Prehospital Evaluation and Management of Traumatic Brain Injury in Children

Interobserver reliability and diagnostic accuracy of prehospital triage for identifying traumatic brain injury in paediatric patients: a systematic review

PURPOSE

The consistency and accuracy of paediatric TBI triage tools can be affected by different factors, such as patients' characteristics and the level of knowledge and skill of the caregiver. This systematic review included all the available data on the level of agreement between paramedics and ED physicians about the reliability of tools to identify paediatric TBI and the diagnostic accuracy of several such tools in prehospital settings when used by paramedics.

METHODS

MEDLINE (OVID), EMBASE (OVID), Cochrane Library (OVID), and CINAHL Plus (EBSCO) databases were searched from inception to 27 October 2022. Quality, bias, and applicability were assessed using COSMIN for interobserver reliability studies and QUADAS-2 tool for diagnostic accuracy studies. Narrative synthesis was employed because data were unsuitable for meta-analysis.

RESULTS

Initial searches identified 660 papers in total. Five met the inclusion criteria. Two studies showed moderate agreement between paramedics and ED physicians for GCS assessment. The PTS overtriage rate was 10% and the undertriage rate was 62%, while the triage tape had an overtriage rate of 18% and an undertriage rate of 68%. Pre-hospital GCS had 86.67% sensitivity and 71.43% specificity [95% CI]: 0.74-0.96 for neurosurgically significant TBI.

CONCLUSION

Low level of GCS agreement and poor diagnostic accuracy may cause further harm to the patient; thus, further studies are recommended to improve the prehospital management of children with head injuries.

The surgical history of head injury in motor vehicle collision

Motor vehicle collisions (MVCs) are a significant cause of head injuries today, but efforts to manage and prevent these injuries extend as far back as the beginning of modern neurosurgery itself. Head trauma in MVCs occurred as far back as 1899, and the surgical literature of the time mentions several cases of children being struck by passing automobiles. By the 1930s, Dr. Claire L. Straith, a Detroit plastic surgeon, recommended changes to automobile design after seeing facial injuries and depressed skull fractures that resulted from automobile accidents. During World War II, Sir Hugh Cairns, a British neurosurgeon, demonstrated the efficacy of motorcycle helmets in preventing serious head injury. In the 1950s, Dr. Frank H. Mayfield, a Cincinnati neurosurgeon on the trauma committee of the American College of Surgeons, made several recommendations, such as adding padded dashboards and seatbelts, to make automobiles safer. Ford implemented the recommendations from Dr. Mayfield and others into a safety package for the 1956 models. Significant work has also been done to prevent head injury in motorsports. Efforts by surgeons, especially neurosurgeons, to prevent head injury in MVCs have saved countless lives, although it is a less frequently celebrated achievement.

A pediatric specific shock index in combination with GMS identifies children with life threatening or severe traumatic brain injury

PURPOSE

We have previously demonstrated that a shock index, pediatric age adjusted (SIPA) accurately identifies severely blunt injured children. We aimed to determine if SIPA could more accurately identify children with severe traumatic brain injury (TBI) than hypotension alone.

METHODS

We performed subset analysis of those children with TBI among a cohort of children age 4-16 years with blunt trauma and injury severity score ≥15 from 1/07 to 6/13. We evaluated the ability of four markers to identify the most severely brain injured children. Markers included hypotension, elevated SIPA, abnormal GCS motor score (GMS), and elevated SIPA or abnormal GMS. We aimed to determine which of these four markers had the highest sensitivity in identifying severely injured children.

RESULTS

Three hundred and ninety-two (392) children were included. Hypotension was present in 24 patients (6%); elevated SIPA in 106 (27 %), abnormal GMS in 172 (44%), and elevated SIPA or abnormal GMS in 206 (53%). All markers were able to accurately identify severely injured children with TBI. Elevated SIPA or abnormal GMS identified a greater percentage of patients with each of seven complications with higher sensitivity than each of the three other markers.

CONCLUSION

Among blunt injured children with TBI, elevated SIPA or abnormal GMS identifies severely brain injured children.

Updates in the general approach to pediatric head trauma and concussion

Acute recognition and management of traumatic brain injury along the spectrum from mild to severe is essential in optimizing neurocognitive outcomes. Concussion is common following head trauma in children, and resulting symptoms can last for months if not diagnosed and managed properly. Emerging evidence and consensus demonstrate that a program of cognitive and physical activity with a graduated return to play, sport, and school may improve outcomes following concussion. "Return to Play" legislation for youth has been adopted by most states. Outcomes of patients with severe traumatic brain injury have improved.

Does a prehospital Glasgow Coma Scale score predict pediatric outcomes?

BACKGROUND

Although the Glasgow Coma Scale (GCS) score is widely used by medical professionals to evaluate and predict neurological outcomes, studies using the prehospital (P) GCS score to predict neurological outcomes in children are few.

OBJECTIVE

The objective of this study was to determine the agreement between the P GCS score and the emergency department (ED) GCS score, and the association between P GCS score and outcomes at hospital discharge in pediatric patients 5 to 18 years of age.

METHODS

Medical record review of children 5 to 18 years old with traumatic brain injury (TBI) was conducted. Children with documented P and ED GCS scores were eligible for enrollment. The hospital records of each enrolled child were reviewed, and the Glasgow outcome score and the disability rating scale scores were calculated. Agreement between the P and ED GCS scores was calculated using χ (κ statistic).

RESULTS

One hundred eighty-five subjects were included. There was strong agreement between P and ED GCS scores (κ = +0.69; confidence interval, 0.57-0.81). The Glasgow outcome score category improved with improving GCS category. The median disability rating scale score was also similar for P and ED GCS scores and was higher with decreasing GCS.

CONCLUSIONS

Our data showed strong agreement between P and ED GCS scores. Also, there was strong association between P GCS scores and short-term outcomes in children with TBI. The results support the use of GCS in prehospital transport destination guidelines for children with TBI.