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Liu YC, Chen IC, Yin HL, Wu YH, Lo SH, Liang WC, Jaw TS, Dai ZK, Hsu JH. Comparisons of characteristics and outcome between abusive head trauma and non-abusive head trauma in a pediatric intensive care unit. J Formos Med Assoc 2023; 122:1183-1188. [PMID: 37268475 DOI: 10.1016/j.jfma.2023.05.019] [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: 10/07/2022] [Revised: 03/27/2023] [Accepted: 05/18/2023] [Indexed: 06/04/2023] Open
Abstract
BACKGROUND Abusive head trauma (AHT) is the leading cause of death in infants with traumatic brain injury (TBI). Early recognition of AHT is important for improving outcomes, but it can be challenging due to its similar presentations with non-abusive head trauma (nAHT). This study aims to compare clinical presentations and outcomes between infants with AHT and nAHT, and to identify the risk factors for poor outcomes of AHT. METHODS We retrospectively analyzed infants of TBI in our pediatric intensive care unit from January 2014 to December 2020. Clinical manifestations and outcomes were compared between patients with AHT and nAHT. Risk factors for poor outcomes in AHT patients were also analyzed. RESULTS 60 patients were enrolled for this analysis, including 18 of AHT (30%) and 42 of nAHT (70%). Compared with those with nAHT, patients with AHT were more likely to have conscious change, seizures, limb weakness, and respiratory failure, but with a fewer incidence of skull fractures. Additionally, clinical outcomes of AHT patients were worse, with more cases undergoing neurosurgery, higher Pediatric Overall Performance Category score at discharge, and more anti-epileptic drug (AED) use after discharge. For AHT patients, conscious change is an independent risk factor for a composite poor outcome of mortality, ventilator dependence, or AED use (OR = 21.9, P = 0.04) CONCLUSION: AHT has a worse outcome than nAHT. Conscious change, seizures and limb weaknesses but not skull fractures are more common in AHT. Conscious change is both an early reminder of AHT and a risk factor for its poor outcomes.
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Affiliation(s)
- Yi-Ching Liu
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - I-Chen Chen
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Hsin-Ling Yin
- Department of Clinical Forensic Medicine, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Yen-Hsien Wu
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shih-Hsing Lo
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chen Liang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Twei-Shiun Jaw
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Medical Imaging, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan; Department of Radiology, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Zen-Kong Dai
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Jong-Hau Hsu
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan; Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan; Department of Pediatrics, School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
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2
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Hymel KP, Boos SC, Armijo-Garcia V, Musick M, Weeks K, Haney SB, Marinello M, Herman BE, Frazier TN, Carroll CL, Even K, Wang M. An analysis of physicians' diagnostic reasoning regarding pediatric abusive head trauma. CHILD ABUSE & NEGLECT 2022; 129:105666. [PMID: 35567958 PMCID: PMC10724711 DOI: 10.1016/j.chiabu.2022.105666] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 04/26/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Physician diagnoses of abusive head trauma (AHT) have been criticized for circular reasoning and over-reliance on a "triad" of findings. Absent a gold standard, analyses that apply restrictive reference standards for AHT and non-AHT could serve to confirm or refute these criticisms. OBJECTIVES To compare clinical presentations and injuries in patients with witnessed/admitted AHT vs. witnessed non-AHT, and with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted. To measure the triad's AHT test performance in patients with witnessed/admitted AHT vs. witnessed non-AHT. PARTICIPANTS AND SETTING Acutely head injured patients <3 years hospitalized for intensive care across 18 sites between 2010 and 2021. METHODS Secondary analyses of existing, combined, cross-sectional datasets. Probability values and odds ratios were used to identify and characterize differences. Test performance measures included sensitivity, specificity, and predictive values. RESULTS Compared to patients with witnessed non-AHT (n = 100), patients with witnessed/admitted AHT (n = 58) presented more frequently with respiratory compromise (OR 2.94, 95% CI: 1.50-5.75); prolonged encephalopathy (OR 5.23, 95% CI: 2.51-10.89); torso, ear, or neck bruising (OR 11.87, 95% CI: 4.48-31.48); bilateral subdural hemorrhages (OR 8.21, 95% CI: 3.94-17.13); diffuse brain hypoxia, ischemia, or swelling (OR 6.51, 95% CI: 3.06-13.02); and dense, extensive retinal hemorrhages (OR 7.59, 95% CI: 2.85-20.25). All differences were statistically significant (p ≤ .001). No significant differences were observed in patients with witnessed/admitted AHT (n = 58) vs. patients diagnosed with AHT not witnessed/admitted (n = 438). The triad demonstrated AHT specificity and positive predictive value ≥0.96. CONCLUSIONS The observed differences in patients with witnessed/admitted AHT vs. witnessed non-AHT substantiate prior reports. The complete absence of differences in patients with witnessed/admitted AHT vs. physician diagnosed AHT not witnessed/admitted supports an impression that physicians apply diagnostic reasoning informed by knowledge of previously reported injury patterns. Concern for abuse is justified in patients who present with "the triad."
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Affiliation(s)
- Kent P Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Stephen C Boos
- Department of Pediatrics, UMass Chan Medical School-Baystate Health, 759 Chestnut Street, Springfield, MA 01199, USA.
| | - Veronica Armijo-Garcia
- University of Texas Health Sciences Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, TX 78229, USA.
| | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, 6621 Fannin Street, Houston, TX 77030, USA.
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, 3243 East Murdoch, Wichita, KS 67208, USA
| | - Suzanne B Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children's Hospital and Medical Center, 8200 Dodge Street, Omaha, NE 68114, USA.
| | - Mark Marinello
- Department of Pediatrics, Children's Hospital of Richmond at VCU, 1250 East Marshall Street, Richmond, VA 23219, USA.
| | - Bruce E Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children's Hospital, 100 North Mario Capecchie Drive, Salt Lake City, UT 84113, USA.
| | - Terra N Frazier
- Department of Pediatrics, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA.
| | - Christopher L Carroll
- Department of Pediatrics, Connecticut Children's Medical Center, 282 Washington Street, Hartford, CT 06106, USA.
| | - Katelyn Even
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children's Hospital, 600 University Drive, Hershey, PA 17033, USA.
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, 700 HMC Crescent Road, Hershey, PA 17033, USA.
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3
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Lee SSJ, Manivel V, Vignakaran S, Hochholzer K, De Alwis C, Espinoza D, Teo SSS. Documentation of paediatric head injuries in a mixed metropolitan emergency department. Emerg Med Australas 2022; 34:738-743. [PMID: 35384296 DOI: 10.1111/1742-6723.13967] [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: 12/11/2020] [Revised: 03/05/2022] [Accepted: 03/08/2022] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Head injuries are a common presentation of children to Australian EDs. Healthcare documentation is an important tool for enhancing patient care. In our study, we aimed to assess the adequacy of paediatric head injury documentation in a mixed ED. METHODS A retrospective analysis of presentations to a mixed ED between 2017 and 2018. Children aged <16 years old with a primary diagnosis of head injury were included. Documentation items based on local head injury guidelines were assessed in both medical and nursing documentation. We compared cases aged <1 and ≥1 year. RESULTS There were 427 presentations that met the case definition. Medical documentation was present in 422 cases and nursing documentation in 310 cases. In combined medical and nursing documentation, items poorly documented include blood pressure (BP; 21.3%) and secondary survey (16.9%). In solely medical documentation, least commonly documented items are high-risk bony injuries (22.5%), high-risk soft tissue injuries (22.3%), seizure (22.0%) and non-accidental injury (3.6%). Glasgow Coma Scale (GCS) was poorly documented in cases aged <1 year (10.9%, P < 0.001). CONCLUSIONS The largest gaps in the documentation of paediatric head injuries were BP and paediatric GCS in infants. Future audits and educational strategies should focus on targeting clinically relevant items that are predictive of serious outcomes.
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Affiliation(s)
| | - Vijay Manivel
- Emergency Department, Nepean Hospital, Sydney, New South Wales, Australia.,Emergency Department, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia.,Nepean Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Suganya Vignakaran
- Paediatrics and Neonatology Department, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia.,Paediatrics and Child Health, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Karina Hochholzer
- Emergency Department, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia.,Emergency Department, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - Chamila De Alwis
- Emergency Department, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia.,Emergency Department, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
| | - David Espinoza
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, New South Wales, Australia
| | - Stephen Sze Shing Teo
- Emergency Department, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia.,Paediatrics and Neonatology Department, Blacktown and Mount Druitt Hospitals, Sydney, New South Wales, Australia.,Paediatrics and Child Health, School of Medicine, Western Sydney University, Sydney, New South Wales, Australia
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4
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Akutsu N, Nonaka M, Narisawa A, Kato M, Harada A, Park YS. Infantile subdural hematoma in Japan: A multicenter, retrospective study by the J-HITs (Japanese head injury of infants and toddlers study) group. PLoS One 2022; 17:e0264396. [PMID: 35213611 PMCID: PMC8880432 DOI: 10.1371/journal.pone.0264396] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 02/08/2022] [Indexed: 11/18/2022] Open
Abstract
Objective
Subdural hematoma in infants or toddlers has often been linked to abuse, but it is not clear how many cases actually occur and how many are suspected of abuse. The purpose of this study was to investigate subdural hematoma in infants and toddlers in Japan.
Methods
This multicenter, retrospective study reviewed the clinical records of children younger than 4 years with head trauma who were diagnosed with any finding on head computed tomography (CT) and/or magnetic resonance imaging (MRI), such as skull fracture and/or intracranial injury. A total of 452 children were included. The group suspected to have been abused was classified as nonaccidental, and the group considered to have been caused by an accident was classified as accidental. Subdural hematoma and other factors were examined on multivariate analysis to identify which factors increase the risk of nonaccidental injuries.
Results
Of the 452 patients, 158 were diagnosed with subdural hematoma. Subdural hematoma was the most common finding intracranial finding in head trauma in infants and toddlers. A total of 51 patients were classified into the nonaccidental group, and 107 patients were classified into the accidental group. The age of patients with subdural hematoma showed a bimodal pattern. The mean age of the accidental group with subdural hematoma was significantly older than that in the nonaccidental group (10.2 months vs 5.9 months, respectively. p < 0.001). Multivariate analysis showed that patients under 5 months old, retinal hemorrhage, and seizure were significant risk factors for nonaccidental injury (odds ratio (OR) 3.86, p = 0.0011; OR 7.63, p < 0.001; OR 2.49, p = 0.03; respectively). On the other hand, the odds ratio for subdural hematoma was 1.96, and no significant difference was observed (p = 0.34).
Conclusions
At least in Japanese children, infantile subdural hematoma was frequently observed not only in nonaccidental but also in accidental injuries. In infants with head trauma, age, the presence of retinal hemorrhage, and the presence of seizures should be considered when determining whether they were abused. Subdural hematoma is also a powerful finding to detect abuse, but care should be taken because, in some ethnic groups, such as the Japanese, there are many accidental cases.
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Affiliation(s)
- Nobuyuki Akutsu
- Department of Neurosurgery, Hyogo Prefectural Kobe Children’s Hospital, Hyogo, Japan
| | - Masahiro Nonaka
- Department of Neurosurgery, Kansai Medical University, Osaka, Japan
- * E-mail:
| | - Ayumi Narisawa
- Department of Neurosurgery, Sendai City Hospital, Miyagi, Japan
| | - Mihoko Kato
- Department of Neurosurgery, Aichi Children’s Health and Medical Center, Aichi, Japan
| | - Atsuko Harada
- Department of Pediatric Neurosurgery, Takatsuki General Hospital, Osaka, Japan
| | - Young-Soo Park
- Department of Neurosurgery, Nara Medical University, Nara, Japan
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Boos SC, Wang M, Karst WA, Hymel KP. Traumatic Head Injury and the Diagnosis of Abuse: A Cluster Analysis. Pediatrics 2022; 149:183816. [PMID: 34890450 PMCID: PMC9645685 DOI: 10.1542/peds.2021-051742] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/27/2021] [Indexed: 01/03/2023] Open
Abstract
OBJECTIVES Data guiding abusive head trauma (AHT) diagnosis rest on case-control studies that have been criticized for circularity. We wished to sort children with neurologic injury using mathematical algorithms, without reference to physicians' diagnoses or predetermined diagnostic criteria, and to compare the results to existing AHT data, physicians' diagnoses, and a proposed triad of findings. METHODS Unsupervised cluster analysis of an existing data set regarding 500 young patients with acute head injury hospitalized for intensive care. Three cluster algorithms were used to sort (partition) patients into subpopulations (clusters) on the basis of 32 reliable (κ > 0.6) clinical and radiologic variables. P values and odds ratios (ORs) identified variables most predictive of partitioning. RESULTS The full cohort partitioned into 2 clusters. Variables substantially (P < .001 and OR > 10 in all 3 cluster algorithms) more prevalent in cluster 1 were imaging indications of brain hypoxemia, ischemia, and/or swelling; acute encephalopathy, particularly when lasting >24 hours; respiratory compromise; subdural hemorrhage or fluid collection; and ophthalmologist-confirmed retinoschisis. Variables substantially (P < .001 and OR < 0.10 in any cluster algorithm) more prevalent in cluster 2 were linear parietal skull fracture and epidural hematoma. Postpartitioning analysis revealed that cluster 1 had a high prevalence of physician-diagnosed abuse. CONCLUSIONS Three cluster algorithms partitioned the population into 2 clusters without reference to predetermined diagnostic criteria or clinical opinion about the nature of AHT. Clinical difference between clusters replicated differences previously described in comparisons of AHT with non-AHT. Algorithmic partition was predictive of physician diagnosis and of the triad of findings heavily discussed in AHT literature.
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Affiliation(s)
- Stephen C. Boos
- Department of Pediatrics, University of Massachusetts Chan Medical School—Baystate, Baystate Medical Center, Springfield, Massachusetts,Address correspondence to Stephen C. Boos, MD, Baystate Medical Center, Family Advocacy Center, 300 Carew St, Springfield, MA 01199. E-mail:
| | - Ming Wang
- Department of Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
| | - Wouter A. Karst
- Department of Forensic Medicine, Netherlands Forensic Institute, The Hague, Netherlands
| | - Kent P. Hymel
- Department of Pediatrics, College of Medicine, Pennsylvania State University and Penn State Health Children’s Hospital, Hershey, Pennsylvania
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6
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Feld K, Ricken T, Feld D, Helmus J, Hahnemann M, Schenkl S, Muggenthaler H, Pfeiffer H, Banaschak S, Karger B, Wittschieber D. Fractures and skin lesions in pediatric abusive head trauma: a forensic multi-center study. Int J Legal Med 2021; 136:591-601. [PMID: 34862583 PMCID: PMC8847172 DOI: 10.1007/s00414-021-02751-4] [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: 07/09/2021] [Accepted: 11/24/2021] [Indexed: 11/29/2022]
Abstract
Abusive head trauma (AHT) and its most common variant, the shaken baby syndrome (SBS), are predominantly characterized by central nervous system-associated lesions. Relatively little data are available on the value of skeletal and skin injuries for the diagnosis of SBS or AHT. Thus, the present study retrospectively investigated 72 cases of living children diagnosed with the explicit diagnosis of SBS during medico-legal examinations at three German university institutes of legal medicine. The risk of circular reasoning was reduced by the presence of 15 cases with confession by perpetrators. Accordingly, the comparison with the 57 non-confession cases yielded no significant differences. Skeletal survey by conventional projection radiography, often incomplete, was found to be performed in 78% of the cases only. Fractures were found in 32% of the cases. The skull (43%) and ribs (48%) were affected most frequently; only 8% of the cases showed classic metaphyseal lesions. In 48% of the cases, healing fractures were present. Skin lesions (hematomas and abrasions) were found in 53% of the cases with the face (76%), scalp (26%), and trunk (50%) being the major sites. In 48% of the cases, healing skin lesions were observed. Nearly 80% of the cases with fractures also showed skin lesions. The data prove that SBS is frequently accompanied by other forms of physical abuse. Therefore, skeletal survey is indispensable and should always be done completely and according to existing imaging guidelines if child abuse is suspected.
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Affiliation(s)
- Katharina Feld
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Tim Ricken
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Dustin Feld
- adiutaByte GmbH, Business Campus, Sankt Augustin, Germany
| | - Janine Helmus
- Institute of Legal Medicine, University Hospital Essen, Essen, Germany
| | | | - Sebastian Schenkl
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Holger Muggenthaler
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany
| | - Heidi Pfeiffer
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Sibylle Banaschak
- Institute of Legal Medicine, University Hospital Cologne, Cologne, Germany
| | - Bernd Karger
- Institute of Legal Medicine, University Hospital Münster, Münster, Germany
| | - Daniel Wittschieber
- Institute of Legal Medicine, Jena University Hospital, Friedrich Schiller University, Am Klinikum 1, 07747, Jena, Germany.
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Hymel KP, Armijo-Garcia V, Musick M, Marinello M, Herman BE, Weeks K, Haney SB, Frazier TN, Carroll CL, Kissoon NN, Isaac R, Foster R, Campbell KA, Tieves KS, Livingston N, Bucher A, Woosley MC, Escamilla-Padilla D, Jaimon N, Kustka L, Wang M, Chinchilli VM, Dias MS, Noll J. A Cluster Randomized Trial to Reduce Missed Abusive Head Trauma in Pediatric Intensive Care Settings. J Pediatr 2021; 236:260-268.e3. [PMID: 33798512 PMCID: PMC8403132 DOI: 10.1016/j.jpeds.2021.03.055] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/25/2021] [Accepted: 03/26/2021] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings. STUDY DESIGN This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures <3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models. RESULTS Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22). CONCLUSIONS PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings. TRIAL REGISTRATION ClinicalTrials.gov: NCT03162354.
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Affiliation(s)
- Kent P. Hymel
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | | | - Matthew Musick
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Mark Marinello
- Department of Pediatrics, Children’s Hospital of Richmond, Richmond, Virginia
| | - Bruce E. Herman
- Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah
| | - Kerri Weeks
- Department of Pediatrics, University of Kansas School of Medicine, Wichita, Kansas
| | - Suzanne B. Haney
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Terra N. Frazier
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | | | - Natalie N. Kissoon
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | - Reena Isaac
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Robin Foster
- Department of Pediatrics, Children’s Hospital of Richmond, Richmond, Virginia
| | - Kristine A. Campbell
- Department of Pediatrics, University of Utah School of Medicine, Primary Children’s Hospital, Salt Lake City, Utah
| | - Kelly S. Tieves
- Department of Pediatrics, Children’s Mercy Hospital, Kansas City, Missouri
| | - Nina Livingston
- Department of Pediatrics, Connecticut Children’s Medical Center, Hartford, Connecticut
| | - Ashley Bucher
- Department of Pediatrics, Penn State College of Medicine, Penn State Health Children’s Hospital, Hershey, Pennsylvania
| | - Maria C. Woosley
- University of Texas Health Sciences Center at San Antonio, San Antonio, Texas
| | | | - Nancy Jaimon
- Department of Pediatrics, Baylor College of Medicine, Texas Children’s Hospital, Houston, Texas
| | - Lucinda Kustka
- Department of Pediatrics, University of Nebraska Medical Center, Children’s Hospital and Medical Center, Omaha, Nebraska
| | - Ming Wang
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Vernon M. Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, Pennsylvania
| | - Mark S. Dias
- Departments of Neurosurgery and Pediatrics, Penn State College of Medicine, Hershey, Pennsylvania
| | - Jennie Noll
- Department of Human Development and Family Studies, Penn State University, State College, Pennsylvania
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8
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Blackwell LS, Martinez M, Fournier-Goodnight A, Figueroa J, Appert A, Vats A, Wali B, Sayeed I, Reisner A. Patterns of Osteopontin Expression in Abusive Head Trauma Compared with Other Causes of Pediatric Traumatic Brain Injury. J Pediatr 2020; 227:170-175. [PMID: 32622673 PMCID: PMC7686267 DOI: 10.1016/j.jpeds.2020.06.080] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To examine levels of plasma osteopontin (OPN), a recently described neuroinflammatory biomarker, in children with abusive head trauma (AHT) compared with children with other types of traumatic brain injury (TBI). STUDY DESIGN The study cohort comprised children aged <4 years diagnosed with TBI and seen in the intensive care unit in a tertiary children's hospital. Patients were classified as having confirmed or suspected AHT or TBI by other mechanisms (eg, motor vehicle accidents), as identified by a Child Protection Team clinician. Serial blood samples were collected at admission and at 24, 48, and 72 hours after admission. Levels of OPN were compared across groups. RESULTS Of 77 patients identified, 24 had confirmed AHT, 12 had suspected AHT, and 41 had TBI. There were no differences in the Glasgow Coma Scale score between the patients with confirmed AHT and those with suspected AHT and those with TBI (median score, 4.5 vs 4 and 7; P = .39). At admission to the emergency department, OPN levels were significantly higher in children with confirmed AHT compared with the other 2 groups (mean confirmed AHT, 471.5 ng/mL; median suspected AHT, 322.3 ng/mL; mean TBI, 278.0 ng/mL; P = .03). Furthermore, the adjusted mean trajectory levels of OPN were significantly higher in the confirmed AHT group compared with the other 2 groups across all subsequent time points (P = <.01). CONCLUSIONS OPN is significantly elevated in children with confirmed AHT compared with those with suspected AHT and those with other types of TBI. OPN expression may help identify children with suspected AHT to aid resource stratification and triage of appropriate interventions for children who are potential victims of abuse.
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Affiliation(s)
- Laura S. Blackwell
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA
| | | | | | | | - Andrew Appert
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Atul Vats
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA,Emory University, Atlanta, GA
| | | | | | - Andrew Reisner
- Department of Neuropsychology, Children’s Healthcare of Atlanta, Atlanta, GA
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9
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Cerebrovascular Complications of Pediatric Blunt Trauma. Pediatr Neurol 2020; 108:5-12. [PMID: 32111560 PMCID: PMC7306436 DOI: 10.1016/j.pediatrneurol.2019.12.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Revised: 12/02/2019] [Accepted: 12/08/2019] [Indexed: 12/13/2022]
Abstract
Ischemic and hemorrhagic stroke can occur in the setting of pediatric trauma, particularly those with head or neck injuries. The risk of stroke appears highest within the first two weeks after trauma. Stroke diagnosis may be challenging due to lack of awareness or concurrent injuries limiting detailed neurological assessment. Other injuries may also complicate stroke management, with competing priorities for blood pressure, ventilator management, or antithrombotic timing. Here we review epidemiology, clinical presentation, and diagnostic approach to blunt arterial injuries including dissection, cerebral sinovenous thrombosis, mineralizing angiopathy, stroke from abusive head trauma, and traumatic hemorrhagic stroke. Owing to the complexities and heterogeneity of concomitant injuries in stroke related to trauma, a single pathway for stroke management is impractical. Therefore providers must understand the goals and possible costs or consequences of stroke management decisions to individualize patient care. We discuss the physiological principles of cerebral perfusion and oxygen delivery, considerations for ventilator strategy when stroke and lung injury are present, and current available evidence of the risks and benefits of anticoagulation to provide a framework for multidisciplinary discussions of cerebrovascular injury management in pediatric patients with trauma.
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Aoki M, Abe T, Saitoh D, Oshima K. Epidemiology, Patterns of treatment, and Mortality of Pediatric Trauma Patients in Japan. Sci Rep 2019; 9:917. [PMID: 30696939 PMCID: PMC6351578 DOI: 10.1038/s41598-018-37579-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Accepted: 12/10/2018] [Indexed: 12/16/2022] Open
Abstract
Limited information exists regarding the epidemiology, patterns of treatment, and mortality of pediatric trauma patients in Japan. To evaluate the characteristics and mortality of pediatric trauma patients in Japan, especially in traffic accidents. This was a retrospective cohort study between 2004 and 2015 from a nationwide trauma registry in Japan. Pediatric trauma patients divided into four age groups: <1 years; 1 ≤ 5 years; 6 ≤ 10 years; and 11 ≤ 15 years. Data on patients' demographics, trauma mechanism and severity, treatments and in-hospital mortality were analyzed between the groups. There were 15,441 pediatric trauma patients during the study period. Among 15,441 pediatric patients, 779 belonged to the <1 year age group, 3,933 to the 1 ≤ 5 years age group, 5,545 to the 6 ≤ 10 age group, and 5,184 to the 11 ≤ 15 years age group. Male injuries (69%) were more frequent than female injuries. Head injuries (44%) were the most frequent and severe. Traffic accidents were the leading cause of trauma (44%). Overall in-hospital mortality was 3.9% and emergency department mortality was 1.4%. In-hospital mortality was 5.3%, 4.7%, 3.0% and 4.0% for the <1 year, 1 ≤ 5 years, 6 ≤ 10 years, and 11 ≤ 15 years age groups respectively. A total of 57% of all trauma deaths were before or upon arrival at hospital. Traffic accidents for the <1 year age group was the highest category of mortality (15%). The overall in-hospital mortality of Japanese pediatric trauma patients was 3.9% based on the nationwide trauma registry of Japan. The main cause of severe trauma was traffic accidents, especially in patients <1 year of age whose mortality was 15%.
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Affiliation(s)
- Makoto Aoki
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Gunma, Japan.
| | - Toshikazu Abe
- Department of General Medicine, Juntendo University, Tokyo, Japan.,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Daizoh Saitoh
- Department of Traumatology and Emergency Medicine, National Defense Medical College, Saitama, Japan
| | - Kiyohiro Oshima
- Department of Emergency Medicine, Gunma University Graduate School of Medicine, Gunma, Japan
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