single-center cohort of pediatric patients with mTBI. METHODS We retrospectively identified pediatric patients with mTBI with repeat CT within 48 hours of injury using an institutional database. RESULTS Among 3867 pediatric patients, 219 patients with mTBI with repeat CT were included. Thirty-eight had ciTBI (17%), 16 (7%) required intensive care unit admission, and 6 (3%) underwent surgery. Median time interval between initial and repeat CT was 7 hours (range, 4-10). Clinical worsening and radiologic progression were evident in 36 (16%) and 24 (11%) patients, respectively. Multivariate analysis showed that 5 pathologic findings (depressed skull fracture, pneumocephalus, epidural hematoma, subdural hematoma, and contusion) on initial CT and radiologic progression on repeat CT were independent predictors of ciTBI. A new scoring system based on these 5 factors on initial CT (IniCT [Initial CT scoring system] score) had excellent discrimination for ciTBI, need for intensive care unit admission, and neurosurgery (area under the curve >0.8). CONCLUSIONS The IniCT scoring system can successfully differentiate low-risk and high-risk patients based on initial CT scan. Zero score can eliminate the need for a routine repeat CT, whereas scores ≥2 should prompt serial neurologic examinations and/or repeat CT depending on the clinical situation.
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Affiliation(s)
- Sahin Hanalioglu
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey; Department of Neurosurgery, Hacettepe University Faculty of Medicine, Ankara, Turkey.
| | - Damla Hanalioglu
- Division of Pediatric Emergency Medicine, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Cagri Elbir
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Ahmet Gulmez
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Omer Selcuk Sahin
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Balkan Sahin
- Department of Neurosurgery, University of Health Sciences, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Turkey
| | - Mehmet Erhan Turkoglu
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
| | - Huseyin Hayri Kertmen
- Department of Neurosurgery, University of Health Sciences, Diskapi Yildirim Beyazit Training and Research Hospital, Ankara, Turkey
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126
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Reynolds RA, Kelly KA, Ahluwalia R, Zhao S, Vance EH, Lovvorn HN, Hanson H, Shannon CN, Bonfield CM. Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center. J Neurosurg Pediatr 2022; 30:255-262. [PMID: 35901741 DOI: 10.3171/2022.6.peds227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Accepted: 06/01/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons-verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy. METHODS Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020. RESULTS The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8-25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed. CONCLUSIONS Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.
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Affiliation(s)
- Rebecca A Reynolds
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Katherine A Kelly
- 3Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Ranbir Ahluwalia
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Shilin Zhao
- 4Department of Biostatistics, Vanderbilt University Medical Center, Nashville
| | - E Haley Vance
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Harold N Lovvorn
- 5Department of Pediatric Surgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville; and
| | - Holly Hanson
- 6Department of Pediatrics, Division of Emergency Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Christopher M Bonfield
- 1Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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127
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Ramgopal S, Lorenz D, Ambroggio L, Navanandan N, Cotter JM, Florin TA. Identifying Potentially Unnecessary Hospitalizations in Children With Pneumonia. Hosp Pediatr 2022; 12:788-806. [PMID: 36000331 PMCID: PMC11315224 DOI: 10.1542/hpeds.2022-006608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To characterize the outcomes of children with community acquired pneumonia (CAP) across 41 United States hospitals and evaluate factors associated with potentially unnecessary admissions. METHODS We performed a cross-sectional study of patients with CAP from 41 United States pediatric hospitals and evaluated clinical outcomes using a composite ordinal severity outcome: mild-discharged (discharged from the emergency department), mild-admitted (hospitalized without other interventions), moderate (provision of intravenous fluids, supplemental oxygen, broadening of antibiotics, complicated pneumonia, and presumed sepsis) or severe (ICU, positive-pressure ventilation, vasoactive infusion, chest drainage, extracorporeal membrane oxygenation, severe sepsis, or death). Our primary outcome was potentially unnecessary admissions (ie, mild-admitted). Among mild-discharged and mild-admitted patients, we constructed a generalized linear mixed model for mild-admitted severity and assessed the role of fixed (demographics and clinical testing) and random effects (institution) on this outcome. RESULTS Of 125 180 children, 68.3% were classified as mild-discharged, 6.6% as mild-admitted, 20.6% as moderate and 4.5% as severe. Among admitted patients (n = 39 692), 8321 (21%) were in the mild-admitted group, with substantial variability in this group across hospitals (median 19.1%, interquartile range 12.8%-28.4%). In generalized linear mixed models comparing mild-admitted and mild-discharge severity groups, hospital had the greatest contribution to model variability compared to all other variables. CONCLUSIONS One in 5 hospitalized children with CAP do not receive significant interventions. Among patients with mild disease, institutional variation is the most important contributor to predict potentially unnecessary admissions. Improved prognostic tools are needed to reduce potentially unnecessary hospitalization of children with CAP.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | - Lilliam Ambroggio
- Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Jillian M. Cotter
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colorado
| | - Todd A. Florin
- Division of Emergency Medicine, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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128
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Vajna de Pava M, Milani GP, Zuccotti GV, Tommasi P, Calvi M, Amoroso A, Montesano P, Boselli G, Castellazzi ML, Agosti M. Multi-centre study found no increased risk of clinically important brain injuries when children presented more than 24 hours after a minor head trauma. Acta Paediatr 2022; 111:2125-2130. [PMID: 35917207 DOI: 10.1111/apa.16507] [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: 02/01/2022] [Revised: 07/07/2022] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
AIM Validated clinical decision rules on neuroimaging are not available for children who are evaluated more than 24 hours after a minor head trauma. We compared clinically important traumatic brain injuries in children who presented with a minor head trauma within, or after, 24 hours. METHODS This was a retrospective analysis of patients aged 0-17 years, who were evaluated for minor head traumas by 5 paediatric emergency departments in Northern Italy between January 2019 and June 2020. Children with clinically important traumatic brain injuries were divided into those who had presented within, and after, 24 hours. RESULTS The study comprised 5,981 children (59.9% boys), with a median age of 2 years, including 243 (4.1%) who had presented more than 24 hours after their minor head trauma. Neuroimaging was performed on 448 (7.5%) patients and the time of presentation had no impact on the rates of clinically important traumatic brain injuries. Multiple logistic regression did not show any association between clinically important traumatic brain injuries and late presentation. CONCLUSION Delayed presentation to a paediatric emergency department after a minor head trauma did not alter the risk of clinically important traumatic brain injuries and the same neuroimaging rules could apply.
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Affiliation(s)
| | - Gregorio Paolo Milani
- Paediatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Clinical Science and Community Health, University of Milan, Italy
| | - Gian Vincenzo Zuccotti
- Department of Paediatrics, Ospedale dei Bambini Vittore Buzzi, Milan, Italy.,Department of Biomedical and Clinical Sciences, University of Milan, Italy
| | - Paola Tommasi
- Department of Paediatrics, Ospedale dei Bambini Vittore Buzzi, Milan, Italy
| | - Matteo Calvi
- Paediatric Emergency Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Angela Amoroso
- Paediatric Emergency Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Paola Montesano
- Department of Emergency Medicine, University Children's Hospital, Spedali Civili, Brescia, Italy
| | - Giulia Boselli
- Department of Emergency Medicine, University Children's Hospital, Spedali Civili, Brescia, Italy
| | - Massimo Luca Castellazzi
- Paediatric Emergency Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massimo Agosti
- Woman and Child Department, ASST dei Sette Laghi, Varese, Italy.,Department of Medicine and Surgery, University of Insubria, Varese, Italy
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129
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Singh S, Hearps S, Nishijima DK, Cheek JA, Borland M, Dalziel S, Holmes J, Kuppermann N, Babl FE, Hoch JS. Cost-effectiveness of patient observation on cranial CT use with minor head trauma. Arch Dis Child 2022; 107:712-718. [PMID: 35193874 DOI: 10.1136/archdischild-2021-323701] [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: 12/10/2021] [Accepted: 02/04/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of planned observation on cranial CT use in children with minor head trauma. DESIGN Planned secondary analysis of a multicentre prospective observation study. SETTING Australia and New Zealand. PATIENTS An analytic cohort of 18 471 children aged <18 years with Glasgow Coma Scale scores 14-15 presenting <24 hours after blunt head trauma stratified by the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk categories. INTERVENTION A plan for observation and immediate CT scan were documented after the initial assessment. The planned observation group included those with planned observation and no immediate plan for CT. MAIN OUTCOME MEASURES Taking an Australian public-funded healthcare perspective, we estimated the cost-effectiveness of planned observation on the adjusted mean costs per child and CT use reduction by net benefit regression analysis using ordinary least squares with robust SEs and bootstrapping. All costs presented in 2018 euros. RESULTS Planned observation in 4945 (27%) children was cost-saving of €85 (95% CI -120 to -51) with 10.4% lower CT use (95% CI 9.6 to 11.2). This strategy was cost-saving for the PECARN high-risk (-€757 (95% CI -961 to -554)) and intermediate-risk (-€52 (95% CI -99 to -4.3)) categories, with 43% (95% CI 39 to 47) and 11% (95% CI 9.6 to 12.4) lower CT use, respectively. The very low-risk category incurred more cost of €86 (95% CI 67 to 104) with planned observation and 0.05% lower CT use (95% CI -0.61 to 0.71). CONCLUSION Planned ED observation in selected children with minor head trauma is cost-effective for reducing CT use for the PECARN intermediate-risk and high-risk categories. TRIAL REGISTRATION NUMBER ACTRN12614000463673.
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Affiliation(s)
- Sonia Singh
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia .,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Stephen Hearps
- Child Neuropsychology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - John Alexander Cheek
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Meredith Borland
- Emergency Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - James Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Center for Healthcare Policy and Research, University of California Davis Health System, Sacramento, California, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
| | - Franz E Babl
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Jeffrey S Hoch
- Center for Healthcare Policy and Research, University of California Davis Health System, Sacramento, California, USA.,Department of Public Health Sciences, University of California Davis, Davis, California, USA
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130
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Leichtes Schädel-Hirn-Trauma im Kindes- und Jugendalter – Update Gehirnerschütterung. Monatsschr Kinderheilkd 2022. [DOI: 10.1007/s00112-022-01518-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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131
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Chardavoyne PC, Montgomery EJ, Montalbano A, Olympia RP. Pediatric Urgent Care Center Management of Traumatic Injuries in Infants and Children: Adherence to Evidence-Based Practice Guidelines. Pediatr Emerg Care 2022; 38:e1440-e1445. [PMID: 35904956 DOI: 10.1097/pec.0000000000002635] [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: 11/26/2022]
Abstract
OBJECTIVES To determine pediatric urgent care (PUC) clinician adherence to evidence-based practice guidelines in the management of pediatric trauma and to evaluate PUC emergency preparedness for conditions such as severe hemorrhage. METHODS A questionnaire covering acute management of 15 pediatric traumatic injuries, awareness of the Stop the Bleed initiative, and presence of emergency equipment and medications was electronically distributed to members of the Society for Pediatric Urgent Care. Clinician management decisions were evaluated against evidence-based practice guidelines. RESULTS Eighty-three completed questionnaires were returned (25% response rate). Fifty-three physician and 25 advanced practice provider (APP) questionnaires were analyzed. Most respondents were adherent to evidence-based practice guidelines in the following scenarios: cervical spine injury; head injury without neurologic symptoms; blunt abdominal injury; laceration without bleeding, foreign body, or signs of infection; first-degree burn; second-degree burn with less than 10% total body surface area; animal bite with and without probable tenosynovitis; and orthopedic fractures. Fever respondents were adherent in the following scenarios: head injury with altered mental status (adherence: physicians, 64%; APPs, 44%) and laceration with foreign body and persistent hemorrhage (adherence: physicians, 52%; APPs, 41%). Most respondents (56%) were unaware of Stop the Bleed and only 48% reported having a bleeding control kit/tourniquet at their urgent care. CONCLUSIONS Providers in our sample demonstrated adherence with pediatric trauma evidence-based practice guidelines. Increased PUC provider trauma care certification, PUC incorporation of Stop the Bleed education, and PUC presence of equipment and medications would further improve emergency preparedness.
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Affiliation(s)
| | | | - Amanda Montalbano
- Department of Pediatrics, Children's Mercy Kansas City, Kansas City, MO
| | - Robert P Olympia
- Departments of Emergency Medicine and Pediatrics, Penn State Hershey Medical Center, Hershey, PA
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132
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Papa L, Rosenthal K, Cook L, Caire M, Thundiyil JG, Ladde JG, Garfinkel A, Braga CF, Tan CN, Ameli NJ, Lopez MA, Haeussler CA, Mendez Giordano D, Giordano PA, Ramirez J, Mittal MK, Zonfrillo MR. Concussion severity and functional outcome using biomarkers in children and youth involved in organized sports, recreational activities and non-sport related incidents. Brain Inj 2022; 36:939-947. [PMID: 35904331 DOI: 10.1080/02699052.2022.2106383] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
This prospective multicenter study evaluated differences in concussion severity and functional outcome using glial and neuronal biomarkers glial Fibrillary Acidic (GFAP) and Ubiquitin C-terminal Hydrolase (UCH-L1) in children and youth involved in non-sport related trauma, organized sports, and recreational activities. Children and youth presenting to three Level 1 trauma centersfollowing blunt head trauma with a GCS 15 with a verified diagnosis of a concussion were enrolled within 6 hours of injury. Traumatic intracranial lesions on CT scan and functional outcome within 3 months of injury were evaluated. 131 children and youth with concussion were enrolled, 81 in the no sports group, 22 in the organized sports group and 28 in the recreational activities group. Median GFAP levels were 0.18, 0.07, and 0.39 ng/mL in the respective groups (p = 0.014). Median UCH-L1 levels were 0.18, 0.27, and 0.32 ng/mL respectively (p = 0.025). A CT scan of the head was performed in 110 (84%) patients. CT was positive in 5 (7%), 4 (27%), and 5 (20%) patients, respectively. The AUC for GFAP for detecting +CT was 0.84 (95%CI 0.75-0.93) and for UCH-L1 was 0.82 (95%CI 0.71-0.94). In those without CT lesions, elevations in UCH-L1 were significantly associated with unfavorable 3-month outcome. Concussions in the 3 groups were of similar severity and functional outcome. GFAP and UCH-L1 were both associated with severity of concussion and intracranial lesions, with the most elevated concentrations in recreational activities .
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Affiliation(s)
- Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA.,Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | | | - Laura Cook
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Michael Caire
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Josef G Thundiyil
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA.,Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Jay G Ladde
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA.,Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Alec Garfinkel
- College of Medicine, California North state University, Elk Grove, California, USA
| | - Carolina F Braga
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Ciara N Tan
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Neema J Ameli
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Marco A Lopez
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Crystal A Haeussler
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Diego Mendez Giordano
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA
| | - Philip A Giordano
- Department of Emergency Medicine, Orlando Regional Medical Center, Orlando, Florida, USA.,Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Jose Ramirez
- Department of Pediatric Emergency Medicine, Arnold Palmer Hospital for Children, Orlando, Florida, USA
| | - Manoj K Mittal
- Division of Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mark R Zonfrillo
- Department of Emergency Medicine, Alpert Medical School of Brown University and Hasbro Children's Hospital, Providence, Rhode Island, USA
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133
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Heo S, Ha J, Jung W, Yoo S, Song Y, Kim T, Cha WC. Decision effect of a deep-learning model to assist a head computed tomography order for pediatric traumatic brain injury. Sci Rep 2022; 12:12454. [PMID: 35864281 PMCID: PMC9304372 DOI: 10.1038/s41598-022-16313-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 07/07/2022] [Indexed: 11/09/2022] Open
Abstract
The study aims to measure the effectiveness of an AI-based traumatic intracranial hemorrhage prediction model in the decisions of emergency physicians regarding ordering head computed tomography (CT) scans. We developed a deep-learning model for predicting traumatic intracranial hemorrhages (DEEPTICH) using a national trauma registry with 1.8 million cases. For simulation, 24 cases were selected from previous emergency department cases. For each case, physicians made decisions on ordering a head CT twice: initially without the DEEPTICH assistance, and subsequently with the DEEPTICH assistance. Of the 528 responses from 22 participants, 201 initial decisions were different from the DEEPTICH recommendations. Of these 201 initial decisions, 94 were changed after DEEPTICH assistance (46.8%). For the cases in which CT was initially not ordered, 71.4% of the decisions were changed (p < 0.001), and for the cases in which CT was initially ordered, 37.2% (p < 0.001) of the decisions were changed after DEEPTICH assistance. When using DEEPTICH, 46 (11.6%) unnecessary CTs were avoided (p < 0.001) and 10 (11.4%) traumatic intracranial hemorrhages (ICHs) that would have been otherwise missed were found (p = 0.039). We found that emergency physicians were likely to accept AI based on how they perceived its safety.
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Affiliation(s)
- Sejin Heo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.,Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Juhyung Ha
- Department of Computer Science, Indiana University Bloomington, Bloomington, IN, USA
| | - Weon Jung
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Suyoung Yoo
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Yeejun Song
- Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Taerim Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.,Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81, Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea. .,Department of Digital Health, Samsung Advanced Institute for Health Sciences and Technology (SAIHST), Sungkyunkwan University, Seoul, Republic of Korea.
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134
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Wallace J, Metz JB, Otjen J, Perez FA, Done S, Brown ECB, Wiester RT, Boos SC, Ganti S, Feldman KW. Extra-axial haemorrhages in young children with skull fractures: abuse or accident? Arch Dis Child 2022; 107:650-655. [PMID: 35190379 DOI: 10.1136/archdischild-2021-322327] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 01/20/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Infant and toddler subdural haemorrhages (SDH) are often considered indicative of abuse or major trauma. However, accidental impact events, such as falls, cause contact extra-axial haemorrhages (EAHs). The current study sought to determine frequency and clinical behaviour of EAHs with infant and toddler accidental and abusive skull fractures. PATIENTS AND METHODS Children aged <4 years with accidental skull fractures and abusive fractures identified by CT at two paediatric tertiary care centres. Clinical data were abstracted by child abuse paediatricians and images were reviewed by paediatric radiologists. Data were analysed using univariate and multivariate logistic regression as well as descriptive statistics. RESULTS Among 227 subjects, 86 (37.9%) had EAHs. EAH was present in 73 (34.8%) accidental and 13 (76.5%) of the abusive injuries. Intracranial haemorrhage rates were not different for children with major or minor accidents but were fewer than abused. EAH was equally common with falls <4 and >4 ft. EAH depths did not differ by mechanism, but 69% of accidental EAHs were localised solely at fracture sites vs 38% abuse. Widespread and multifocal EAHs were more common with abuse. Children with abuse or major accidental injuries presented with lower initial Glasgow Coma Scales than those with minor accidents. Abused children had initial loss of consciousness more often than those with either minor or major accidents. CONCLUSIONS Simple contact EAHs were common among children with minor and major accidental skull fractures. Accidental EAHs were more localised with less neurological dysfunction than abusive.
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Affiliation(s)
- Jordan Wallace
- Pediatrics, Seattle Children's Hospital, Seattle, Washington, USA
| | - James Benson Metz
- Pediatrics, University of Vermont Children's Hospital, Burlington, Vermont, USA
| | - Jeffrey Otjen
- Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | | | - Stephen Done
- Radiology, Seattle Children's Hospital, Seattle, Washington, USA
| | - Emily C B Brown
- Research Clinical Core, Seattle Children's Hospital, Seattle, Washington, USA
| | - Rebecca T Wiester
- Research Clinical Core, Seattle Children's Hospital, Seattle, Washington, USA
| | - Stephen C Boos
- Pediatrics, Baystate Medical Center, Springfield, Massachusetts, USA
| | - Sheila Ganti
- Research Clinical Core, Seattle Children's Hospital, Seattle, Washington, USA
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135
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Patterson KN, Nordin A, Beyene TJ, Onwuka A, Bergus K, Horvath KZ, Sribnick EA, Thakkar RK. Implementation of a Level 1 Neuro Trauma Activation at a Tertiary Pediatric Trauma Center. J Surg Res 2022; 275:308-317. [DOI: 10.1016/j.jss.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Revised: 12/08/2021] [Accepted: 02/10/2022] [Indexed: 11/16/2022]
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136
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Ramgopal S, Lorenz D, Navanandan N, Cotter JM, Shah SS, Ruddy RM, Ambroggio L, Florin TA. Validation of Prediction Models for Pneumonia Among Children in the Emergency Department. Pediatrics 2022; 150:e2021055641. [PMID: 35748157 PMCID: PMC11127179 DOI: 10.1542/peds.2021-055641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/12/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Several prediction models have been reported to identify patients with radiographic pneumonia, but none have been validated or broadly implemented into practice. We evaluated 5 prediction models for radiographic pneumonia in children. METHODS We evaluated 5 previously published prediction models for radiographic pneumonia (Neuman, Oostenbrink, Lynch, Mahabee-Gittens, and Lipsett) using data from a single-center prospective study of patients 3 months to 18 years with signs of lower respiratory tract infection. Our outcome was radiographic pneumonia. We compared each model's area under the receiver operating characteristic curve (AUROC) and evaluated their diagnostic accuracy at statistically-derived cutpoints. RESULTS Radiographic pneumonia was identified in 253 (22.2%) of 1142 patients. When using model coefficients derived from the study dataset, AUROC ranged from 0.58 (95% confidence interval, 0.52-0.64) to 0.79 (95% confidence interval, 0.75-0.82). When using coefficients derived from original study models, 2 studies demonstrated an AUROC >0.70 (Neuman and Lipsett); this increased to 3 after deriving regression coefficients from the study cohort (Neuman, Lipsett, and Oostenbrink). Two models required historical and clinical data (Neuman and Lipsett), and the third additionally required C-reactive protein (Oostenbrink). At a statistically derived cutpoint of predicted risk from each model, sensitivity ranged from 51.2% to 70.4%, specificity 49.9% to 87.5%, positive predictive value 16.1% to 54.4%, and negative predictive value 83.9% to 90.7%. CONCLUSIONS Prediction models for radiographic pneumonia had varying performance. The 3 models with higher performance may facilitate clinical management by predicting the risk of radiographic pneumonia among children with lower respiratory tract infection.
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Affiliation(s)
- Sriram Ramgopal
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Douglas Lorenz
- Department of Bioinformatics and Biostatistics, University of Louisville, Louisville, Kentucky
| | - Nidhya Navanandan
- Sections of Emergency Medicine, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Jillian M. Cotter
- Pediatric Hospital Medicine, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Samir S. Shah
- Divisions of Hospital Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Richard M. Ruddy
- Emergency Medicine, Cincinnati Children’s Hospital Medical Center and University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Lilliam Ambroggio
- Sections of Emergency Medicine, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Pediatric Hospital Medicine, Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
- Department of Pediatrics, Children’s Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Todd A. Florin
- Division of Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
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137
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Television-Related Head Injuries in Children: A Secondary Analysis of a Large Cohort Study of Head-Injured Children in the Pediatric Emergency Care Applied Research Network. Pediatr Emerg Care 2022; 38:326-331. [PMID: 26555312 DOI: 10.1097/pec.0000000000000605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of the study was to describe the epidemiology, cranial computed tomography (CT) findings, and clinical outcomes of children with blunt head trauma after television tip-over injuries. METHODS We performed a secondary analysis of children younger than 18 years prospectively evaluated for blunt head trauma at 25 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from June 2004 to September 2006. Children injured from falling televisions were included. Patients were excluded if injuries occurred more than 24 hours before ED evaluation or if neuroimaging was obtained before evaluation. Data collected included age, race, sex, cranial CT findings, and clinical outcomes. Clinically important traumatic brain injuries (ciTBIs) were defined as death from TBI, neurosurgery, intubation for more than 24 hours for the TBI, or hospital admission of 2 nights or more for the head injury, in association with TBI on CT. RESULTS A total of 43,904 children were enrolled into the primary study and 218 (0.5%; 95% confidence interval [CI], 0.4% to 0.6%) were struck by falling televisions. The median (interquartile range) age of the 218 patients was 3.1 (1.9-4.9) years. Seventy-five (34%) of the 218 underwent CT scanning. Ten (13.3%; 95% CI, 6.6% to 23.2%) of the 75 patients with an ED CT had traumatic findings on cranial CT scan. Six patients met the criteria for ciTBI. Three of these patients died. All 6 patients with ciTBIs were younger than 5 years. CONCLUSIONS Television tip-overs may cause ciTBIs in children, including death, and the most severe injuries occur in children 5 years or younger. These injuries may be preventable by simple preventive measures such as anchoring television sets with straps.
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138
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Podolak OE, Arbogast KB, Master CL, Sleet D, Grady MF. Pediatric Sports-Related Concussion: An Approach to Care. Am J Lifestyle Med 2022; 16:469-484. [PMID: 35860366 PMCID: PMC9290185 DOI: 10.1177/1559827620984995] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 11/18/2020] [Accepted: 12/11/2020] [Indexed: 08/14/2023] Open
Abstract
Sports-related concussion (SRC) is a common sports injury in children and adolescents. With the vast amount of youth sports participation, an increase in awareness of concussion and evidence that the injury can lead to consequences for school, sports and overall quality of life, it has become increasingly important to properly diagnose and manage concussion. SRC in the student athlete is a unique and complex injury, and it is important to highlight the differences in the management of child and adolescent concussion compared with adults. This review focuses on the importance of developing a multimodal systematic approach to diagnosing and managing pediatric sports-related concussion, from the sidelines through recovery.
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Affiliation(s)
- Olivia E. Podolak
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kristy B. Arbogast
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - Christina L. Master
- Center for Injury Research and Prevention, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
| | - David Sleet
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Matthew F. Grady
- Sports Medicine and Performance Center, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
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139
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Remick KE, Bartley KA, Gonzales L, MacRae KS, Edgerton EA. Consensus-driven model to establish paediatric emergency care measures for low-volume emergency departments. BMJ Open Qual 2022; 11:bmjoq-2021-001803. [PMID: 35803615 PMCID: PMC9272131 DOI: 10.1136/bmjoq-2021-001803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 06/19/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Katherine E Remick
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Krystle A Bartley
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Louis Gonzales
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
| | - Kate S MacRae
- Gonzaga University College of Arts and Sciences, Spokane, Washington, USA
| | - Elizabeth A Edgerton
- Pediatrics, The University of Texas at Austin Dell Medical School, Austin, Texas, USA
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140
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Kooper CC, Oosterlaan J, Bruining H, Engelen M, Pouwels PJW, Popma A, van Woensel JBM, Buis DR, Steenweg ME, Hunfeld M, Königs M. Towards PErsonalised PRognosis for children with traumatic brain injury: the PEPR study protocol. BMJ Open 2022; 12:e058975. [PMID: 35768114 PMCID: PMC9244717 DOI: 10.1136/bmjopen-2021-058975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 06/16/2022] [Indexed: 11/06/2022] Open
Abstract
INTRODUCTION Traumatic brain injury (TBI) in children can be associated with poor outcome in crucial functional domains, including motor, neurocognitive and behavioural functioning. However, outcome varies between patients and is mediated by complex interplay between demographic factors, premorbid functioning and (sub)acute clinical characteristics. At present, methods to understand let alone predict outcome on the basis of these variables are lacking, which contributes to unnecessary follow-up as well as undetected impairments in children. Therefore, this study aims to develop prognostic models for the individual outcome of children with TBI in a range of important developmental domains. In addition, the potential added value of advanced neuroimaging data and the use of machine learning algorithms in the development of prognostic models will be assessed. METHODS AND ANALYSIS 210 children aged 4-18 years diagnosed with mild-to-severe TBI will be prospectively recruited from a research network of Dutch hospitals. They will be matched 2:1 to a control group of neurologically healthy children (n=105). Predictors in the model will include demographic, premorbid and clinical measures prospectively registered from the TBI hospital admission onwards as well as MRI metrics assessed at 1 month post-injury. Outcome measures of the prognostic models are (1) motor functioning, (2) intelligence, (3) behavioural functioning and (4) school performance, all assessed at 6 months post-injury. ETHICS AND DISSEMINATION Ethics has been obtained from the Medical Ethical Board of the Amsterdam UMC (location AMC). Findings of our multicentre prospective study will enable clinicians to identify TBI children at risk and aim towards a personalised prognosis. Lastly, findings will be submitted for publication in open access, international and peer-reviewed journals. TRIAL REGISTRATION NUMBER NL71283.018.19 and NL9051.
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Affiliation(s)
- Cece C Kooper
- Department of Pediatrics, Emma Neuroscience Group, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Amsterdam Neuroscience Research Institute, Amsterdam, The Netherlands
| | - Jaap Oosterlaan
- Department of Pediatrics, Emma Neuroscience Group, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
| | - Hilgo Bruining
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Amsterdam Neuroscience Research Institute, Amsterdam, The Netherlands
- Department of Child and Youth Psychiatry, Emma Children's Hospital, Amsterdam UMC location Vrije Universiteit Amsterdam, N=You centre, Amsterdam, Netherlands
| | - Marc Engelen
- Department of Pediatric Neurology, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
- Amsterdam Leukodystrophy Center, Amsterdam, The Netherlands
| | - Petra J W Pouwels
- Amsterdam Neuroscience Research Institute, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Arne Popma
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Child and Youth Psychiatry, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Job B M van Woensel
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Pediatric Intensive Care Unit, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Dennis R Buis
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
- Department of Neurosurgery, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | | | - Maayke Hunfeld
- Department of Pediatric Neurology, Erasmus MC Sophia Children Hospital, Rotterdam, The Netherlands
| | - Marsh Königs
- Department of Pediatrics, Emma Neuroscience Group, Emma Children's Hospital, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
- Amsterdam Reproduction and Development Research Institute, Amsterdam, The Netherlands
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141
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Heiman E, Hessing E, Berliner E, Cytter-Kuint R, Barak-Corren Y, Weiser G. "Feed and Swaddle" method of Infants Undergoing Head CT for minor head injury in the pediatric emergency department - A comparative case review. Eur J Radiol 2022; 154:110399. [PMID: 35738167 DOI: 10.1016/j.ejrad.2022.110399] [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: 02/18/2022] [Revised: 05/29/2022] [Accepted: 06/04/2022] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Brain imaging for suspected significant head injuries in pediatric emergency departments is an important and time-sensitive procedure. The use of sedation to successfully complete imaging can be limited due to young age and other injury related factors. Using a non-pharmacological method using feeding and swaddling can be used. This may obviate the need for sedation but can be time consuming. METHODS A retrospective study of all children undergoing brain imaging for head injury during the years 2016-2021. Use of sedation, time to completion and imaging findings were compared. RESULTS Of 281 children requiring brain imaging, 268 (95.4%) were completed using the feed and swaddle method. Time to imaging completion was similar between sedation and feed and swaddle groups (85.5 min vs. 86 min). Abnormal findings on imaging were found in 186 (69.4%) in the feed and swaddle group and in 10 (77%) of the sedation group. No adverse events were seen in the sedation group. CONCLUSION Using the feed and swaddle method can help lower the need for sedation in the under 1 year age group with a successful and timely completion of brain imaging.
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Affiliation(s)
- Eyal Heiman
- Pediatric Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Evelyn Hessing
- Pediatric Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Elihay Berliner
- Pediatric Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Ruth Cytter-Kuint
- Pediatric Radiology Unit, Shaare Zedek Medical Center, Jerusalem, Israel
| | | | - Giora Weiser
- Pediatric Emergency Department, Shaare Zedek Medical Center, Jerusalem, Israel; Faculty of Medicine of the Hebrew University of Jerusalem, Israel.
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142
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Hu R, Fan KY, Pandey P, Hu Z, Yau O, Teng M, Wang P, Li T, Ashraf M, Singla R. Insights from teaching artificial intelligence to medical students in Canada. COMMUNICATIONS MEDICINE 2022; 2:63. [PMID: 35668847 PMCID: PMC9166802 DOI: 10.1038/s43856-022-00125-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 05/12/2022] [Indexed: 11/09/2022] Open
Abstract
Clinical artificial intelligence (AI) applications are rapidly developing but existing medical school curricula provide limited teaching covering this area. Here we describe an AI training curriculum we developed and delivered to Canadian medical undergraduates and provide recommendations for future training.
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Affiliation(s)
- Ricky Hu
- School of Medicine, Queen’s University, Kingston, ON Canada
- School of Biomedical Engineering, The University of British Columbia, Vancouver, BC Canada
| | - Kevin Y. Fan
- Department of Radiation Oncology, The University of Toronto, Toronto, ON Canada
| | - Prashant Pandey
- School of Biomedical Engineering, The University of British Columbia, Vancouver, BC Canada
| | - Zoe Hu
- School of Medicine, Queen’s University, Kingston, ON Canada
| | - Olivia Yau
- Faculty of Medicine, The University of British Columbia, Vancouver, BC Canada
| | - Minnie Teng
- Faculty of Medicine, The University of British Columbia, Vancouver, BC Canada
| | - Patrick Wang
- School of Medicine, Queen’s University, Kingston, ON Canada
| | - Toni Li
- School of Medicine, Queen’s University, Kingston, ON Canada
| | - Mishal Ashraf
- School of Biomedical Engineering, The University of British Columbia, Vancouver, BC Canada
| | - Rohit Singla
- School of Medicine, Queen’s University, Kingston, ON Canada
- Faculty of Medicine, The University of British Columbia, Vancouver, BC Canada
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143
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Abstract
ABSTRACT Trauma remains the leading cause of morbidity and mortality in children and youth 1 to 19 years old in the United States. Providing timely care with a systematic approach is essential for emergently addressing life-threatening injuries and ongoing assessment. The primary survey is focused on identifying and managing life-threatening injuries. The secondary survey is focused on identifying and managing other important injuries. Over the past decade, there have been important advances in the evidence supporting the management of multisystem trauma in the pediatric patient by the emergency medicine clinician. In addition, the emergence of diagnostics, such as point-of-care ultrasound, aids decision making in the evaluation and management of the pediatric trauma patient. The purpose of this article is to review the initial systematic diagnostic approach and the emergent management of multisystem injuries from blunt force trauma in children in the emergency department and provide insight into the aspects of care that are still evolving.
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Affiliation(s)
- Megan M Hannon
- From the Instructor, Division of Emergency Medicine and Department of Orthopaedic Surgery, Boston Children's Hospital, Boston, MA
| | - Leah K Middelberg
- Fellow, Division of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH
| | - Lois K Lee
- Associate Professor, Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Grant L, Joo P, Nemnom MJ, Thiruganasambandamoorthy V. Machine learning versus traditional methods for the development of risk stratification scores: a case study using original Canadian Syncope Risk Score data. Intern Emerg Med 2022; 17:1145-1153. [PMID: 34734350 DOI: 10.1007/s11739-021-02873-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 10/13/2021] [Indexed: 12/23/2022]
Abstract
Artificial Intelligence and machine learning (ML) methods are promising for risk-stratification, but the added benefit over traditional statistical methods remains unclear. We compared predictive models developed using machine learning (ML) methods to the Canadian Syncope Risk Score (CSRS), a risk-tool developed with logistic regression for predicting serious adverse events (SAE) after emergency department (ED) disposition for syncope. We used the prospective multicenter cohort data collected for CSRS development at 11 Canadian EDs over an 8-year period to develop four ML models to predict 30-day SAE (death, arrhythmias, MI, structural heart disease, pulmonary embolism, hemorrhage) after ED disposition. The CSRS derivation and validation cohorts were used for training and testing, respectively, and the 43 variables used included demographics, medical history, vital signs, ECG findings, blood tests and the diagnostic impression of the emergency physician. Performance was assessed using the area under the receiver-operating-characteristics curve (AUC) and calibration curves. Of the 4030 patients in the training set and 3819 patients in the test set overall, 286 (3.6%) patients suffered 30-day SAE. The AUCs for model validation in test data were CSRS 0.902 (0.877-0.926), regularized regression 0.903 (0.877-0.928), gradient boosting 0.914 (0.894-0.934), deep neural network 0.906 (0.883-0.929), simplified gradient boosting 0.904 (0.881-0.927). The AUCs and calibration slopes for the ML models and CSRS were similar. Two ML models used fewer predictors than the CSRS but matched its performance. Overall, the ML models matched the CSRS in performance, with some models using fewer predictors.
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Affiliation(s)
- Lars Grant
- Department of Emergency Medicine, McGill University, Montreal, QC, Canada
- Lady Davis Research Institute, Montreal, QC, Canada
- Jewish General Hospital, Montreal, QC, Canada
| | - Pil Joo
- The Ottawa Hospital, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Emergency Medicine, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada
| | - Venkatesh Thiruganasambandamoorthy
- The Ottawa Hospital, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Emergency Medicine, Ottawa Hospital Research Institute, 1053 Carling Avenue, Ottawa, ON, K1Y 4E9, Canada.
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, ON, Canada.
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145
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Greenberg JK, Olsen MA, Johnson GW, Ahluwalia R, Hill M, Hale AT, Belal A, Baygani S, Foraker RE, Carpenter CR, Ackerman LL, Noje C, Jackson EM, Burns E, Sayama CM, Selden NR, Vachhrajani S, Shannon CN, Kuppermann N, Limbrick DD. Measures of Intracranial Injury Size Do Not Improve Clinical Decision Making for Children With Mild Traumatic Brain Injuries and Intracranial Injuries. Neurosurgery 2022; 90:691-699. [PMID: 35285454 PMCID: PMC9117421 DOI: 10.1227/neu.0000000000001895] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 12/05/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND When evaluating children with mild traumatic brain injuries (mTBIs) and intracranial injuries (ICIs), neurosurgeons intuitively consider injury size. However, the extent to which such measures (eg, hematoma size) improve risk prediction compared with the kids intracranial injury decision support tool for traumatic brain injury (KIIDS-TBI) model, which only includes the presence/absence of imaging findings, remains unknown. OBJECTIVE To determine the extent to which measures of injury size improve risk prediction for children with mild traumatic brain injuries and ICIs. METHODS We included children ≤18 years who presented to 1 of the 5 centers within 24 hours of TBI, had Glasgow Coma Scale scores of 13 to 15, and had ICI on neuroimaging. The data set was split into training (n = 1126) and testing (n = 374) cohorts. We used generalized linear modeling (GLM) and recursive partitioning (RP) to predict the composite of neurosurgery, intubation >24 hours, or death because of TBI. Each model's sensitivity/specificity was compared with the validated KIIDS-TBI model across 3 decision-making risk cutoffs (<1%, <3%, and <5% predicted risk). RESULTS The GLM and RP models included similar imaging variables (eg, epidural hematoma size) while the GLM model incorporated additional clinical predictors (eg, Glasgow Coma Scale score). The GLM (76%-90%) and RP (79%-87%) models showed similar specificity across all risk cutoffs, but the GLM model had higher sensitivity (89%-96% for GLM; 89% for RP). By comparison, the KIIDS-TBI model had slightly higher sensitivity (93%-100%) but lower specificity (27%-82%). CONCLUSION Although measures of ICI size have clear intuitive value, the tradeoff between higher specificity and lower sensitivity does not support the addition of such information to the KIIDS-TBI model.
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Affiliation(s)
- Jacob K. Greenberg
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Margaret A. Olsen
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Gabrielle W. Johnson
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Ranbir Ahluwalia
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
| | - Madelyn Hill
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA;
| | - Andrew T. Hale
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA;
| | - Ahmed Belal
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA;
| | - Shawyon Baygani
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA;
| | - Randi E. Foraker
- Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Christopher R. Carpenter
- Department of Emergency Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
| | - Laurie L. Ackerman
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA;
| | - Corina Noje
- Department of Anesthesiology and Critical Care Medicine, Division of Pediatric Critical Care Medicine, The Charlotte R. Bloomberg Children's Center, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA;
| | - Eric M. Jackson
- Neurological Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA;
| | - Erin Burns
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA;
| | - Christina M. Sayama
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA;
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA;
| | - Nathan R. Selden
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon, USA;
- Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon, USA;
| | - Shobhan Vachhrajani
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA;
- Department of Pediatrics, Wright State University, Dayton, Ohio, USA;
| | - Chevis N. Shannon
- Division of Neurosurgery, Dayton Children's Hospital, Dayton, Ohio, USA;
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis, School of Medicine, Sacramento, California, USA;
- Department of Pediatrics, University of California Davis, School of Medicine, Sacramento, California, USA
| | - David D. Limbrick
- Department of Neurological Surgery, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA;
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146
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Eser P, Corabay S, Ozmarasali AI, Ocakoglu G, Taskapilioglu MO. The association between hematologic parameters and intracranial injuries in pediatric patients with traumatic brain injury. Brain Inj 2022; 36:740-749. [PMID: 35608540 DOI: 10.1080/02699052.2022.2077442] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
OBJECTIVE Analyzing the association between hematologic parameters and abnormal cranial computerized tomography (CT) findings after head trauma. MATERIAL AND METHODS A total of 287 children with isolated traumatic brain injury (TBI) were divided into the 'normal' (NG), 'linear fracture' (LFG) and 'intraparenchymal injury' groups (IPG) based on head CT findings. Demographical/clinical data and laboratory results were obtained from medical records. RESULTS The neutrophil-lymphocyte ratio was markedly higher in the LFG (p = 0.010 and p = 0.016, respectively) and IPG (p = 0.004 and p < 0.001, respectively) compared with NG. Lower lymphocyte-monocyte ratio (p = 0.044) and higher red cell distribution width-platelet ratio (RPR) (p = 0.030) were associated with intraparenchymal injuries. Patients requiring neurosurgical intervention had higher neutrophil-lymphocyte ratio (p = 0.026) and RPR values (p = 0.031) and lower platelet counts (p = 0.035). Lower levels of erythrocytes (p = 0.005), hemoglobin (p = 0.003) and hematocrit (p = 0.002) were associated with severe TBI and unfavorable outcome (p = 0.012, p = 0.004 and p = 0.006, respectively). CONCLUSIONS Hematologic parameters are useful in predicting the presence of abnormal cranial CT findings in children with TBI in association with injury severity; surgery need and clinical outcome.
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Affiliation(s)
- Pinar Eser
- Department of Neurosurgery, Bursa Uludag University Faculty of Medicine, Turkey, Bursa
| | - Seniha Corabay
- Department of Biostatistics, Bursa Uludag University Faculty of Medicine, Turkey, Bursa
| | - Ali Imran Ozmarasali
- Department of Neurosurgery, Bursa Uludag University Faculty of Medicine, Turkey, Bursa
| | - Gokhan Ocakoglu
- Department of Biostatistics, Bursa Uludag University Faculty of Medicine, Turkey, Bursa
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147
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Wickbom F, Persson L, Olivecrona Z, Undén J. Management of paediatric traumatic brain injury in Sweden: a national cross-sectional survey. Scand J Trauma Resusc Emerg Med 2022; 30:35. [PMID: 35551626 PMCID: PMC9097395 DOI: 10.1186/s13049-022-01022-4] [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: 09/01/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
Background Previous studies have shown variations in management routines for children with traumatic brain injury (TBI) in Sweden. It is unknown if this management has changed after the publication of the Scandinavian Neurotrauma Committee guidelines in 2016 (SNC16). Also, knowledge of current practice routines may guide development of an efficient implementation strategy for the guidelines. The aim of this study is therefore to describe current management routines in paediatric TBI on a hospital/organizational level in Sweden. Secondary aims are to analyse differences in management over time, to assess the current dissemination status of the SNC16 guideline and to analyse possible variations between hospitals. Methods This is a sequential, cross-sectional, structured survey in five sections, covering initial management routines for paediatric TBI in Sweden. Respondents, with profound knowledge of local management routines and recommendations, were identified for all Swedish hospitals with an emergency department managing children (age 0–17 year) via phone/mail before distribution of the survey. Responses were collected via an on-line survey system during June 2020–March 2021. Data are presented as descriptive statistics and comparisons were made using Fisher exact test, when applicable. Results 71 of the 76 identified hospitals managed patients with TBI of all ages and 66 responded (response rate 93%). 56 of these managed children and were selected for further analysis. 76% (42/55) of hospitals have an established guideline to aid in clinical decision making. Children with TBI are predominately managed by inexperienced doctors (84%; 47/56), primarily from non-paediatric specialities (75%; 42/56). Most hospitals (75%; 42/56) have the possibility to admit and observe children with TBI of varying degrees and almost all centres have complete access to neuroradiology (96%; 54/56). In larger hospitals, it was more common for nurses to discharge patients without doctor assessment when compared to smaller hospitals (6/9 vs. 9/47; p < 0.001). Presence of established guidelines (14/51 vs. 42/55; p < 0.001) and written observation routines (16/51 vs. 29/42; p < 0.001) in hospitals have increased significantly since 2006. Conclusions TBI management routines for children in Sweden still vary, with some differences occurring over time. Use of established guidelines, written observation routines and information for patients/guardians have all improved. These results form a baseline for current management and may also aid in guideline implementation. Supplementary Information The online version contains supplementary material available at 10.1186/s13049-022-01022-4.
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Affiliation(s)
- Fredrik Wickbom
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden. .,Lund University, Lund, Sweden.
| | - Linda Persson
- Department of Orthopaedics, Halland Hospital, Halmstad, Sweden
| | - Zandra Olivecrona
- Department of Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Örebro, Sweden
| | - Johan Undén
- Department of Operation and Intensive Care, Halland Hospital, Halmstad, Sweden.,Lund University, Lund, Sweden
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148
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Cicogna A, Minca G, Posocco F, Corno F, Basile C, Da Dalt L, Bressan S. Non-ionizing Imaging for the Emergency Department Assessment of Pediatric Minor Head Trauma. Front Pediatr 2022; 10:881461. [PMID: 35633980 PMCID: PMC9132372 DOI: 10.3389/fped.2022.881461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 04/22/2022] [Indexed: 11/13/2022] Open
Abstract
Minor blunt head trauma (MHT) represents a common reason for presentation to the pediatric emergency department (ED). Despite the low incidence of clinically important traumatic brain injuries (ciTBIs) following MHT, many children undergo computed tomography (CT), exposing them to the risk associated with ionizing radiation. The clinical predictions rules developed by the Pediatric Emergency Care Applied Research Network (PECARN) for MHT are validated accurate tools to support decision-making about neuroimaging for these children to safely reduce CT scans. However, a few non-ionizing imaging modalities have the potential to contribute to further decrease CT use. This narrative review provides an overview of the evidence on the available non-ionizing imaging modalities that could be used in the management of children with MHT, including point of care ultrasound (POCUS) of the skull, near-infrared spectroscopy (NIRS) technology and rapid magnetic resonance imaging (MRI). Skull ultrasound has proven an accurate bedside tool to identify the presence and characteristics of skull fractures. Portable handheld NIRS devices seem to be accurate screening tools to identify intracranial hematomas also in pediatric MHT, in selected scenarios. Both imaging modalities may have a role as adjuncts to the PECARN rule to help refine clinicians' decision making for children at high or intermediate PECARN risk of ciTBI. Lastly, rapid MRI is emerging as a feasible and accurate alternative to CT scan both in the ED setting and when repeat imaging is needed. Advantages and downsides of each modality are discussed in detail in the review.
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Affiliation(s)
| | | | | | | | | | | | - Silvia Bressan
- Division of Pediatric Emergency Medicine, Department of Women’s and Children’s Health, University of Padova, Padua, Italy
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149
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Deana C, Vetrugno L, Stefani F, Bassi F, Bove T. Transcranial Doppler in a child: A most valuable imaging modality. ULTRASOUND (LEEDS, ENGLAND) 2022; 30:167-172. [PMID: 35509297 PMCID: PMC9058393 DOI: 10.1177/1742271x21998059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 02/01/2021] [Indexed: 05/03/2023]
Abstract
Introduction Pediatric brain injury is a common cause of emergency department (ED) referral. Although severe traumatic brain damage is less frequent, it could be primarily managed by non-pediatric critical care physicians called in for advice. Clinical evaluation is important, but radiology is of particular value in the case of severe brain injury. Transcranial Doppler may help the physician through neuromonitoring. Case Report We report the case of a 3-year-old male child brought into the pediatric ED for a moderate head injury. His neurological status deteriorated rapidly, making endotracheal intubation and mechanical ventilation necessary. Computed tomography (CT) of the head revealed brain contusion and post-traumatic subarachnoidal hemorrhage. Discussion Transcranial Doppler was performed at the standard transtemporal evaluation window, and it showed normal vascularization of the entire anterior brain. This result permitted performance of the control CT scan to be postponed. In this case, basic knowledge of transcranial ultrasound proved to be useful, and we believe it could also be useful to other colleagues faced with similar situations even if they are not dedicated to pediatric critically ill patients. Conclusion Doppler ultrasound in the pediatric population is a valuable bedside tool. Together with clinical evaluation and radiology, it completes the set of techniques necessary for continuous neuromonitoring.
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Udine, Italy
- Cristian Deana, Anesthesia and Intensive Care 1, Anesthesia and Intensive Care Department, Academic Hospital S. Maria della Misericordia, Azienda Sanitaria Universitaria Friuli Centrale, Piazzale S. M. della Misericordia, 15 - 33100 Udine, Italy.
| | - Luigi Vetrugno
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Udine, Italy
- Medical Department, University of Udine, Udine, Italy
| | - Francesca Stefani
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Udine, Italy
| | - Flavio Bassi
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Udine, Italy
| | - Tiziana Bove
- Department of Anesthesia and Intensive Care, Academic Hospital of Udine, Udine, Italy
- Medical Department, University of Udine, Udine, Italy
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Sullivan BG, Grigorian A, Lekawa M, Dolich MO, Schubl SD, Barrios C, Joe VC, Borazjani B, Nahmias J. Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury. Pediatr Emerg Care 2022; 38:e1262-e1265. [PMID: 35482503 DOI: 10.1097/pec.0000000000002588] [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: 11/26/2022]
Abstract
OBJECTIVES Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level. METHODS The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis. RESULTS The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001). CONCLUSIONS In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.
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Affiliation(s)
- Brittany G Sullivan
- From the Department of Surgery, University of California Irvine Medical Center, Orange, CA
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