Increased morbidity and mortality of traumatic brain injury in victims of nonaccidental trauma

Identifying Children at Risk for Maltreatment Using Emergency Medical Services' Data: An Exploratory Study

The objective of this study was to use natural language processing to query Emergency Medical Services (EMS) electronic health records (EHRs) to identify variables associated with child maltreatment. We hypothesized the variables identified would show an association between the Emergency Medical Services encounter and risk of a children maltreatment report. This study is a retrospective cohort study of children with an EMS encounter from 1/1/11-12/31/18. NLP of EMS EHRs was conducted to generate single words, bigrams and trigrams. Clinically plausible risk factors for child maltreatment were established, where presence of the word(s) indicated presence of the hypothesized risk factor. The EMS encounters were probabilistically linked to child maltreatment reports. Univariable associations were assessed, and a multivariable logistic regression was conducted to determine a final set of predictors. 11 variables showed an association in the multivariable modeling. Sexual, abuse, chronic condition, developmental delay, unconscious on arrival, criminal activity/police, ingestion/inhalation/exposure, and <2 years old showed positive associations with child maltreatment reports. Refusal and DOA/PEA/asystole held negative associations. This study demonstrated that through EMS EHRs, risk factors for child maltreatment can be identified. A future direction of this work include developing a tool that screens EMS EHRs for households at risk for maltreatment.

Functional status impairment at six-month follow-up is independently associated with child physical abuse mechanism

BACKGROUND

Children with abusive injuries have worse mortality, length-of-stay, complications, and healthcare costs compared to those sustaining an accidental injury. Long-term functional impairment is common in children with abusive head trauma but has not been examined in a cohort with heterogeneous body region injuries.

OBJECTIVE

To assess for an independent association between child physical abuse and functional impairment at discharge and six-month follow-up.

PARTICIPANTS AND SETTING

Seriously injured children (<15 years) treated at seven pediatric trauma centers.

METHODS

Functional status was compared between child physical abuse and accidental injury groups at discharge and six-month follow-up. Functional impairment was defined at discharge ("new domain morbidity") as a change from pre-injury ≥2 points in any of the six domains of the Functional Status Scale (FSS), and impairment at six-month follow-up as an abnormal total FSS score.

RESULTS

Children with abusive injuries accounted for 10.5% (n = 45) of the cohort. New domain morbidity was present in 17.8% (n = 8) of child physical abuse patients at discharge, with 10% (n = 3) of children having an abnormal FSS at six-months. There were no differences in new domain morbidity at hospital discharge between children injured by abuse and or accidental injury. However, children injured by physical abuse were 4.09 (2.15, 7.78) times more likely to have functional impairment at six months.

CONCLUSIONS

Child physical abuse is an independent risk factor for functional impairment at six-month follow-up. Functional status measurement for this high-risk group of children should be routinely measured and incorporated into trauma center quality assessments.

Associations of initial haemodynamic profiles and neurological outcomes in children with traumatic brain injury: a secondary analysis

INTRODUCTION

Initial low systolic blood pressure (SBP) in paediatric traumatic brain injury (TBI) is associated with mortality. There is limited literature on how other haemodynamic parameters including heart rate (HR); diastolic blood pressure (DBP); mean arterial pressure (MAP); and shock index, paediatric age-adjusted (SIPA) affect not only mortality but also long-term neurological outcomes in paediatric TBI. We aimed to analyse the associations of these haemodynamic variables (HR, SBP, MAP, DBP and SIPA) with mortality and long-term neurological outcomes in isolated moderate-to-severe paediatric TBI.

METHODS

This was a secondary analysis of our primary study that analysed the association of TBI-associated coagulopathy with mortality and neurological outcome in isolated, moderate-to-severe paediatric head injury. A trauma registry-based, retrospective study of children <18 years old who presented to the emergency department with isolated, moderate-to-severe TBI from January 2010 to December 2016 was conducted. The association between initial haemodynamic variables and less favourable outcomes using Glasgow Outcome Scale-Extended Paediatric) at 6 months post injury was analysed using logistic regression.

RESULTS

Among 152 children analysed, initial systolic and diastolic hypotension (<5th percentile) (OR) for SBP 11.40, 95% CI 3.60 to 36.05, p<0.001; OR for DBP 15.75, 95% CI 3.09 to 80.21, p<0.001) and Glasgow Coma Scale scores <8 (OR 14.50, 95% CI 3.65 to 57.55, p<0.001) were associated with 'moderate-to-severe neurological disabilities', 'vegetative state' and 'death'. After adjusting for confounders, only SBP was significant (adjusted OR 5.68, 95% CI 1.40 to 23.08, p=0.015).

CONCLUSIONS

Initial systolic hypotension was independently associated with mortality and moderate-to-severe neurological deficits at 6 months post injury. Further work is required to understand if early correction of hypotension will improve long-term outcomes.

Mild traumatic brain injury affects the features of migraine

BACKGROUND

Headache is one of the most common symptoms after concussion, and mild traumatic brain injury (mTBI) is a risk factor for chronic migraine (CM). However, there remains a paucity of data regarding the impact of mTBI on migraine-related symptoms and clinical course.

METHODS

Of 2161 migraine patients who participated in the American Registry for Migraine Research between February 2016 and March 2020, 1098 completed questions assessing history of TBI (50.8%). Forty-four patients reported a history of moderate to severe TBI, 413 patients reported a history of mTBI. Patients' demographics, headache symptoms and triggers, history of physical abuse, allodynia symptoms (ASC-12), migraine disability (MIDAS), depression (PHQ-2), and anxiety (GAD-7) were compared between migraine groups with (n = 413) and without (n = 641) a history of mTBI. Either the chi-square-test or Fisher's exact test, as appropriate, was used for the analyses of categorical variables. The Mann-Whitney test was used for the analyses of continuous variables. Logistic regression models were used to compare variables of interest while adjusting for age, gender, and CM.

RESULTS

A significantly higher proportion of patients with mTBI had CM (74.3% [307/413] vs. 65.8% [422/641], P = 0.004), had never been married or were divorced (36.6% [147/402] vs. 29.4% [187/636], P = 0.007), self-reported a history of physical abuse (24.3% [84/345] vs. 14.3% [70/491], P <  0.001), had mild to severe anxiety (50.5% [205/406] vs. 41.0% [258/630], P = 0.003), had headache-related vertigo (23.0% [95/413] vs. 15.9% [102/640], P = 0.009), and difficulty finding words (43.0% [174/405] vs. 32.9% [208/633], P <  0.001) in more than half their attacks, and headaches triggered by lack of sleep (39.4% [155/393] vs. 32.6% [198/607], P = 0.018) and reading (6.6% [26/393] vs. 3.0% [18/607], P = 0.016), compared to patients without mTBI. Patients with mTBI had significantly greater ASC-12 scores (median [interquartile range]; 5 [1-9] vs. 4 [1-7], P < 0.001), MIDAS scores (42 [18-85] vs. 34.5 [15-72], P = 0.034), and PHQ-2 scores (1 [0-2] vs. 1 [0-2], P = 0.012).

CONCLUSION

Patients with a history of mTBI are more likely to have a self-reported a history of physical abuse, vertigo, and allodynia during headache attacks, headaches triggered by lack of sleep and reading, greater headache burden and headache disability, and symptoms of anxiety and depression. This study suggests that a history of mTBI is associated with the phenotype, burden, clinical course, and associated comorbid diseases in patients with migraine, and highlights the importance of inquiring about a lifetime history of mTBI in patients being evaluated for migraine.

Acquired Brain Injury in the Context of Family Violence: A Systematic Scoping Review of Incidence, Prevalence, and Contributing Factors

Brain injury is often a precursor to, or result of, family violence. Yet there is little research identifying the connection of these two phenomena. The health cost (personal or societal) of brain injury within the family violence context is difficult to ascertain. Family violence can lead to lifelong psychological or physical scars and even death. A systematic review was conducted over three databases using Medical Subject Heading terms to investigate incidence, prevalence, and contributing factors of brain injury within a family violence context. Inclusion criteria were primary studies, any person who experienced traumatic brain injury in a familial context. Seven hundred and seven studies of varied designs were initially identified with 43 meeting inclusion criteria. Data were extracted and a deductive narrative synthesis was performed. The accuracy and generalizability of incidence and prevalence statistics was hindered by underreporting of family violence and the specificity of some of the population groups (e.g., female inmates). The factors contributing to brain injury within the family violence context had multifactorial causation and varied greatly across the populations studied. Five social determinants of health were identified: biological, behavioral, structural, social, and environmental. These factors included age and gender of parent/baby, crying as an antecedent of family violence, previous exposure to abuse as a child, hostile living environments, previous trauma, financial pressures, employment status, housing availability, and exposure to natural disasters. Future investigation into the nexus between brain injury and family violence is required; however, this is complicated due to global inconsistency of definitions, assessment tools, and research methods used.

Risk factors for avoidable transfer to a pediatric trauma center among patients 2 years and older

BACKGROUND

Effective and sustainable pediatric trauma care requires systems of regionalization and interfacility transfer. Avoidable transfer, also known as secondary overtriage, occurs when a patient is transferred to a regional trauma center after initial evaluation at another facility that is capable of providing definitive care. The purpose of this study was to identify risk factors for avoidable transfer among pediatric trauma patients in southwest Florida.

METHODS

All pediatric trauma patients 2 years and older transferred from outlying hospitals to the emergency department of a single state-designated pediatric trauma center between 2009 and 2017 were obtained from the institutional registry. Transfers were classified as avoidable if the patient suffered only minor injuries (International Classification of Diseases-9th Rev. Injury Severity Score > 0.9), did not require invasive procedures or intensive care unit monitoring, and was discharged within 48 hours. Demographics and injury characteristics were compared for avoidable and nonavoidable transfers. Logistic regression was used to estimate the independent effects of age, sex, insurance type, mechanism of injury, diagnosis, within region versus out-of-region residence, suspected nonaccidental trauma, and abnormal Glasgow Coma Scale score on the risk of avoidable transfer.

RESULTS

A total of 3,876 transfer patients met inclusion criteria, of whom 1,628 (42%) were classified as avoidable. Among avoidable transfers, 29% had minor head injuries (isolated skull fractures, concussions, and mild traumatic brain injury not otherwise specified), and 58% received neurosurgery consultation. On multivariable analysis, the strongest risk factors for avoidable transfer were diagnoses of isolated skull fracture or concussion. Suspected nonaccidental trauma was predictive of nonavoidable transfer.

CONCLUSION

Among injured children 2 years and older, those with minor head injuries were at greatest risk for avoidable transfer. Many were transferred because of a perceived need for evaluation by a pediatric neurosurgeon. Future projects seeking to reduce avoidable transfers should focus on children with isolated skull fractures and concussions, in whom there is no suspicion of nonaccidental trauma.

LEVEL OF EVIDENCE

Therapeutic/care management, level IV.

Neonatal head injuries: A prospective Paediatric Research in Emergency Departments International Collaborative cohort study

AIM

To characterise the causes, clinical characteristics and short-term outcomes of neonates who presented to paediatric emergency departments with a head injury.

METHODS

Secondary analysis of a prospective data set of paediatric head injuries at 10 emergency departments in Australia and New Zealand. Patients without neuroimaging were followed up by telephone call. We extracted epidemiological information, clinical findings and outcomes in neonates (≤28 days).

RESULTS

Of 20 137 children with head injuries, 93 (0.5%) occurred in neonates. These were mostly fall-related (75.2%), commonly from a care giver's arms, or due to being accidentally struck by a person/object (20.4%). There were three cases of non-accidental head injuries (3.2%). Most neonates were asymptomatic (67.7%) and many had no findings on examination (47.3%). Most neonates had a Glasgow Coma Scale 15 (89.2%) or 14 (7.5%). A total of 15.1% presented with vomiting and 5.4% were abnormally drowsy. None had experienced a loss of consciousness. The most common findings on examination were scalp haematoma (28.0%) and possible palpable skull fracture (6.5%); 8.6% underwent computed tomography brain scan and 4.3% received an ultrasound. Five of eight computed tomography scan (5.4% of neonates overall) showed traumatic brain injury and two of four (2.2% overall) had traumatic brain injury on ultrasound. Thirty-seven percent were admitted, one patient was intubated and none had neurosurgery or died.

CONCLUSIONS

Neonatal head injuries are rare with a mostly benign short-term outcome and are appropriate for observation. However, non-accidental injuries need to be considered.

Advances and Future Directions of Diagnosis and Management of Pediatric Abusive Head Trauma: A Review of the Literature

Abusive head trauma (AHT) is broadly defined as injury of the skull and intracranial contents as a result of perpetrator-inflicted force and represents a persistent and significant disease burden in children under the age of 4 years. When compared to age-matched controls with typically single occurrence accidental traumatic brain injury (TBI), mortality after AHT is disproportionately high and likely attributable to key differences between injury phenotypes. This article aims to review the epidemiology of AHT, summarize the current state of AHT diagnosis, treatment, and prevention as well as areas for future directions of study. Despite neuroimaging advances and an evolved understanding of AHT, early identification remains a challenge for contemporary clinicians. As such, the reported incidence of 10–30 per 100,000 infants per year may be a considerable underestimate that has not significantly decreased over the past several decades despite social campaigns for public education such as “Never Shake a Baby.” This may reflect caregivers in crisis for whom education is not sufficient without support and intervention, or dangerous environments in which other family members are at risk in addition to the child. Acute management specific to AHT has not advanced beyond usual supportive care for childhood TBI, and prevention and early recognition remain crucial. Moreover, AHT is frequently excluded from studies of childhood TBI, which limits the precise translation of important brain injury research to this population. Repeated injury, antecedent abuse or neglect, delayed medical attention, and high rates of apnea and seizures on presentation are important variables to be considered. More research, including AHT inclusion in childhood TBI studies with comparisons to age-matched controls, and translational models with clinical fidelity are needed to better elucidate the pathophysiology of AHT and inform both clinical care and the development of targeted therapies. Clinical prediction rules, biomarkers, and imaging modalities hold promise, though these have largely been developed and validated in patients after clinically evident AHT has already occurred. Nevertheless, recognition of warning signs and intervention before irreversible harm occurs remains the current best strategy for medical professionals to protect vulnerable infants and toddlers.

Transcranial Doppler ultrasound findings in children with moderate-to-severe traumatic brain injury following abusive head trauma

PURPOSE

Abusive head trauma (AHT) is the leading cause of fatal head injuries for children under 2 years. The objective was to evaluate, using transcranial Doppler ultrasound (TCD), whether children with AHT have a similar neurovascular response to injury compared with children without AHT.

METHODS

Retrospective sub-analysis of previously prospectively acquired data in a pediatric intensive care unit in a level 1 trauma hospital. TCD was performed daily until hospital day 8, discharge, or death. Neurologic outcome was assessed using the Glasgow Outcome Scale Extended (GOS-E Peds) at 1 month from initial injury.

RESULTS

Sixty-nine children aged 1 day to 17 years with moderate-to-severe traumatic brain injury were enrolled. Fifteen children suffered AHT and 54 had no suspicion for AHT. Fifteen children with AHT underwent 80 serial TCD examinations; 54 children without AHT underwent 308 exams. After standardization for age and gender normative values, there was no statistically significant difference in mean cerebral blood flow velocity of the middle cerebral artery (V_MCA) between children with and without AHT. There was no difference in the incidence of extreme cerebral blood flow velocity (CBFV, greater or less than 2 standard deviations from normative value) between groups. Within the AHT group, there were no statistically significant differences in V_MCA between children with a favorable (GOS-E Peds 1-4) versus unfavorable neurologic outcome (GOS-E Peds 5-8).

CONCLUSION

Children with AHT have no significant differences in V_MCA or percentage of extreme CBFV in the middle cerebral artery compared to with those without AHT.

Characterizing injury severity in nonaccidental trauma: Does Injury Severity Score miss the mark?

BACKGROUND

Children suffering nonaccidental trauma (NAT) are at high risk of death. It is unclear whether markers of injury severity for trauma center/system benchmarking such as Injury Severity Score (ISS) adequately characterize this. Our objective was to evaluate mortality prediction of ISS in children with NAT compared with accidental trauma (AT).

METHODS

Pediatric patients younger than 16 years from the Pennsylvania state trauma registry 2000 to 2013 were included. Logistic regression predicted mortality from ISS for NAT and AT patients. Multilevel logistic regression determined the association between mortality and ISS while adjusting for age, vital signs, and injury pattern in NAT and AT patients. Similar models were performed for head Abbreviated Injury Scale (AIS). Sensitivity analysis examined impaired functional independence at discharge as an alternate outcome.

RESULTS

Fifty thousand five hundred seventy-nine patients were included with 1,866 (3.7%) NAT patients. Nonaccidental trauma patients had a similar rate of mortality at an ISS of 13 as an ISS of 25 for AT patients. Nonaccidental trauma patients also have higher mortality for a given head AIS level (range, 1.2-fold to 5.9-fold higher). Injury Severity Score was a significantly greater predictor of mortality in AT patients (adjusted odds rations [AOR], 1.14; 95% confidence interval [CI], 1.13-1.15; p < 0.01) than NAT patients (AOR, 1.09; 95% CI, 1.07-1.12; p < 0.01) per 1-point ISS increase, while head injury was a significantly greater predictor of mortality in NAT patients (AOR, 3.48; 95% CI, 1.54-8.32; p < 0.01) than AT patients (AOR, 1.21; 95% CI, 0.95-1.45; p = 0.12). Nonaccidental trauma patients had a higher rate of impaired functional independence at any given ISS or head AIS level than AT patients.

CONCLUSION

Nonaccidental trauma patients have higher mortality and impaired function at a given ISS/head AIS than AT patients. Conventional ISS thresholds may underestimate risk and head injury is a more important predictor of mortality in the NAT population. These findings should be considered in system performance improvement and benchmarking efforts that rely on ISS for injury characterization.

LEVEL OF EVIDENCE

Epidemiologic study, level III.

Recognition and nursing management of abusive head trauma in children

Abusive head trauma (AHT) describes an injury to the head caused by a deliberate impact or shaking by a parent or carer. It can cause significant morbidity and mortality in infants, and is most commonly seen in those aged under 2 years. The initial presentation of AHT can include vague symptoms and the correct diagnosis may be missed by health professionals. Subdural haematoma, brain oedema and retinal haemorrhages are well-known features associated with AHT. However, other conditions such as birth trauma, accidental falls in infants and bleeding disorders can all mimic AHT, thus making its recognition difficult. Suspicion of AHT should lead to initiation of safeguarding procedures alongside organising neurological imaging to identify skull fracture and/or intracranial lesions. This article highlights different aspects of the clinical presentation of AHT and its management. Safeguarding and recognising child abuse is vital and requires every member of the multidisciplinary team to remain vigilant. An illustrative case study is included to highlight some of the challenges that health professionals working in different clinical set-ups are likely to come across while managing an infant with AHT.

Long-term outcomes in children with moderate to severe traumatic brain injury: a single-centre retrospective study

Traumatic brain injury (TBI) is a significant cause of mortality and disability in the pediatric population. Non-accidental trauma (NAT) has specifically been reported to result in more severe injury as compared to accidental mechanisms of injury. We aim to investigate the long-term neurological outcomes in children with moderate to severe traumatic brain injury. Our secondary aim is to evaluate the difference in outcomes between children presenting with NAT and non-NAT, in our study population. We performed a retrospective study in a tertiary pediatric hospital between January 2008 to October 2017 of all patients with TBI <16 years old with a Glasgow Coma Scale (GCS) ≤13. The dual primary outcomes were mortality and Paediatric Functional Independence Measure (WeeFIM) scores, recorded at the start of rehabilitation, discharge, 3 months and 6 months post-injury. The secondary outcome was the development of post-traumatic epilepsy. There were 68 patients with a median age of 4.5 [interquartile range (IQR) 1.0-9.0] years old. The most common presenting symptom was vomiting for children <2 years (11/20, 55.0%) while confusion and disorientation were common for those ≥2 years (27/48, 56.3%). WeeFIM scores at the start of rehabilitation [median 122.0, IQR 33.8-126.0] improved at 6 months post-injury (median 126.0, IQR 98.5-126.0). There was a greater incidence of post-traumatic epilepsy in age <2 years (6/20, 30.0%) compared to age ≥2 years (1/48, 2.1%) (p = .002). When comparing NAT versus non-NAT survivors, cognition WeeFIM scores were significantly different at the start of rehabilitation (p = .017) and at 3 months post-injury (p = .025). NAT predicts for poorer long-term outcomes, specifically in cognition, as measured by WeeFIM scores. Younger children <2 years had a higher incidence of post-traumatic epilepsy compared to older children.

A review of children with severe trauma admitted to pediatric intensive care in Queensland, Australia

Background

The aim of this study is to review patient characteristics, injury patterns, and outcomes of trauma cases admitted to pediatric intensive care in Children’s Health Queensland, Brisbane, Queensland, Australia.

Methods

Routinely recorded data collected prospectively from the Children’s Health Queensland Trauma Service registry from November 2008 to October 2015 were reviewed. Demographic and clinical characteristics of trauma cases in children under 16 years of age are described, and their association with age and mortality analyzed.

Results

There were 542 cases of pediatric trauma identified and 66.4% were male. The overall mortality since January 2012 was 11.1%. The median injury severity score (ISS) was 11 (IQR = 9–22), 48.2% (n = 261) had an ISS > 12 and 41.7% (n = 226) patients had an ISS > 15. The most common injury patterns were isolated head injury (29.7%; n = 161) and multiple trauma (31.2%; n = 169). In 28.4% of cases (n = 154) surgery was required. The home was reported to be the most common place of injury (37.6%; n = 204). Children aged 0–4 years were least likely to survive their injury (15.3% mortality) compared with the 5–9 (5.6% mortality) and 10–15 (9.0% mortality) age groups. Higher mortality was associated with more severe injuries, abdomen/spine/thorax injuries, inflicted injuries, drowning and hanging.

Conclusion

This description of major pediatric trauma cases admitted to pediatric intensive care in Children’s Health Queensland, Australia, will inform future pediatric major trauma service requirements as it identifies injury patterns and profiles, injury severity, management and mortality across different age groups.

SDH and EDH in children up to 18 years of age-a clinical collective in the view of forensic considerations

Providing concise proof of child abuse relies heavily on clinical findings, such as certain patterns of injury or otherwise not plausibly explainable trauma. Subdural hemorrhaging has been identified as a common occurrence in abused children whereas epidural hemorrhaging is related to accidents. In order to explore this correlation, we retrospectively analyzed clinical data of children under 19 years of age diagnosed with either injury. Reviewing 56 cases of epidural and 38 cases of subdural bleeding, it was shown that subdural bleeding is more common in young children and extremely often a result of suspected abuse in children under 2 years of age. Epidural hemorrhaging however never was found in the context of suspected abuse, was unrelated to other injuries typical for abuse, and did not see a statistically significant increase in any age group. In conformity with currently theorized mechanisms of injury for both types of bleeding, we found that subdural hemorrhaging in young children is closely associated with abuse whereas epidural bleeding is not.

Prognostic factors of acute neurological outcomes in infants with traumatic brain injury

PURPOSE

The purpose of this study is to clarify risk factors for poor neurological outcomes and distinctive characteristics in infants with traumatic brain injury.

METHODS

The study retrospectively reviewed data of 166 infants with traumatic intracranial hemorrhage from three tertiary institutions in Japan between 2002 and 2013. Univariate and multivariate analyses were used to identify clinical symptoms, vital signs, physical findings, and computed tomography findings associated with poor neurological outcomes at discharge from the intensive care unit.

RESULTS

In univariate analysis, bradypnea, tachycardia, hypotension, dyscoria, retinal hemorrhage, subdural hematoma, cerebral edema, and a Glasgow Coma Scale (GCS) score of ≤ 12 were significantly associated with poor neurological outcomes (P < 0.05). In multivariate analysis, a GCS score of ≤ 12 (OR = 130.7; 95% CI, 7.3-2323.2; P < 0.001), cerebral edema (OR = 109.1; 95% CI, 7.2-1664.1; P < 0.001), retinal hemorrhage (OR = 7.2; 95% CI, 1.2-42.1; P = 0.027), and Pediatric Index of Mortality 2 score (OR = 1.6; 95% CI, 1.1-2.3; P = 0.018) were independently associated with poor neurological outcomes. Incidence of bradypnea in infants with a GCS score of ≤ 12 (25/42) was significantly higher than that in infants with GCS score of > 12 (27/90) (P = 0.001).

CONCLUSIONS

Infants with a GCS score of ≤ 12 are likely to have respiratory disorders associated with traumatic brain injury. Physiological disorders may easily lead to secondary brain injury, resulting in poor neurological outcomes. Secondary brain injury should be prevented through early interventions based on vital signs and the GCS score.

Pediatric Major Head Injury: Not a Minor Problem

Traumatic brain injury is a highly prevalent and devastating cause of morbidity and mortality in children. A rapid, stepwise approach to the traumatized child should proceed, addressing life-threatening problems first. Management focuses on preventing secondary injury from physiologic extremes such as hypoxemia, hypotension, prolonged hyperventilation, temperature extremes, and rapid changes in cerebral blood flow. Initial Glasgow Coma Score, hyperglycemia, and imaging are often prognostic of outcome. Surgically amenable lesions should be evacuated promptly. Reduction of intracranial pressure through hyperosmolar therapy, decompressive craniotomy, and seizure prophylaxis may be considered after stabilization. Nonaccidental trauma should be considered when evaluating pediatric trauma patients.

Prevention and recognition of abusive head trauma: training for healthcare professionals in Vietnam

AIM

This study presents results from an intervention designed to improve identification and response to abusive head trauma in a tertiary paediatric hospital in Vietnam.

METHODS

One hundred and sixteen healthcare professionals (paediatric medical and nursing staff) completed a clinical training programme and participated in its evaluation. A pre-post-test and follow-up design was used to evaluate the outcomes. Questionnaires were used to collect data prior to training, at six weeks and at six months. Generalised linear modelling was used to examine changes in diagnostic skills and knowledge of the consequences of shaken baby syndrome (SBS) (a form of abusive head trauma), its prevention and treatment.

RESULTS

At baseline, awareness and knowledge reflected no former abusive head trauma training. Following the intervention, participants had an increased awareness of shaken baby syndrome and the potential consequences of shaking infants and had acquired techniques to inform parents how to manage the crying infant.

CONCLUSION

The intervention was effective in raising awareness of shaken baby syndrome and its consequences amongst the participating healthcare professionals in Vietnam. Training can improve detection and prevention of abusive head trauma, and the intervention has the potential to be adapted for similar settings internationally.

Abusive Head Trauma and Mortality-An Analysis From an International Comparative Effectiveness Study of Children With Severe Traumatic Brain Injury

OBJECTIVES

Small series have suggested that outcomes after abusive head trauma are less favorable than after other injury mechanisms. We sought to determine the impact of abusive head trauma on mortality and identify factors that differentiate children with abusive head trauma from those with traumatic brain injury from other mechanisms.

DESIGN

First 200 subjects from the Approaches and Decisions in Acute Pediatric Traumatic Brain Injury Trial-a comparative effectiveness study using an observational, cohort study design.

SETTING

PICUs in tertiary children's hospitals in United States and abroad.

PATIENTS

Consecutive children (age < 18 yr) with severe traumatic brain injury (Glasgow Coma Scale ≤ 8; intracranial pressure monitoring).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Demographics, injury-related scores, prehospital, and resuscitation events were analyzed. Children were dichotomized based on likelihood of abusive head trauma. A total of 190 children were included (n = 35 with abusive head trauma). Abusive head trauma subjects were younger (1.87 ± 0.32 vs 9.23 ± 0.39 yr; p < 0.001) and a greater proportion were female (54.3% vs 34.8%; p = 0.032). Abusive head trauma were more likely to 1) be transported from home (60.0% vs 33.5%; p < 0.001), 2) have apnea (34.3% vs 12.3%; p = 0.002), and 3) have seizures (28.6% vs 7.7%; p < 0.001) during prehospital care. Abusive head trauma had a higher prevalence of seizures during resuscitation (31.4 vs 9.7%; p = 0.002). After adjusting for covariates, there was no difference in mortality (abusive head trauma, 25.7% vs nonabusive head trauma, 18.7%; hazard ratio, 1.758; p = 0.60). A similar proportion died due to refractory intracranial hypertension in each group (abusive head trauma, 66.7% vs nonabusive head trauma, 69.0%).

CONCLUSIONS

In this large, multicenter series, children with abusive head trauma had differences in prehospital and in-hospital secondary injuries which could have therapeutic implications. Unlike other traumatic brain injury populations in children, female predominance was seen in abusive head trauma in our cohort. Similar mortality rates and refractory intracranial pressure deaths suggest that children with severe abusive head trauma may benefit from therapies including invasive monitoring and adherence to evidence-based guidelines.

Child maltreatment in U.S. emergency departments: Imaging and admissions

OBJECTIVE

We report imaging and admission ratios for children with definitive and suggestive maltreatment in a national sample of emergency departments (EDs).

METHODS

Using the 2012 Nationwide Emergency Department Sample (NEDS), we generated national estimates of ED visits for children <10 years with both definitive and suggestive maltreatment. Outcomes were admission/transfer ratios for children <10years and screening ratios by skeletal surveys and head computed tomography (CT) for children <2 years with suspected physical abuse. We compared hospitals with low, medium, and high pediatric ED volumes using multivariable logistic regression.

RESULTS

The 2012 national estimate of U.S. ED visits (children <10years) with definitive maltreatment is 14,457 (95% CI: 11,987-16,928). Suggestive child maltreatment was seen in an additional 103,392 (95% CI: 90,803-115,981) pediatric ED visits. After controlling for patient case mix, high volume hospitals had a significantly higher adjusted odds ratio (AOR) of admission/transfer among definitive cases (AOR=1.74, 95% CI: 1.08-2.81), and medium volume hospitals had a higher odds of admission/transfer among suggestive cases (AOR=1.24, 95% CI: 1.02-1.50) when compared with low volume hospitals. In hospitals with reliable reporting of imaging procedures, high volume hospitals reported skeletal surveys (age <2 years) significantly more often than low volume hospitals, AOR=3.32 (95% CI: 1.25-8.84); the AORs for head CT did not differ by hospital volume.

CONCLUSIONS

Low volume hospitals were less likely to screen by skeletal survey, but head CT ratios were not affected by ED volume. Low volume hospitals were also less likely to admit or transfer.

Continuous electroencephalography in pediatric traumatic brain injury: Seizure characteristics and outcomes

BACKGROUND

Traumatic brain injury (TBI) is a major cause of pediatric morbidity and mortality. Secondary injury that occurs as a result of a direct impact plays a crucial role in patient prognosis. The guidelines for the management of severe TBI target treatment of secondary injury. Posttraumatic seizure, one of the secondary injury sequelae, contributes to further damage to the injured brain. Continuous electroencephalography (cEEG) helps detect both clinical and subclinical seizure, which aids early detection and prompt treatment.

OBJECTIVE

The aim of this study was to examine the relationship between cEEG findings in pediatric traumatic brain injury and neurocognitive/functional outcomes.

METHODS

This study focuses on a subgroup of a larger prospective parent study that examined children admitted to a level-1 trauma hospital. The subgroup included sixteen children admitted to the pediatric intensive care unit (PICU) who received cEEG monitoring. Characteristics included demographics, cEEG reports, and antiseizure medication. We also examined outcome scores at the time of discharge and 4-6weeks postdischarge using the Glasgow Outcome Scale - Extended Pediatrics and center-based speech pathology neurocognitive/functional evaluation scores.

RESULTS

Sixteen patients were included in this study. Patients with severe TBI made up the majority of those that received cEEG monitoring. Nonaccidental trauma was the most frequent TBI etiology (75%), and subdural hematoma was the most common lesion diagnosed by CT scan (75%). Fifteen patients received antiseizure medication, and levetiracetam was the medication of choice. Four patients (25%) developed seizures during PICU admission, and 3 patients had subclinical seizures that were detected by cEEG. One of these patients also had both a clinical and subclinical seizure. Nonaccidental trauma was an etiology of TBI in all patients with seizures. Characteristics of a nonreactive pattern, severe/burst suppression, and lack of sleep architecture, on cEEG, were associated with poor neurocognitive/functional outcome.

CONCLUSION

Continuous electroencephalography demonstrated a pattern that associated seizures and poor outcomes in patients with moderate to severe traumatic brain injury, particularly in a subgroup of patients with nonaccidental trauma. Best practice should include institution-based TBI cEEG protocols, which may detect seizure activity early and promote outcomes. Future studies should include examination of individual cEEG characteristics to help improve outcomes in pediatric TBI.

A profile of suspected child abuse as a subgroup of major trauma patients

Introduction

Non-accidental injury (NAI) in children is an important cause of major injury. The Trauma Audit Research Network (TARN) recently analysed data on the demographics of paediatric trauma and highlighted NAI as a major cause of death and severe injury in children. This paper examined TARN data to characterise accidental versus abusive cases of major injury.

Methods

The national trauma registry of England and Wales (TARN) database was interrogated for the classification of mechanism of injury in children by intent, from January 2004 to December 2013. Contributing hospitals’ submissions were classified into accidental injury (AI), suspected child abuse (SCA) or alleged assault (AA) to enable demographic and injury comparisons.

Results

In the study population of 14 845 children, 13 708 (92.3%, CI 91.9% to 92.8%) were classified as accidental injury, 368 as alleged assault (2.5%, CI 2.2% to 2.7%) and 769 as SCA (5.2%, CI 4.8% to 5.5%). Nearly all cases of severely injured children suffering trauma because of SCA occurred in the age group of 0–5 years (751 of 769, 97.7%), with 76.3% occurring in infants under the age of 1 year. Compared with accidental injury, suspected victims of abuse have higher overall injury severity scores, have a higher proportion of head injury and a threefold higher mortality rate of 7.6% (CI 5.51% to 9.68%) vs 2.6% (CI 2.3% to 2.9%).

Conclusions

This study highlights that major injury occurring as a result of SCA has a typical demographic pattern. These children tend to be under 12 months of age, with more severe injury. Understanding these demographics could help receiving hospitals identify children with major injuries resulting from abuse and ensure swift transfer to specialist care.

A Qualitative Study Exploring Factors Associated with Provider Adherence to Severe Pediatric Traumatic Brain Injury Guidelines

Despite demonstrated improvement in patient outcomes with use of the Pediatric Traumatic Brain Injury (TBI) Guidelines (Guidelines), there are differential rates of adherence. Provider perspectives on barriers and facilitators to adherence have not been elucidated. This study aimed to identify and explore in depth the provider perspective on factors associated with adherence to the Guidelines using 19 focus groups with nurses and physicians who provided acute management for pediatric patients with TBI at five university-affiliated Level 1 trauma centers. Data were examined using deductive and inductive content analysis. Results indicated that three inter-related domains were associated with clinical adherence: 1) perceived guideline credibility and applicability to individual patients, 2) implementation, dissemination, and enforcement strategies, and 3) provider culture, communication styles, and attitudes towards protocols. Specifically, Guideline usefulness was determined by the perceived relevance to the individual patient given age, injury etiology, and severity and the strength of the evidence. Institutional methods to formally endorse, codify, and implement the Guidelines into the local culture were important. Providers wanted local protocols developed using interdisciplinary consensus. Finally, a culture of collaboration, including consistent, respectful communication and interdisciplinary cooperation, facilitated adherence. Provider training and experience, as well as attitudes towards other standardized care protocols, mirror the use and attitudes towards the Guidelines. Adherence was determined by the interaction of each of these guideline, institutional, and provider factors acting in concert. Incorporating provider perspectives on barriers and facilitators to adherence into hospital and team protocols is an important step toward improving adherence and ultimately patient outcomes.

The Effect of Hemoglobin Levels on Mortality in Pediatric Patients with Severe Traumatic Brain Injury

Objective. There is increasing evidence of adverse outcomes associated with blood transfusions for adult traumatic brain injury patients. However, current evidence suggests that pediatric traumatic brain injury patients may respond to blood transfusions differently on a vascular level. This study examined the influence of blood transfusions and anemia on the outcome of pediatric traumatic brain injury patients. Design. A retrospective cohort analysis of severe pediatric traumatic brain injury (TBI) patients was undertaken to investigate the association between blood transfusions and anemia on patient outcomes. Measurements and Main Results. One hundred and twenty patients with severe traumatic brain injury were identified and included in the analysis. The median Glasgow Coma Scale (GCS) was 6 and the mean hemoglobin (Hgb) on admission was 115.8 g/L. Forty-three percent of patients (43%) received at least one blood transfusion and the mean hemoglobin before transfusion was 80.1 g/L. Multivariable regression analysis revealed that anemia and the administration of packed red blood cells were not associated with adverse outcomes. Factors that were significantly associated with mortality were presence of abusive head trauma, increasing PRISM score, and low GCS after admission. Conclusion. In this single centre retrospective cohort study, there was no association found between anemia, blood transfusions, and hospital mortality in a pediatric traumatic brain injury patient population.

Development of a systematic protocol to identify victims of non-accidental trauma

PURPOSE

Each year, nearly 1 million children in the USA are victims of non-accidental trauma (NAT). Missed diagnosis or poor case management often leads to repeat/escalation injury. Victims of recurrent NAT are at higher risk for severe morbidity and mortality resulting from abuse. The objective of this review is to describe the evolution and implementation of this tool and evaluate our institutional response to NAT prior to implementation.

METHODS

A systematic guideline for the evaluation of pediatric patients in which NAT is suspected or confirmed was developed and implemented at a level II pediatric trauma hospital. To understand the state of our institution prior to implementation of the guideline, a review of 117 confirmed NAT cases at our hospital over the prior 4 years was conducted.

RESULTS

In the absence of a systematic management guideline, important and relevant social and family history red flags were often missing in the initial evaluation. Patients with perineal bruising experienced significantly higher mortality than patients without perineal bruising (27.3 vs. 5.7%; p = 0.03) and were significantly more likely to require surgery (45.5 vs. 14.2%; p = 0.02).

CONCLUSION

Development and implementation of a standardized tool for the differentiation and diagnosis of NAT and creation of a structured electronic medical record note should improve the description and documentation of child abuse cases in a community hospital setting. A retrospective analysis demonstrated that in the absence of such a tool, management of NAT may be inconsistent or incomplete. Perineal injury is an especially ominous red flag finding.

Hospital-acquired pneumonia is an independent predictor of poor global outcome in severe traumatic brain injury up to 5 years after discharge

BACKGROUND

Long-term outcomes following traumatic brain injury (TBI) correlate with initial head injury severity and other acute factors. Hospital-acquired pneumonia (HAP) is a common complication in TBI. Limited information exists regarding the significance of infectious complications on long-term outcomes after TBI. We sought to characterize risks associated with HAP on outcomes 5 years after TBI.

METHODS

This study involved data from the merger of an institutional trauma registry and the Traumatic Brain Injury Model Systems outcome data. Individuals with severe head injuries (Abbreviated Injury Scale [AIS] score ≥ 4) who survived to rehabilitation were analyzed. Primary outcome was Glasgow Outcome Scale-Extended (GOSE) at 1, 2, and 5 years. GOSE was dichotomized into low (GOSE score < 6) and high (GOSE score ≥ 6). Logistic regression was used to determine adjusted odds of low GOSE score associated with HAP after controlling for age, sex, head and overall injury severity, cranial surgery, Glasgow Coma Scale (GCS) score, ventilation days, and other important confounders. A general estimating equation model was used to analyze all outcome observations simultaneously while controlling for within-patient correlation.

RESULTS

A total of 141 individuals met inclusion criteria, with a 30% incidence of HAP. Individuals with and without HAP had similar demographic profiles, presenting vitals, head injury severity, and prevalence of cranial surgery. Individuals with HAP had lower presenting GCS score. Logistic regression demonstrated that HAP was independently associated with low GOSE scores at follow-up (1 year: odds ratio [OR], 6.39; 95% confidence interval [CI], 1.76-23.14; p = 0.005) (2 years: OR, 7.30; 95% CI, 1.87-27.89; p = 0.004) (5-years: OR, 6.89; 95% CI, 1.42-33.39; p = 0.017). Stratifying by GCS score of 8 or lower and early intubation, HAP remained a significant independent predictor of low GOSE score in all strata. In the general estimating equation model, HAP continued to be an independent predictor of low GOSE score (OR, 4.59; 95% CI, 1.82-11.60; p = 0.001).

CONCLUSION

HAP is independently associated with poor outcomes in severe TBI extending 5 years after injury. This suggests that precautions should be taken to reduce the risk of HAP in individuals with severe TBI.

LEVEL OF EVIDENCE

Prognostic study, level III.

Paediatric trauma on the Last Frontier: an 11-year review of injury mechanisms, high-risk injury patterns and outcomes in Alaskan children

Background

Paediatric trauma system development in Alaska is complicated by a vast geographic coverage area, wide regional variations in environment and culture, and a lack of available published data.

Objective

To provide a detailed description of paediatric trauma mechanisms, high-risk injury patterns and outcomes in Alaska.

Design

This retrospective study included all children aged 17 years or younger in the State of Alaska Trauma Registry database admitted with traumatic injury between 2001 and 2011. Each injury record was reviewed individually and assigned a mechanism based on Centers for Disease Control E-codes. Geographic definitions were based on existing Emergency Medical Services regions. Mechanisms were compared by geographic region, patient demographics, injury characteristics and outcome. Subgroup analysis of fatal injuries was performed to identify causes of death.

Results

Of 5,547 patients meeting inclusion criteria, the most common mechanisms of injury were falls (39%), motor vehicle collisions (10%) and all-terrain vehicle (ATV) accidents (9%). The overall case fatality rate was 2%. Mechanisms with the greatest risk of death were gunshot wounds (21%), pedestrians struck by motorized vehicles (9%) and motor vehicle collisions (5%). These 3 mechanisms accounted for 15% of injuries but 60% of deaths in the overall cohort. Injury patterns involving combined central nervous system (CNS) and torso injuries were unusual but especially lethal, occurring in 3% of patients but carrying a case fatality rate of 18%. Although the distribution of mechanisms was generally similar for each geographic region, ATV and snowmobile injuries were significantly more common in remote areas (23% remote vs. 7% non-remote, p < 0.0001).

Conclusions

Mechanisms of paediatric trauma in Alaska have widely varying impacts on outcome and show some variation by region. Highest-risk mechanisms include gunshot wounds and motorized vehicle-related accidents. Prevention efforts should give special attention to CNS injury prevention, ATV and snowmobile safety in remote areas, and optimization of management of multisystem trauma. Further studies should investigate predictors of outcome in greater detail.

Outcomes of pediatric severe traumatic brain injury patients treated in adult trauma centers with and without added qualifications in pediatrics - United States, 2009

Background

Pediatric traumatic brain injury (TBI) is an important public health problem and little is known about site of care and outcomes of children with severe TBI. Across the country, most injured children are treated in adult trauma centers (ATCs). Recent literature suggests that ATCs with added qualifications in pediatrics (ATC-AQs) can have improved outcomes for pediatric trauma patients overall. This study characterizes the population of pediatric severe TBI patients treated at ATCs and investigates the effect of treatment at ATC-AQs versus ATCs on mortality.

Methods

Using the 2009 National Trauma Data Bank, pediatric (age 0–17 years old) severe TBI (head Abbreviated Injury Scale score ≥3) patient visits at level I and II ATCs and ATC-AQs were analyzed for patient and hospital characteristics. The primary outcome was in-patient mortality. Multivariate analysis was performed on propensity score weighted populations to investigate effect of treatment at ATC-AQs versus ATCs on survival.

Results

A total of 7,057 pediatric severe TBI patient visits in 398 level I and II trauma centers were observed, with 3,496 (49.5%) at ATC-AQs and 3,561 (50.5%) at ATCs. The mortality rate was 8.6% at ATC-AQs versus 10.3% at ATCs (p =0.0144). After adjusting for differences in case mix, patient, and hospital characteristics, mortality was not significantly different for patients treated in ATC-AQs versus ATCs (aOR = 0.896, 95% CI = 0.629–1.277). Mortality was significantly associated with age, length of hospital stay, firearm injury, GCS score, and head AIS (p <0.0001). Higher mortality odds were also associated with being uninsured (aOR = 2.102, 95% CI = 1.159–3.813), and the presence of additional non-TBI severe injuries (aOR = 1.936 95% CI = 1.175-3.188).

Conclusions

After defining comparable populations, this study demonstrated no significant difference in mortality for pediatric severe TBI patients treated at ATC-AQs versus ATCs. Being younger, uninsured, and having severe injuries was associated with increased mortality. This study is limited by the exclusion of transferred patients and potentially underestimates differences in outcomes. Further research is needed to clarify the role of ATC additional pediatric qualifications in the treatment of severe TBI.

Electronic supplementary material

The online version of this article (doi:10.1186/2197-1714-1-15) contains supplementary material, which is available to authorized users.