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Lorton F, Lagares A, de la Cruz J, Méjan O, Pavlov V, Sapin V, Poca MA, Lehner M, Biberthaler P, Chauviré-Drouard A, Gras-Le-Guen C, Scherdel P. 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. BMJ Open 2024; 14:e083531. [PMID: 38754888 PMCID: PMC11097883 DOI: 10.1136/bmjopen-2023-083531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 04/23/2024] [Indexed: 05/18/2024] Open
Abstract
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.
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Affiliation(s)
- Fleur Lorton
- Nantes Université, CHU Nantes, INSERM, Department of Paediatric Emergency, CIC 1413, F-44000 Nantes, France
| | - Alfonso Lagares
- Department of Neurosurgery,Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria imas12, Departamento de Cirugía, Facultad de Medicina, Universidad Complutense de Madrid, Madrid, Spain
| | - Javier de la Cruz
- Hospital Universitario 12 de Octubre, Instituto de Investigación Sanitaria imas12, RICORS-SAMID, Madrid, Spain
| | - Odile Méjan
- Research and Development Immunoassay, bioMerieux SA, Marcy l'Etoile, France
| | | | - Vincent Sapin
- Biochemistry and Molecular Genetic Department, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | - Maria Antonia Poca
- Department of Neurosurgery and Neurotraumatology and Neurosurgery Research Unit,Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, Barcelona, Spain
| | - Markus Lehner
- Department of Pediatric Surgery, Children's Hospital Lucerne, University of Lucerne, CH-6000 Lucerne, Switzerland
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar, Ismaningerstr 22, Technical University Munich, Munich, Germany
| | - Anne Chauviré-Drouard
- Nantes Université, CHU Nantes, INSERM, Department of Paediatric Emergency, CIC 1413, F-44000 Nantes, France
| | - Christèle Gras-Le-Guen
- Nantes Université, CHU Nantes, INSERM, Department of Paediatric Emergency, CIC 1413, F-44000 Nantes, France
| | - Pauline Scherdel
- Nantes Université, CHU Nantes, INSERM, Department of Paediatric Emergency, CIC 1413, F-44000 Nantes, France
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Ciorba MC, Maegele M. Polytrauma in Children. DEUTSCHES ARZTEBLATT INTERNATIONAL 2024; 121:291-297. [PMID: 38471125 DOI: 10.3238/arztebl.m2024.0036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 02/12/2024] [Accepted: 02/12/2024] [Indexed: 03/14/2024]
Abstract
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.
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Affiliation(s)
- Monica Christine Ciorba
- Department of Orthopedics, Trauma Surgery and Sports Traumatology, Cologne-Merheim Medical Center, University of Witten/Herdecke, Cologne, Germany; Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Cologne-Merheim Campus, Cologne, Germany
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Proctor A, Lyttle M, Billing J, Shaw P, Simpson J, Voss S, Benger JR. 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. BMJ Open 2024; 14:e078363. [PMID: 38355171 PMCID: PMC10868315 DOI: 10.1136/bmjopen-2023-078363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
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.
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Affiliation(s)
| | - Mark Lyttle
- Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | | | | | | | - Sarah Voss
- Health and Life Sciences, University of the West of England, Bristol, UK
| | - Jonathan Richard Benger
- Academic Department of Emergency Care, The University Hospitals NHS Foundation Trust, Bristol, UK
- Faculty of Health & Life Sciences, University of the West of England, Bristol, UK
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Singh S, Hearps S, Nishijima DK, Cheek JA, Borland M, Dalziel S, Holmes J, Kuppermann N, Babl FE, Hoch JS. Cost-effectiveness of patient observation on cranial CT use with minor head trauma. Arch Dis Child 2022; 107:712-718. [PMID: 35193874 DOI: 10.1136/archdischild-2021-323701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/04/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To evaluate the cost-effectiveness of planned observation on cranial CT use in children with minor head trauma. DESIGN Planned secondary analysis of a multicentre prospective observation study. SETTING Australia and New Zealand. PATIENTS An analytic cohort of 18 471 children aged <18 years with Glasgow Coma Scale scores 14-15 presenting <24 hours after blunt head trauma stratified by the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk categories. INTERVENTION A plan for observation and immediate CT scan were documented after the initial assessment. The planned observation group included those with planned observation and no immediate plan for CT. MAIN OUTCOME MEASURES Taking an Australian public-funded healthcare perspective, we estimated the cost-effectiveness of planned observation on the adjusted mean costs per child and CT use reduction by net benefit regression analysis using ordinary least squares with robust SEs and bootstrapping. All costs presented in 2018 euros. RESULTS Planned observation in 4945 (27%) children was cost-saving of €85 (95% CI -120 to -51) with 10.4% lower CT use (95% CI 9.6 to 11.2). This strategy was cost-saving for the PECARN high-risk (-€757 (95% CI -961 to -554)) and intermediate-risk (-€52 (95% CI -99 to -4.3)) categories, with 43% (95% CI 39 to 47) and 11% (95% CI 9.6 to 12.4) lower CT use, respectively. The very low-risk category incurred more cost of €86 (95% CI 67 to 104) with planned observation and 0.05% lower CT use (95% CI -0.61 to 0.71). CONCLUSION Planned ED observation in selected children with minor head trauma is cost-effective for reducing CT use for the PECARN intermediate-risk and high-risk categories. TRIAL REGISTRATION NUMBER ACTRN12614000463673.
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Affiliation(s)
- Sonia Singh
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia .,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - Stephen Hearps
- Child Neuropsychology, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA
| | - John Alexander Cheek
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Meredith Borland
- Emergency Medicine, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Divisions of Paediatrics and Emergency Medicine, University of Western Australia, Crawley, Western Australia, Australia
| | - Stuart Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
| | - James Holmes
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Center for Healthcare Policy and Research, University of California Davis Health System, Sacramento, California, USA
| | - Nathan Kuppermann
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, California, USA.,Department of Pediatrics, University of California Davis School of Medicine, Sacramento, California, USA
| | - Franz E Babl
- Department of Paediatrics, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Parkville, Victoria, Australia.,Emergency Department, Royal Children's Hospital Melbourne, Parkville, Victoria, Australia
| | - Jeffrey S Hoch
- Center for Healthcare Policy and Research, University of California Davis Health System, Sacramento, California, USA.,Department of Public Health Sciences, University of California Davis, Davis, California, USA
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Choi JI, Kim SD. Pediatric Minor Traumatic Brain Injury : Growing Skull Fracture, Traumatic Cerebrospinal Fluid Leakage, Concussion. J Korean Neurosurg Soc 2022; 65:348-353. [PMID: 35468709 PMCID: PMC9082117 DOI: 10.3340/jkns.2021.0280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Revised: 02/08/2022] [Accepted: 02/16/2022] [Indexed: 11/27/2022] Open
Abstract
Traumatic brain injury (TBI) is a major public health issue that causes significant morbidity and mortality in the pediatric population. Pediatric minor TBIs are the most common and are widely underreported because not all patients seek medical attention. The specific management of these patients is distinct from that of adult patients because of the different physiologies in these age groups. This article focuses on minor TBIs, particularly growing skull fractures, traumatic cerebrospinal fluid leakage, and concussion.
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Affiliation(s)
- Jong-Il Choi
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea
| | - Sang-Dae Kim
- Department of Neurosurgery, Korea University Ansan Hospital, Ansan, Korea
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Nozawa M, Matsuura J, Iwata K, Shiomi N. Verification of Usefulness of Pediatric Head Trauma Imaging Protocol Combining Computerized Tomography, Observation Unit, and Magnetic Resonance Imaging. Pediatr Emerg Care 2022; 38:e628-e634. [PMID: 35100764 DOI: 10.1097/pec.0000000000002379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
METHODS This prospective observational study conducted in our hospital between October 2016 and September 2019 included 1946 patients aged 0 to 15 years with head trauma, of whom 1137 were analyzed. Computed tomography scan rate and imaging examination (CT or MRI) rate of our protocol were investigated. Sensitivity and negative predictive value (NPV) were calculated. We also compared our protocol and other clinical decision rules with respect to CT scan rate, sensitivity, and NPV in the same cohort and outcomes. RESULTS The CT scan rate of our protocol was 7.9%, and the imaging examination rate, including MRI, was 12.2%. When the outcome was set to intracranial injury, the sensitivity and NPV of our protocol were each 100%. The CT scan rates in each cohort were 14.5% for PECARN (8.1% for our protocol), 34.7% for CATCH (23.2% for ours), and 13.6% for CHALICE (7.9% for ours). The sensitivity and NPV in each cohort were 100% and 100% for PECARN (92.3% and 100% for ours), 64.7% and 92.6% for CATCH (100% and 100% for ours), and 83.9% and 99.5% for CHALICE (100% and 100% for ours), respectively. CONCLUSIONS The protocol we created by combining CT, observation unit, and MRI was considered to be useful for practice in pediatric head injury cases.
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Affiliation(s)
| | - Jun Matsuura
- From the Pediatric Emergency Care and Transport Medicine
| | - Kentaro Iwata
- From the Pediatric Emergency Care and Transport Medicine
| | - Naoto Shiomi
- Emergency and Critical Care Medicine, Emergency Medical Care Center, Saiseikai Shiga Hospital, Shiga, Japan
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Tsao J, Hook M, Shah P, Bingham PM. Implementation of Pediatric Emergency Care Applied Research Network Guidelines for Traumatic Brain Injury in a Rural Tertiary Care Center. Pediatr Emerg Care 2021; 37:513-518. [PMID: 32541400 DOI: 10.1097/pec.0000000000002124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate changes in imaging practices for pediatric head trauma after publication of the Pediatric Emergency Care Applied Research Network (PECARN) guidelines, explore areas for quality improvement regarding neuroradiology referrals. We also sought to determine the prevalence of incidental findings discovered on computed tomographies (CTs) attained for minor head trauma and ascertain disposition in these cases. METHODS This retrospective study was conducted at a rural academic center and included 156 children who received CTs for head trauma between 2005 and 2015. Subjects were divided into 2 groups: pre-PECARN publication and post-PECARN publication. Electronic medical records were reviewed to determine whether or not head CTs were obtained according to PECARN guidelines. The proportion of scanned cases and incidental findings in each group was then compared. RESULTS Significantly more subjects met PECARN criteria for head CT during the pre-PECARN period (67.1% vs 50.6%, P = 0.04). Among those who met PECARN criteria, severe mechanism of injury was the most common criterion met in both groups (43.8% pre-PECARN and 26.5% post-PECARN). Nine (5.7%) subjects had incidental findings (similar for both study periods), of which 3 prompted additional diagnostic testing or invasive intervention. Among those who did not meet PECARN criteria, the most common mechanism of injury was fall (<3 ft). CONCLUSIONS Implementation of PECARN guidelines at our center remained limited in the 5 years after publication of this practice guide. Clinically insignificant incidental findings were often detected and may heighten patient anxiety.
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Affiliation(s)
- Jackie Tsao
- From the Department of Neurosciences, Robert Larner, MD, School of Medicine
| | | | - Purvi Shah
- From the Department of Neurosciences, Robert Larner, MD, School of Medicine
| | - Peter M Bingham
- Division of Pediatric Neurology, the University of Vermont Medical Center, Burlington, VT
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Ukwuoma OI, Allareddy V, Allareddy V, Rampa S, Rose JA, Shein SL, Rotta AT. Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head Injury. Pediatr Emerg Care 2021; 37:e384-e390. [PMID: 30256318 DOI: 10.1097/pec.0000000000001618] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
OBJECTIVES Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN). METHODS We used the nationwide ED sample (2008-2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed. RESULTS Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals. CONCLUSIONS There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.
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Affiliation(s)
- Onyinyechi I Ukwuoma
- From the UH Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, OH
| | | | | | - Sankeerth Rampa
- Management & Marketing Department, School of Business, Rhode Island College, Providence, RI
| | - Jerri A Rose
- From the UH Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, OH
| | - Steven L Shein
- From the UH Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, OH
| | - Alexandre T Rotta
- From the UH Rainbow Babies & Children's Hospital, Case Western Reserve School of Medicine, Cleveland, OH
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Shope C, Alshareef M, Larrew T, Bolling C, Reagan J, Yazdani M, Spampinato M, Eskandari R. Utility of a pediatric fast magnetic resonance imaging protocol as surveillance scanning for traumatic brain injury. J Neurosurg Pediatr 2021; 27:475-481. [PMID: 33545669 DOI: 10.3171/2020.8.peds20496] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 08/19/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Traumatic brain injury (TBI) is a prevalent pediatric pathology in the modern emergency department. Computed tomography (CT) is utilized for detection of TBI and can result in cumulatively high radiation exposure. Recently, a fast brain magnetic resonance imaging (fbMRI) protocol has been employed for rapid imaging of hydrocephalus in pediatric patients. The authors investigate the utility of a modified trauma-focused fbMRI (t-fbMRI) protocol as an alternative to surveillance CT in the setting of acute TBI in pediatric patients, thus reducing radiation exposure while improving diagnostic yield. METHODS A retrospective review was performed at the authors' institution for all pediatric patients who had undergone t-fbMRI within 72 hours of an initial CT scan, using a 1.5- or 3-T MR scanner for trauma indications. Forty patients met the study inclusion criteria. The authors performed a comparison of findings on the reads of CT and fbMRI, and a board-certified neuroradiologist conducted an independent review of both modalities. RESULTS T-fbMRI outperformed CT in specificity, sensitivity, and negative predictive value for all injury pathologies measured, except for skull fractures. T-fbMRI demonstrated a sensitivity of 100% in the detection of extraaxial bleed, intraventricular hemorrhage, and subarachnoid hemorrhage and had a sensitivity of 78% or greater for epidural hematoma, subdural hematoma, and intraparenchymal hemorrhage. T-fbMRI yielded a specificity of 100% for all types of intracranial hemorrhages, with a corresponding negative predictive value that exceeded that for CT. CONCLUSIONS In pediatric populations, the t-fbMRI protocol provides a valid alternative to CT in the surveillance of TBI and intracranial hemorrhage. Although not as sensitive in the detection of isolated skull fractures, t-fbMRI can be used to monitor pathologies implicated in TBI patients while minimizing radiation exposure from traditional surveillance imaging.
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Affiliation(s)
- Chelsea Shope
- 1College of Medicine, Medical University of South Carolina; and
| | | | | | - Christopher Bolling
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Justin Reagan
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Milad Yazdani
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
| | - Maria Spampinato
- 3Radiology, Medical University of South Carolina, Charleston, South Carolina
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Donnezan D, Delteil C, Moreau E, Bremond V, Boutin A, Bresson V, Tuchtan L, Piercecchi MD. Injuries from alleged accidental minor head trauma in a prospective cohort of children aged 0-3 years in an emergency department. Leg Med (Tokyo) 2021; 49:101846. [PMID: 33497971 DOI: 10.1016/j.legalmed.2021.101846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 01/04/2021] [Accepted: 01/07/2021] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Minor head trauma in the child, whether accidental or inflicted, is a frequent reason for seeking medical attention. Our aim is to describe the characteristics of minor head trauma in children aged 0-3 years and the resulting injuries. This in order to help the clinician to suspect and thelegal expert to confirm intentional abuse. STUDY DESIGN Children aged from 0 to 3 years with minor head trauma and attending the pediatric emergency department were included in the study between January 2013 and June 2014. The correlation between the characteristics of trauma and the resulting injuries was analyzed using a prospective data collection questionnaire completed by the physicians who cared for the child. RESULTS A total of 709 children with minor head trauma were included in the study. In nearly 90% of cases, fall height was less than 1 m. Only one-third of children aged less than 6 months had external head injury. Low-intensity trauma, such as a low-velocity fall from a height of less than 1.5 m does not cause intracranial injury. External injuries were more frequent in children who had a fall with an anterior impact, while internal injuries were found only in posterior and lateral impacts. CONCLUSION In the context of minor head trauma, the physician must be vigilant and must ask for a full and clear description of the trauma, its mechanisms and other characteristics, when external or internal head injuries are observed in children aged less than 6 months.
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Affiliation(s)
- Diane Donnezan
- Department of Legal Medicine, Hôpital Saint Jean, Perpignan Hospital Center, Perpignan, France
| | - Clémence Delteil
- Department of Legal Medicine, Hôpital de la Timone, Marseille University Hospital Center, Marseille, France; Aix Marseille Univ, CNRS, EFS, ADES, Marseille, France.
| | - Emilie Moreau
- Pediatric Emergencies, Hôpital de la Timone, Marseille University Hospital Center, Marseille, France
| | - Valérie Bremond
- Pediatric Emergencies, Hôpital de la Timone, Marseille University Hospital Center, Marseille, France
| | - Aurélie Boutin
- Pediatric Emergencies, Hôpital de la Timone, Marseille University Hospital Center, Marseille, France
| | - Violaine Bresson
- Pediatric Emergencies, Hôpital de la Timone, Marseille University Hospital Center, Marseille, France
| | - Lucile Tuchtan
- Department of Legal Medicine, Hôpital de la Timone, Marseille University Hospital Center, Marseille, France; Aix Marseille Univ, CNRS, EFS, ADES, Marseille, France
| | - Marie-Dominique Piercecchi
- Department of Legal Medicine, Hôpital de la Timone, Marseille University Hospital Center, Marseille, France; Aix Marseille Univ, CNRS, EFS, ADES, Marseille, France
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Elmoheen A, Salem W, Bashir K. Reducing unnecessary CT scan of the head for minor paediatric head injuries at the emergency department. BMJ Open Qual 2021; 10:bmjoq-2020-000973. [PMID: 33414251 PMCID: PMC7797283 DOI: 10.1136/bmjoq-2020-000973] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 11/29/2020] [Accepted: 12/14/2020] [Indexed: 11/19/2022] Open
Abstract
The CT scan is a determining imaging study in the diagnosis and treatment of head trauma; however, its indiscriminate application can have serious consequences for patients and the health system. More than 45% of CT scans of the head requested for minor head injuries in the paediatric age group in the emergency department were not correctly indicated according to international guidelines. The root of such a high percentage was misinformation and lack of knowledge about the ideal parameters for requesting a CT scan for minor head injuries. To achieve this, survey-based interventions and educational programmes were conducted to improve understanding of international guidelines and access to this information, which was the most important parameter during this project. A decreasing rate of CT scans for paediatric minor head injuries was demonstrated at the rate of 17%, achieving a reduction by more than 47% after the implementation of the interventions. Besides, misinformation and documentation deficits improved by more than 30%. Quality improvement methods decreased misinformation and improved access to information, which reduced errors in the indication of CT scans of the head in the paediatric age group and increased efficiency of patient care.
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Affiliation(s)
- Amr Elmoheen
- Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Waleed Salem
- Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
| | - Khalid Bashir
- Emergency Medicine, Hamad Medical Corporation, Doha, Qatar
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12
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Lorton F, Simon-Pimmel J, Masson D, Launay E, Gras-Le Guen C, Scherdel P. Impact of routine S100B protein assay on CT scan use in children with mild traumatic brain injury. Clin Chem Lab Med 2020; 59:875-882. [PMID: 33554555 DOI: 10.1515/cclm-2020-1293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/05/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVES To evaluate the impact of implementing a modified Pediatric Emergency Care Applied Research Network (PECARN) rule including the S100B protein assay for managing mild traumatic brain injury (mTBI) in children. METHODS A before-and-after study was conducted in a paediatric emergency department of a French University Hospital from 2013 to 2015. We retrospectively included all consecutive children aged 4 months to 15 years who presented mTBI and were at intermediate risk for clinically important traumatic brain injury (ciTBI). We compared the proportions of CT scans performed and of in-hospital observations before (2013-2014) and after (2014-2015) implementation of a modified PECARN rule including the S100B protein assay. RESULTS We included 1,062 children with mTBI (median age 4.5 years, sex ratio [F/M] 0.73) who were at intermediate risk for ciTBI: 494 (46.5%) during 2013-2014 and 568 (53.5%) during 2014-2015. During 2014-2015, S100B protein was measured in 451 (79.4%) children within 6 h after mTBI. The proportion of CT scans and in-hospital observations significantly decreased between the two periods, from 14.4 to 9.5% (p=0.02) and 73.9-40.5% (p<0.01), respectively. The number of CT scans performed to identify a single ciTBI was reduced by two-thirds, from 18 to 6 CT scans, between 2013-2014 and 2014-2015. All children with ciTBI were identified by the rules. CONCLUSIONS The implementation of a modified PECARN rule including the S100B protein assay significantly decreased the proportion of CT scans and in-hospital observations for children with mTBI who were at intermediate risk for ciTBI.
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Affiliation(s)
- Fleur Lorton
- Clinical Investigation Centre, Inserm 1413, University Hospital, Nantes, France.,Department of Pediatrics and Pediatric Emergency, University Hospital, Nantes, France
| | - Jeanne Simon-Pimmel
- Department of Pediatrics and Pediatric Emergency, University Hospital, Nantes, France
| | - Damien Masson
- Biochemistry Department, University Hospital, Nantes, France
| | - Elise Launay
- Clinical Investigation Centre, Inserm 1413, University Hospital, Nantes, France.,Department of Pediatrics and Pediatric Emergency, University Hospital, Nantes, France
| | - Christèle Gras-Le Guen
- Clinical Investigation Centre, Inserm 1413, University Hospital, Nantes, France.,Department of Pediatrics and Pediatric Emergency, University Hospital, Nantes, France
| | - Pauline Scherdel
- Clinical Investigation Centre, Inserm 1413, University Hospital, Nantes, France
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Singh S, Hearps SJC, Borland ML, Dalziel SR, Neutze J, Donath S, Cheek JA, Kochar A, Gilhotra Y, Phillips N, Williams A, Lyttle MD, Bressan S, Hoch JS, Oakley E, Holmes JF, Kuppermann N, Babl FE. The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma. Acad Emerg Med 2020; 27:832-843. [PMID: 32064711 DOI: 10.1111/acem.13942] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 02/03/2020] [Accepted: 02/14/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND Management of children with minor blunt head trauma often includes a period of observation to determine the need for cranial computed tomography (CT). Our objective was to estimate the effect of planned observation on CT use for each Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) risk group among children with minor head trauma. METHODS This was a secondary analysis of a prospective observational study at 10 emergency departments (EDs) in Australia and New Zealand, including 18,471 children < 18 years old, presenting within 24 hours of blunt head trauma, with Glasgow Coma Scale scores of 14 to 15. The planned observation cohort was defined by those with planned observation and no immediate plan for cranial CT. The comparison cohort included the rest of the patients who were either not observed or for whom a decision to obtain a cranial CT was made immediately after ED assessment. The outcome clinically important TBI (ciTBI) was defined as death due to head trauma, neurosurgery, intubation for > 24 hours for head trauma, or hospitalization for ≥ 2 nights in association with a positive cranial CT scan. We estimated the odds of cranial CT use with planned observation, adjusting for patient characteristics, PECARN TBI risk group, history of seizure, time from injury, and hospital clustering, using a generalized linear model with mixed effects. RESULTS The cranial CT rate in the total cohort was 8.6%, and 0.8% had ciTBI. The planned observation group had 4,945 (27%) children compared to 13,526 (73%) in the no planned observation group. Cranial CT use was significantly lower with planned observation (adjusted odds ratio [OR] = 0.2, 95% confidence interval [CI] = 0.1 to 0.1), with no difference in missed ciTBI rates. There was no difference in the odds of cranial CT use with planned observation for the group at very low risk for ciTBI (adjusted OR = 0.9, 95% CI = 0.5 to 1.4). Planned observation was associated with significantly lower cranial CT use in patients at intermediate risk (adjusted OR = 0.2, 95% CI = 0.2 to 0.3) and high risk (adjusted OR = 0.1, 95% CI = 0.0 to 0.1) for ciTBI. CONCLUSIONS Even in a setting with low overall cranial CT rates in children with minor head trauma, planned observation was associated with decreased cranial CT use. This strategy can be safely implemented on selected patients in the PECARN intermediate- and higher-risk groups for ciTBI.
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Affiliation(s)
- Sonia Singh
- From the Murdoch Children's Research Institute Melbourne Australia
- the Department of Paediatrics University of Melbourne Melbourne Australia
- and the University of California Davis Medical Center Sacramento CA USA
| | | | - Meredith L. Borland
- the Perth Children's Hospital Perth Australia
- and the Divisions of Paediatrics and Emergency Medicine School of Medicine University of Western Australia Perth Australia
| | - Stuart R. Dalziel
- the Starship Children's Health Auckland New Zealand
- and the Departments of Surgery and Paediatrics: Child and Youth Health University of Auckland Auckland New Zealand
| | | | - Susan Donath
- From the Murdoch Children's Research Institute Melbourne Australia
- the Department of Paediatrics University of Melbourne Melbourne Australia
| | - John A. Cheek
- From the Murdoch Children's Research Institute Melbourne Australia
- the Department of Paediatrics University of Melbourne Melbourne Australia
- the Royal Children's Hospital Melbourne Australia
| | - Amit Kochar
- the Women's & Children's Hospital Adelaide Australia
| | - Yuri Gilhotra
- the Queensland Children's Hospital Brisbane Australia
| | - Natalie Phillips
- the Queensland Children's Hospital Brisbane Australia
- and the Child Health Research Centre University of Queensland Brisbane Australia
| | - Amanda Williams
- From the Murdoch Children's Research Institute Melbourne Australia
| | - Mark D. Lyttle
- From the Murdoch Children's Research Institute Melbourne Australia
- the Bristol Royal Hospital for Children Bristol UK
- and the Academic Department of Emergency Care University of the West of England Bristol UK
| | - Silvia Bressan
- From the Murdoch Children's Research Institute Melbourne Australia
- the Department of Women's and Children's Health University of Padova Padova Italy
| | - Jeffrey S. Hoch
- the Division of Health Policy and Management Department of Public Health Sciences University of California at Davis Davis CA USA
- and the Center for Healthcare Policy and Research University of California at Davis Sacramento CA USA
| | - Ed Oakley
- From the Murdoch Children's Research Institute Melbourne Australia
- the Department of Paediatrics University of Melbourne Melbourne Australia
- the Royal Children's Hospital Melbourne Australia
| | - James F. Holmes
- the Division of Health Policy and Management Department of Public Health Sciences University of California at Davis Davis CA USA
- and the Department of Emergency Medicine University of California Davis School of Medicine Sacramento CA USA
| | - Nathan Kuppermann
- and the Department of Emergency Medicine University of California Davis School of Medicine Sacramento CA USA
- and the Department of Pediatrics University of California Davis School of Medicine Sacramento CA USA
| | - Franz E. Babl
- From the Murdoch Children's Research Institute Melbourne Australia
- the Department of Paediatrics University of Melbourne Melbourne Australia
- the Royal Children's Hospital Melbourne Australia
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14
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Gizli G, Durak VA, Koksal O. The comparison of PECARN, CATCH, AND CHALICE criteria in children under the age of 18 years with minor head trauma in emergency department. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920930510] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
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.
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Affiliation(s)
- Gizem Gizli
- Department of Emergency Medicine, Van Yüzüncü Yıl University, Van, Turkey
| | - Vahide Aslihan Durak
- Department of Emergency Medicine, Faculty of Medicine, School of Medicine, Uludağ University, Bursa, Turkey
| | - Ozlem Koksal
- Department of Emergency Medicine, Faculty of Medicine, School of Medicine, Uludağ University, Bursa, Turkey
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Curran JA, Cassidy C, Bishop A, Wozney L, Plint AC, Ritchie K, Straus SE, Wong H, Newton A, Jabbour M, MacPhee S, Breneol S, Burns E, Chorney J, Lawton J, Doyle M, MacKay R, Zemek R, Penney T, Grimshaw J. Codesigning discharge communication interventions with healthcare providers, youth and parents for emergency practice settings: EDUCATE study protocol. BMJ Open 2020; 10:e038314. [PMID: 32398342 PMCID: PMC7223275 DOI: 10.1136/bmjopen-2020-038314] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2020] [Revised: 04/14/2020] [Accepted: 04/17/2020] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Discharge communication is an important aspect of patient care but frequently has shortcomings in emergency departments (EDs). In a paediatric context, youth or parents with young children often leave the ED with minimal opportunity to ask questions or to ensure comprehension of important information. Strategies for improving discharge communication have primarily targeted patients and/or parents, although neither group has been engaged in intervention design or implementation. Furthermore, ED healthcare providers (HCPs), important actors in discharge communication practice, are rarely consulted regarding intervention design decisions. We will generate evidence to enhance discharge communication by engaging youth, parents and HCPs in the codesign of ED discharge communication strategies (EDUCATE) for asthma and minor head injury. METHODS AND ANALYSIS This mixed methods study will take place at two academic paediatric EDs in Canada. The study will occur in two phases: (A) codesign and refinement of the intervention prototypes; and (B) usability testing of the prototypes. During the first phase, two codesign teams (one for each condition) will follow a series of structured design meetings based on the Behavior Change Wheel to develop the EDUCATE interventions. Each codesign team (composed of youth, parents, HCPs and study researchers) will collaborate to identify priority target behaviours and acceptable components to include in the interventions. During the second phase, we will conduct usability testing in two EDs with a group of youth, parents and HCPs to refine the interventions. Two cycles of usability testing will be conducted with intervention refinement occurring at the end of each cycle. ETHICS AND DISSEMINATION Informed consent will be obtained from all participants. Ethics approval for this study has been obtained from the Research Ethics Board, IWK Health Centre. Results from this study will form the basis of a future effectiveness implementation trial. Key findings will be presented at national and international conferences and published within peer-reviewed journals.
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Affiliation(s)
- Janet A Curran
- Department of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- Department of Pediatrics, IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Christine Cassidy
- Department of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | | | - Lori Wozney
- Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Amy C Plint
- Department of Pediatrics, University of Ottawa, Ottawa, Ontario, Canada
| | - Krista Ritchie
- Faculty of Education, Mount Saint Vincent University, Halifax, Nova Scotia, Canada
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute, Saint Mike's, Toronto, Ontario, Canada
| | - Helen Wong
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Amanda Newton
- Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada
| | - Mona Jabbour
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
| | | | - Sydney Breneol
- Department of Nursing, Dalhousie University, Halifax, Nova Scotia, Canada
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | - Emma Burns
- IWK Health Centre, Halifax, Nova Scotia, Canada
| | | | | | | | | | - Roger Zemek
- Department of Pediatrics, CHEO, Ottawa, Ontario, Canada
| | | | - Jeremy Grimshaw
- Clinical Epidemiology Program, Ottawa Health Research Institute, Ottawa, Ontario, Canada
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16
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Eapen N, Borland ML, Phillips N, Kochar A, Dalton S, Cheek JA, Gilhotra Y, Neutze J, Lyttle MD, Donath S, Crowe L, Dalziel SR, Oakley E, Williams A, Hearps S, Bressan S, Babl FE. Neonatal head injuries: A prospective Paediatric Research in Emergency Departments International Collaborative cohort study. J Paediatr Child Health 2020; 56:764-769. [PMID: 31868278 DOI: 10.1111/jpc.14736] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 08/15/2019] [Accepted: 12/02/2019] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Nitaa Eapen
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Schools of Medicine, Divisions of Emergency Medicine and Paediatrics, University of Western Australia, Perth, Western Australia, Australia
| | - Natalie Phillips
- Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Child Health Research Centre, The University of Queensland, Medical Research Institute, Brisbane, Queensland, Australia.,Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Amit Kochar
- Emergency Department, Women's and Children's Hospital, Adelaide, South Australia, Australia
| | - Sarah Dalton
- Emergency Department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
| | - John A Cheek
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Monash Medical Centre, Melbourne, Victoria, Australia
| | - Yuri Gilhotra
- Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia
| | - Jocelyn Neutze
- Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand
| | - Mark D Lyttle
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Emergency Department, Bristol Royal Hospital for Children, Bristol, United Kingdom.,Faculty of Health & Life Sciences, University of the West of England, Bristol, United Kingdom
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Louise Crowe
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Health, Auckland, New Zealand.,Liggins Institute, University of Auckland, Auckland, New Zealand
| | - Ed Oakley
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
| | - Amanda Williams
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Stephen Hearps
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Silvia Bressan
- Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Women's and Child Heath, University of Padova, Padova, Italy
| | - Franz E Babl
- Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.,Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia
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17
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Kochar A, Borland ML, Phillips N, Dalton S, Cheek JA, Furyk J, Neutze J, Lyttle MD, Hearps S, Dalziel S, Bressan S, Oakley E, Babl FE. Association of clinically important traumatic brain injury and Glasgow Coma Scale scores in children with head injury. Emerg Med J 2020; 37:127-134. [DOI: 10.1136/emermed-2018-208154] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Revised: 11/04/2019] [Accepted: 12/17/2019] [Indexed: 11/04/2022]
Abstract
ObjectiveHead injury (HI) is a common presentation to emergency departments (EDs). The risk of clinically important traumatic brain injury (ciTBI) is low. We describe the relationship between Glasgow Coma Scale (GCS) scores at presentation and risk of ciTBI.MethodsPlanned secondary analysis of a prospective observational study of children<18 years who presented with HIs of any severity at 10 Australian/New Zealand centres. We reviewed all cases of ciTBI, with ORs (Odds Ratio) and their 95% CIs (Confidence Interval) calculated for risk of ciTBI based on GCS score. We used receiver operating characteristic (ROC) curves to determine the ability of total GCS score to discriminate ciTBI, mortality and need for neurosurgery.ResultsOf 20 137 evaluable patients with HI, 280 (1.3%) sustained a ciTBI. 82 (29.3%) patients underwent neurosurgery and 13 (4.6%) died. The odds of ciTBI increased steadily with falling GCS. Compared with GCS 15, odds of ciTBI was 17.5 (95% CI 12.4 to 24.6) times higher for GCS 14, and 484.5 (95% CI 289.8 to 809.7) times higher for GCS 3. The area under the ROC curve for the association between GCS and ciTBI was 0.79 (95% CI 0.77 to 0.82), for GCS and mortality 0.91 (95% CI 0.82 to 0.99) and for GCS and neurosurgery 0.88 (95% CI 0.83 to 0.92).ConclusionsOutside clinical decision rules, decreasing levels of GCS are an important indicator for increasing risk of ciTBI, neurosurgery and death. The level of GCS should drive clinician decision-making in terms of urgency of neurosurgical consultation and possible transfer to a higher level of care.
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18
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Nozawa M, Mishina H, Tsuji S, Takayama JI. Low plasma D-dimer predicts absence of intracranial injury and skull fracture. Pediatr Int 2020; 62:22-28. [PMID: 31758836 DOI: 10.1111/ped.14063] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 07/02/2019] [Accepted: 10/02/2019] [Indexed: 01/09/2023]
Abstract
BACKGROUND Intracranial injury (ICI) is a leading cause of morbidity in children; however, the use of computed tomography (CT) to evaluate ICI has significant risks in children. A recent study suggests D-dimer is associated with ICI. We surveyed the performance of plasma D-dimer in ruling out ICI or skull fracture (SF) in children with head trauma. METHODS In a cross-sectional study in the Emergency Department (ED) at the National Center for Child Health and Development in Tokyo, Japan we reviewed the medical records of all children age 0-16 years brought to the ED with head trauma from January 2010 to July 2013, who underwent CT based on established clinical criteria and had plasma D-dimer measured. We evaluated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) of plasma D-dimer, using abnormal findings on CT (ICI, SF) as the criterion standard. We repeated analysis after stratification by age (<2 years, ≥2 years). RESULTS Among 364 eligible children (112 children <2 year of age), abnormal findings on CT were demonstrated in 33.8% (123/364). With the cut-off set at 0.5 μg/mL, sensitivity was 100.0% (95% confidence interval [CI]: 95.6-100.0%), specificity 34.0% (95%CI: 28.1-40.4%), PPV 43.6% (95%CI: 37.7-49.6%), NPV 100.0% (95%CI: 93.5-100%). After stratification by age (<2 years and ≥2 years), sensitivity (100.0% and 100.0%) and NPV (100.0% and 100.0%) remained high in both age groups. CONCLUSIONS Low plasma D-dimer (≤0.5 μg/mL) is useful to limit the use of CT in children by excluding traumatic ICI or SF.
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Affiliation(s)
- Masahiro Nozawa
- Emergency Service and Transport Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Hiroki Mishina
- Healthcare Epidemiology, Kyoto University Graduate School of Medicine and Public Health, Kyoto, Japan
| | - Satoshi Tsuji
- Emergency Service and Transport Medicine, National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - John I Takayama
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA
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Rowe C, Wiesendanger K, Polet C, Kuppermann N, Aronoff S. Derivation and Validation of a Simplified Clinical Prediction Rule for Identifying Children at Increased Risk for Clinically Important Traumatic Brain Injuries Following Minor Blunt Head Trauma. THE JOURNAL OF PEDIATRICS: X 2020. [DOI: 10.1016/j.ympdx.2020.100026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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20
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Sources of Variability in Pediatric Head Computed Tomography Use Among Emergency Departments in New Jersey. Pediatr Emerg Care 2020; 36:21-25. [PMID: 31895199 DOI: 10.1097/pec.0000000000002016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Published guidelines have been developed to limit ionizing radiation exposure in children related to diagnostic computed tomography (CT). This study examines the sources of variability in head CT use in children in emergency departments (EDs) in New Jersey despite the presence of such consensus recommendations. METHODS The New Jersey Hospital Association (NJHA) Clinical Repository was queried for study data on all patients younger than 18 years discharged from the ED over a 1-year period. Patient information collected included: treating hospital, patient age, discharge diagnosis, use of head CT, children's hospital (CH) certification, presence of licensed in-patient pediatric beds, association with a hospital system and hospital annual pediatric ED volume. A potential diagnosis requiring a head CT (PDRCT) was defined as one of the following discharge diagnoses: Head Injury, Seizure, Syncope or Headache. Analysis of CT use per 10,000 ED visits was performed through ANOVA, analysis of means for variances, and χ. RESULTS A total of 735,866 ED visits were examined with 16,942 (2.3%) undergoing head CTs. Mean Pediatric Head CT use per 10,000 ED visits for the state was 275 (±16; range, 27-640). During the study period 47,169 (6.4%) ED visits met the PDRCT criteria, 11,495 (27%) of which underwent head CTs. Mean Pediatric Head CT use in this group per 10,000 PDRCT visits was 2948 (±152; range, 728-5806). Characteristics associated with lowest use of head CTs in the PDRCT group included: ED census greater than 10,000 visits per year, CH designation, and younger patient. The presence of in-patient pediatric beds and association with a hospital system with or without an in system CH were not associated with lower head CT use. CONCLUSIONS Despite existing recommendation regarding head CTs in children, there exists a large degree of variability in use of this diagnostic study in EDs in New Jersey.
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Zanetto L, Da Dalt L, Daverio M, Dunning J, Frigo AC, Nigrovic LE, Bressan S. Systematic review and meta-analysis found significant risk of brain injury and neurosurgery in alert children after a post-traumatic seizure. Acta Paediatr 2019; 108:1841-1849. [PMID: 30951221 DOI: 10.1111/apa.14810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2018] [Revised: 03/19/2019] [Accepted: 04/02/2019] [Indexed: 10/27/2022]
Abstract
AIM This study aimed to determine the frequency of traumatic brain injury (TBI) on neuroimaging and the need for emergency neurosurgery in children with normal mental status following a post-traumatic seizure (PTS). METHODS We searched six electronic databases from inception to October 15, 2018, to identify studies including children under 18 years with head injury and a Glasgow Coma Score of 15 after an immediate PTS. Relevant non-English articles were translated to determine eligibility. RESULTS We performed random effect meta-analyses and assessed heterogeneity with I2 . The pooled estimate of the frequency of TBI, from seven studies, was 13.0% (95% CI: 4.0-26.1; I2 = 81%). Data on the need of emergency neurosurgery were reported in four studies and the pooled estimate of its frequency was 2.3% (95% CI: 0.0-9.9; I2 = 86%). Two studies reported on children with isolated PTS without any other signs of head injury, representing 0.1% of patients in both studies, for a total of 76 children. Of these, only three had TBI and one underwent neurosurgery. CONCLUSION Children with immediate PTS and normal mental status frequently have TBI with a substantial need for neurosurgery. Clinicians should strongly consider neuroimaging for these children, although prolonged observation may be considered for those with isolated PTS.
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Affiliation(s)
- Lorenzo Zanetto
- Division of Emergency Medicine Department of Women's and Children's Health University of Padova Padova Italy
| | - Liviana Da Dalt
- Division of Emergency Medicine Department of Women's and Children's Health University of Padova Padova Italy
| | - Marco Daverio
- Division of Emergency Medicine Department of Women's and Children's Health University of Padova Padova Italy
| | - Joel Dunning
- Department of Cardiothoracic Surgery James Cook University Hospital Middlesbrough UK
| | - Anna Chiara Frigo
- Unit of Biostatistics, Epidemiology and Public Health Department of Cardiac, Thoracic and Vascular Sciences University of Padova Padova Italy
| | - Lise E. Nigrovic
- Division of Emergency Medicine Harvard Medical School Boston Children's Hospital Boston MA USA
| | - Silvia Bressan
- Division of Emergency Medicine Department of Women's and Children's Health University of Padova Padova Italy
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Bertsimas D, Dunn J, Steele DW, Trikalinos TA, Wang Y. Comparison of Machine Learning Optimal Classification Trees With the Pediatric Emergency Care Applied Research Network Head Trauma Decision Rules. JAMA Pediatr 2019; 173:648-656. [PMID: 31081856 PMCID: PMC6515573 DOI: 10.1001/jamapediatrics.2019.1068] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/29/2019] [Indexed: 02/04/2023]
Abstract
Importance Computed tomographic (CT) scanning is the standard for the rapid diagnosis of intracranial injury, but it is costly and exposes patients to ionizing radiation. The Pediatric Emergency Care Applied Research Network (PECARN) rules for identifying children with minor head trauma who are at very low risk of clinically important traumatic brain injury (ciTBI) are widely used to triage CT imaging. Objective To examine whether optimal classification trees (OCTs), which are novel machine-learning classifiers, improve on PECARN rules' predictive accuracy. Design, Setting, and Participants A secondary analysis of prospective, publicly available data on emergency department visits for head trauma used by the PECARN group to develop their tool was conducted to derive OCT-based prediction rules for ciTBI in a development cohort and compare their predictive performance vs the PECARN rules in a validation cohort among children who were younger than 2 years and 2 years or older. Data on 42 412 children with head trauma and without severely altered mental status who were examined between June 1, 2004, and September 30, 2006, were gathered from 25 emergency departments in North America participating in PECARN. Data analysis was conducted from September 15, 2016, to December 18, 2018. Main Outcomes and Measures The outcome was ciTBI, with predictive performance measured by estimating the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for the OCT and the PECARN rules. The OCT and PECARN rules' performance was compared by estimating ratios for each measure. Results Of the 42 412 children (15 996 [37.7%] girls) included in the analysis, 10 718 were younger than 2 years (25.3%; mean [SD] age, 11.6 [0.6] months) and 31 694 were 2 years or older (74.7%; age, 9.1 [4.9] years). Compared with PECARN rules, OCTs misclassified 0 vs 1 child with ciTBI in the younger and 10 vs 9 children with ciTBI in the older cohort, and correctly identified more children with very low risk of ciTBI in the younger (7605 vs 5701) and older (20 594 vs 18 134) cohorts. In the validation cohorts, compared with the PECARN rules, the OCTs had statistically significantly better specificity (in the younger cohort: 69.3%; 95% CI, 67.4%-71.2% vs 52.8%; 95% CI, 50.8%-54.9%; in the older cohort: 65.6%; 95% CI, 64.5%-66.8% vs 57.6%; 95% CI, 56.4%-58.8%), positive predictive value (odds ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively), and positive likelihood ratio (risk ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively). There were no statistically significant differences in the sensitivity, negative predictive value, and negative likelihood ratio between the 2 sets of rules. Conclusions and Relevance If implemented, OCTs may help reduce the number of unnecessary CT scans, without missing more patients with ciTBI than the PECARN rules.
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Affiliation(s)
- Dimitris Bertsimas
- Operations Research Center, Massachusetts Institute of Technology, Cambridge
| | - Jack Dunn
- Operations Research Center, Massachusetts Institute of Technology, Cambridge
| | - Dale W. Steele
- Departments of Emergency Medicine and Pediatrics, Alpert Medical School, Brown University, Providence, Rhode Island
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Thomas A. Trikalinos
- Center for Evidence Synthesis in Health, Brown University School of Public Health, Providence, Rhode Island
| | - Yuchen Wang
- Operations Research Center, Massachusetts Institute of Technology, Cambridge
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Khalifa M, Gallego B. Grading and assessment of clinical predictive tools for paediatric head injury: a new evidence-based approach. BMC Emerg Med 2019; 19:35. [PMID: 31200643 PMCID: PMC6570950 DOI: 10.1186/s12873-019-0249-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/03/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many clinical predictive tools have been developed to diagnose traumatic brain injury among children and guide the use of computed tomography in the emergency department. It is not always feasible to compare tools due to the diversity of their development methodologies, clinical variables, target populations, and predictive performances. The objectives of this study are to grade and assess paediatric head injury predictive tools, using a new evidence-based approach, and to provide emergency clinicians with standardised objective information on predictive tools to support their search for and selection of effective tools. METHODS Paediatric head injury predictive tools were identified through a focused review of literature. Based on the critical appraisal of published evidence about predictive performance, usability, potential effect, and post-implementation impact, tools were evaluated using a new framework for grading and assessment of predictive tools (GRASP). A comprehensive analysis was conducted to explain why certain tools were more successful. RESULTS Fourteen tools were identified and evaluated. The highest-grade tool is PECARN; the only tool evaluated in post-implementation impact studies. PECARN and CHALICE were evaluated for their potential effect on healthcare, while the remaining 12 tools were only evaluated for predictive performance. Three tools; CATCH, NEXUS II, and Palchak, were externally validated. Three tools; Haydel, Atabaki, and Buchanich, were only internally validated. The remaining six tools; Da Dalt, Greenes, Klemetti, Quayle, Dietrich, and Güzel did not show sufficient internal validity for use in clinical practice. CONCLUSIONS The GRASP framework provides clinicians with a high-level, evidence-based, comprehensive, yet simple and feasible approach to grade, compare, and select effective predictive tools. Comparing the three main tools which were assigned the highest grades; PECARN, CHALICE and CATCH, to the remaining 11, we find that the quality of tools' development studies, the experience and credibility of their authors, and the support by well-funded research programs were correlated with the tools' evidence-based assigned grades, and were more influential, than the sole high predictive performance, on the wide acceptance and successful implementation of the tools. Tools' simplicity and feasibility, in terms of resources needed, technical requirements, and training, are also crucial factors for their success.
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Affiliation(s)
- Mohamed Khalifa
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Road, North Ryde, Sydney, NSW, 2113, Australia.
| | - Blanca Gallego
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Lowy Cancer Research Centre, Level 4, Cnr High &, Botany St, Kensington, Sydney, NSW, 2052, Australia
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Dalziel K, Cheek JA, Fanning L, Borland ML, Phillips N, Kochar A, Dalton S, Furyk J, Neutze J, Dalziel SR, Lyttle MD, Bressan S, Donath S, Molesworth C, Hearps SJ, Oakley E, Babl FE. A Cost-Effectiveness Analysis Comparing Clinical Decision Rules PECARN, CATCH, and CHALICE With Usual Care for the Management of Pediatric Head Injury. Ann Emerg Med 2019; 73:429-439. [DOI: 10.1016/j.annemergmed.2018.09.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 11/16/2022]
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Kim SK, Jung JH, Lee JH, Jung JY, Kwon H, Paek SH, Kwak YH, Kim DK. The difference of Use of CT in the general versus pediatric emergency departments for adolescent patients in the same tertiary hospital. Clin Exp Emerg Med 2019; 6:19-24. [PMID: 30786703 PMCID: PMC6453689 DOI: 10.15441/ceem.17.274] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2017] [Accepted: 11/02/2017] [Indexed: 01/17/2023] Open
Abstract
OBJECTIVE The use of computed tomography (CT) in pediatric patients has decreased since the association between radiation and cancer risk has been reported. However, in adolescent patients being treated as adult patients, there has been a high incidence of CT use in emergency departments (EDs). Thus, this study aimed to evaluate the CT use in adolescent patients with complaints of headache or abdominal pain in the general and pediatric EDs of the same hospital. METHODS A retrospective chart review of patients aged 15 to 18 years, who presented with headache or abdominal pain at the general and pediatric EDs of Seoul National University Hospital from January 2010 to December 2014, was conducted. RESULTS A total of 407 adolescent patients with complaints of headache and 980 with abdominal pain were included in this study. The adolescent patients in the general ED were more likely to undergo CT scans than those in the pediatric ED, with both patients having headache (42.4% vs. 20.5%, respectively, P<0.001) and abdominal pain (29.0% vs. 18.4%, respectively, P<0.001). There was no statistical difference in the rates of positive CT findings between the general and pediatric EDs. The frequency of visits to the general ED was associated with high rates of CT use in adolescent patients with complaints of headache (odds ratio, 3.95; 95% confidence interval, 2.01 to 7.77) and those with abdominal pain (odds ratio, 1.76; 95% confidence interval, 1.18 to 2.64). CONCLUSION The ED setting influences the use of CT on adolescent patients, and a child-friendly environment could reduce the radiation risks.
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Affiliation(s)
- Seul Ki Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Jin Hee Jung
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea.,Department of Preventive Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Jin Hee Lee
- Department of Emergency Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Jae Yun Jung
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyuksool Kwon
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Korea
| | - So Hyun Paek
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Young Ho Kwak
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Do Kyun Kim
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
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26
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Impact of the Pediatric Emergency Care Applied Research Network (PECARN) guidelines on emergency department use of head computed tomography at a level I safety-net trauma center. Emerg Radiol 2018; 26:45-52. [PMID: 30259227 DOI: 10.1007/s10140-018-1645-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 09/11/2018] [Indexed: 01/20/2023]
Abstract
PURPOSE To evaluate whether the emergency department usage of head computed tomography (CT) on pediatric patients with minor head trauma changed after publication of the Pediatric Emergency Care Applied Research Network (PECARN) head CT guidelines and to identify risk factors associated with performing head CT on patients without a PECARN guideline indication. METHODS This retrospective study included 484 patients 18 years of age or younger who presented to the emergency department with head injury and a total Glasgow Coma Scale score ≥ 14 between September 2005 and July 2014. Based on the guideline publication date of September 2009, the study cohort was stratified into pre-guideline and post-guideline groups. Head CT performance, indications, and findings were compared between study periods. Logistic regression was used to identify risk factors associated with performing a non-indicated head CT. RESULTS The rate of head CTs performed did not significantly change in the post-guideline period (96.6% vs. 95.7%, p = 0.63). There was no significant difference in the proportion of head CTs performed in patients with indications for head CT (100.0% vs. 100.0%) nor in patients without an indication for head CT (85.7% vs. 82.6%, p = 0.65) between the study periods. Females were significantly more likely to have a non-indicated head CT (OR: 2.73, 95% CI: 1.67-4.45) performed. CONCLUSIONS Head CT ordering practices for pediatric patients with head injury did not change at a level I trauma center after publication of the PECARN head CT guidelines.
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Gonzalez LK, Yellin S, Arroyo AC. Point-of-Care Ultrasound in the Pediatric Emergency Department: Where We're at, Where We're Going. Adv Pediatr 2018; 65:121-142. [PMID: 30053920 DOI: 10.1016/j.yapd.2018.04.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Laura K Gonzalez
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Maimonides Medical Center, 4082 10th Avenue, Brooklyn, NY 11219, USA
| | - Sharon Yellin
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, New York Presbyterian Brooklyn Methodist Hospital, 506 6th Street, Brooklyn, NY 11215, USA
| | - Alexander C Arroyo
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Maimonides Medical Center, 4082 10th Avenue, Brooklyn, NY 11219, USA.
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28
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Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study. Ann Emerg Med 2018; 71:703-710. [DOI: 10.1016/j.annemergmed.2018.01.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 12/26/2017] [Accepted: 01/05/2018] [Indexed: 11/22/2022]
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29
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Broers MC, Niermeijer JMF, Kotsopoulos IAW, Lingsma HF, Bruinenberg JFM, Catsman-Berrevoets CE. Evaluation of management and guideline adherence in children with mild traumatic brain injury. Brain Inj 2018; 32:1028-1039. [PMID: 29775090 DOI: 10.1080/02699052.2018.1469047] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
AIM To evaluate the management and guideline adherence in children with mild traumatic brain injury (MTBI) in emergency departments (ED) in the Netherlands. METHODS A multicentre cohort study was conducted, including children younger than 18 years with MTBI who presented within 24 hours after trauma in the ED of hospitals in the southwest region of the Netherlands, in 2014. Primary outcome measures for management were percentages of performed computed tomography (CT) scans and hospital admissions. Guideline adherence was defined as percentages of correctly following the guideline. Secondary outcome measures were differences in management and guideline adherence between hospitals. RESULTS About 563 patients were analysed. Hospital admission was the most frequently performed management type (49.2% hospital admission vs. 30.9% CT). In only 49.7% of patients, the guideline was followed correctly. A substantial overuse of hospital admission (35%) and underuse of CT (40.1%) were found. Percentages of hospital admission and CT varied between 39.4-55.6% and 23.3-44.1%, respectively, across hospitals. Percentages of correctly following the guideline varied between 39.2-64.9% across hospitals. CONCLUSION These findings suggest that physicians in the participating hospitals prefer hospital admission of children with MTBI instead of CT despite the current recommendations of the national MTBI guideline in the Netherlands.
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Affiliation(s)
- Merel C Broers
- a Department of Paediatric Neurology , Erasmus University Hospital - Sophia Children's Hospital , Rotterdam , The Netherlands
| | | | | | - Hester F Lingsma
- d Department of Public Health , Erasmus University Medical Centre , Rotterdam , The Netherlands
| | - Jos F M Bruinenberg
- e Department of Paediatrics , Elisabeth-TweeSteden Hospital , Tilburg , The Netherlands
| | - Coriene E Catsman-Berrevoets
- a Department of Paediatric Neurology , Erasmus University Hospital - Sophia Children's Hospital , Rotterdam , The Netherlands
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Da Dalt L, Parri N, Amigoni A, Nocerino A, Selmin F, Manara R, Perretta P, Vardeu MP, Bressan S. Italian guidelines on the assessment and management of pediatric head injury in the emergency department. Ital J Pediatr 2018; 44:7. [PMID: 29334996 PMCID: PMC5769508 DOI: 10.1186/s13052-017-0442-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2017] [Accepted: 12/18/2017] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVE We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury. METHODS These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text. CONCLUSIONS Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.
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Affiliation(s)
- Liviana Da Dalt
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Niccolo' Parri
- Department of Pediatric Emergency Medicine and Trauma Center, Meyer University Children's Hospital, Florence, Italy
| | - Angela Amigoni
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Agostino Nocerino
- Department of Pediatrics, S. Maria della Misericordia University Hospital, University of Udine, Udine, Italy
| | - Francesca Selmin
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy
| | - Renzo Manara
- Department of Radiology, Neuroradiology Unit, University of Salerno, Salerno, Italy
| | - Paola Perretta
- Neurosurgery Unit, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Maria Paola Vardeu
- Pediatric Emergency Department, Regina Margherita Pediatric Hospital, Torino, Italy
| | - Silvia Bressan
- Pediatric Emergency Department-Intensive Care Unit, Department of Woman's and Child's Health, University of Padova, Via Giustiniani 2, 35128, Padova, Italy.
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Kobe IO, Qureshi MM, Hassan S, Oluoch-Olunya DL. The impact of the introduction of PECARN head CT rules on the utilisation of head CT scans in a private tertiary hospital in Sub-Saharan Africa. Childs Nerv Syst 2017; 33:2147-2152. [PMID: 28856440 DOI: 10.1007/s00381-017-3577-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 08/16/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND The decision to order head CT scans to rule out clinically significant traumatic brain injury in mild head injury in children is made on the basis of clinical decision rules of which the Paediatric Emergency Care Applied Research Network (PECARN) CT head rules have been found to be most sensitive. PURPOSES The purpose of this study is to determine the proportion of head CT scans done for children with mild head injury and to determine disposition of patients from casualty after the introduction of PECARN head CT rules compared to the period before. The research question is "will introduction of the PECARN CT head rules reduce the proportion of head CT scans requested for children under 18 years with mild head injury at the AKUHN?" METHODS A before and after quasi experimental study with a study population including all children under 18 years presenting to the AKUHN with mild head injury and a Glasgow coma scale of 14 and above on presentation. Sample size was 85. RESULTS A total of 42 patients files were analysed in the before study while 43 patients were selected for the after study. The median age was 5 years. The proportion of head CT scans reduced from 56% in the before group to 33% in the after group with no missed clinically significant traumatic brain injury. More patients were discharged home after evaluation in the after group (81%) than in the before group (58%). CONCLUSIONS The number of head CT scans ordered reduced without missing any clinically significant traumatic brain injury.
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Affiliation(s)
- Isaac O Kobe
- Department of Surgery, The Aga Khan University Hospital, P.O BOX 30270-00100, Nairobi, Kenya.
| | - Mahmoud M Qureshi
- Department of Surgery, The Aga Khan University Hospital, P.O BOX 30270-00100, Nairobi, Kenya
| | - Saidi Hassan
- Department of Surgery, The Aga Khan University Hospital, P.O BOX 30270-00100, Nairobi, Kenya
| | - David L Oluoch-Olunya
- Department of Surgery, The Aga Khan University Hospital, P.O BOX 30270-00100, Nairobi, Kenya
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Singh N, Singhal A. Challenges in minor TBI and indications for head CT in pediatric TBI-an update. Childs Nerv Syst 2017; 33:1677-1681. [PMID: 29149393 DOI: 10.1007/s00381-017-3535-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 07/06/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Pediatric head trauma is one of the commonest presentations to emergency departments. Over 90% of such head injuries are considered mild, but still present risk acute clinical deterioration and longer term morbidity. Identifying which children are at risk of clinically important brain injuries remains challenging and much of the data on minor head injuries is based on the adult population. CHALLENGES IN PEDIATRICS Children, however, are different, both anatomically and in terms of mechanism of injury, to adults and, even within the pediatric group, there are differences with age and stage of development. IMAGING CT scans have added to the repertoire of clinicians in the assessment of pediatric head injury population, but judicious use is required given radiation exposure, malignancy risk, and resource constraints. Guidelines and head injury rules have been developed, for adults and children, to support decision-making in the emergency department though whether their use is applicable to all population groups is debatable. Further challenges in mild pediatric head trauma also include appropriate recommendations for school attendance and physical activity after discharge. FURTHER DEVELOPMENTS Concern remains for second-impact syndrome and, in the longer term, for post-concussive syndrome and further research in both is still needed. Furthermore, the development of clinical decision rules raises further questions on the purpose of admitting children with minor head injuries and answering this question may aid the evolution of clinical decision guidelines. CONCLUSIONS The next generation of catheter with homogeneous flow patterns based on parametric designs may represent a step forward for the treatment of hydrocephalus, by possibly broadening their lifespan.
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Affiliation(s)
- Navneet Singh
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada
| | - Ash Singhal
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, 4480 Oak Street, Room K3-159, Vancouver, British Columbia, V6H 3V4, Canada.
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Clinical observation: A safe alternative to radiology in infants with mild traumatic brain injury. ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Observación clínica: una alternativa segura a la radiología en lactantes con traumatismo craneoencefálico leve. An Pediatr (Barc) 2017; 87:164-169. [DOI: 10.1016/j.anpedi.2016.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2016] [Revised: 09/26/2016] [Accepted: 09/29/2016] [Indexed: 11/24/2022] Open
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Babl FE, Borland ML, Phillips N, Kochar A, Dalton S, McCaskill M, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Lyttle MD, Bressan S, Donath S, Molesworth C, Jachno K, Ward B, Williams A, Baylis A, Crowe L, Oakley E, Dalziel SR. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet 2017; 389:2393-2402. [PMID: 28410792 DOI: 10.1016/s0140-6736(17)30555-x] [Citation(s) in RCA: 170] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/21/2016] [Accepted: 12/06/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and CHALICE) in a large sample of children. METHODS In this prospective observational study, we included children and adolescents (aged <18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged <2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury [TBI], need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13-15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673. FINDINGS Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (<1%) underwent neurosurgery, and 15 (<1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7-100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4-100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2-99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2-93·4; 125/141) and CHALICE (92·3%, 89·2-94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules. INTERPRETATION The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules. FUNDING National Health and Medical Research Council, Emergency Medicine Foundation, Perpetual Philanthropic Services, WA Health Targeted Research Funds, Townsville Hospital Private Practice Fund, Auckland Medical Research Foundation, A + Trust.
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Affiliation(s)
- Franz E Babl
- Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
| | - Meredith L Borland
- Princess Margaret Hospital for Children, Perth, WA, Australia; Schools of Paediatrics and Child Health and Primary, Aboriginal and Rural Healthcare, University of Western Australia, Crawley, WA, Australia
| | - Natalie Phillips
- Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Amit Kochar
- Women's & Children's Hospital, Adelaide, SA, Australia
| | - Sarah Dalton
- The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Mary McCaskill
- The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - John A Cheek
- Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Monash Medical Centre, Melbourne, VIC, Australia
| | - Yuri Gilhotra
- Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Jeremy Furyk
- The Townsville Hospital, Townsville, QLD, Australia
| | | | - Mark D Lyttle
- Murdoch Children's Research Institute, Melbourne, VIC, Australia; Bristol Royal Hospital for Children, Bristol, UK; Academic Department of Emergency Care, University of the West of England, Bristol, UK
| | - Silvia Bressan
- Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | | | - Kim Jachno
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Brenton Ward
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Amanda Williams
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Amy Baylis
- Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Louise Crowe
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ed Oakley
- Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Stuart R Dalziel
- Starship Children's Health, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
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Kemp A, Nickerson E, Trefan L, Houston R, Hyde P, Pearson G, Edwards R, Parslow RC, Maconochie I. Selecting children for head CT following head injury. Arch Dis Child 2016; 101:929-34. [PMID: 27449674 PMCID: PMC5050290 DOI: 10.1136/archdischild-2015-309078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 04/02/2016] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Indicators for head CT scan defined by the 2007 National Institute for Health and Care Excellence (NICE) guidelines were analysed to identify CT uptake, influential variables and yield. DESIGN Cross-sectional study. SETTING Hospital inpatient units: England, Wales, Northern Ireland and the Channel Islands. PATIENTS Children (<15 years) admitted to hospital for more than 4 h following a head injury (September 2009 to February 2010). INTERVENTIONS CT scan. MAIN OUTCOME MEASURES Number of children who had CT, extent to which NICE guidelines were followed and diagnostic yield. RESULTS Data on 5700 children were returned by 90% of eligible hospitals, 84% of whom were admitted to a general hospital. CT scans were performed on 30.4% of children (1734), with a higher diagnostic yield in infants (56.5% (144/255)) than children aged 1 to 14 years (26.5% (391/1476)). Overall, only 40.4% (984 of 2437 children) fulfilling at least one of the four NICE criteria for CT actually underwent one. These children were much less likely to receive CT if admitted to a general hospital than to a specialist centre (OR 0.52 (95% CI 0.45 to 0.59)); there was considerable variation between healthcare regions. When indicated, children >3 years were much more likely to have CT than those <3 years (OR 2.35 (95% CI 2.08 to 2.65)). CONCLUSION Compliance with guidelines and diagnostic yield was variable across age groups, the type of hospital and region where children were admitted. With this pattern of clinical practice the risks of both missing intracranial injury and overuse of CT are considerable.
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Affiliation(s)
- A Kemp
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - E Nickerson
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - L Trefan
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - R Houston
- Research fellow CMACE (at the time of the project). Placements Manager at Kids Company, London, UK
| | - P Hyde
- Paediatric Intensive Care Unit, Southampton Children's Hospital, Southampton, UK
| | - G Pearson
- Consultant in Intensive Care, Birmingham Children's Hospital, Birmingham, UK
| | - R Edwards
- Department of Neurosurgery, Bristol Hospital for Children, Bristol, UK
| | - RC Parslow
- Senior Lecturer in Epidemiology, Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - I Maconochie
- Paediatric Emergency Medicine Consultant, Imperial College NHS Healthcare Trust, London, UK
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Lorton F, Poullaouec C, Legallais E, Simon-Pimmel J, Chêne MA, Leroy H, Roy M, Launay E, Gras-Le Guen C. Validation of the PECARN clinical decision rule for children with minor head trauma: a French multicenter prospective study. Scand J Trauma Resusc Emerg Med 2016; 24:98. [PMID: 27488722 PMCID: PMC4973103 DOI: 10.1186/s13049-016-0287-3] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 07/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To date, the Pediatric Emergency Care Applied Research Network (PECARN) rule for identifying children who are at very low risk of clinically-important traumatic brain injuries after minor head trauma has not been validated prospectively in an independent population. Our goal was to evaluate the diagnostic performance of the PECARN clinical decision rule in a French pediatric population in multiple clinical settings. METHODS We conducted a multicenter, prospective, non-interventional cohort study of patients with minor head trauma who presented to three emergency departments in France. We enrolled patients younger than 16 years of age seeking a consultation within 24 h of head trauma with Glasgow Coma Scale scores of 14-15. RESULTS During the study period, we included 1499 children of which 421 (28 %) were under 2 years of age, and 955 (64 %) were male. A cranial computed tomography (CT) scan was performed on 76 patients (5.1 %). Of the 1499 included patients, 9 children (0.6 %) had a clinically-important traumatic brain injury, and none were classified as very low risk by the PECARN rule. In our study, the sensitivity of this clinical decision rule was 100 % (95 % CI 66.4 to 100 %), the specificity was 69.9 % (95 % CI 67.5 to 72.2 %) and the negative predictive value was 100 % (95 % CI 99.7 to 100 %). DISCUSSION Our study confirmed the good predictive performances of the PECARN clinical decision rule for minor head trauma in children. The PECARN rule performed similarly to our study and to its internal validation study. CONCLUSIONS We conducted an external validation study of the PECARN clinical decision rule for the detection of clinically-important traumatic brain injuries in children with minor head trauma, according to the methodological standards. The PECARN rule successfully identified all patients with clinically-important traumatic brain injuries, with a limited use of CT scans. Conducting a broad validation study with a large cohort is a prerequisite to provide sufficient statistical power before authorizing its implementation and generalization. TRIAL REGISTRATION This study has been registered in ClinicalTrials.gov with identifier number: NCT02752711 on April 27, 2016.
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Affiliation(s)
- F Lorton
- Department of Pediatric Emergency, University Hospital, Quai Moncousu, 44093, Nantes Cédex 01, France. .,INSERM CIC 1413, University Hospital, 38 bd Jean Monnet, 44093, Nantes Cédex 01, France.
| | - C Poullaouec
- Department of Pediatric Emergency, University Hospital, Quai Moncousu, 44093, Nantes Cédex 01, France
| | - E Legallais
- Department of Pediatric Emergency, University Hospital, Quai Moncousu, 44093, Nantes Cédex 01, France
| | - J Simon-Pimmel
- Department of Pediatric Emergency, University Hospital, Quai Moncousu, 44093, Nantes Cédex 01, France
| | - M A Chêne
- Department of Pediatrics, Hospital of Saint-Nazaire, 11 bd Georges Charpak, 44 606, Saint-Nazaire Cédex, France
| | - H Leroy
- Department of Emergency, Departmental Hospital of Vendée, Les Oudairies, 85925, La Roche sur Yon Cédex 9, France
| | - M Roy
- Department of Pediatric Emergency, University Hospital, Quai Moncousu, 44093, Nantes Cédex 01, France
| | - E Launay
- Department of Pediatrics, University Hospital, Quai Moncousu, 44093, Nantes Cédex 01, France
| | - C Gras-Le Guen
- Department of Pediatric Emergency, University Hospital, Quai Moncousu, 44093, Nantes Cédex 01, France.,INSERM CIC 1413, University Hospital, 38 bd Jean Monnet, 44093, Nantes Cédex 01, France
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Shiomi N, Echigo T, Hino A, Hashimoto N, Yamaki T. Criteria for CT and Initial Management of Head Injured Infants: A Review. Neurol Med Chir (Tokyo) 2016; 56:442-8. [PMID: 27194179 PMCID: PMC4945601 DOI: 10.2176/nmc.ra.2015-0318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Criteria for computed tomography (CT) to head injured infants have not been established. Since the identification of neurological findings is difficult in infants, examination by CT may be necessary in some cases, but it may be difficult to perform CT because of problems with radiation exposure and body movement. Moreover, even though no intracranial abnormality was found immediately after injury, abnormal findings may appear after several hours. From this viewpoint, course observation after injury may be more important than CT in the initial treatment of head trauma in infants. The complaints and neurological manifestations of infants, particularly those aged 2 or younger, are frequently unclear; therefore, there is an opinion that CT is recommended for all pediatric patients. However, the appropriateness of its use should be determined after confirming the mechanism of injury, consciousness level, neurological findings, and presence/absence of a history of abuse. Among the currently available rules specifying criteria for CT of infants with head trauma, the Pediatric Emergency Care Applied Research Network (PECARN) study may be regarded as reliable at present. In Japan, where the majority of emergency hospitals are using CT, it may be necessary to develop criteria for CT in consideration of the actual situation. CT diagnosis for pediatric head trauma is not always necessary. When no imaging is performed, this should be fully explained at the initial treatment before selecting course observation at home. Checking on a state of the patients by telephone is useful for both patients and physicians.
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Affiliation(s)
- Naoto Shiomi
- Emergency and critical care medicine, Saiseikai Shiga Hospital
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39
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Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Republished: Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Postgrad Med J 2015; 91:634-8. [DOI: 10.1136/postgradmedj-2013-305004rep] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Cowley LE, Morris CB, Maguire SA, Farewell DM, Kemp AM. Validation of a Prediction Tool for Abusive Head Trauma. Pediatrics 2015. [PMID: 26216332 DOI: 10.1542/peds.2014-3993] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Abusive head trauma (AHT) may be missed in the clinical setting. Clinical prediction tools are used to reduce variability in practice and inform decision-making. From a systematic review and individual patient data analysis we derived the Predicting Abusive Head Trauma (PredAHT) tool, using multilevel logistic regression to predict likelihood of AHT. This study aims to externally validate the PredAHT tool. METHODS Consecutive children aged <36 months admitted with an intracranial injury, confirmed as abusive or nonabusive, to 2 sites used in the original model were ascertained. Details of 6 influential features were recorded (retinal hemorrhage, rib and long -bone fractures, apnea, seizures, and head or neck bruising). We estimated the likelihood of an unrecorded feature being present with multiple imputation; analysis included sensitivity, specificity, and area under the curve, with 95% confidence intervals (CIs). RESULTS Data included 133 non-AHT cases and 65 AHT cases, 97% of children were <24 months old. Consistent with original predictions, when ≥3 features were present in a child <36 months old with intracranial injury, the estimated probability of AHT was >81.5% (95% CI, 63.3-91.8). The sensitivity of the tool was 72.3% (95% CI, 60.4-81.7), the specificity was 85.7% (95% CI, 78.8-90.7), area under the curve 0.88 (95% CI, 0.823-0.926). CONCLUSIONS When tested on novel data, the PredAHT tool performed well. This tool has the potential to contribute to decision-making in these challenging cases. An implementation study is needed to explore its performance and utility within the child protection process.
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Affiliation(s)
- Laura Elizabeth Cowley
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, United Kingdom; and
| | | | - Sabine Ann Maguire
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, United Kingdom; and
| | - Daniel Mark Farewell
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, United Kingdom; and
| | - Alison Mary Kemp
- Department of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, United Kingdom; and
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Samuel N, Jacob R, Eilon Y, Mashiach T, Shavit I. Falls in young children with minor head injury: A prospective analysis of injury mechanisms. Brain Inj 2015; 29:946-50. [PMID: 25955119 DOI: 10.3109/02699052.2015.1017005] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
BACKGROUND Fall is a common mechanism of injury (MOI) in young children and an important risk factor for traumatic brain injury (TBI). Most children who fall have a minor head injury (MHI), defined as a blunt head trauma that occurred in a patient who is conscious and responsive. OBJECTIVE To seek a possible association between MOI and injury severity. METHODS A single centre cohort study was conducted. Data were collected on patients aged 0-2 years with MHI. Clinically-significant TBI (csTBI), defined as head injury resulting in death, intubation or neurosurgery, was the primary outcome measure. Traumatic finding on CT scan (TFCT) was the secondary outcome measure. RESULTS Five hundred and ninety-five patients were analysed. Eight types of falls were identified: from ground-level, down stairs, from a bed, from a changing table, from furniture, from adult-hold, from a playground-device and from a stroller/baby-carriage. One patient (0.16%) had csTBI. Thirty-one (5.2%) underwent CT scans, TFCT was diagnosed in 17 (2.8%) patients; 10 (1.7%) linear skull-fractures, two (0.3%) depressed skull-fractures and five (0.8%) intracranial haemorrhages. Regression analysis did not reveal a statistically significant association between any of the MOI and the presence of TFCT. CONCLUSIONS The risk for csTBI was low and no association was found between MOI and injury severity.
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McCarthy MT, Kosofsky BE. Clinical features and biomarkers of concussion and mild traumatic brain injury in pediatric patients. Ann N Y Acad Sci 2015; 1345:89-98. [DOI: 10.1111/nyas.12736] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Matthew T. McCarthy
- Department of Pediatrics; NewYork-Presbyterian/Weill Cornell Medical Center; New York New York
| | - Barry E. Kosofsky
- Department of Pediatrics; NewYork-Presbyterian/Weill Cornell Medical Center; New York New York
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Wintermark M, Sanelli PC, Anzai Y, Tsiouris AJ, Whitlow CT, Druzgal TJ, Gean AD, Lui YW, Norbash AM, Raji C, Wright DW, Zeineh M. Imaging Evidence and Recommendations for Traumatic Brain Injury: Conventional Neuroimaging Techniques. J Am Coll Radiol 2015; 12:e1-14. [DOI: 10.1016/j.jacr.2014.10.014] [Citation(s) in RCA: 100] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2014] [Revised: 10/14/2014] [Accepted: 10/18/2014] [Indexed: 12/14/2022]
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ACR Appropriateness Criteria head trauma--child. J Am Coll Radiol 2014; 11:939-47. [PMID: 25164794 DOI: 10.1016/j.jacr.2014.07.017] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2014] [Accepted: 07/08/2014] [Indexed: 12/11/2022]
Abstract
Head trauma is a frequent indication for cranial imaging in children. CT is considered the first line of study for suspected intracranial injury because of its wide availability and rapid detection of acute hemorrhage. However, the majority of childhood head injuries occur without neurologic complications, and particular consideration should be given to the greater risks of ionizing radiation in young patients in the decision to use CT for those with mild head trauma. MRI can detect traumatic complications without radiation, but often requires sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment and exposes the patient to potential anesthesia risks. MRI may be helpful in patients with suspected nonaccidental trauma, with which axonal shear injury and ischemia are more common and documentation is critical, as well as in those whose clinical status is discordant with CT findings. Advanced techniques, such as diffusion tensor imaging, may identify changes occult by standard imaging, but data are currently insufficient to support routine clinical use. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 3 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
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Muñoz-Santanach D, Trenchs Sainz de la Maza V, González Forster E, Luaces Cubells C. [Children with minor head injury in the emergency department: Is skull radiography necessary for children under 2 years?]. Neurocirugia (Astur) 2014; 25:149-53. [PMID: 24930859 DOI: 10.1016/j.neucir.2014.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2013] [Revised: 05/02/2014] [Accepted: 05/08/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Current guidelines on the management of mild head trauma (traumatic brain injury/TBI) do not include the presence of a skull fracture in determining the risk of intracranial injury. However, in our setting cranial radiography is still performed frequently to rule out the presence of skull fracture. OBJECTIVE To estimate the prevalence of clinically-important traumatic brain injuries (ciTBI) in children younger than two years of age with mild TBI. PATIENTS AND METHODS Descriptive observational study. All children attended in emergency department with mild TBI (Glasgow ≥14 points) for a year were included. We defined ciTBI as intracranial injuries that caused death or required neurosurgery, intubation for more than 24 hours, inotropic drugs or mechanical ventilation. RESULTS The study included 854 children, of which 457 (53.5%) were male. The median patient age was 11.0 months (P25-75: 7.5-17.0 months). In 741 cases (86.8%) the mechanism of TBI was a fall. In 438 cases (51.3%) skull radiography was performed. Eleven children (1.3%) had intracranial injury, but none met the criteria for ciTBI (estimated prevalence of ciTBI was 0%; CI 95%: 0%-0.4%). CONCLUSION Children younger than two years of age with mild TBI have low prevalence of ciTBI. Consequently, it is possible to monitor children younger than two years with a TBI without performing skull radiography.
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Affiliation(s)
- David Muñoz-Santanach
- Servicio de Urgencias, Hospital Sant Joan de Déu Barcelona, Esplugues de Llobregat, Barcelona, España
| | | | - Elisa González Forster
- Servicio de Urgencias, Hospital Sant Joan de Déu Barcelona, Esplugues de Llobregat, Barcelona, España
| | - Carles Luaces Cubells
- Servicio de Urgencias, Hospital Sant Joan de Déu Barcelona, Esplugues de Llobregat, Barcelona, España.
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Babl FE, Lyttle MD, Bressan S, Borland M, Phillips N, Kochar A, Dalziel SR, Dalton S, Cheek JA, Furyk J, Gilhotra Y, Neutze J, Ward B, Donath S, Jachno K, Crowe L, Williams A, Oakley E. A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC Pediatr 2014; 14:148. [PMID: 24927811 PMCID: PMC4074143 DOI: 10.1186/1471-2431-14-148] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 05/27/2014] [Indexed: 12/05/2022] Open
Abstract
Background Head injuries in children are responsible for a large number of emergency department visits. Failure to identify a clinically significant intracranial injury in a timely fashion may result in long term neurodisability and death. Whilst cranial computed tomography (CT) provides rapid and definitive identification of intracranial injuries, it is resource intensive and associated with radiation induced cancer. Evidence based head injury clinical decision rules have been derived to aid physicians in identifying patients at risk of having a clinically significant intracranial injury. Three rules have been identified as being of high quality and accuracy: the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) from Canada, the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) from the UK, and the prediction rule for the identification of children at very low risk of clinically important traumatic brain injury developed by the Pediatric Emergency Care Applied Research Network (PECARN) from the USA. This study aims to prospectively validate and compare the performance accuracy of these three clinical decision rules when applied outside the derivation setting. Methods/design This study is a prospective observational study of children aged 0 to less than 18 years presenting to 10 emergency departments within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network in Australia and New Zealand after head injuries of any severity. Predictor variables identified in CATCH, CHALICE and PECARN clinical decision rules will be collected. Patients will be managed as per the treating clinicians at the participating hospitals. All patients not undergoing cranial CT will receive a follow up call 14 to 90 days after the injury. Outcome data collected will include results of cranial CTs (if performed) and details of admission, intubation, neurosurgery and death. The performance accuracy of each of the rules will be assessed using rule specific outcomes and inclusion and exclusion criteria. Discussion This study will allow the simultaneous comparative application and validation of three major paediatric head injury clinical decision rules outside their derivation setting. Trial registration The study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR)-
ACTRN12614000463673 (registered 2 May 2014).
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Affiliation(s)
- Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Flemington Rd, Parkville Vic 3052, Australia.
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Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, Nigrovic LE. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child 2014; 99:427-31. [PMID: 24431418 DOI: 10.1136/archdischild-2013-305004] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
OBJECTIVE The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury (TBI) age-based clinical prediction rules identify children at very low risk of a significant head injury who can safely avoid CT. Our goal was to independently validate these prediction rules. DESIGN Cross-sectional study. SETTING Two paediatric emergency departments located in USA and in Italy. PATIENTS All children presenting within 24 h of a head injury with a Glasgow Coma Score of ≥14. INTERVENTION Assessment of PECARN TBI clinical predictors. MAIN OUTCOME MEASURE Clinically important TBI defined as head injury resulting in death, intubation for >24 h, neurosurgery or two or more nights of hospitalisation for the management of head trauma. RESULTS During the study period, we included 2439 children (91% of eligible patients), of which 959 (39%) were <2 years of age and 1439 (59%) were male. Of the study patients, 373 (15%) had a CT performed, 69 (3%) had traumatic findings on their CT and 19 (0.8%) had a clinically important TBI. None of the children with a clinically important TBI were classified as very low risk by the PECARN TBI prediction rules (overall sensitivity 100%; 95% CI 83.2% to 100%, specificity 55%, 95% CI 52.5% to 56.6%, and negative predictive value 100%, 95% CI 99.6% to 100%). CONCLUSIONS In our external validation, the age-based PECARN TBI prediction rules accurately identified children at very low risk for a clinically significant TBI and can be used to assist CT decision making for children with minor blunt head trauma.
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Affiliation(s)
- Deborah Schonfeld
- Division of Emergency Medicine, Boston Children's Hospital, , Boston, Massachusetts, USA
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von Heideken J, Svensson T, Iversen M, Ekbom A, Janarv PM. Femur shaft fracture at a young age and the risk of subsequent severe injuries during childhood: a cohort study. BMC Pediatr 2014; 14:62. [PMID: 24589362 PMCID: PMC3974004 DOI: 10.1186/1471-2431-14-62] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 02/24/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND A child who suffers a fracture or a soft-tissue injury at a young age faces an increased risk of subsequent injuries during childhood. This risk could be related to personal and family characteristics or to lower-than-average bone-mineral density. The purpose of this nationwide cohort study was to estimate the association between a femur shaft fracture at a young age and the subsequent risk of hospitalization for injuries during childhood. METHODS We compared the subsequent risk of hospitalization for injuries during childhood among 1,404 children (exposed) who were one to three years of age when they suffered a femur shaft fracture with the risk among 13,814 randomly selected, gender- and age-matched femur fracture-free children (unexposed). Hazard ratios (HRs) and 95% confidence intervals (CIs) for severe injuries defined as fractures or soft-tissue injuries requiring hospital admission were estimated in a Cox proportional hazards model. RESULTS Exposed children exhibited no significantly increased risk of upper-extremity fractures or soft-tissue injuries during childhood, regardless of sex and follow-up time. Boys exhibited a 162% increased risk of suffering a lower leg fracture requiring hospital admission (HR?=?2.62, 95% CI: 1.45-4.71), but the refracture risk was not significant for girls 2.02 (0.58-6.97). CONCLUSIONS We found an increased risk for subsequent fractures in the lower leg that requires inpatient care during childhood for boys, but not for girls, who were one to three years of age when they first suffered a femur shaft fracture. This increased fracture risk is probably not simply the result of greater risk-taking among boys. The explanation might relate to factors affecting the bone quality of the lower leg.
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Affiliation(s)
- Johan von Heideken
- Department of Women's and Children's Health, Karolinska Institutet, Karolinska University Hospital, Solna, SE 171 77, Stockholm, Sweden.
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Vestergaard V, Astrand R, Romner B. A survey of the management of paediatric minor head injury. Acta Neurol Scand 2014; 129:168-72. [PMID: 23763509 DOI: 10.1111/ane.12158] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2013] [Indexed: 11/30/2022]
Abstract
OBJECTIVES To investigate present established routines and standards in managing minor head-injured children in Danish hospitals, a survey of present management practice was conducted. MATERIALS AND METHODS A cross-sectional mail survey, detailing clinical and radiological examinations, in-hospital observation, discharge criteria and follow-up, was performed on all 46 hospitals treating children with minor head injury in Denmark. RESULTS Of the 46 hospitals, 33% report having established written criteria for the referral and management of children with minor head injury. Ten (22%) of the 46 hospitals are so-called injury clinics, where only nurses are employed. All state that they use the Glasgow Coma Scale (GCS) and/or the paediatric GCS to assess the level of consciousness; 15% use the paediatric GCS exclusively. None perform routine radiological examinations. Criteria for early discharge are established in 98% of the hospitals. All hospitals provide written instructions for observations at home before discharge. CONCLUSION The management of children with minor head injury varies between hospitals in Denmark. Local management guidelines are either lacking or mainly based on those of adults. Hence, there is a need for the development of minor head injury guidelines specifically designed for the management of children.
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Affiliation(s)
- V. Vestergaard
- Department of Neurosurgery; Rigshospitalet; Copenhagen Denmark
| | - R. Astrand
- Department of Neurosurgery; Rigshospitalet; Copenhagen Denmark
| | - B. Romner
- Department of Neurosurgery; Rigshospitalet; Copenhagen Denmark
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Munivenkatappa A, Deepika A, Prathyusha V, Devi I, Shukla D. Can an abnormal CT scan be predicted from common symptoms after mild head injury in children? J Pediatr Neurosci 2014; 8:183-7. [PMID: 24470808 PMCID: PMC3888031 DOI: 10.4103/1817-1745.123659] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Children have non specific symptoms after mild head injury (MHI). It is difficult to define indication of CT scan among them. We aimed at identification of predictors of CT scan findings after MHI. MATERIALS AND METHODS Children aged ≤12 years with GCS 13-15 after head injury were retrospectively evaluated for their clinical and CT scan findings during January to March 2010. The variables used for detection of abnormal (positive) CT scan were age, gender, cause of injury (road traffic accident, fall, and assault), loss of consciousness, vomiting, ear or nose bleed, seizure, and GCS score. RESULTS A total of 133 children were included in study. Sixty nine (51.9%) children had abnormal CT findings. There was no statistical difference in patients with normal vs abnormal CT scan for presence of any of the variables evaluated. CONCLUSION An abnormal CT scan cannot be reliably ruled out in a child with MHI based on symptoms; hence a policy of liberal CT scan based on clinical acumen is advisable.
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Affiliation(s)
- Ashok Munivenkatappa
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Akhil Deepika
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Vasuki Prathyusha
- Department of Biostatistics, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
| | - Dhaval Shukla
- Department of Neurosurgery, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, Karnataka, India
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