Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study

Identification of severely injured children at very low risk of emergent surgery: A national trauma registry study

OBJECTIVE

The number of pediatric trauma patients requiring surgical interventions has been steadily decreasing allowing for a judicious approach to immediately available resources. This study aimed to derive and validate a prediction rule that reliably identifies injured children who are at very low risk for requiring emergency surgery upon emergency department (ED) arrival.

METHODS

A retrospective cohort study of data included in the Israeli National Trauma Registry from January 1, 2011, through December 31, 2020, was conducted. We included children aged 0-14 years who presented to EDs from the scene of injury and were hospitalized. We excluded patients transferred between facilities or with isolated burns. The primary outcome was emergency operative intervention (EOI) performed within one hour of ED arrival. We tested mechanism, GCS, heart rate, and blood pressure as candidate predictors. We then randomized patients to two cohorts, derived and internally validated a prediction rule.

RESULTS

During the study period, 83,859 children met enrollment criteria. The median age was 6 years (IQR 2-10) and 56,867 (67.8 %) were male; 75,450 (90.0 %) sustained blunt trauma. One hundred sixty-nine (0.20 %) children underwent EOI. In the derivation and validation cohorts, 34,138 (81.4 %) and 34,271 (81.7 %) patients, were classified as low risk based on blunt trauma mechanism, normal GCS (15), and low-risk heart rate (according to age). Of those, 8 (0.02 %) and 13 (0.04 %) required an EOI, respectively. In the validation cohort, the prediction rule for EOI had a sensitivity of 84 % (95 % CI 75-91), a specificity of 82 % (95 % CI 81-82), and a negative predictive value of 99.96 % (95 % CI 99.94-99.98). Among children with an Injury Severity Score>15, the sensitivity was 87 % (95 % CI 77-94), the specificity of 57 % (95 % CI 54-59), and the negative predictive value was 98.97 % (95 % CI 98.13-99.44).

CONCLUSIONS

A limited set of physiologic parameters, readily available at hospital admission can effectively identify injured children at very low risk for emergent surgery. For these children, immediate deployment of surgical resources may not be necessary.

Correlation between early computed tomography findings and neurological outcome in pediatric traumatic brain injury patients

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children. Head computed tomography (CT) is frequently utilized for evaluating trauma-related characteristics, selecting treatment options, and monitoring complications in the early stages. This study assessed the relationship between cranial CT findings and early and late neurological outcomes in pediatric TBI patients admitted to the pediatric intensive care unit (PICU). The study included children aged 1 month to 18 years who were admitted to the PICU due to TBI between 2014 and 2020. Sociodemographic data, clinical characteristics, and cranial CT findings were analyzed. Patients were categorized based on their Glasgow Coma Scale (GCS) score. Of the 129 patients, 83 (64%) were male, and 46 (36%) were female, with a mean age of 6.8 years. Falls (n = 51, 39.5%) and in-vehicle traffic accidents (n = 35, 27.1%) were the most common trauma types observed. Normal brain imaging findings were found in 62.7% of the patients, while 37.3% exhibited intracranial pathology. Hemorrhage was the most frequent CT finding. Severe TBI (n = 26, p = 0.032) and mortality (n = 9, p = 0.017) were more prevalent in traffic accidents. The overall mortality rate in the study population was 10.1%. In children with TBI, cranial CT imaging serves as an essential initial method for patients with neurological manifestations. Particularly, a GCS score of ≤ 8, multiple hemorrhages, diffuse cerebral edema, and intraventricular bleeding are associated with sequelae and mortality.

Medical Coders' Use of the ICD-10-CM "Unspecified" Codes for Head and Brain Injury in Emergency Department Settings

CONTEXT

In the emergency department (ED) setting, prioritizing triage and patient care may lead to challenges in capturing detailed documentation necessary for specific International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) coding in medical records. Consequently, the prevalent use of the "unspecified head injury" code poses concerns about the precision of ED-based administrative billing claims data when analyzed for public health surveillance of nonfatal traumatic brain injuries (TBIs). Understanding the perspective of medical coders can illuminate coding processes and opportunities to enhance coding accuracy for TBI and other head injuries in the ED.

OBJECTIVE

This evaluation explores medical coders' perspectives and challenges when assigning ICD-10-CM codes to head injuries in the ED.

DESIGN

This qualitative evaluation utilized a phenomenological approach, which employed semi-structured interviews to understand medical coders' perspectives, processes, and coding determinations for head injuries in the ED.

SETTING

Interviews were conducted using a HIPAA-compliant video-based platform between July 2022 and January 2023.

PARTICIPANTS

Seventeen medical coders with ED coding experience were interviewed. Their backgrounds were diverse, though most had more than 15 years of experience.

MAIN OUTCOMES

Four qualitative themes emerged, which highlighted challenges with lack of detailed documentation, defaulting to unspecified codes, time, and productivity pressure, and additional insights into coders' assumptions and code determination processes.

RESULTS

Medical coders expressed challenges assigning ICD-10-CM codes to the highest level of specificity, citing issues including insufficient documentation by ED providers and terminology variations. Workplace time constraints and pressure for expedited claims also led to defaulting to unspecified codes.

CONCLUSIONS

This evaluation highlights the need for improved documentation consistency and detail in ED records to facilitate accurate ICD-10-CM coding. Alleviating time pressures, improving algorithms, and offering specialized training opportunities to medical coders could be helpful steps to improve coding specificity and data accuracy for head injuries in the ED.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Sports Related Concussion

Sports-related concussions (SRC) have been a topic of interest for decades and are a prevalent risk of sports participation. The definition of SRC continues to evolve but includes a plausible mechanism and associated symptoms of injury. Rates of concussion vary among sports, and many sports have adopted rule changes to limit this risk for its athletes. There has been a considerable effort to prevent the occurrence of SRC, as well as a focus on safe return to learn and sport alike. There is growing concern about the ramifications of concussions, which will continue to warrant further investigation.

Overutilization of head computed tomography in cases of mild traumatic brain injury: a systematic review and meta-analysis

Head computed tomography (CT) is the preferred imaging modality for mild traumatic brain injury (mTBI). The routine use of head CT in low-risk individuals with mild TBI offers no clinical benefit but also causes notable health and financial burden. Despite the availability of related guidelines, studies have reported considerable rate of non-indicated head CT requests. The objectives were to provide an overall estimate for the head CT overutilization rate and to identify the factors contributing to the overuse. A systematic review of PubMed, Scopus, Web of Science, and Embase databases was conducted up to November 2023, following PRISMA and MOOSE guidelines. Two reviewers independently selected eligible articles and extracted data. Quality assessment was performed using a bias risk tool, and a random-effects model was used for data synthesis. Fourteen studies, encompassing 28,612 patients, were included, with 27,809 undergoing head CT scans. Notably, 75% of the included studies exhibited a moderate to high risk of bias. The overutilization rate for pediatric and adult patients was 27% (95% CI: 5-50%) and 32% (95% CI: 21-44%), respectively. An alternative rate, focusing on low-risk pediatric patients, was 54% (95% CI: 20-89%). Overutilization rates showed no significant difference between teaching and non-teaching hospitals. Patients with mTBI from falls or assaults were less likely to receive non-indicated scans. There was no significant association between physician specialty or seniority and overuse, nor between patients' age or sex and the likelihood of receiving a non-indicated scan. Approximately one-third of head CT scans in mTBI cases are avoidable, underscoring the necessity for quality improvement programs to reduce unnecessary imaging and its associated burdens.

CT in pediatric trauma patients

The decision as to whether to perform a computed tomography (CT) examination in severe pediatric trauma poses a challenge. The therapeutic benefit of computed tomography in injured children is lower compared to adults, while the potential negative effects of ionizing radiation may be higher. Thus, the threshold for CT should be higher. Centers that less frequently treat pediatric cases tend to conduct more whole-body CT examinations than dedicated pediatric trauma centers, indicating a clinical overestimation of injury severity with subsequently unnecessary imaging due to inexperience. On the other hand, a CT scan that is not performed but is actually necessary can also have negative consequences if an injury is detected with a delay. An injured child presents a challenging situation for all involved healthcare providers, and thus requires a structured approach to decision-making.Selective literature review of the benefits and risks of CT in injured children, as well as indications for whole-body and region-specific CT imaging.This article provides an overview of current guidelines, recent insight into radiation protection and the benefits of CT in injured children, and evidence-based decision criteria for choosing the appropriate modality based on the mechanism of injury and the affected body region. · Whole-body CT has less of an influence on treatment decisions and mortality in severely injured children than in adults.. · For radiation protection reasons, the indication should be determined more conservatively in children than in adult trauma patients.. · The indication for CT should ideally be determined separately for each region of the body.. · Ultrasound and MRI are a good alternative for the primary diagnostic workup in many situations.. · Appelhaus S, Schönberg SO, Weis M. CT in pediatric trauma patients. Fortschr Röntgenstr 2024; DOI 10.1055/a-2341-7559.

Diagnostic potential of IL6 and other blood-based inflammatory biomarkers in mild traumatic brain injury among children

Objectives

Inflammatory biomarkers, as indicators of biological states, provide a valuable approach for accurate and reproducible measurements, crucial for the effective management of mild traumatic brain injury (mTBI) in pediatric patients. This study aims to assess the diagnostic utility of blood-based inflammatory markers IL6, IL8, and IL10 in children with mTBI, including those who did not undergo computed tomography (CT) scans.

Methods

A prospective multicentric cohort study involving 285 pediatric mTBI patients was conducted, stratified into CT-scanned and non-CT-scanned groups within 24 h post-trauma, alongside 74 control subjects. Biomarker levels were quantitatively analyzed using ELISA. Sensitivity and specificity metrics were calculated to determine the diagnostic efficacy of each biomarker.

Results

A total of 223 mTBI patients (78%) did not undergo CT scan examination but were kept in observation for symptoms monitoring at the emergency department (ED) for more than 6 h (in-hospital-observation patients). Among CT-scanned patients (n = 62), 14 (23%) were positive (CT+). Elevated levels of IL6 and IL10 were found in mTBI children compared to controls. Within mTBI patients, IL6 was significantly increased in CT+ patients compared to both CT- and in-hospital-observation patients. No significant differences were observed for IL8 among the compared groups. IL6 yielded a specificity of 48% in identifying CT- and in-hospital-observation patients, with 100% sensitivity in excluding all CT+ cases. These performances were maintained whether IL6 was measured within 6 h or within 24 h after the trauma.

Conclusion

The inflammatory marker IL6 emerges as a robust biomarker, showing promising stratification value for pediatric mTBI patients undergoing CT scans or staying in observation in a pediatric ED.

The Florida Geriatric Head Trauma CT Clinical Decision Rule

BACKGROUND

Several clinical decision rules have been devised to guide head computed tomography (CT) use in patients with minor head injuries, but none have been validated in patients 65 years or older. We aimed to derive and validate a head injury clinical decision rule for older adults.

METHODS

We conducted a secondary analysis of an existing dataset of consecutive emergency department (ED) patients >65 years old with blunt head trauma. The main predictive outcomes were significant intracranial injury and Need for Neurosurgical Intervention on CT. The secondary outcomes also considered in the model development and validation were All Injuries and All Intracranial Injuries. Predictor variables were identified using multiple variable logistic regression, and clinical decision rule models were developed in a split-sample derivation cohort and then tested in an independent validation cohort.

RESULTS

Of 5776 patients, 233 (4.0%) had significant intracranial injury and an additional 104 (1.8%) met CT criteria for Need for Neurosurgical Intervention. The best performing model, the Florida Geriatric Head Trauma CT Clinical Decision Rule, assigns points based on several clinical variables. If the points totaled 25 or more, a CT scan is indicated. The included predictors were arrival via Emergency Medical Services (+30 points), Glasgow Coma Scale (GCS) <15 (+20 points), GCS <14 (+50 points), antiplatelet medications (+17 points), loss of consciousness (+16 points), signs of basilar skull fracture (+50 points), and headache (+20 points). Utilizing this clinical decision rule in the validation cohort, a point total ≥25 had a sensitivity and specificity of 100.0% (95% CI: 96.0-100) and 12.3% (95% CI: 10.9-13.8), respectively, for significant intracranial injury and Need for Neurosurgical Intervention.

CONCLUSIONS

The Florida Geriatric Head Trauma CT Clinical Decision Rule has the potential to reduce unnecessary CT scans in older adults, without compromising safe emergency medicine practice.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Policy Statement

Advanced imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is an integral component to the evaluation and management of ill and injured children in the emergency department. As with any test or intervention, the benefits and potential impacts on management must be weighed against the risks to ensure that high-value care is being delivered. There are important considerations specific to the pediatric patient related to the ordering and interpretation of advanced imaging. This policy statement provides guidelines for institutions and those who care for children to optimize the use of advanced imaging in the emergency department setting and was coauthored by experts in pediatric and general emergency medicine, pediatric radiology, and pediatric surgery. The intent is to guide decision-making where children may access care.

What are the Characteristics of Oral Injuries Caused by Playground Equipment?

PURPOSE

Studies regarding oral injuries from playground equipment in children remain limited. This study aimed to clarify the characteristics of oral injury caused by playground equipment and identify associations with concomitant head injury.

METHODS

Children treated between 2011 and 2021 at an oral surgery clinic for oral injuries from playground equipment were retrospectively investigated. The following factors were analyzed: demographic characteristics, mechanism of injury, type of equipment causing the injury, classification of oral injury, and whether the Department of Emergency and Critical Care Medicine was consulted regarding the head injury. The data collected were statistically analyzed using the Fisher-Freeman-Halton test with significance adopted at the 5% level.

RESULTS

This study analyzed data from 82 children. Injuries were concentrated in age groups of 2 to 3 years (32.9%), 4 to 5 years (28.0%), and 6 to 7 years (25.6%). Regarding the mechanism of injury, falls were more common (89.0%) than impact/striking (11.0%). The type of equipment most frequently causing injury was slides (29.3%), followed by swings (23.2%) and iron bars (18.3%). Injuries were classified as soft tissue injury alone (56.1%) or tooth injury and/or jaw fracture (43.9%). Consultation with the Department of Emergency and Critical Care Medicine for head injury was uncommon (13.4%), and all consultations for brain injury diagnosed minor injuries.

CONCLUSION

Oral injuries caused by playground equipment were frequent between 2 and 7 years old. The most common cause was falls, with most injuries caused by slides, swings, or iron bars. Approximately half of the oral injuries were soft tissue injuries only, while the other half were associated with tooth and/or jaw injuries. Department of Emergency and Critical Care Medicine consultations for head trauma were uncommon and consistently confirmed minor injuries.

Traumatic brain injuries in paediatric patients: individual vs. team sports-related hospitalizations

Paediatric sport participation continues to increase in the United States, with a corresponding increase in sports-related concussions or traumatic brain injuries (TBIs). It is important to recognize which sports are at elevated risk and identify risk factors for hospital admission and length of stay (LOS). Paediatric patients (ages 5-18) from 2008 to 2014 were identified from the Healthcare Cost and Utilization Project (HCUP) National Inpatient Sample (NIS). Eight hundred and ninety-four patients included those who were hospitalized with a TBI resulting from participation in an individual (451 patients) or team (443 patients) sport. We evaluated the differences in LOS and total charges between individual and team sports and found that compared to team sports, TBI patients in individual sports had significantly longer hospital stays compared to team sports (1.75 days versus 1.34 days, p < 0.001) and costlier ($27,333 versus $19,069, p < 0.001) hospital stays. This may be due to reduced awareness and reduced compliance with return-to-play protocols in individual sports. Safety education information at a young age, increased awareness of TBIs, and additional medical support for individual sports as well as team sports may help mitigate these findings.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Using mobile health to expedite access to specialty care for youth presenting to the emergency department with concussion at highest risk of developing persisting symptoms: a protocol paper for a non-randomised hybrid implementation-effectiveness trial

INTRODUCTION

Paediatric concussion is a common injury. Approximately 30% of youth with concussion will experience persisting postconcussion symptoms (PPCS) extending at least 1 month following injury. Recently, studies have shown the benefit of early, active, targeted therapeutic strategies. However, these are primarily prescribed from the specialty setting. Early access to concussion specialty care has been shown to improve recovery times for those at risk for persisting symptoms, but there are disparities in which youth are able to access such care. Mobile health (mHealth) technology has the potential to improve access to concussion specialists. This trial will evaluate the feasibility of a mHealth remote patient monitoring (RPM)-based care handoff model to facilitate access to specialty care, and the effectiveness of the handoff model in reducing the incidence of PPCS.

METHODS AND ANALYSIS

This study is a non-randomised type I, hybrid implementation-effectiveness trial. Youth with concussion ages 13-18 will be enrolled from the emergency department of a large paediatric healthcare network. Patients deemed a moderate-to-high risk for PPCS using the predicting and preventing postconcussive problems in paediatrics (5P) stratification tool will be registered for a web-based chat platform that uses RPM to collect information on symptoms and activity. Those patients with escalating or plateauing symptoms will be contacted for a specialty visit using data collected from RPM to guide management. The primary effectiveness outcome will be the incidence of PPCS, defined as at least three concussion-related symptoms above baseline at 28 days following injury. Secondary effectiveness outcomes will include the number of days until return to preinjury symptom score, clearance for full activity and return to school without accommodations. The primary implementation outcome will be fidelity, defined as the per cent of patients meeting specialty care referral criteria who are ultimately seen in concussion specialty care. Secondary implementation outcomes will include patient-defined and clinician-defined appropriateness and acceptability.

ETHICS AND DISSEMINATION

This study was approved by the Institutional Review Board of the Children's Hospital of Philadelphia (IRB 22-019755). Study findings will be published in peer-reviewed journals and disseminated at national and international meetings.

TRIAL REGISTRATION NUMBER

NCT05741411.

Advances in pediatric emergency from 2023

Most children receive emergency care by general emergency physicians and not in designated children's hospitals. There are unique considerations in the care of children that differ from the care of adults. Many management principles can be extrapolated from adult studies, but the unique pathophysiology of pediatric disease requires specialized attention and management updates. This article highlights ten impactful articles from the year 2023 whose findings can improve the care of children in the Emergency Department (ED). These studies address pediatric resuscitation, traumatic arrest, septic shock, airway management, nailbed injuries, bronchiolitis, infant fever, cervical spine injuries, and cancer risk from radiation (Table 1). The findings in these articles have the potential to impact the evaluation and management of children (Table 2).

Emergency Department Evaluation of Young Infants With Head Injury

OBJECTIVES

We compared the emergency department (ED) evaluation and outcomes of young head-injured infants to older children.

METHODS

Using the Pediatric Health Information Systems database, we performed a retrospective, cross-sectional analysis of children <2 years old with isolated head injuries (International Classification of Diseases, 10th Revision, diagnoses) at one of 47 EDs from 2015 to 2019. Our primary outcome was utilization of diagnostic cranial imaging. Secondary outcomes were diagnosis of traumatic brain injury (TBI), clinically important TBI, and mortality. We compared outcomes between the youngest infants (<3 months old) and children 3 to 24 months old.

RESULTS

We identified 112 885 ED visits for children <2 years old with isolated head injuries. A total of 62 129 (55%) were by males, and 10 325 (9.1%) were by infants <3 months of age. Compared with older children (12-23 months old), the youngest infants were more likely to: Undergo any diagnostic cranial imaging (50.3% vs 18.3%; difference 31.9%, 95% confidence interval [CI] 35.0-28.9%), be diagnosed with a TBI (17.5% vs 2.7%; difference 14.8%, 95% CI 16.4%-13.2%) or clinically important TBI (4.6% vs 0.5%; difference 4.1%, 95% CI 3.8%-4.5%), and to die (0.3% vs 0.1%; difference 0.2%, 95% CI 0.3%-0.1%). Among those undergoing computed tomography or MRI, TBIs were significantly more common in the youngest infants (26.4% vs 8.8%, difference 17.6%, 95% CI 16.3%-19.0%).

CONCLUSIONS

The youngest infants with head injuries are significantly more likely to undergo cranial imaging, be diagnosed with brain injuries, and die, highlighting the need for a specialized approach for this vulnerable population.

Risk factors for clinically important traumatic brain injury in minor head injury in older people

BACKGROUND AND OBJECTIVES

The incidence of traumatic brain injury (TBI) in older individuals is increasing with an increase in the older population. For older people, the required medical interventions and hospitalization following minor head injury have negative impacts, which have not been reported in literature up till now. We aimed to investigate the risk factors for clinically important traumatic brain injury (ciTBI) in older patients with minor head injury.

METHODS

This is a retrospective single-center cohort study. Older patients aged ≥65 years presenting with head injury and a Glasgow Coma Scale (GCS) score of ≥13 upon arrival at the hospital between January 1, 2018, and October 31, 2021, were included. Patients with an injury duration of ≥24 h were excluded. The primary outcome was defined as ciTBI (including death, surgery, intubation, medical interventions, and hospital stays of ≥2 nights). Multiple logistic regression analysis was conducted to identify the risk factors.

RESULTS

A total of 296 patients were included initially, and 6 of them were excluded subsequently. ciTBI was identified in 62 cases. According to the results of the multiple logistic regression analysis, GCS scores of ≤14 (OR 3.72, 95% CI 1.89-7.30), high-risk mechanisms of injury (OR 2.80, 95% CI 1.39-5.64), vomiting (OR 5.01, 95% CI 1.19-21.1), and retrograde amnesia (OR 6.90, 95% CI 3.37-14.1) were identified as risk factors.

CONCLUSION

In older patients with minor head injury, GCS ≤14, high-risk mechanisms of injury, vomiting, and retrograde amnesia are risk factors for ciTBI.

Management of Pediatric Mild Traumatic Brain Injury Patients: S100b, Glial Fibrillary Acidic Protein, and Heart Fatty-Acid-Binding Protein Promising Biomarkers

Children are highly vulnerable to mild traumatic brain injury (mTBI). Blood biomarkers can help in their management. This study evaluated the performances of biomarkers, in discriminating between children with mTBI who had intracranial injuries (ICIs) on computed tomography (CT+) and (1) patients without ICI (CT-) or (2) both CT- and in-hospital-observation without CT patients. The aim was to rule out the need of unnecessary CT scans and decrease the length of stay in observation in the emergency department (ED). Newborns to teenagers (≤16 years old) with mTBI (Glasgow Coma Scale > 13) were included. S100b, glial fibrillary acidic protein (GFAP), and heart fatty-acid-binding protein (HFABP) performances to identify patients without ICI were evaluated through receiver operating characteristic curves, where sensitivity was set at 100%. A total of 222 mTBI children sampled within 6 h since their trauma were reported. Nineteen percent (n = 43/222) underwent CT scan examination, whereas the others (n = 179/222) were kept in observation at the ED. Sixteen percent (n = 7/43) of the children who underwent a CT scan had ICI, corresponding to 3% of all mTBI-included patients. When sensibility (SE) was set at 100% to exclude all patients with ICI, GFAP yielded 39% specificity (SP), HFABP 37%, and S100b 34% to rule out the need of CT scans. These biomarkers were even more performant: 52% SP for GFAP, 41% for HFABP, and 39% for S100b, when discriminating CT+ versus both in-hospital-observation and CT- patients. These markers can significantly help in the management of patients in the ED, avoiding unnecessary CT scans, and reducing length of stay for children and their families.

Artificial Intelligence in Pediatric Emergency Medicine: Applications, Challenges, and Future Perspectives

The dawn of Artificial intelligence (AI) in healthcare stands as a milestone in medical innovation. Different medical fields are heavily involved, and pediatric emergency medicine is no exception. We conducted a narrative review structured in two parts. The first part explores the theoretical principles of AI, providing all the necessary background to feel confident with these new state-of-the-art tools. The second part presents an informative analysis of AI models in pediatric emergencies. We examined PubMed and Cochrane Library from inception up to April 2024. Key applications include triage optimization, predictive models for traumatic brain injury assessment, and computerized sepsis prediction systems. In each of these domains, AI models outperformed standard methods. The main barriers to a widespread adoption include technological challenges, but also ethical issues, age-related differences in data interpretation, and the paucity of comprehensive datasets in the pediatric context. Future feasible research directions should address the validation of models through prospective datasets with more numerous sample sizes of patients. Furthermore, our analysis shows that it is essential to tailor AI algorithms to specific medical needs. This requires a close partnership between clinicians and developers. Building a shared knowledge platform is therefore a key step.

Association of initial assessment variables and mortality in severe pediatric traumatic brain injury

Background

Predictive scales have been used to prognosticate long-term outcomes of traumatic brain injury (TBI), but gaps remain in predicting mortality using initial trauma resuscitation data. We sought to evaluate the association of clinical variables collected during the initial resuscitation of intubated pediatric severe patients with TBI with in-hospital mortality.

Methods

Intubated pediatric trauma patients <18 years with severe TBI (Glasgow coma scale (GCS) score ≤8) from January 2011 to December 2020 were included. Associations between initial trauma resuscitation variables (temperature, pulse, mean arterial blood pressure, GCS score, hemoglobin, international normalized ratio (INR), platelet count, oxygen saturation, end tidal carbon dioxide, blood glucose and pupillary response) and mortality were evaluated with multivariable logistic regression.

Results

Among 314 patients, median age was 5.5 years (interquartile range (IQR): 2.2-12.8), GCS score was 3 (IQR: 3-6), Head Abbreviated Injury Score (hAIS) was 4 (IQR: 3-5), and most had a severe (25-49) Injury Severity Score (ISS) (48.7%, 153/314). Overall mortality was 26.8%. GCS score, hAIS, ISS, INR, platelet count, and blood glucose were associated with in-hospital mortality (all p<0.05). As age and GCS score increased, the odds of mortality decreased. Each 1-point increase in GCS score was associated with a 35% decrease in odds of mortality. As hAIS, INR, and blood glucose increased, the odds of mortality increased. With each 1.0 unit increase in INR, the odds of mortality increased by 1427%.

Conclusions

Pediatric patients with severe TBI are at substantial risk for in-hospital mortality. Studies are needed to examine whether earlier interventions targeting specific parameters of INR and blood glucose impact mortality.

Performance of glial fibrillary acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase L1 (UCH-L1) biomarkers in predicting CT scan results and neurological outcomes in children with traumatic brain injury (BRAINI-2 paediatric study): protocol of a European prospective multicentre study

INTRODUCTION

In light of the burden of traumatic brain injury (TBI) in children and the excessive number of unnecessary CT scans still being performed, new strategies are needed to limit their use while minimising the risk of delayed diagnosis of intracranial lesions (ICLs). Identifying children at higher risk of poor outcomes would enable them to be better monitored. The use of the blood-based brain biomarkers glial fibrillar acidic protein (GFAP) and ubiquitin carboxy-terminal hydrolase-L1 (UCH-L1) could help clinicians in this decision. The overall aim of this study is to provide new knowledge regarding GFAP and UCH-L1 in order to improve TBI management in the paediatric population.

METHODS AND ANALYSIS

We will conduct a European, prospective, multicentre study, the BRAINI-2 paediatric study, in 20 centres in France, Spain and Switzerland with an inclusion period of 30 months for a total of 2880 children and adolescents included. To assess the performance of GFAP and UCH-L1 used separately and in combination to predict ICLs on CT scans (primary objective), 630 children less than 18 years of age with mild TBI, defined by a Glasgow Coma Scale score of 13-15 and with a CT scan will be recruited. To evaluate the potential of GFAP and UCH-L1 in predicting the prognosis after TBI (secondary objective), a further 1720 children with mild TBI but no CT scan as well as 130 children with moderate or severe TBI will be recruited. Finally, to establish age-specific reference values for GFAP and UCH-L1 (secondary objective), we will include 400 children and adolescents with no history of TBI.

ETHICS AND DISSEMINATION

This study has received ethics approval in all participating countries. Results from our study will be disseminated in international peer-reviewed journals. All procedures were developed in order to assure data protection and confidentiality.

TRIAL REGISTRATION NUMBER

NCT05413499.

Increasing Use of Rapid Magnetic Resonance Imaging for Children with Blunt Head Injury

OBJECTIVE

To increase the percentage of patients who undergo rapid magnetic resonance imaging (rMRI) rather than computed tomography (CT) for evaluation of mild traumatic brain injury (TBI) from 45% in 2020 to 80% by December 2021.

STUDY DESIGN

This was a quality improvement initiative targeted to patients presenting to the pediatric emergency department presenting with mild TBI, with baseline data collected from January 2020 to December 2020. From January 2021 to August 2021, we implemented a series of improvement interventions and tracked the percentage of patients undergoing neuroimaging who received rMRI as their initial study. Balancing measures included proportion of all patients with mild TBI who underwent neuroimaging of any kind, proportion of patients requiring sedation, emergency department length of stay, and percentage with clinically important TBI.

RESULTS

The utilization of rMRI increased from a baseline of 45% to a mean of 92% in the intervention period. Overall neuroimaging rates did not change significantly after the intervention (19.8 vs 23.2%, P = .24). There was no difference in need for anxiolysis (12 vs 7%, P = .30) though emergency department length of stay was marginally increased (1.4 vs 1.7 hours, P = < 0.01).

CONCLUSION

In this quality improvement initiative, transition to rMRI as the primary imaging modality for the evaluation of minor TBI was achieved at a level 1 pediatric trauma center with no significant increase in overall use of neuroimaging.

Polytrauma in Children

BACKGROUND

Inadequate clinical experience still causes uncertainty in the acute diagnostic evaluation and treatment of polytrauma in children (with or without coagulopathy). This review deals with the main aspects of the acute care of severely injured children in the light of current guidelines and other relevant literature, in particular airway control, volume and coagulation management, acute diagnostic imaging, and blood coagulation studies in the shock room.

METHODS

This review is based on literature retrieved by a selective search in PubMed, Medline (OVIDSP), the Cochrane Central Register of Controlled Trials, and Epistemonikos covering the period January 2001 to August 2023. Review articles and the updated S2k clinical practice guideline on polytrauma management in childhood were considered.

RESULTS

Most accidents in childhood occur at home and in the child's free time, with varying mechanisms and patterns of injury depending on age. The outcome of treatment depends largely on the presence or absence or traumatic brain injury, which affects 66% of children with polytrauma and is thus the most common type of injury in this group, and of hemorrhagic shock with or without coagulopathy. Acute care follows the ABCDE algorithms with attention to special features in children, including age-specific reference values. According to a registry study, coagulopathy and hypovolemic shock are associated with 22% and 17% mortality, respec - tively. Treatment in a pediatric trauma reference center of the trauma network is recommended. Computed tomography (CT) should be carried out in children in accordance with defined criteria (PECARN), as a team decision and with the use of age-specific low-dose CT protocols. In children as in adults, viscoelasticity-based point-of-care tests enable the prompt diagnosis of relevant coagulopathies and their treatment in consideration of age-specific target values. The administration of tranexamic acid remains controversial.

CONCLUSION

4% of polytrauma patients are children. Because children differ from adults both anatomically and physiologically, the diagnostic evaluation and management of polytrauma in children presents a special challenge. The evidence base for pediatric polytrauma management is still inadequate; current recommendations are based on consensus, in consideration of the special features of children compared to adults.

Utility of brain imaging in pediatric patients with a suspected accidental spinal injury but no brain injury-related symptoms

PURPOSE

Imaging is the gold standard in diagnosing traumatic brain injury, but unnecessary scans should be avoided, especially in children and adolescents. Clinical decision-making rules often help to distinguish the patients who need imaging, but if spinal trauma is suspected, concomitant brain imaging is often conducted. Whether the co-occurrence of brain and spine injuries is high enough to justify head imaging in patients without symptoms suggesting brain injury is unknown.

OBJECTIVE

This study aims to assess the diagnostic yield of brain MRI in pediatric patients with suspected or confirmed accidental spinal trauma but no potential brain injury symptoms.

METHODS

We retrospectively reviewed the medical and imaging data of pediatric patients (under 18 years old) who have undergone concomitant MRI of the brain and spine because of acute spinal trauma in our emergency radiology department over a period of 8 years. We compared the brain MRI findings in patients with and without symptoms suggesting brain injury and contrasted spine and brain MRI findings.

RESULTS

Of 179 patients (mean age 11.7 years, range 0-17), 137 had symptoms or clinical findings suggesting brain injury, and 42 did not. None of the patients without potential brain injury symptoms had traumatic findings in brain MRI. This finding also applied to patients with high-energy trauma (n = 47) and was unrelated to spinal MRI findings.

CONCLUSION

Pediatric accidental trauma patients with suspected or confirmed spine trauma but no symptoms or clinical findings suggesting brain injury seem not to benefit from brain imaging.

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

BACKGROUND

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

METHODS

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

FINDINGS

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

INTERPRETATION

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

FUNDING

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

Evaluating the Utility of Repeat Computed Tomography Scans in Patients with Isolated Mild Traumatic Subarachnoid Hemorrhage

BACKGROUND

Traumatic subarachnoid hemorrhage (tSAH) is a common consequence of head trauma. Treatment of patients with tSAH commonly involves serial computed tomography (CT) scans to assess for expansile hemorrhage. However, growing evidence suggests that these patients rarely deteriorate or require neurosurgical intervention. We assessed the utility of repeat CT scans in adult patients with isolated tSAH and an intact initial neurological examination.

METHODS

Patients presenting to Mass General Brigham hospitals with tSAH between 2000 and 2021 were eligible for inclusion in this retrospective cohort study. Patients were excluded if subarachnoid hemorrhage was nontraumatic, they experienced another form of intracerebral hemorrhage, or they had a documented Glasgow Coma Scale score of ≤12 and/or poor presenting neurological examination. Univariate and multivariate regression models were used for statistical analysis.

RESULTS

Overall, 405 patients were included (191 male). The most common mechanism of trauma was fall from standing (58%). The mean number of total CT scans for all patients was 2.3, with 329 patients (80%) receiving ≥2 scans. In 309 patients, no significant neurological symptoms were present. No patients developed acute neurological deterioration or required neurosurgical intervention related to their bleed, although 5 patients had mild hemorrhagic expansion on follow-up imaging.

CONCLUSIONS

In this study, repeat imaging rarely demonstrated meaningful hemorrhagic expansion in this cohort of neurologically intact patients with isolated tSAH. In these patients with mild traumatic brain injury, excessive CT scans are perhaps unlikely to affect patient management and may present unnecessary burden to patients and hospital systems.

Canadian Association of Radiologists Trauma Diagnostic Imaging Referral Guideline

The Canadian Association of Radiologists (CAR) Trauma Expert Panel consists of adult and pediatric emergency and trauma radiologists, emergency physicians, a family physician, a patient advisor, and an epidemiologist/guideline methodologist. After developing a list of 21 clinical/diagnostic scenarios, a systematic rapid scoping review was undertaken to identify systematically produced referral guidelines that provide recommendations for 1 or more of these clinical/diagnostic scenarios. Recommendations from 49 guidelines and contextualization criteria in the Grading of Recommendations, Assessment, Development and Evaluations (GRADE) for guidelines framework were used to develop 50 recommendation statements across the 21 scenarios related to the evaluation of traumatic injuries. This guideline presents the methods of development and the recommendations for head, face, neck, spine, hip/pelvis, arms, legs, superficial soft tissue injury foreign body, chest, abdomen, and non-accidental trauma.

Comparison and Utility of Intravenous Iodinated Contrast in Chest, Abdomen, Pelvis Computerized Tomography for Trauma Patients With Blunt Mechanism of Injury Before and After the May 9, 2022 Global Contrast Shortage at a Level II Trauma Center

Background: Intravenous (IV) contrast improves the sensitivity and specificity of injury detection in computerized tomography (CT). Its use is recommended in the workup of trauma patients by the American College of Surgeons and American College of Radiology. On May 9, 2022, the Food and Drug Administration declared a shortage of iodinated contrast due to the COVID-19 pandemic. Although the shortage has ended, the temporary lack of IV contrast forced physicians to be prudent in ordering CT scans with IV contrast. We sought to determine if there was a change in the percentage of CT contrast studies performed during the contrast shortage and if this change affected patient outcomes.Methods: Retrospective chart review was performed on all adult tier 2 trauma patients at a 619-bed community-based level II trauma center who received CT chest, abdomen, and pelvis imaging as initial workup for blunt trauma from 5/9/2021-6/30/2021 (pre-shortage) and 5/9/2022-6/30/2022 (during shortage).Results: Patients were predominantly male with median age of 31-52 and of White or Hispanic ethnicity. Before the contrast shortage, all 110 trauma patients were scanned with contrast. During the shortage, 29 of 114 patients were scanned with contrast (P < 0.001). Injuries were identified in 59% of patients scanned with contrast (P < 0.001). There were no significant differences in blood transfusion needs, repeat CT, disposition, or mortality when comparing pre-shortage to during shortage or when comparing between non-contrast and contrast studies during the shortage.Discussion: There was a decrease in the percentage of CT contrast studies performed during the shortage. A higher percentage of injuries were identified in the patients scanned with contrast. However, there were no significant differences in patient outcomes. Certain trauma patients may be safely scanned without contrast.

Comparing Accuracy of Night Radiology Interpretations for Pediatric Trauma: Radiology Residents Versus Attending Teleradiologists

Background: Overnight radiology coverage for pediatric trauma patients (PTPs) is addressed with a combination of on-call radiology residents (RRs) and/or attending teleradiologists (ATs); however, the accuracy of these two groups has not been investigated for PTPs. We aimed to compare the accuracy of RRs vs AT interpretations of computed tomography (CT) scans for PTPs. Methods: Pediatric trauma patients (<18 years old) at a single level-I adult/level-II pediatric trauma center were studied in a retrospective analysis (3/2019-5/2020). Computed tomography scans interpreted by both RRs and ATs were included. Radiology residents were compared to ATs for time to interpretation (TTI) and accuracy compared to faculty attending radiologist interpretation, using the validated RADPEER scoring system. Additionally, RR and AT accuracies were compared to a previously studied adult cohort during the same time-period. Results: 42 PTPs (270 interpretations) and 1053 adults (8226 interpretations) were included. Radiology residents had similar rates of discrepancy (13.3% vs 13.3%), major discrepancy (4.4% vs 4.4%), missed findings (9.6% vs 12.6%), and overcalls (3.7% vs .7%) vs ATs (all P > .05). Mean TTI was shorter for RRs (55.9 vs 90.4 minutes, P < .001). Radiology residents had a higher discrepancy rate for PTPs (13.3% vs 7.5%, P = .01) than adults. Attending teleradiologists had a similar discrepancy rate for PTPs and adults (13.3% vs 8.9%, P = .07). Discussion: When interpreting PTP CT imaging, RRs had similar discrepancy rates but faster TTI than ATs. Radiology residents had a higher discrepancy rate for PTP CTs than RR interpretation of adult patients, indicating both RRs and ATs need more focused training in the interpretation of PTP studies.

Validation of the Scandinavian guidelines for minor and moderate head trauma in children: protocol for a pragmatic, prospective, observational, multicentre cohort study

INTRODUCTION

Mild traumatic brain injury is common in children and it can be challenging to accurately identify those in need of urgent medical intervention. The Scandinavian guidelines for management of minor and moderate head trauma in children, the Scandinavian Neurotrauma Committee guideline 2016 (SNC16), were developed to aid in risk stratification and decision-making in Scandinavian emergency departments (EDs). This guideline has been validated externally with encouraging results, but internal validation in the intended healthcare system is warranted prior to broad clinical implementation.

OBJECTIVE

We aim to validate the diagnostic accuracy of the SNC16 to predict clinically important intracranial injuries (CIII) in paediatric patients suffering from blunt head trauma, assessed in EDs in Sweden and Norway.

METHODS AND ANALYSIS

This is a prospective, pragmatic, observational cohort study. Children (aged 0-17 years) with blunt head trauma, presenting with a Glasgow Coma Scale of 9-15 within 24 hours postinjury at an ED in 1 of the 16 participating hospitals, are eligible for inclusion. Included patients are assessed and managed according to the clinical management routines of each hospital. Data elements for risk stratification are collected in an electronic case report form by the examining doctor. The primary outcome is defined as CIII within 1 week of injury. Secondary outcomes of importance include traumatic CT findings, neurosurgery and 3-month outcome. Diagnostic accuracy of the SNC16 to predict endpoints will be assessed by point estimate and 95% CIs for sensitivity, specificity, likelihood ratio, negative predictive value and positive predictive value.

ETHICS AND DISSEMINATION

The study is approved by the ethical board in both Sweden and Norway. Results from this validation will be published in scientific journals, and a tailored development and implementation process will follow if the SNC16 is found safe and effective.

TRIAL REGISTRATION NUMBER

NCT05964764.

Identification and Evaluation of Non-Accidental Trauma in the Pediatric Population: A Clinical Review

Non-accidental trauma (NAT) is a major cause of morbidity and mortality for children around the world and most significantly impacts children under one year of age. Prompt and comprehensive treatment of these children relies on a high index of suspicion from any medical provider that treats pediatric patients. This review discusses those most at risk for experiencing NAT, and common initial presentations, to assist providers in the identification of potential victims. In addition, this review provides guidance on the recommended workup for these patients so that the full extent of associated injuries may be identified and the appropriate healthcare team may be assembled.

Clinical characteristics associated with pediatric traumatic intracranial hemorrhage

PURPOSE

Traumatic brain injury (TBI) can cause significant morbidity and mortality in the pediatric population. Brain CT is the mainstay in the diagnosis of intracranial hemorrhage (ICH). The aim of this study was to explore the clinical characteristics that can predict ICH on brain CT in pediatric TBI patients, to assist physicians in deciding on the use of brain CT.

METHODS

A total of 475 pediatric TBI patients who underwent brain CT within 24 h after injury from January 2012 to December 2021 in the level 1 trauma center in Thailand were included in this cross-sectional study. Clinical data and brain CT findings were collected. Logistic regression analysis was applied to evaluate clinical characteristics that could predict ICH on brain CT in pediatric TBI patients. A p value was less than 0.05 being indicated that the difference is statistically significant. R software version 3.6.1 was used to statistical analysis.

RESULTS

The mean age of included cases was 7.7 years (interquartile range (IQR) 3.5 - 12.6 years). ICH was found in 98 (20.63%) pediatric patients based on brain CT findings. On multivariable analysis, high blunt energy injury (odds ratio (OR) = 2.79, 95% CI 1.27 - 6.11, p = 0.010), motor vehicle accidents (OR = 2.04, 95% CI: 1.14 - 3.67, p = 0.017), Glasgow coma scale score <13 (OR = 4.28, 95% CI: 1.87 - 9.78, p < 0.001), palpable skull fractures (OR = 7.30, 95% CI: 1.44 - 37.04, p = 0.016), signs of basilar skull fracture (OR = 6.10, 95% CI: 2.16 - 17.24, p < 0.001), and vomiting ≥ 3 times (OR = 2.60, 95% CI: 1.17 - 5.77, p = 0.022) were statistically significant predictive factors for ICH in pediatric TBI patients.

CONCLUSION

These factors might aid clinicians in making an appropriate decision regarding the use of brain CT in pediatric TBI cases.

Serum S100B Level in the Management of Pediatric Minor Head Trauma: A Randomized Clinical Trial

Importance

Minor head trauma (HT) is one of the most common causes of hospitalization in children. A diagnostic test could prevent unnecessary hospitalizations and cranial computed tomographic (CCT) scans.

Objective

To evaluate the effectiveness of serum S100B values in reducing exposure to CCT scans and in-hospital observation in children with minor HT.

Design, Setting, and Participants

This multicenter, unblinded, prospective, interventional randomized clinical trial used a stepped-wedge cluster design to compare S100B biomonitoring and control groups at 11 centers in France. Participants included children and adolescents 16 years or younger (hereinafter referred to as children) admitted to the emergency department with minor HT. The enrollment period was November 1, 2016, to October 31, 2021, with a follow-up period of 1 month for each patient. Data were analyzed from March 7 to May 29, 2023, based on the modified intention-to-treat and per protocol populations.

Interventions

Children in the control group had CCT scans or were hospitalized according to current recommendations. In the S100B biomonitoring group, blood sampling took place within 3 hours after minor HT, and management depended on serum S100B protein levels. If the S100B level was within the reference range according to age, the children were discharged from the emergency department. Otherwise, children were treated as in the control group.

Main Outcomes and Measures

Proportion of CCT scans performed (absence or presence of CCT scan for each patient) in the 48 hours following minor HT.

Results

A total of 2078 children were included: 926 in the control group and 1152 in the S100B biomonitoring group (1235 [59.4%] boys; median age, 3.2 [IQR, 1.0-8.5] years). Cranial CT scans were performed in 299 children (32.3%) in the control group and 112 (9.7%) in the S100B biomonitoring group. This difference of 23% (95% CI, 19%-26%) was not statistically significant (P = .44) due to an intraclass correlation coefficient of 0.32. A statistically significant 50% reduction in hospitalizations (95% CI, 47%-53%) was observed in the S100B biomonitoring group (479 [41.6%] vs 849 [91.7%]; P < .001).

Conclusions and Relevance

In this randomized clinical trial of effectiveness of the serum S100B level in the management of pediatric minor HT, S100B biomonitoring yielded a reduction in the number of CCT scans and in-hospital observation when measured in accordance with the conditions defined by a clinical decision algorithm.

Trial Registration

ClinicalTrials.gov Identifier: NCT02819778.

Predicting suicide death after emergency department visits with mental health or self-harm diagnoses

OBJECTIVE

Use health records data to predict suicide death following emergency department visits.

METHODS

Electronic health records and insurance claims from seven health systems were used to: identify emergency department visits with mental health or self-harm diagnoses by members aged 11 or older; extract approximately 2500 potential predictors including demographic, historical, and baseline clinical characteristics; and ascertain subsequent deaths by self-harm. Logistic regression with lasso and random forest models predicted self-harm death over 90 days after each visit.

RESULTS

Records identified 2,069,170 eligible visits, 899 followed by suicide death within 90 days. The best-fitting logistic regression with lasso model yielded an area under the receiver operating curve of 0.823 (95% CI 0.810-0.836). Visits above the 95th percentile of predicted risk included 34.8% (95% CI 31.1-38.7) of subsequent suicide deaths and had a 0.303% (95% CI 0.261-0.346) suicide death rate over the following 90 days. Model performance was similar across subgroups defined by age, sex, race, and ethnicity.

CONCLUSIONS

Machine learning models using coded data from health records have moderate performance in predicting suicide death following emergency department visits for mental health or self-harm diagnosis and could be used to identify patients needing more systematic follow-up.

Acute Fluid Biomarkers for Diagnosis and Prognosis in Children with Mild Traumatic Brain Injury: A Systematic Review

BACKGROUND AND OBJECTIVE

Fluid biomarkers have the potential to improve the accuracy of diagnosis and prognosis in children with mild traumatic brain injury. Our primary objective was to assess the diagnostic and prognostic utility of acute blood and fluid biomarkers in children with mild traumatic brain injury.

METHODS

We performed a systematic review of the published literature in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology. Fluid biomarker studies assessing pediatric mild traumatic brain injury diagnosis or prognosis were included if blood or fluids were sampled within 24 h of injury.

RESULTS

Thirty-two studies involving 4743 patients were included comprising 25 diagnostic studies and ten prognostic studies with three studies assessing both diagnosis and prognosis. Sixteen of the 25 diagnostic studies reported the area under the receiver operating characteristic curve (AUC) for predicting abnormal computed tomography scans of the head; S100 calcium binding protein B (S100B, N = 6 studies, AUC range 0.67-1.00), glial fibrillary acidic protein (N = 5, AUC range 0.41-0.85), ubiquitin C-terminal hydrolase (N = 3, AUC 0.59 and 0.83), neuron specific enolase (N = 1, AUC 0.99), total tau (N = 1, AUC 0.65), and interleukin-6 (N = 1, AUC 0.61). In four of the ten prognostic studies, increased acute serum S100B levels, tumor necrosis factor-α, or interleukin-8 were associated with post-concussive symptoms or fatigue from 3 to 12 months post-injury.

CONCLUSIONS

The largest amount of evidence supported the potential use of S100B, glial fibrillary acidic protein, and UCH-L1, but there was mixed accuracy for diagnosis and prognostication for all biomarkers in pediatric mTBI.

Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis

OBJECTIVE

Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care.

DESIGN

Systematic mapping review and narrative synthesis.

DATA SOURCES

Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED.

ELIGIBILITY CRITERIA

Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury.

DATA EXTRACTION AND SYNTHESIS

We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis.

RESULTS

Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories.

CONCLUSION

Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.

Entropy removal of medical diagnostics

Shannon entropy is a core concept in machine learning and information theory, particularly in decision tree modeling. To date, no studies have extensively and quantitatively applied Shannon entropy in a systematic way to quantify the entropy of clinical situations using diagnostic variables (true and false positives and negatives, respectively). Decision tree representations of medical decision-making tools can be generated using diagnostic variables found in literature and entropy removal can be calculated for these tools. This concept of clinical entropy removal has significant potential for further use to bring forth healthcare innovation, such as quantifying the impact of clinical guidelines and value of care and applications to Emergency Medicine scenarios where diagnostic accuracy in a limited time window is paramount. This analysis was done for 623 diagnostic tools and provided unique insights into their utility. For studies that provided detailed data on medical decision-making algorithms, bootstrapped datasets were generated from source data to perform comprehensive machine learning analysis on these algorithms and their constituent steps, which revealed a novel and thorough evaluation of medical diagnostic algorithms.

Bibliometric and visualization analysis of radiation brain injury from 2003 to 2023

Background

Over the past two decades, the field of radiation brain injury has attracted the attention of an increasing number of brain scientists, particularly in the areas of molecular pathology and therapeutic approaches. Characterizing global collaboration networks and mapping development trends over the past 20 years is essential.

Objective

The aim of this paper is to examine significant issues and future directions while shedding light on collaboration and research status in the field of radiation brain injury.

Methods

Bibliometric studies were performed using CiteSpaceR-bibliometrix and VOSviewer software on papers regarding radiation brain injury that were published before November 2023 in the Web of Science Core Collection.

Results

In the final analysis, we found 4,913 records written in 1,219 publications by 21,529 authors from 5,007 institutions in 75 countries. There was a noticeable increase in publications in 2014 and 2021. The majority of records listed were produced by China, the United States, and other high-income countries. The largest nodes in each cluster of the collaboration network were Sun Yat-sen University, University of California-San Francisco, and the University of Toronto. Galldiks N, Barnett GH, Langen KJ and Kim JH are known to be core authors in the field. The top 3 keywords in that time frame are radiation, radiation necrosis, and radiation-therapy.

Conclusions

The objective and thorough bibliometric analysis also identifies current research hotspots and potential future paths, providing a retrospective perspective on RBI and offering useful advice to researchers choosing research topics. Future development directions include the integration of multi-omics methodologies and novel imaging techniques to improve RBI's diagnostic effectiveness and the search for new therapeutic targets.

Computed Tomography Overuse in Pediatric Minor Head Trauma: Insights from a Single-Center Experience

BACKGROUND

Minor head trauma is a common reason for emergency department visits in children, but many of these cases are not clinically significant. Despite established criteria for selecting patients who require computed tomography (CT), concerns about overuse of CT persist. This study aimed to determine the frequency of clinically important traumatic brain injury by retrospectively evaluating cranial CT scans in children categorized as very low risk for such injuries based on PECARN prediction rules.

MATERIALS AND METHODS

Cranial CT scans of 941 minor head trauma cases were assessed for the presence, type, and number of calvarial bone fractures. Concomitant bleeding and treatment approaches were also recorded.

RESULTS

Among 881 patients (93.6%), cranial CT scans did not reveal any lesions apart from soft tissue edema. None of the cases had clinically important traumatic brain injury or required neurosurgical intervention.

DISCUSSION AND CONCLUSION

The study demonstrated that 93.6% of cranial CT scans for pediatric minor head trauma were negative, indicating a concerningly high rate of CT overuse. Although prediction rules exist, their application in clinical practice is not always optimal. Given the principle of "first, do no harm," proper patient selection is crucial to avoid unnecessary exposure to ionizing radiation.

Clinical Predictors of Major Intrathoracic Injury in Pediatric Blunt Trauma

OBJECTIVES

Blunt trauma in pediatric patients accounts for a significant proportion of pediatric death from traumatic injury. Currently, there are no clinical decision-making tools available to guide imaging choice in the evaluation of pediatric patients with blunt thoracic trauma (BTT). This study aimed to analyze the rates of missed major intrathoracic injuries on chest x-ray (CXR) and identify clinical risk factors associated with major intrathoracic injuries to formulate a clinical decision-making tool for computed tomography (CT) use in pediatric patients with BTT.

METHODS

We performed a retrospective single-center study using an institutional trauma database of pediatric patients. Inclusion criteria included age, blunt trauma, and patients who received a CXR and thoracic CT within 24 hours of presentation. Thoracic CT findings were graded as major, minor, or none, and comparison CXR was used to determine the rate of missed thoracic injuries. Eighty-four patient variables were then collected, and clinically relevant variables associated with major intrathoracic injuries were placed in a logistic regression model to determine the best predictors of major injury in pediatric BTT patients.

RESULTS

A total of 180 patients (48.3%) had CXR that missed an injury that was seen on thoracic CT. In our cohort, 20 patients (5.4%) had major injuries that were missed on CXR. Characteristics correlating with major thoracic injuries were older age (odds ratio [OR], 1.125; 95% confidence interval [CI], 1.015-1.247), chest pain (OR, 4.907; 95% CI, 2.173-11.083), abnormal chest auscultation (OR, 3.564; 95% CI, 1.406-9.035), and tachycardia (OR, 2.876; 95% CI, 1.256-6.586). Using these 4 variables, receiver operating characteristic analysis revealed an area under the curve of 0.7903.

CONCLUSIONS

Pediatric BTT patients older than 15 years with tachycardia, chest pain, or abnormal chest auscultation are at increased risk for major intrathoracic injuries and may benefit from thoracic CT.

Mild Traumatic Brain Injury Characteristics and Symptoms in Preschool Children: How Do They Differ to School Age Children? A Multicenter Prospective Observational Study

OBJECTIVE

To investigate if preschool children differ to school age children with mild traumatic brain injury (TBI) with respect to injury causes, clinical presentation, and medical management.

DESIGN

A secondary analysis of a dataset from a large, prospective and multisite cohort study on TBI in children aged 0-18 years, the Australian Paediatric Head Injury Rules Study.

SETTING

Nine pediatric emergency departments (ED) and 1 combined adult and pediatric ED located across Australia and New Zealand.

PARTICIPANTS

7080 preschool aged children (2-5 years) were compared with 5251 school-age children (6-12 years) with mild TBI (N= (N=12,331) MAIN OUTCOME MEASURES: Clinical report form on medical symptoms, injury causes, and management.

RESULTS

Preschool children were less likely to be injured with a projectile than school age children (P<.001). Preschool children presented with less: loss of consciousness (P<.001), vomiting (P<.001), drowsiness (P=.002), and headache (P<.001), and more irritability and agitation (P=.003), than school-age children in the acute period after mild TBI. Preschool children were less likely to have neuroimaging of any kind (P<.001) or to be admitted for observation than school age children (P<.001).

CONCLUSIONS

Our large prospective study has demonstrated that preschool children with mild TBI experience a different acute symptom profile to older children. There are significant clinical implications with symptoms post-TBI used in medical management to aid decisions on neuroimaging and post-acute intervention.

"What If?": Caregivers' Experiences Following Early Childhood Concussion

OBJECTIVE

Little is known about the symptoms, signs, and management guidelines for children under the age of 6 years after they sustain a concussion. Caregivers of such young children may have unique concerns and encounter different challenges from those of school-age children given the distinctive developmental characteristics of the early childhood period. This study aimed to explore the experience of caregivers through semistructured interviews to inform clinical practice.

METHODS

Fifty caregivers of children aged 6 months to 5.99 years were interviewed 3 months postinjury for this qualitative study to document their experience in relation to their child's accident, recovery, and healthcare provisions.

RESULTS

Four main themes were identified: (1) visible changes associated with caregiver concerns, (2) a roller-coaster of emotions after the injury, (3) healthcare providers' role in addressing the need for reassurance, and (4) the need for better information after the injury.

CONCLUSION

The findings provide critical insight into the unique experiences and information needs of caregivers of young children who sustain concussion. The challenges identified can inform healthcare professionals regarding the needs of caregivers after early concussion and contribute to building a knowledge base for the development of age-appropriate anticipatory guidance for caregiver mental health and child recovery.

The Observation of Pediatric Skull Fractures Without an Associated Brain Injury in a Non-Trauma Center

Introduction Young children experiencing head trauma are prone to skull fractures. Pediatric skull fractures are distinct from adults as they have a greater capacity to undergo remodeling. The objective of this study was to evaluate whether children with isolated skull fractures without an underlying brain injury and normal neurological exam require a transfer to a tertiary hospital with pediatric neurosurgery service. Methods A retrospective chart review was performed to review children under five years old presenting to the emergency department of a non-pediatric trauma center with an isolated skull fracture resulting from head trauma without intracerebral hemorrhage between 2015 and 2021. The inclusion criteria consisted of children who have isolated skull fractures without underlying injuries and normal neurological examination. We reviewed these patients' injury characteristics, disposition, and clinical outcomes. The t-test and chi-square were used for evaluating the groups and evaluating the transfer to a dedicated trauma care facility. Results We identified 26 children who had isolated skull fractures with no underlying brain injury and normal neurological examination. The two most common mechanisms of injury were falls (64%) and motor vehicle collisions (MVC) (11%). The median age of patients was six months old. The location of the skull fractures was as follows: parietal (46%), occipital (19%), temporal (15%), frontal (7.7%), occipital + parietal (7.7%), and parietal + frontal (3.8%). Four fractures were depressed (15%) and the remainder were non-displaced. Eleven children with skull fractures (42%) were transferred to a designated pediatric trauma center and the remaining 58% were hospitalized for observation and monitored at the primary hospital. None of the children with skull fractures required intubation or other advanced interventions. Conclusion In this relatively limited sample, approximately one-third of the children with isolated skull fractures without brain injury were managed successfully in a non-tertiary care center. However, none of them required surgical intervention. Thus, we propose that patients akin to those in this study can be observed at a local hospital without being transferred to a pediatric trauma center.

Limitations in the use of automated mental status detection for clinical decision support

BACKGROUND

Clinical decision support (CDS) tools improve adherence to evidence-based practices but are dependent upon data quality in the electronic health record (EHR). Mental status is an integral component of many risk stratification scores, but it is not known whether EHR-measures of altered mental status are reliable. The Glasgow Coma Scale (GCS) is a measure of altered mentation that is widely adopted and entered in the EHR in structured format. We sought to determine the accuracy GCS < 15 as an EHR-measure of altered mentation compared to ED provider documentation.

METHODS

In patients presenting to an academic Emergency Department (ED) with pneumonia we abstracted GCS values entered by nurses during routine care and in a randomly selected subset manually reviewed provider documentation for evidence of altered mental status. We defined eConfusion as present if GCS < 15 at any point during the ED encounter. We then calculated the CURB-65 score and corresponding suggested disposition using each method. Performance of eConfusion and corresponding CURB-65 compared to manual versions was measured using agreement (Cohen's K), sensitivity, and specificity.

RESULTS

Among 300 randomly selected encounters, 47 (16 %) had eConfusion present and 46 (15 %) had evidence of altered mental status in provider documentation with Cohen's K 0.73. eConfusion had 78 % sensitivity and 96 % specificity for provider documented altered mental status. When input into CURB-65 to recommend inpatient disposition, eConfusion had 95 % sensitivity, and recommended discordant disposition for 3 %.

CONCLUSIONS

There was modest agreement between eConfusion and provider documentation of altered mental status. eConfusion had good specificity but low sensitivity which resulted in under-estimation of the CURB-65 score and occasional inappropriate disposition recommendations compared to provider documentation. These data do not support the use of GCS as a measure for altered mentation for use in CDS tools in the ED.

Variability of the optic nerve sheath diameter on brain computed tomography in Turkish children based on sex and age

BACKGROUND

Optic nerve sheath diameter (ONSD) measurement is a noninvasive method that can be used for intracranial pressure monitoring. Several studies have investigated normal ONSD values in children, but no general consensus has been reached yet.

OBJECTIVES

The aim of our study was to reveal normal ONSD, eyeball transverse diameter (ETD), and ONSD/ETD values on brain computed tomography (CT) in healthy children aged 1 month to 18 years.

METHODS

Children admitted to the emergency department with minor head trauma and had normal brain CT were included in the study. The demographic characteristics of the patients (age and sex) were recorded, and the patients were divided into four age groups: 1 month to 2 years, 2 to 4 years, 4 to 10 years, and 10 to 18 years.

RESULTS

The images of 332 patients were analyzed. When the median values of all measurement parameters (right and left ONSD, ETD, and ONSD/ETD) were compared between the right and left eyes, no statistically significant differences were found. When the same parameters were compared according to age group, the ONSD and ETD values differed significantly (values of males were found to be higher), but the ONSD proximal/ETD and ONSD middle/ETD values did not differ significantly.

CONCLUSION

In our study, normal ONSD, ETD, and ONSD/ETD values were determined according to age and sex in healthy children. As the ONSD/ETD index did not statistically significantly differ according to age and sex, diagnostic studies for traumatic brain injuries can be performed using the index.

Management of Acute Injury and Illness in Pediatric Athletes by Athletic Trainers: Compliance With Emergency Medicine and Athletic Trainer Evidence-Based Guidelines

OBJECTIVE

This study aimed to determine athletic trainer compliance with emergency medicine and athletic training evidence-based guidelines for the on-the-field management of common pediatric sports-related injury and illness.

METHODS

A questionnaire was distributed electronically to selected members of the National Athletic Trainer Association. The questionnaire included 10 clinical scenarios describing common sports-related injury/illness (closed head injury, cervical spine injury, blunt chest injury, blunt abdominal injury, ankle injury, knee injury with laceration, heat-related illness). On-the-field management decisions for each scenario were compared with selected emergency medicine and athletic training guidelines.

RESULTS

Analysis was performed on 564 completed questionnaires (9% response rate). Responders were compliant with practice guidelines for both emergency medicine and athletic training except for blunt chest trauma with tachycardia, closed head injury with loss of consciousness, closed head injury with repetitive speech, closed head injury with a fall higher than 5 feet, cervical spine injury with paresthesias, and heat-related illness with persistent symptoms. Discrepancies between emergency medicine and athletic training guidelines included closed head injury with repetitive speech, closed head injury and height of fall, closed head injury and unequal pupils, and cervical spine injury with neck pain and paresthesias.

CONCLUSIONS

Based on our sample, athletic trainers were compliant with many guidelines supported by both emergency medicine and athletic training. We identified several deficiencies in the availability of evidence-based guidelines and discrepancies between these guidelines and athletic trainer responses. To provide optimal care to pediatric athletes who sustain injury or illness, emergency medicine and athletic training organizations should collaborate to improve these discrepancies.