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Güneysu ST, Güleryüz OD, Kürklü E, Çağlar AA, Çolak Ö. Traumatic brain injury detection performance of the infant scalp score in children younger than 2 years in the pediatric emergency department. Eur J Trauma Emerg Surg 2023; 49:1673-1681. [PMID: 36056932 DOI: 10.1007/s00068-022-02085-9] [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: 05/20/2022] [Accepted: 08/08/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Our study sought to externally validate the Infant Scalp Score (ISS) within an international pediatric emergency department (PED) setting. The ISS for pediatric Closed Head Injury (CHI), includes age, hematoma localization, and size, and has the potential to predict the presence of Traumatic Brain Injury (TBI) on computed tomography. We aimed to describe a potentially low risk cohort of children younger than 24 months with CHI and scalp hematomas, where clinicians may limit diagnostic radiation exposure to this vulnerable patient population. METHODS This single-center retrospective study was conducted in Gazi University. Faculty of Medicine, Pediatric Emergency Department, a tertiary trauma care hospital. We reviewed patients (< 24 months) with CHI and scalp hematoma who visited the PED of our institution between January 1, 2019, and June 30, 2021 for rates of TBI and clinically important TBI (ciTBI). RESULTS 380 cases met inclusion criteria for this study. The median age was 11 months and 58.7% were male children. 121 (31.8%) patients underwent CT, and 57% (n:69) of these studies were normal. TBI on CT was found in 26 (21.5%) patients with ciTBI was detected in 5 (1.3%) patients. All children with TBI were noted to have ISS scores of ≥ 5. Hematoma location OR 18.9 (95% CI, 3.4-105.1) and hematoma size OR 3.0 (95% CI, 1.2-7.3) were positively associated with presence of TBI. CONCLUSIONS Children with ISS scores of ≥ 5 were noted to have increased rates of both TBI and ciTBI. CHI related scalp hematomas located in the temporal/parietal region or with a size greater than 3 cm were associated with increased rates of TBI. Within the context of this study, ISS scores of 4 or less represented a lower risk for TBI and ciTBI. Future research on this potentially low risk pediatric CHI cohort is needed.
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Affiliation(s)
- Songül Tomar Güneysu
- Division of Pediatric Emergency, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey.
| | - Okşan Derinöz Güleryüz
- Division of Pediatric Emergency, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ece Kürklü
- Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
| | - Ayla Akca Çağlar
- Division of Pediatric Emergency, Department of Pediatrics, Ankara City Hospital, Ankara, Turkey
| | - Özlem Çolak
- Division of Pediatric Emergency, Department of Pediatrics, Gazi University Faculty of Medicine, Ankara, Turkey
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Roche S, Crombé A, Benhamed A, Hak JF, Dabadie A, Fauconnier-Fatus C, Rega A, Pech-Gourg G, Tazarourte K, Seux M, Acquier A, Gorincour G. Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France. JAMA Netw Open 2023; 6:e2311092. [PMID: 37129895 PMCID: PMC10155067 DOI: 10.1001/jamanetworkopen.2023.11092] [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: 05/03/2023] Open
Abstract
Importance Pediatric traumatic brain injuries (TBIs) are a leading cause of death and disability. The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide a framework for requesting head computed tomography (HCT) after pediatric head trauma (PHT); however, quantitative data are lacking regarding both TBIs found on HCT and justification of the HCT request according to the PECARN guidelines. Objectives To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request. Design, Setting, and Participants This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022. Exposure All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines. Main Outcomes and Measures Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture. Results Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians. Conclusion and Relevance In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.
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Affiliation(s)
| | - Amandine Crombé
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
- Department of Radiology, Pellegrin University Hospital, Bordeaux, France
- Models in Oncology (MONC) Team, INRIA Bordeaux Sud-Ouest, CNRS UMR 5251 & Bordeaux University, Talence, France
| | - Axel Benhamed
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Jean-François Hak
- Assistance Publique-Hôpitaux de Marseille, Marseille, France
- LIIE, Aix Marseille University, Marseille, France
- CERIMED, Aix Marseille University, Marseille, France
| | - Alexia Dabadie
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
- Assistance Publique-Hôpitaux de Marseille, Marseille, France
| | | | | | | | - Karim Tazarourte
- Service SAMU-Urgences, Centre Hospitalier Universitaire Édouard Herriot, Hospices Civils de Lyon, Lyon, France
| | - Mylène Seux
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
| | - Adrien Acquier
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
- CHU de Dijon, Dijon, France
| | - Guillaume Gorincour
- IMADIS, Lyon, Bordeaux, Marseille, Dijon, France
- ELSAN, Clinique Bouchard, Marseille, France
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Abstract
Brain injury in children is a major public health problem, causing substantial morbidity and mortality. Cause of pediatric brain injury varies widely and can be from a primary neurologic cause or as a sequela of multisystem illness. This review discusses the emerging field of pediatric neurocritical care (PNCC), including current techniques of imaging, treatment, and monitoring. Future directions of PNCC include further expansion of evidence-based practice guidelines and establishment of multidisciplinary PNCC services within institutions.
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Affiliation(s)
- Ajit A Sarnaik
- Central Michigan University College of Medicine, Carls Building, Pediatric Critical Care, Children's Hospital of Michigan, 3901 Beaubien Avenue, Detroit, MI 48201, USA.
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4
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Bressan S, Eapen N, Phillips N, Gilhotra Y, Kochar A, Dalton S, Cheek JA, Furyk J, Neutze J, Williams A, Hearps S, Donath S, Oakley E, Singh S, Dalziel SR, Borland ML, Babl FE. PECARN algorithms for minor head trauma: Risk stratification estimates from a prospective PREDICT cohort study. Acad Emerg Med 2021; 28:1124-1133. [PMID: 34236116 DOI: 10.1111/acem.14308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Revised: 05/11/2021] [Accepted: 05/25/2021] [Indexed: 01/21/2023]
Abstract
BACKGROUND The Pediatric Emergency Care Applied Research Network (PECARN) head trauma clinical decision rules informed the development of algorithms that risk stratify the management of children based on their risk of clinically important traumatic brain injury (ciTBI). We aimed to determine the rate of ciTBI for each PECARN algorithm risk group in an external cohort of patients and that of ciTBI associated with different combinations of high- or intermediate-risk predictors. METHODS This study was a secondary analysis of a large multicenter prospective data set, including patients with Glasgow Coma Scale scores of 14 or 15 conducted in Australia and New Zealand. We calculated ciTBI rates with 95% confidence intervals (CIs) for each PECARN risk category and combinations of related predictor variables. RESULTS Of the 15,163 included children, 4,011 (25.5%) were aged <2 years. The frequency of ciTBI was 8.5% (95% CI = 6.0%-11.6%), 0.2% (95% CI = 0.0%-0.6%), and 0.0% (95% CI = 0.0%-0.2%) in the high-, intermediate-, and very-low-risk groups, respectively, for children <2 years and 5.7% (95% CI = 4.4%-7.2%), 0.7% (95% CI = 0.5%-1.0%), and 0.0% (95% CI = 0.0%-0.1%) in older children. The isolated high-risk predictor with the highest risk of ciTBI was "signs of palpable skull fracture" for younger children (11.4%, 95% CI = 5.3%-20.5%) and "signs of basilar skull fracture" in children ≥2 years (11.1%, 95% CI = 3.7%-24.1%). For older children in the intermediate-risk category, the presence of all four predictors had the highest risk of ciTBI (25.0%, 95% CI = 0.6%-80.6%) followed by the combination of "severe mechanism of injury" and "severe headache" (7.7%, 95% CI = 0.2%-36.0%). The very few children <2 years at intermediate risk with ciTBI precluded further analysis. CONCLUSIONS The risk estimates of ciTBI for each of the PECARN algorithms risk group were consistent with the original PECARN study. The risk estimates of ciTBI within the high- and intermediate-risk predictors will help further refine clinical judgment and decision making on neuroimaging.
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Affiliation(s)
- Silvia Bressan
- Department of Women's and Children's Health University of Padova Padova Italy
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Nitaa Eapen
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
| | - Natalie Phillips
- Queensland Children's Hospital Brisbane Queensland Australia
- Child Health Research Centre University of Queensland Brisbane Queensland Australia
| | - Yuri Gilhotra
- Queensland Children's Hospital Brisbane Queensland Australia
| | - Amit Kochar
- Emergency Department Women's & Children's Hospital Adelaide South Australia Australia
| | - Sarah Dalton
- Emergency Department The Children's Hospital at Westmead Sydney New South Wales Australia
| | - John A. Cheek
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
- Emergency Department Royal Children's Hospital Melbourne Victoria Australia
- Emergency Department Monash Medical Centre Melbourne Victoria Australia
| | - Jeremy Furyk
- Emergency Department The Townsville Hospital Townsville Queensland Australia
- Emergency Department University Hospital Geelong Geelong Victoria Australia
- School of Medicine Faculty of Health Deakin University Geelong Victoria Australia
| | - Jocelyn Neutze
- Emergency Department Kidzfirst Middlemore Hospital Auckland New Zealand
| | - Amanda Williams
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Stephen Hearps
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
| | - Susan Donath
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
| | - Ed Oakley
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
- Emergency Department Royal Children's Hospital Melbourne Victoria Australia
| | - Sonia Singh
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
- Emergency Department Royal Children's Hospital Melbourne Victoria Australia
- University of California Davis Medical Center Sacramento California USA
| | - Stuart R. Dalziel
- Emergency Department Starship Children's Health Auckland New Zealand
- Departments of Surgery and Paediatrics: Child and Youth Health University of Auckland Auckland New Zealand
| | - Meredith L. Borland
- Emergency Department Perth Children's Hospital Perth Western Australia Australia
- Divisions of Emergency Medicine and Paediatrics School of Medicine University of Western Australia Perth Western Australia Australia
| | - Franz E. Babl
- Clinical Sciences Murdoch Children's Research Institute Melbourne Victoria Australia
- Department of Paediatrics and Centre for Integrated Critical Care Faculty of Medicine, Dentistry and Health Sciences University of Melbourne Melbourne Victoria Australia
- Emergency Department Royal Children's Hospital Melbourne Victoria Australia
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Wang J, Hu Y, Wu P. Risk factors for positive brain CT scan in children with traumatic brain injury and GCS = 15: A retrospective study. Medicine (Baltimore) 2021; 100:e24543. [PMID: 33530283 PMCID: PMC7850729 DOI: 10.1097/md.0000000000024543] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 01/08/2021] [Indexed: 01/05/2023] Open
Abstract
It is controversial whether it is necessary to carry out head computed tomography (CT) examination for children who had a traumatic brain injury (TBI) but are conscious (Glasgow Coma Scale (GCS) = 15). The present study explored the risk/predictive factors of positive CT results in children with mild closed head injury and GCS = 15.This was a retrospective study of children (0-18 years of age) with TBI and GCS = 15 and treated at the First People's Hospital of Wenling between 06/2013 and 06/2018. The outcome was a positive head plain CT result. Univariable and multivariable logistic regression analyses were carried out to determine the factors independently associated with positive CT results.A total of 279 children were included. The majority of the injured were boys (180/279, 64.5%). The top three causes of injury were traffic accidents (100/279, 35.8%), falling from height (92/279, 33.0%), and tumble (72/279, 25.8%). The top three clinical symptoms were headache (201/279, 72.0%), scalp hematoma (133/279, 47.7%), and nausea with or without vomiting (105/279, 37.6%). The multivariable analysis showed that scalp hematoma (OR = 3.040, 95%CI: 1.791-5.159, P < .0001), ear and nostril bleeding or periorbital soft tissue contusion (OR = 2.234, 95%CI: 1.087-4.590, P = .029), and nausea with or without vomiting (OR = 2.186, 95%CI: 1.255-3.810, P = .006) were independently associated with positive results of head CT.For children with TBI and GCS = 15, the factors independently associated with positive CT results are scalp hematoma, ear and nostril bleeding or periorbital soft tissue contusion, and nausea with or without vomiting.
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Affiliation(s)
- Junyou Wang
- Department of Neurosurgery, The First People's Hospital of Wenling, Wenling
| | - Yan Hu
- Department of Gynecology and Obstetrics, Taizhou Central Hospital
| | - Panxing Wu
- Department of Neurosurgery, Taizhou Central Hospital, Jiaojiang, China
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Alexandridis G, Verschuuren EW, Rosendaal AV, Kanhai DA. Evidence base for point-of-care ultrasound (POCUS) for diagnosis of skull fractures in children: a systematic review and meta-analysis. Emerg Med J 2020; 39:30-36. [PMID: 33273039 PMCID: PMC8717482 DOI: 10.1136/emermed-2020-209887] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Blunt head trauma is a common presentation to emergency departments (EDs). Identifying skull fractures in children is important as they are known factor of risk for traumatic brain injury (TBI). Currently, CT is the reference standard for diagnosing skull fractures and TBIs in children. Identifying skull fractures with point-of-care ultrasound (POCUS) may help risk-stratify children for TBI following blunt trauma. The purpose of this study is to evaluate the sensitivity, specificity, positive predictive value and negative predictive value of POCUS in identifying skull fractures in children. METHODS A systematic search was performed on 17 July 2020 in Ovid Medline, Cochrane Library, Google Scholar, Web of Science and Embase. Prospective studies reporting skull fractures diagnosed with ultrasound in children younger than 18 years due to blunt head injury were included. Studies that did not confirm the fracture with CT were excluded. The quality of studies was evaluated using the QUADAS-2 tool. Data were extracted from the eligible studies to calculate outcomes such as sensitivity and specificity; when possible overall outcomes were calculated. RESULTS Seven studies were included. All eligible studies included patients for whom the decision to perform a CT scan was made in advance. Overall, the included studies demonstrated low risk of bias or had minor concerns regarding risk of bias. The pooled data (n=925) demonstrated a sensitivity of 91%, specificity of 96%, positive predictive value of 88% and negative predictive value of 97%. CONCLUSION The included studies demonstrate minor methodological limitations. Overall, the evidence suggests that POCUS is a valid option for diagnosing skull fractures in children visiting the ED after blunt head injury.
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Affiliation(s)
- Georgios Alexandridis
- Emergency Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands .,Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Eva W Verschuuren
- Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Arthur V Rosendaal
- Emergency Medicine, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
| | - Danny A Kanhai
- Pediatrics, Franciscus Gasthuis en Vlietland, Rotterdam, Zuid-Holland, The Netherlands
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7
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Harbert A, Bradford K, Ritter V, Northam WT, Quinsey C. National Imaging Trends in Pediatric Traumatic Brain Injury and Hydrocephalus. World Neurosurg 2020; 139:e399-e405. [PMID: 32305606 DOI: 10.1016/j.wneu.2020.04.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 03/31/2020] [Accepted: 04/02/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVE Reduction in use of computed tomography (CT) in favor of rapid-sequence magnetic resonance imaging (MRI) to decrease pediatric radiation exposure has varied across institutions in the United States. The aims of this study were to understand national trends in CT and rapid-sequence MRI usage and identify variables affecting imaging practices and obstacles to CT reduction. METHODS This was a retrospective review of deidentified discharge data for children with hydrocephalus and traumatic brain injury (TBI) in the Healthcare Cost and Utilization Project Kids' Inpatient Database in 2000, 2003, 2006, 2009, 2012, and 2016. Utilization of MRI without contrast and CT was extracted using International Classification of Diseases, Ninth Revision, and International Classification of Diseases, Tenth Revision, codes. Hospital region and age cohorts were extracted and used to categorize data. χ2 tests and logistic regression were used for analysis. RESULTS Hospitalizations utilizing CT decreased (P < 0.05) and hospitalizations utilizing MRI increased (P < 0.05) overall in both diagnosis groups throughout the years analyzed. However, there was significant regional variation in imaging. The Northeast had higher CT rates (P < 0.05) and the South had lower CT rates in patients with hydrocephalus and TBI (P < 0.05). No regional variation was found for rates of MRI use in patients with TBI. CONCLUSIONS Nationwide, the average number of discharges after hospitalizations utilizing CT in patients with hydrocephalus and TBI has decreased, while discharges after hospitalizations utilizing MRI as an alternative imaging modality have increased. Despite successful overall CT reduction, significant regional variation exists within this trend showing inconsistent reduction of CT use.
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Affiliation(s)
- Allie Harbert
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Kathleen Bradford
- Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Victor Ritter
- Department of Biostatistics, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Weston T Northam
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
| | - Carolyn Quinsey
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA.
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8
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Harbert A, Northam W, Elton S, Quinsey C. Targeted head CT reduction for pediatric patients with hydrocephalus and traumatic brain injury: academic center institutional experience as an example of opportunities for further improvement. Childs Nerv Syst 2020; 36:583-589. [PMID: 31696289 DOI: 10.1007/s00381-019-04376-w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 09/16/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE Recent studies aim to reduce radiation exposure associated with computed tomography (CT) using rapid-sequence magnetic resonance imaging (MRI). We evaluated imaging modalities used for hydrocephalus and traumatic brain injury (TBI) to identify opportunities for further radiation exposure reduction. METHODS Pediatric (≤ 18 years) patients, with either hydrocephalus or TBI receiving a head CT or head MRI from 2009 to 2017, were quantified using ICD9, ICD10, and CPT codes at a large university hospital. The odds ratios of receiving each imaging modality year-to-year and receiving a MRI or CT in a given year with each diagnosis were calculated. RESULTS Beginning in 2015, hydrocephalus patients were more likely to receive a MRI vs CT (p < 0.0001), with likelihood increasing in the following 2 years. TBI patients were more likely to receive a CT than an MRI from 2009 to 2017. There was a smaller overall decrease in CT scans in TBI patients (p < 0.05) than hydrocephalus patients (p < 0.0001) and a larger increase in MRI use in hydrocephalus patients (p < 0.05) than TBI patients (p < 0.05) from 2009 to 2017. CONCLUSIONS Use of CT to evaluate hydrocephalus significantly decreased over the last 3-year time period. However, CT use for TBI patients was inconsistent and did not decrease proportionally, potentially representing a belief that CT is more effective than MRI for detecting hemorrhage. There was greater use of MRI as an alternate imaging method in hydrocephalus patients than TBI patients. Head injury remains an area of improvement to decrease pediatric radiation exposure at our institution and may be an area in need of attention more broadly.
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Affiliation(s)
- Allie Harbert
- University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Weston Northam
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Scott Elton
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Carolyn Quinsey
- Department of Neurosurgery, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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9
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Berger RP, Furtado AD, Flom LL, Fromkin JB, Panigrahy A. Implementation of a brain injury screen MRI for infants at risk for abusive head trauma. Pediatr Radiol 2020; 50:75-82. [PMID: 31901990 DOI: 10.1007/s00247-019-04506-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 07/19/2019] [Accepted: 08/12/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Head computed tomography (CT) is the current standard of care for evaluating infants at high risk of abusive head trauma. OBJECTIVE To both assess the feasibility of using a previously developed magnetic resonance imaging (MRI) brain injury screen (MRBRscreen) in the acute care setting in place of head CT to identify intracranial hemorrhage in high-risk infants and to compare the accuracy of a rapid imaging pulse sequence (single-shot T2 fast spin echo [ssT2FSE]) to a conventional pulse sequence (conventional T2 fast spin echo [conT2FSE]). MATERIALS AND METHODS This was a quality improvement initiative to evaluate infants <12 months of age who were screened for intracranial hemorrhage using an MRBRscreen as part of clinical care. The MRBRscreen included axial conT2FSE, axial gradient recalled echo, coronal T1-weighted inversion recovery, axial diffusion-weighted image and an axial ssT2FSE. A comparison of ssT2FSE to conT2FSE with respect to lesion detection was also performed. RESULTS Of 158 subjects, the MRBRscreen was able to be completed in 155 (98%); 9% (14/155) were abnormal. Ninety-four percent (137/145) of subjects underwent only an MRBRscreen and avoided both radiation from head CT and sedation from MRI. The axial ssT2FSE and conT2FSE results were congruent 99% of the time. CONCLUSION An MRBRscreen in place of a head CT is feasible and potentially could decrease head CT use by more than 90% in this population. Using a rapid ssT2FSE in place of a conT2FSE can reduce total scan time without losing lesion detection. If an MRBRscreen is readily available, physicians' threshold to perform neuroimaging may be lowered and lead to earlier detection of abusive head trauma.
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Affiliation(s)
- Rachel P Berger
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4117 Penn Ave., Pittsburgh, PA, 15224, USA.
| | - Andre D Furtado
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Lynda L Flom
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Janet B Fromkin
- Department of Pediatrics, UPMC Children's Hospital of Pittsburgh, 4117 Penn Ave., Pittsburgh, PA, 15224, USA
| | - Ashok Panigrahy
- Department of Radiology, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
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10
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Nigrovic LE, Kuppermann N. Children With Minor Blunt Head Trauma Presenting to the Emergency Department. Pediatrics 2019; 144:peds.2019-1495. [PMID: 31771961 DOI: 10.1542/peds.2019-1495] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 11/24/2022] Open
Abstract
In our state-of-the-art review, we summarize the best-available evidence for the optimal emergency department management of children with minor blunt head trauma. Minor blunt head trauma in children is a common reason for emergency department evaluation, although clinically important traumatic brain injuries (TBIs) as a result are uncommon. Cranial computed tomography (CT) scanning is the reference standard for the diagnosis of TBIs, although they should be used judiciously because of the risk of lethal malignancy from ionizing radiation exposure, with the greatest risk to the youngest children. Available TBI prediction rules can assist with CT decision-making by identifying patients at either low risk for TBI, for whom CT scans may safely be obviated, or at high risk, for whom CT scans may be indicated. For clinical prediction rules to change practice, however, they require active implementation. Observation before CT decision-making in selected patients may further reduce CT rates without missing children with clinically important TBIs. Future work is also needed to incorporate patient and family preferences into these decision-making algorithms when the course of action is not clear.
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Affiliation(s)
- Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
| | - Nathan Kuppermann
- Departments of Emergency Medicine and.,Pediatrics, School of Medicine, University of California, Davis, Davis, California; and.,UC Davis Health, Sacramento, California
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11
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Lehner M, Deininger S, Wendling-Keim D. Management des Schädel-Hirn-Traumas im Kindesalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00770-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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12
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Emergency Department Care of Young Children at Risk for Traumatic Brain Injury: What Are We Doing and Do Parents Understand? Pediatr Emerg Care 2019; 35:468-473. [PMID: 28121973 DOI: 10.1097/pec.0000000000001042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES The aims of the study were to describe emergency department (ED) management of young children with head injury and to assess parental comfort level and perceptions of ED care. METHODS This was a prospective observational study of children younger than 5 years who presented to a pediatric ED after head injury. Children were eligible if clinical observation was an appropriate ED management option per the Pediatric Emergency Care Academic Research Network's neuroimaging clinical decision rule. Demographics, injury variables, and ED clinician surveys explaining the care provided were collected at time of study enrollment. Parents were subsequently contacted to assess understanding of ED management and comfort with care. RESULTS One hundred four children were enrolled with a mean (standard deviation) age of 1.19 (1.34) years. Thirty (29%) had emergent neuroimaging and 59 (57%) were placed into a period of observation per clinician report. A total of 37 children received a head computed tomography, of which 21 (57%) were normal. Eighty-four parents (81%) completed the phone follow-up. Of these children, there was a significant difference between whether parents and clinicians reported that the child had been clinically observed in the ED (P < 0.0001). Parents of children who did not receive a head CT were more likely to be uncomfortable with the decision to obtain neuroimaging compared with those who did receive a head CT (P = 0.003). CONCLUSIONS Parents are not always comfortable with the medical care practices provided and are often unaware of clinical observation when it does occur. Better parent-clinician communication could improve parental understanding and reduce overall discomfort.
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Parri N, Crosby BJ, Mills L, Soucy Z, Musolino AM, Da Dalt L, Cirilli A, Grisotto L, Kuppermann N. Point-of-Care Ultrasound for the Diagnosis of Skull Fractures in Children Younger Than Two Years of Age. J Pediatr 2018; 196:230-236.e2. [PMID: 29499992 DOI: 10.1016/j.jpeds.2017.12.057] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Revised: 10/30/2017] [Accepted: 12/19/2017] [Indexed: 12/30/2022]
Abstract
OBJECTIVES To determine the accuracy of skull point-of-care ultrasound (POCUS) for identifying fractures in children younger than 2 years of age with signs of head trauma, and the ability of POCUS to identify the type and depth of fracture depression. STUDY DESIGN This was a multicenter, prospective, observational study of children younger than 2 years of age with nontrivial mechanisms of injury and signs of scalp/skull trauma. Patients were enrolled if they underwent computed tomography (CT). Patients underwent clinical evaluation, in addition to a cranial POCUS in the emergency department (ED). From the POCUS examinations, we documented whether fractures were present or absent, their location, characteristics, and depth. POCUS and CT findings were compared to calculate the diagnostic accuracy. RESULTS We enrolled a convenience sample of 115 of 151 (76.1%) eligible patients. Of the 115 enrolled, 88 (76.5%) had skull fractures. POCUS had a sensitivity of 80 of 88 (90.9%; 95% CI 82.9-96.0) and a specificity of 23 of 27 (85.2%; 95% CI 66.3-95.8) for identifying skull fractures. Agreement between POCUS and CT to identify the type of fracture as linear, depressed, or complex was 84.4% (97 of 115) with a kappa of 0.75 (95% CI 0.70-0.84). CONCLUSIONS POCUS performed by emergency physicians may identify the type and depth of fractures in infants with local physical signs of head trauma with substantial accuracy. Emergency physicians should consider POCUS as an adjunct to clinical evaluation and prediction rules for traumatic brain injuries in children younger than 2 years of age.
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Affiliation(s)
- Niccolò Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer Children's Hospital, Firenze, Italy.
| | - Bradley J Crosby
- Emergency Department, Dixie Regional Medical Center, St. George, UT
| | - Lisa Mills
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Zachary Soucy
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA
| | - Anna Maria Musolino
- Emergency Department, Bambino Gesù Children's Hospital, IRCCS Rome, Rome, Italy
| | - Liviana Da Dalt
- Department of Woman's and Child's Health, University of Padova, Padova, Italy
| | - Angela Cirilli
- Department of Emergency Medicine, Long Island Jewish Medical Center & Cohen Children's Medical Center, New Hyde Park, NY
| | - Laura Grisotto
- Department of Statistics G. Parenti, University of Florence and ISPO Cancer Prevention and Research Institute, Florence, Italy
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California, Davis School of Medicine, Sacramento, CA; Department of Pediatrics, University of California, Davis School of Medicine, Sacramento, CA
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Da Dalt L, Parri N, Amigoni A, Nocerino A, Selmin F, Manara R, Perretta P, Vardeu MP, Bressan S. Italian guidelines on the assessment and management of pediatric head injury in the emergency department. Ital J Pediatr 2018; 44:7. [PMID: 29334996 PMCID: PMC5769508 DOI: 10.1186/s13052-017-0442-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/18/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury. METHODS These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text. CONCLUSIONS Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.
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Affiliation(s)
- Liviana Da Dalt
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Niccolo' Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Angela Amigoni
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Agostino Nocerino
- Department of Pediatrics, S. Maria della Misericordia University Hospital, University of Udine, Udine, Italy
| | - Francesca Selmin
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Renzo Manara
- Department of Radiology, Neuroradiology Unit, University of Salerno, Salerno, Italy
| | - Paola Perretta
- Neurosurgery Unit, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Maria Paola Vardeu
- Pediatric Emergency Department, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Silvia Bressan
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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Singh N, Singhal A. Challenges in minor TBI and indications for head CT in pediatric TBI-an update. Childs Nerv Syst 2017; 33:1677-1681. [PMID: 29149393 DOI: 10.1007/s00381-017-3535-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/06/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pediatric head trauma is one of the commonest presentations to emergency departments. Over 90% of such head injuries are considered mild, but still present risk acute clinical deterioration and longer term morbidity. Identifying which children are at risk of clinically important brain injuries remains challenging and much of the data on minor head injuries is based on the adult population. CHALLENGES IN PEDIATRICS Children, however, are different, both anatomically and in terms of mechanism of injury, to adults and, even within the pediatric group, there are differences with age and stage of development. IMAGING CT scans have added to the repertoire of clinicians in the assessment of pediatric head injury population, but judicious use is required given radiation exposure, malignancy risk, and resource constraints. Guidelines and head injury rules have been developed, for adults and children, to support decision-making in the emergency department though whether their use is applicable to all population groups is debatable. Further challenges in mild pediatric head trauma also include appropriate recommendations for school attendance and physical activity after discharge. FURTHER DEVELOPMENTS Concern remains for second-impact syndrome and, in the longer term, for post-concussive syndrome and further research in both is still needed. Furthermore, the development of clinical decision rules raises further questions on the purpose of admitting children with minor head injuries and answering this question may aid the evolution of clinical decision guidelines. CONCLUSIONS The next generation of catheter with homogeneous flow patterns based on parametric designs may represent a step forward for the treatment of hydrocephalus, by possibly broadening their lifespan.
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Affiliation(s)
- Navneet Singh
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada
| | - Ash Singhal
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada.
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Abstract
Pediatric neurocritical care is a growing subspecialty of pediatric intensive care that focuses on the management of acute neurological diseases in children. A brief history of the field of pediatric neurocritical care is provided. Neuromonitoring strategies for children are reviewed. Management of major categories of acute childhood central neurologic diseases are reviewed, including treatment of diseases associated with intracranial hypertension, seizures and status epilepticus, stroke, central nervous system infection and inflammation, and hypoxic-ischemic injury.
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Affiliation(s)
- Christopher M. Horvat
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
| | - Haifa Mtaweh
- Department of Pediatrics, Toronto Sick Children’s Hospital, Toronto, CA
| | - Michael J. Bell
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA
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Jeong JH, Lee JH, Kim K, Rhee JE, Kim TY, Jo YH, Kim YJ, Lee JH, Kang C, Lee SH, Kim J, Park CJ, Kwon H. Change in guardians' preference for computed tomography after explanation by emergency physicians in pediatric head injury. Clin Exp Emerg Med 2016; 2:226-235. [PMID: 27752602 PMCID: PMC5052906 DOI: 10.15441/ceem.14.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2015] [Revised: 09/11/2015] [Accepted: 09/12/2015] [Indexed: 12/24/2022] Open
Abstract
Objective Head injury in children is a common problem presenting to emergency departments, and cranial computed tomography scanning is the diagnostic standard for these patients. Several decision rules are used to determine whether computed tomography scans should be used; however, the use of computed tomography scans is often influenced by guardians’ preference toward the scans. The objective of this study was to identify changes in guardian preference for minor head injuries after receiving an explanation based on the institutional clinical practice guideline. Methods A survey was conducted between July 2010 and June 2012. Patients younger than 16 years with a Glasgow Coma Scale score of 15 after a head injury and their guardians were included. Pre- and post-explanation questionnaires were given to guardians to assess their preference for computed tomography scans and factors related to the degree of preference. Treating physicians explained the risks and benefits of cranial computed tomography scanning using the institutional clinical practice guideline. Guardian preference for a computed tomography scan was examined using a 100-mm visual analog scale. Results In total, 208 patients and their guardians were included in this survey. Guardian preference for computed tomography scans was significantly reduced after explanation (46.7 vs. 17.4, P<0.01). Pre-explanation preference and the strength of the physician recommendation to get a computed tomography were the most important factors affecting pre- and post-explanation changes in preferences. Conclusion Explanation of the risks and benefits of cranial computed tomography scans using the institutional clinical practice guideline may significantly reduce guardian preference for computed tomography scans.
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Affiliation(s)
- Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Jin Hee Lee
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea; Department of Emergency Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Kyuseok Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Joong Eui Rhee
- Department of Emergency Medicine, Samsung Medical Center, Seoul, Korea
| | - Tae Yun Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - You Hwan Jo
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Yu Jin Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Hyuk Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Joonghee Kim
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Chan Jong Park
- Department of Emergency Medicine, Veterans Health Service Medical Center, Seoul, Korea
| | - Hyuksool Kwon
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
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Andrade FP, Montoro R, Oliveira R, Loures G, Flessak L, Gross R, Donnabella C, Puchnick A, Suzuki L, Regacini R. Pediatric minor head trauma: do cranial CT scans change the therapeutic approach? Clinics (Sao Paulo) 2016; 71:606-610. [PMID: 27759850 PMCID: PMC5054767 DOI: 10.6061/clinics/2016(10)09] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 08/04/2016] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES: 1) To verify clinical signs correlated with appropriate cranial computed tomography scan indications and changes in the therapeutic approach in pediatric minor head trauma scenarios. 2) To estimate the radiation exposure of computed tomography scans with low dose protocols in the context of trauma and the additional associated risk. METHODS: Investigators reviewed the medical records of all children with minor head trauma, which was defined as a Glasgow coma scale ≥13 at the time of admission to the emergency room, who underwent computed tomography scans during the years of 2013 and 2014. A change in the therapeutic approach was defined as a neurosurgical intervention performed within 30 days, hospitalization, >12 hours of observation, or neuro-specialist evaluation. RESULTS: Of the 1006 children evaluated, 101 showed some abnormality on head computed tomography scans, including 49 who were hospitalized, 16 who remained under observation and 36 who were dismissed. No patient underwent neurosurgery. No statistically significant relationship was observed between patient age, time between trauma and admission, or signs/symptoms related to trauma and abnormal imaging results. A statistically significant relationship between abnormal image results and a fall higher than 1.0 meter was observed (p=0.044). The mean effective dose was 2.0 mSv (0.1 to 6.8 mSv), corresponding to an estimated additional cancer risk of 0.05%. CONCLUSION: A computed tomography scan after minor head injury in pediatric patients did not show clinically relevant abnormalities that could lead to neurosurgical indications. Patients who fell more than 1.0 m were more likely to have changes in imaging tests, although these changes did not require neurosurgical intervention; therefore, the use of computed tomography scans may be questioned in this group. The results support the trend of more careful indications for cranial computed tomography scans for children with minor head trauma.
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Affiliation(s)
- Felipe P Andrade
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
- E-mail:
| | - Roberto Montoro
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Renan Oliveira
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Gabriela Loures
- Hospital Infantil Sabará, Departamento de Diagnóstico por Imagem, São Paulo/SP, Brazil
| | - Luana Flessak
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Roberta Gross
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Camille Donnabella
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
| | - Andrea Puchnick
- Universidade Federal de São Paulo (UNIFESP), Departamento de Diagnóstico por Imagem, São Paulo/SP, Brazil
| | - Lisa Suzuki
- Hospital Infantil Sabará, Departamento de Diagnóstico por Imagem, São Paulo/SP, Brazil
| | - Rodrigo Regacini
- Universidade Anhembi Morumbi, Laboratório de Simulação, São Paulo/SP, Brazil
- Hospital Infantil Sabará, Departamento de Diagnóstico por Imagem, São Paulo/SP, Brazil
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19
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Tham E, Swietlik M, Deakyne S, Hoffman JM, Grundmeier RW, Paterno MD, Rocha BH, Schaeffer MH, Pabbathi D, Alessandrini E, Ballard D, Goldberg HS, Kuppermann N, Dayan PS. Clinical Decision Support for a Multicenter Trial of Pediatric Head Trauma: Development, Implementation, and Lessons Learned. Appl Clin Inform 2016; 7:534-42. [PMID: 27437059 DOI: 10.4338/aci-2015-10-cr-0144] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2015] [Accepted: 04/04/2016] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION For children who present to emergency departments (EDs) due to blunt head trauma, ED clinicians must decide who requires computed tomography (CT) scanning to evaluate for traumatic brain injury (TBI). The Pediatric Emergency Care Applied Research Network (PECARN) derived and validated two age-based prediction rules to identify children at very low risk of clinically-important traumatic brain injuries (ciTBIs) who do not typically require CT scans. In this case report, we describe the strategy used to implement the PECARN TBI prediction rules via electronic health record (EHR) clinical decision support (CDS) as the intervention in a multicenter clinical trial. METHODS Thirteen EDs participated in this trial. The 10 sites receiving the CDS intervention used the Epic(®) EHR. All sites implementing EHR-based CDS built the rules by using the vendor's CDS engine. Based on a sociotechnical analysis, we designed the CDS so that recommendations could be displayed immediately after any provider entered prediction rule data. One central site developed and tested the intervention package to be exported to other sites. The intervention package included a clinical trial alert, an electronic data collection form, the CDS rules and the format for recommendations. RESULTS The original PECARN head trauma prediction rules were derived from physician documentation while this pragmatic trial led each site to customize their workflows and allow multiple different providers to complete the head trauma assessments. These differences in workflows led to varying completion rates across sites as well as differences in the types of providers completing the electronic data form. Site variation in internal change management processes made it challenging to maintain the same rigor across all sites. This led to downstream effects when data reports were developed. CONCLUSIONS The process of a centralized build and export of a CDS system in one commercial EHR system successfully supported a multicenter clinical trial.
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Affiliation(s)
- Eric Tham
- Children's Hospital Colorado, Aurora, CO; University of Colorado, Denver, CO
| | | | | | - Jeffrey M Hoffman
- Department Pediatrics, Section of Emergency Medicine, Nationwide Children's Hospital, Columbus, OH; Ohio State University College of Medicine, Columbus, OH
| | - Robert W Grundmeier
- Center for Biomedical Informatics, The Children's Hospital of Philadelphia, Philadelphia, PA; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia PA
| | - Marilyn D Paterno
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Beatriz H Rocha
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | | | | | | | - Dustin Ballard
- Kaiser Permanente, San Rafael Medical Center ; Kaiser Permanente, Division of Research, Oakland, CA
| | - Howard S Goldberg
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine , Sacramento, CA
| | - Peter S Dayan
- Pediatrics, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons , New York, NY
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Shiomi N, Echigo T, Hino A, Hashimoto N, Yamaki T. Criteria for CT and Initial Management of Head Injured Infants: A Review. Neurol Med Chir (Tokyo) 2016; 56:442-8. [PMID: 27194179 PMCID: PMC4945601 DOI: 10.2176/nmc.ra.2015-0318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Criteria for computed tomography (CT) to head injured infants have not been established. Since the identification of neurological findings is difficult in infants, examination by CT may be necessary in some cases, but it may be difficult to perform CT because of problems with radiation exposure and body movement. Moreover, even though no intracranial abnormality was found immediately after injury, abnormal findings may appear after several hours. From this viewpoint, course observation after injury may be more important than CT in the initial treatment of head trauma in infants. The complaints and neurological manifestations of infants, particularly those aged 2 or younger, are frequently unclear; therefore, there is an opinion that CT is recommended for all pediatric patients. However, the appropriateness of its use should be determined after confirming the mechanism of injury, consciousness level, neurological findings, and presence/absence of a history of abuse. Among the currently available rules specifying criteria for CT of infants with head trauma, the Pediatric Emergency Care Applied Research Network (PECARN) study may be regarded as reliable at present. In Japan, where the majority of emergency hospitals are using CT, it may be necessary to develop criteria for CT in consideration of the actual situation. CT diagnosis for pediatric head trauma is not always necessary. When no imaging is performed, this should be fully explained at the initial treatment before selecting course observation at home. Checking on a state of the patients by telephone is useful for both patients and physicians.
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Affiliation(s)
- Naoto Shiomi
- Emergency and critical care medicine, Saiseikai Shiga Hospital
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21
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Flom L, Fromkin J, Panigrahy A, Tyler-Kabara E, Berger RP. Development of a screening MRI for infants at risk for abusive head trauma. Pediatr Radiol 2016; 46:519-26. [PMID: 26589303 PMCID: PMC4814308 DOI: 10.1007/s00247-015-3500-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/10/2015] [Accepted: 11/02/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Abusive head trauma (AHT) is an important cause of morbidity in infants. Identifying which well-appearing infants are at risk for AHT and need neuroimaging is challenging, and concern about radiation exposure limits the use of head CT. Availability of an MRI protocol that is highly sensitive for intracranial hemorrhage would allow for AHT screening of well-appearing infants without exposing them to radiation. OBJECTIVE To develop a screening MRI protocol to identify intracranial hemorrhage in well-appearing infants at risk for AHT. MATERIALS AND METHODS Infants enrolled in a parent study of well-appearing infants at increased risk for AHT were eligible for the current study if they underwent both head CT and conventional brain MRI. A derivation cohort of nine infants with AHT was used to identify sequences that provided the highest sensitivity for intracranial hemorrhage. A validation cohort of 78 infants including both controls with normal neuroimaging and cases with AHT was used to evaluate the accuracy of the selected sequences. RESULTS Three pulse sequences - axial T2, axial gradient recalled echo (GRE) and coronal T1-W inversion recovery - were 100% sensitive for intracranial hemorrhage in the derivation cohort. The same sequences were 100% sensitive (25/25) and 83% specific (44/53) for intracranial hemorrhage in the validation cohort. CONCLUSION A screening MRI protocol including axial T2, axial GRE and coronal T1-W inversion recovery sequences is highly sensitive for intracranial hemorrhage and may be useful as a screening tool to differentiate well-appearing infants at risk for AHT who should undergo head CT from those who can safely be discharged without head CT. Additional research is needed to evaluate the feasibility of this approach in clinical practice.
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Affiliation(s)
- Lynda Flom
- Department of Radiology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Janet Fromkin
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, 4401 Penn Ave., Pittsburgh, PA 15224, USA
| | - Ashok Panigrahy
- Department of Radiology, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Elizabeth Tyler-Kabara
- Department of Neurosurgery, Children’s Hospital of Pittsburgh of UPMC, McGowan Institute for Regenerative Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Rachel P. Berger
- Department of Pediatrics, Children’s Hospital of Pittsburgh of UPMC, University of Pittsburgh, 4401 Penn Ave., Pittsburgh, PA 15224, USA,Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA, USA
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Évaluation des recommandations de la SFMU sur la prise en charge du traumatisme crânien léger dans une cohorte de nourrissons n’ayant pas acquis la marche : étude rétrospective incluant 1 910 enfants de 2007 à 2011 admis aux urgences pédiatriques de l’hôpital des Enfants du CHU de Toulouse. ANNALES FRANCAISES DE MEDECINE D URGENCE 2016. [DOI: 10.1007/s13341-016-0624-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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23
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Mehta H, Acharya J, Mohan AL, Tobias ME, LeCompte L, Jeevan D. Minimizing Radiation Exposure in Evaluation of Pediatric Head Trauma: Use of Rapid MR Imaging. AJNR Am J Neuroradiol 2015; 37:11-8. [PMID: 26381555 DOI: 10.3174/ajnr.a4464] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 05/20/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE With >473,000 annual emergency department visits for children with traumatic brain injuries in the United States, the risk of ionizing radiation exposure during CT examinations is a real concern. The purpose of this study was to assess the validity of rapid MR imaging to replace CT in the follow-up imaging of patients with head trauma. MATERIALS AND METHODS A retrospective review of 103 pediatric patients who underwent initial head CT and subsequent follow-up rapid MR imaging between January 2010 and July 2013 was performed. Patients had minor head injuries (Glasgow Coma Scale, >13) that required imaging. Initial head CT was performed, with follow-up rapid MR imaging completed within 48 hours. A board-certified neuroradiologist, blinded to patient information and scan parameters, then independently interpreted the randomized cases. RESULTS There was almost perfect agreement in the ability to detect extra-axial hemorrhage on rapid MR imaging and CT (κ = 0.84, P < .001). Evaluation of hemorrhagic contusion/intraparenchymal hemorrhage demonstrated a moderate level of agreement between MR imaging and CT (κ = 0.61, P < .001). The ability of MR imaging to detect a skull fracture also showed a substantial level of agreement with CT (κ = 0.71, P < .001). Detection of diffuse axonal injury demonstrated a slight level of agreement between MR imaging and CT (κ = 0.154, P = .04). However, the overall predictive agreement for the detection of an axonal injury was 91%. CONCLUSIONS Rapid MR imaging is a valid technique for detecting traumatic cranial injuries and an adequate examination for follow-up imaging in lieu of repeat CT.
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Affiliation(s)
- H Mehta
- From the Departments of Radiology (H.M., J.A., L.L.)
| | - J Acharya
- From the Departments of Radiology (H.M., J.A., L.L.)
| | - A L Mohan
- Neurosurgery (A.L.M., M.E.T., D.J.), New York Medical College, Valhalla, New York
| | - M E Tobias
- Neurosurgery (A.L.M., M.E.T., D.J.), New York Medical College, Valhalla, New York
| | - L LeCompte
- From the Departments of Radiology (H.M., J.A., L.L.)
| | - D Jeevan
- Neurosurgery (A.L.M., M.E.T., D.J.), New York Medical College, Valhalla, New York
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Roguski M, Morel B, Sweeney M, Talan J, Rideout L, Riesenburger RI, Madan N, Hwang S. Magnetic resonance imaging as an alternative to computed tomography in select patients with traumatic brain injury: a retrospective comparison. J Neurosurg Pediatr 2015; 15:529-34. [PMID: 25700122 DOI: 10.3171/2014.10.peds14128] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Traumatic head injury (THI) is a highly prevalent condition in the United States, and concern regarding excess radiation-related cancer mortality has placed focus on limiting the use of CT in the evaluation of pediatric patients with THI. Given the success of rapid-acquisition MRI in the evaluation of ventriculoperitoneal shunt malfunction in pediatric patient populations, this study sought to evaluate the sensitivity of MRI in the setting of acute THI. METHODS Medical records of 574 pediatric admissions for THI to a Level 1 trauma center over a 10-year period were retrospectively reviewed to identify patients who underwent both CT and MRI examinations of the head within a 5-day period. Thirty-five patients were found, and diagnostic images were available for 30 patients. De-identified images were reviewed by a neuroradiologist for presence of any injury, intracranial hemorrhage, diffuse axonal injury (DAI), and skull fracture. Radiology reports were used to calculate interrater reliability scores. Baseline demographics and concordance analysis was performed with Stata version 13. RESULTS The mean age of the 30-patient cohort was 8.5 ± 6.7 years, and 63.3% were male. The mean Injury Severity Score was 13.7 ± 9.2, and the mean Glasgow Coma Scale score was 9 ± 5.7. Radiology reports noted 150 abnormal findings. CT scanning missed findings in 12 patients; the missed findings included DAI (n = 5), subarachnoid hemorrhage (n = 6), small subdural hematomas (n = 6), cerebral contusions (n = 3), and an encephalocele. The CT scan was negative in 3 patients whose subsequent MRI revealed findings. MRI missed findings in 13 patients; missed findings included skull fracture (n = 5), small subdural hematomas (n = 4), cerebral contusions (n = 3), subarachnoid hemorrhage (n = 3), and DAI (n = 1). MRI was negative in 1 patient whose preceding CT scan was read as positive for injury. Although MRI more frequently reported intracranial findings than CT scanning, there was no statistically significant difference between CT and MRI in the detection of any intracranial injury (p = 0.63), DAI (p = 0.22), or intracranial hemorrhage (p = 0.25). CT scanning tended to more frequently identify skull fractures than MRI (p = 0.06). CONCLUSIONS MRI may be as sensitive as CT scanning in the detection of THI, DAI, and intracranial hemorrhage, but missed skull fractures in 5 of 13 patients. MRI may be a useful alternative to CT scanning in select stable patients with mild THI who warrant neuroimaging by clinical decision rules.
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Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med 2014; 64:145-52, 152.e1-5. [PMID: 24635987 PMCID: PMC4731042 DOI: 10.1016/j.annemergmed.2014.01.030] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 01/24/2014] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE We evaluate the diagnostic accuracy of clinical decision rules and physician judgment for identifying clinically important traumatic brain injuries in children with minor head injuries presenting to the emergency department. METHODS We prospectively enrolled children younger than 18 years and with minor head injury (Glasgow Coma Scale score 13 to 15), presenting within 24 hours of their injuries. We assessed the ability of 3 clinical decision rules (Canadian Assessment of Tomography for Childhood Head Injury [CATCH], Children's Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE], and Pediatric Emergency Care Applied Research Network [PECARN]) and 2 measures of physician judgment (estimated of <1% risk of traumatic brain injury and actual computed tomography ordering practice) to predict clinically important traumatic brain injury, as defined by death from traumatic brain injury, need for neurosurgery, intubation greater than 24 hours for traumatic brain injury, or hospital admission greater than 2 nights for traumatic brain injury. RESULTS Among the 1,009 children, 21 (2%; 95% confidence interval [CI] 1% to 3%) had clinically important traumatic brain injuries. Only physician practice and PECARN identified all clinically important traumatic brain injuries, with ranked sensitivities as follows: physician practice and PECARN each 100% (95% CI 84% to 100%), physician estimates 95% (95% CI 76% to 100%), CATCH 91% (95% CI 70% to 99%), and CHALICE 84% (95% CI 60% to 97%). Ranked specificities were as follows: CHALICE 85% (95% CI 82% to 87%), physician estimates 68% (95% CI 65% to 71%), PECARN 62% (95% CI 59% to 66%), physician practice 50% (95% CI 47% to 53%), and CATCH 44% (95% CI 41% to 47%). CONCLUSION Of the 5 modalities studied, only physician practice and PECARN identified all clinically important traumatic brain injuries, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.
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Affiliation(s)
- Joshua S Easter
- Denver Emergency Center for Children, Department of Emergency Medicine, Denver Health, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Emergency Medicine, Bon Secours St. Mary's Hospital, Richmond, VA; Department of Emergency Medicine, University of Virginia, Charlottesville, VA.
| | - Katherine Bakes
- Denver Emergency Center for Children, Department of Emergency Medicine, Denver Health, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | | | - Emily Caruso
- Denver Emergency Center for Children, Department of Emergency Medicine, Denver Health, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jason S Haukoos
- Denver Emergency Center for Children, Department of Emergency Medicine, Denver Health, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Epidemiology, Colorado School of Public Health, Aurora, CO
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External validation of the Blunt Abdominal Trauma in Children (BATiC) score. J Trauma Acute Care Surg 2014; 76:1282-7. [DOI: 10.1097/ta.0000000000000175] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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[Home falls in infants before walking acquisition]. Arch Pediatr 2013; 20:484-91. [PMID: 23562734 DOI: 10.1016/j.arcped.2013.02.071] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2012] [Revised: 01/11/2013] [Accepted: 02/23/2013] [Indexed: 11/23/2022]
Abstract
UNLABELLED Minor head trauma is frequent among infants and leads to numerous visits to emergency departments for neurological assessment to evaluate the value of cerebral CT scan with the risk for traumatic brain injuries (TBI). OBJECTIVES To analyze the epidemiological characteristics of nonwalking infants admitted after falling at home and to analyze associated factors for skull fractures and TBI. PATIENTS AND METHODS Between January 2007 and December 2011, all children aged 9 months or younger and admitted after a home fall to the pediatric emergency unit of a tertiary children's hospital were included. The data collected were age, sex, weight and height, body mass index; geographic origin, referral or direct admission, mode of transportation; month, day and time of admission; causes of the fall, alleged fall height, presence of an eyewitness, type of landing surface; Glasgow Coma Scale (GCS) score, application of the head trauma protocol, location and type of injuries, cerebral CT scan results, length of hospital stay, progression, and neglect or abuse situations. RESULTS DESCRIPTIVE ANALYSIS: within the study period, 1910 infants were included. Fifty-four percent of children were aged less than 6 months with a slight male prevalence (52%). Falls from parental bed and infant carriers accounted for the most frequent fall circumstances. GCS score on admission was equal to 14 or 15 in 99% of cases. A cerebral CT scan was performed in 34% of children and detected 104 skull fractures and 55 TBI. Infants aged less than 1 month had the highest rate of TBI (8.5%). Eleven percent of patients were hospitalized. A situation of abuse was identified in 51 infants (3%). UNIVARIATE ANALYSIS: Male children and infants aged less than 3 months had a higher risk of skull fractures (P = 0.03 and P = 0.0003, respectively). In the TBI group, children were younger (3.8 ± 2.6 months versus 5.4 ± 2.5 months, P < 0.0001), fell from a higher height (90.2 ± 29.5 cm versus 70.9 ± 28.7 cm, P < 0.0001), were more often admitted on a weekend or day off, and had more skull fractures (54% versus 6%, P < 0.001). MULTIVARIATE ANALYSIS: all variables showing P < 0.2 in the univariate analysis were entered into the model. In the final model, three variables continued to be associated with a risk of TBI: being referred by a physician (OR 4.6 [2.2-9.6], P < 0.0001), being younger than 3 months old (OR 3.1 [1.7-5.7], P = 0.0002), falling from a height greater than 90 cm (OR 3.1 [1.7-5.6], P = 0.0002). COMMENTS Before walking acquisition, children are particularly vulnerable and have the highest rate of TBI after a vertical fall. In this age group, the rate of abuse is also higher. Given this double risk, numerous cerebral CT scans are performed (35-40% of the target population). This protocol, however, leads to a low proportion of detected TBI (<10%) compared to the high number of CT scans and an additional risk of irradiation. CONCLUSION As no validated predictive score exists and pending the contribution of the S-100B protein assay, the identification of infants at high risk for TBI and justifying neuroimaging is based on the search for predisposing factors and circumstances.
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