Current controversies in the management of minor pediatric head injuries

The comparison of PECARN, CATCH, AND CHALICE criteria in children under the age of 18 years with minor head trauma in emergency department

Introduction:

Minor head traumas constitute a significant part of childhood injuries. The incidence of intracranial pathologies in children with minor head trauma varies in the range of 3%–5%, but it is higher among younger infants. The criteria of the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events are the most frequently accepted clinical decision-making criteria that were developed for selective computerized tomography requests. This study was conducted to assess the diagnostic performances of the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria in Turkish society, determine their validity, and find the most suitable algorithm for cranial imaging in children with minor head trauma.

Methods:

This study retrospectively examined the data of patients under the age of 18 years who were admitted to the Emergency Medicine Department of Uludağ University Medical Faculty due to minor head trauma; 530 patients were included as they complied with the criteria. The exclusion criteria were being any trauma patients above the age of 18 years, Glasgow Coma Scale <13, pregnant patients, hemorrhagic diathesis, using anticoagulants, patients with penetrant trauma, patients with priorly known brain tumor, and patients with neurological diseases. The patients were divided into group based on the Pediatric Emergency Care Applied Research Network, Canadian Assessment of Tomography for Childhood Head Injury, and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events Criteria.

Results:

Among all patients, 37.40% were female and 62.60% were male. Abnormal computed tomography findings such as epidural bleeding, subdural bleeding, and skull fractures were detected in 44 of the patients. The sensitivity of the Pediatric Emergency Care Applied Research Network criteria was 72.4%, the specificity was 54.5%, the sensitivity of the Canadian Assessment of Tomography for Childhood Head Injury criteria was 57.8%, the specificity was 50%, the sensitivity of the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria was 87.7%, and the specificity was 20%.

Conclusion:

Given the populations to which the rules apply, it is understood that the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events criteria is more determinative in detecting pathological computed tomography outcomes compared to Pediatric Emergency Care Applied Research Network and Canadian Assessment of Tomography for Childhood Head Injury.

Concussion: A Global Perspective

Concussion, also referred to as mild traumatic brain injury (MTBI), is a common pediatric condition. This article reviews global perspectives on the epidemiology, treatment, and prognosis of concussion in children. A Pubmed search was conducted using Clinical Queries with the key terms "concussion" and "mild traumatic brain injury," and the search was limited to "children." The search strategy included meta-analyses, randomized controlled trials, clinical trials, and reviews. The majority of publications were from Canada and the United States. Prevalence estimates vary widely according to case definition and studied population. Due to under-reporting and to the widely varying definitions of concussion, it is difficult to estimate how common the condition is. Common causes of concussions include sports injuries, motor vehicle collisions, bicycle accidents, falls, and assaults. Diagnosis is mainly clinical. Because concussion results from a disturbance in brain function rather than structural injury, neuroimaging studies, such as computed tomography and magnetic resonance imaging, are not routinely recommended. Treatment generally involves physical and cognitive rest, with a gradual return to activities, whereas prolonged rest may actually worsen outcomes. Helmets when bicycling, skiing, snowboarding, motor biking, placing age limits on certain types of contact sports, and encouragement of fair play are recommended to decrease the impact of head injuries but they do not prevent concussions. Overall outcomes are generally favorable. The symptoms and signs of concussion usually resolve within 10 days; most patients recover in 48-72 hours. Global perspectives on management and prognosis are lacking. Concussions or MTBIs are common childhood injuries and the prognosis is good but information is predominantly from Canada and the USA. Research in other countries in particular low and middle income countries is vital to have a global perspective on MTBI.

Paediatric mild head injury: is routine admission to a tertiary trauma hospital necessary?

BACKGROUND

Previous studies have shown that children with isolated linear skull fractures have excellent clinical outcomes and low risk of surgery. We wish to identify other injury patterns within the spectrum of paediatric mild head injury, which need only conservative management. Children with low risk of evolving neurosurgical lesions could be safely managed in primary hospitals.

METHODS

We retrospectively analysed all children with mild head injury (i.e. admission Glasgow coma score 13-15) and skull fracture or haematoma on a head computed tomography scan admitted to Westmead Children's Hospital, Sydney over the years 2009-2014. Data were collected regarding demographics, clinical findings, mechanism of injury, head computed tomography scan findings, neurosurgical intervention, outcome and length of admission. Wilcoxon paired test was used with P value <0.05 considered significant.

RESULTS

Four hundred and ten children were analysed. Three hundred and eighty-one (93%) children were managed conservatively, 18 (4%) underwent evacuation of extradural haematoma (TBI surgery) and 11 (3%) needed fracture repair surgery. Two children evolved a surgical lesion 24 h post-admission. Only 17 of 214 children transferred from peripheral hospitals needed neurosurgery. Overall outcomes: zero deaths, one needed brain injury rehabilitation and 63 needed child protection unit intervention. Seventy-five percentage of children with non-surgical lesions were discharged within 2 days. Eighty-three percentage of road transfers were discharged within 3 days.

CONCLUSIONS

Children with small intracranial haematomas and/or skull fractures who need no surgery only require brief inpatient symptomatic treatment and could be safely managed in primary hospitals. Improved tertiary hospital transfer guidelines with protocols to manage clinical deterioration could have cost benefit without risking patient safety.

Current management of penetrating injuries of the soft palate

Children present to emergency departments with soft palate impalement injuries on an infrequent though periodic basis. Although these usually heal without treatment, internal carotid artery thrombosis occurs on rare occasions due to vessel compression causing intimal disruption. Thirty-two cases have been reported in the English literature. Hospital observation for up to 72 hours had been recommended previously for all of these injuries because of a, “lucid interval,” usually present before onset of neurologic symptoms. Subsequent studies have shown a very low occurrence of carotid injury and support outpatient observation similar to that after minor head injury. This is further justified by the lack of evidence that any diagnostic study or therapeutic measure alters the ultimate prognosis and outcome. Laceration repair is suggested for retained foreign bodies, through and through injury, or if a large hanging flap is present. Antibiotic indications are not well defined but should be considered for lacerations over 1 to 2 cm in length.

Management of pediatric mild traumatic brain injury

mTBI is a very common and underdiagnosed problem in the pediatric population. While most children who receive appropriate management recover uneventfully (80%-90%), referral to a concussion specialist is necessary for those with a complicated course. Fortunately, further improvements in identifying those children who have sustained an mTBI, coupled with strict adherence to the Return to Learn and Return to Play protocols, will ultimately lead to better long-term outcomes.

Indications of brain computed tomography scan in children younger than 3 years of age with minor head trauma

Objective. To investigate the indications to receive brain computed tomography (CT) scan and to define the pathological findings in children younger than three years of age with minor head trauma in emergency departments. Methods. In this study, hospital case notes of 1350 children attending the emergency department of Bitlis State Hospital between January 2011 and June 2013 were retrospectively reviewed. 508 children under 3 years of age with minor head trauma were included in this study. We also asked 37 physicians about the indications for requiring CT in these children. Results. This study included 508 children, 233 (45,9%) of whom were female and 275 were male. In 476 (93,7%) children, the brain CT was completely normal. 89,2% of physicians asked in the emergency department during that time interval reported that they requested CT scan to protect themselves against malpractice litigation. Conclusion. In infants and children with minor head trauma, most CT scans were unnecessary and the fear of malpractice litigation of physicians was the most common reason for requesting a CT.

Long-term outcomes and prognostic factors in pediatric patients with severe traumatic brain injury and elevated intracranial pressure

OBJECT

The management strategies and outcomes in pediatric patients with elevated intracranial pressure (ICP) following severe traumatic brain injury (TBI) are examined in this study.

METHODS

This study was a retrospective review of a prospectively acquired pediatric trauma database. More than 750 pediatric patients with brain injury were seen over a 10-year period. Records were retrospectively reviewed to determine interventions for correcting ICP, and surviving patients were contacted prospectively to determine functional status and quality of life. Only patients with 2 years of follow-up were included in the study.

RESULTS

Ninety-six pediatric patients (age range 3-18 years) were identified with a Glasgow Coma Scale score<8 and elevated ICP>20 mm Hg on presentation. The mean injury severity score was 65 (range 30-100). All patients were treated using a standardized head injury protocol. The mean time course until peak ICP was 69 hours postinjury (range 2-196 hours). Intracranial pressure control was achieved in 82 patients (85%). Methods employed to achieve ICP control included maximal medical therapy (sedation, hyperosmolar therapy, and paralysis) in 34 patients (35%), ventriculostomy in 23 patients (24%), and surgery in 39 patients (41%). Fourteen patients (15%) had refractory ICP despite all interventions, and all of these patients died. Seventy-two patients (75%) were discharged from the hospital, whereas 24 (25%) died during hospitalization. Univariate and multivariate analysis revealed that the presence of vascular injury, refractory ICP, and cisternal effacement at presentation had the highest correlation with subsequent death (p<0.05). Mean follow-up was 53 months (range 11-126 months). Three patients died during the follow-up period (2 due to infections and 1 committed suicide). The mean 2-year Glasgow Outcome Scale score was 4 (median 4, range 1-5). The mean patient competency rating at follow-up was 4.13 out of 5 (median 4.5, range 1-4.8). Univariate analysis revealed that the extent of intracranial and systemic injuries had the highest correlation with long-term quality of life (p<0.05).

CONCLUSIONS

Controlling elevated ICP is an important factor in patient survival following severe pediatric TBI. The modality used for ICP control appears to be less important. Long-term follow-up is essential to determine neurocognitive sequelae associated with TBI.

The prognostic value of injury severity, location of event, and age at injury in pediatric traumatic head injuries

AIMS

To estimate the prognostic value of injury severity, location of event, and demographic parameters, for symptoms of pediatric traumatic head injury (THI) 4 years later.

METHODS

Data were collected prospectively from Reykjavik City Hospital on all patients age 0-19 years, diagnosed with THI (n = 408) during one year. Information was collected on patient demographics, location of traumatic event, cause of injury, injury severity, and ICD-9 diagnosis. Injury severity was estimated according to the Head Injury Severity Scale (HISS). Four years post-injury, a questionnaire on late symptoms attributed to the THI was sent.

RESULTS

Symptoms reported were more common among patients with moderate/severe THI than among others (p < 0.001). The event location had prognostic value (p < 0.05). Overall, 72% of patients with moderate/severe motor vehicle-related THI reported symptoms. There was a curvilinear age effect (p < 0.05). Symptoms were least frequent in the youngest age group, 0-4 years, and most frequent in the age group 5-14 years. Gender and urban/rural residence were not significantly related to symptoms.

CONCLUSIONS

Motor vehicle related moderate/severe THI resulted in a high rate of late symptoms. Location had a prognostic value. Patients with motor vehicle-related THI need special consideration regardless of injury severity.

Management of mild head injury in the pediatric patient

SUMMARY MHI is a common disorder in t he pediatric population. While most children recover uneventfully, a small percentage has persistence of symptoms and long-term sequelae. Determining the optimal timing for return to play can be difficult, but adherence to guidelines may reduce the risk of compounding the injury.

Urban-rural differences in pediatric traumatic head injuries: A prospective nationwide study

AIMS

To estimate differences in the incidence of recorded traumatic head injuries by gender, age, severity, and geographical area.

METHODS

The study was prospective and nationwide. Data were collected from all hospitals, emergency units and healthcare centers in Iceland regarding all Icelandic children and adolescents 0-19 years old consecutively diagnosed with traumatic head injuries (N = 550) during a one-year period.

RESULTS

Annual incidence of minimal, mild, moderate/severe, and fatal head injuries (ICD-9 850-854) was 6.41 per 1000, with 95% confidence interval (CI) 5.9, 7.0. Annual incidence of minimal head injuries (ICD-9 850) treated at emergency units was 4.65 (CI 4.2, 5.1) per 1000, mild head injuries admitted to hospital (ICD-9 850) was 1.50 (CI 1.3, 1.8) per 1000, and moderate/severe nonfatal injuries (ICD-9 851-854) was 0.21 (CI 0.1, 0.3) per 1000. Death rate was 0.05 (CI 0.0, 0.1) per 1000. Young children were at greater risk of sustaining minimal head injuries than older ones. Boys were at greater risk than girls were. In rural areas, incidence of recorded minimal head injuries was low.

CONCLUSIONS

Use of nationwide estimate of the incidence of pediatric head injury shows important differences between urban and rural areas as well as between different age groups.

Pediatric minor closed head injury

Many studies have found conflicting evidence over the use of clinical indicators to predict intracranial injury in pediatric mild head injury. Although altered mental status, loss of consciousness, and abnormal neurologic examination have all been found to be more prevalent among head-injured children, studies have observed inconsistent results over their specificity and predictive value. Children older than 2 years have been evaluated, managed, and studied differently than those less than 2 years old. Evidence strongly supports a lower threshold to perform a CT scan in younger children because they have a higher risk of significant brain injury after blunt head trauma.

Mild traumatic brain injury in children: practice guidelines for emergency department and hospitalized patients. The Trauma Program, The Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine

Mild traumatic brain injury (MTBI) is a frequent occurrence in children. Current practice in treating such injuries varies in terms of evaluative studies, length of observation, need for inpatient hospitalization, sports restrictions, and follow-up. A multidisciplinary panel of experts from a level I pediatric trauma center was convened to develop and implement a clinical pathway to improve the quality and consistency of care provided to children after MTBI. The clinical pathway, based on current literature and expert consensus, provides a management guideline for the management of MTBI in the emergency department through discharge. The algorithm provides reasonable management options based on the child's clinical presentation, history, and age. Exemplary care of children and their families after MTBI includes appropriate patient/family education. Standardized discharge instructions for MTBI were developed to provide comprehensive information in a succinct and easy-to-read format. The instructions for home management focus on expected symptoms and guidance for when to seek further medical attention. They also incorporate injury prevention, return to sports guidelines, and resources for additional information.

The importance of serial neurologic examination and repeat cranial tomography in acute evolving epidural hematoma

Computed tomography (CT) has revolutionized the diagnosis and management of head-injured patients, and its increasing availability has led to its liberal use. CT scanning provides excellent anatomic detail of the brain as fixed static images, but the dynamic nature of human physiology means that many injury patterns will evolve in time. We describe an 8-year-old child who had fallen 8 feet from a tree. He had a brief loss of consciousness but a normal neurologic evaluation on arrival to the emergency department (ED). He underwent expedited cranial CT scanning, which revealed no acute brain injury. Two and one half hours later, the patient had a mild depression in consciousness, prompting a second CT scan in the ED, which revealed an acute epidural hematoma. He had acute surgical evacuation of the hematoma and made a full neurologic recovery. This case illustrates that a single early CT examination may at times provide a false sense of security and underscores the importance of serial neurologic examinations.