The risk of intra-cranial haemorrhage in those presenting late to the ED following a head injury: a systematic review

Multi-centre study found no increased risk of clinically important brain injuries when children presented more than 24 hours after a minor head trauma

AIM

Validated clinical decision rules on neuroimaging are not available for children who are evaluated more than 24 hours after a minor head trauma. We compared clinically important traumatic brain injuries in children who presented with a minor head trauma within, or after, 24 hours.

METHODS

This was a retrospective analysis of patients aged 0-17 years, who were evaluated for minor head traumas by 5 paediatric emergency departments in Northern Italy between January 2019 and June 2020. Children with clinically important traumatic brain injuries were divided into those who had presented within, and after, 24 hours.

RESULTS

The study comprised 5,981 children (59.9% boys), with a median age of 2 years, including 243 (4.1%) who had presented more than 24 hours after their minor head trauma. Neuroimaging was performed on 448 (7.5%) patients and the time of presentation had no impact on the rates of clinically important traumatic brain injuries. Multiple logistic regression did not show any association between clinically important traumatic brain injuries and late presentation.

CONCLUSION

Delayed presentation to a paediatric emergency department after a minor head trauma did not alter the risk of clinically important traumatic brain injuries and the same neuroimaging rules could apply.

The Use of PECARN and CATCH Rules in Children With Minor Head Trauma Presenting to Emergency Department 24 Hours After Injury

OBJECTIVE

Major studies (PECARN [Pediatric Emergency Care Applied Research Network], CATCH [Canadian Assessment of Childhood Head Injury]) that regulate the use of computed tomography (CT) algorithms in children with minor head trauma (MHT) have been conducted among children presenting in 24 hours after injury. In this study, we aimed to compare use and results of PECARN and CATCH rules in children presenting in and after 24 hours following injury.

METHODS

Records of children who were admitted to emergency department and underwent CT imaging because of MHT during a 5-year period were retrospectively reviewed. Efficacy of PECARN and CATCH rules was investigated for predicting traumatic CT findings in patients presenting in and after 24 hours. Logistic regression was performed to evaluate whether presenting after 24 hours affected the ability of guidelines in predicting traumatic CT findings.

RESULTS

This study included 2490 patients who met the criteria. Of these patients, 6.7% (168/2490) presented after 24 hours following injury. Traumatic CT findings were found in 6.7% (168/2490) of patients. This rate was 6.9% (161/2322) in those presenting in 24 hours and 4.2% (7/168) in those presenting after 24 hours, and there was no significant difference in the incidence of traumatic CT findings between the 2 groups (P = 0.17). Among children presenting in 24 hours, the sensitivity of PECARN was 96.3% (95% confidence interval [CI], 91.7%-98.5%), whereas the sensitivity of CATCH was 91.9% (95% CI, 86.3%-95.4%) in detecting traumatic intracranial injury. The sensitivity of both PECARN and CATCH was 85.7% (95% CI, 42.0%-99.2%) among children presenting after 24 hours. Presence of CT scan indication according to PECARN statistically predicted intracranial damage, and this was not affected by the admission time.

CONCLUSIONS

Patients with MHT presenting after 24 hours following injury constitute a clinically important population. Regardless of the admission time, current guidelines predict traumatic CT abnormalities.

Computed tomography findings in young children with minor head injury presenting to the emergency department greater than 24h post injury

BACKGROUND

Large studies which developed decision rules for the use of Computed tomography (CT) in children with minor head trauma excluded children with late presentation (more than 24h).

OBJECTIVE

To assess the prevalence of significant traumatic brain injury (TBI) on CT in infants with head trauma presenting to the emergency department (ED) more than 24h from the injury.

METHODS

A retrospective chart review of infants less than 24 months old referred for head CT because of traumatic brain injury from January 2004 to December 2014 in Assaf-Harofeh medical center was conducted. We used the PECARN definitions of TBI on CT to define significant CT findings.

RESULTS

344 cases were analyzed, 68 with late presentation. There was no significant difference in the age between children with late and early presentation (mean 11.4 (SD 5.6) month vs 10. 5 (SD 7.0) month, P=0.27). There was no significant difference between the groups in the incidence of significant TBI (22% vs 19%, p=0.61). Any TBI on CT (e.g. fracture) was found in 43 (63%) patients with late presentation compared with 116 (42%) patients with early presentation (p=0.002, OR 2.37, 95% CI 1.37-4.1).

CONCLUSION

A similar rate of CT-identified traumatic brain injury was detected in both groups.‏ There was no significant difference in the incidence of significant TBI on CT between the groups.‏ Young children presenting to the ED more than 24 hours after the injury may have abnormal findings on CT.