Vomiting With Head Trauma and Risk of Traumatic Brain Injury

Polytrauma in Children

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Clinical characteristics associated with pediatric traumatic intracranial hemorrhage

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Justification of Indication for Cranial CT Imaging after Mild Traumatic Brain Injury According to the Current National Guidelines

The primary aim was to evaluate the compliance of cranial CT indication with the national guideline-based decision rules in patients after mTBI. The secondary aim was to determine the incidence of CT pathologies among justified and unjustified CT scans and to investigate the diagnostic value of these decision rules. This is a retrospective, single-center study on 1837 patients (mean age = 70.7 years) referred to a clinic of oral and maxillofacial surgery following mTBI over a five-year period. The current national clinical decision rules and recommendations for mTBI were retrospectively applied to calculate the incidence of unjustified CT imaging. The intracranial pathologies among the justified and unjustified CT scans were presented using descriptive statistical analysis. The performance of the decision rules was ascertained by calculating the sensitivity, specificity, and predictive values. A total of 123 intracerebral lesions were radiologically detected in 102 (5.5%) of the study patients. Most (62.1%) of the CT scans strictly complied with the guideline recommendations, and 37.8% were not justified and likely avoidable. A significantly higher incidence of intracranial pathology was observed in patients with justified CT scans compared with patients with unjustified CT scans (7.9% vs. 2.5%, p < 0.0001). Patients with loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures presented pathologic CT findings more frequently (p < 0.05). The decision rules identified CT pathologies with 92.28% sensitivity and 39.08% specificity. To conclude, compliance with the national decision rules for mTBI was low, and more than a third of the CT scans performed were identified as "likely avoidable". A higher incidence of pathologic CT findings was detected in patients with justified cranial CT imaging. The investigated decision rules showed a high sensitivity but low specificity for predicting CT pathologies.

Clinical Indicators for Primary Cranial CT Imaging after Mild Traumatic Brain Injury-A Retrospective Analysis

The primary aim was to determine the clinical indicators for primary cranial CT imaging in patients after mild traumatic brain injury (mTBI). The secondary aim was to evaluate the need for post-traumatic short-term hospitalization based on primary clinical and CT findings. This was an observational retrospective single-centre study of all the patients who were admitted with mTBI over a five-year period. Demographic and anamnesis data, the clinical and radiological findings, and the outcome were analyzed. An initial cranial CT (CT0) was performed at admission. Repeat CT scans (CT1) were performed after positive CT0 findings and in cases with in-hospital secondary neurological deterioration. Intracranial hemorrhage (ICH) and the patient's outcome were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between the clinical variables and the pathologic CT findings. A total of 1837 patients (mean age: 70.7 years) with mTBI were included. Acute ICH was detected in 102 patients (5.5%), with a total of 123 intracerebral lesions. In total, 707 (38.4%) patients were admitted for 48 h for in-hospital observation and six patients underwent an immediate neurosurgical intervention. The prevalence of delayed ICH was 0.05%. A Glasgow Coma Scale (GCS) of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of fracture were identified as clinical factors with significantly higher risk of acute ICH. None of the 110 CT1 presented clinical relevance. A GCS of <15, loss of consciousness, amnesia, seizures, cephalgia, somnolence, dizziness, nausea, and clinical signs of cranial fractures should be considered absolute indicators for primary cranial CT imaging. The reported incidence of immediate and delayed traumatic ICH was very low and hospitalization should be decided individually considering both the clinical and CT findings.

Management of older adults after mild head trauma in an oral and maxillofacial surgery clinic

PURPOSE

The primary aim was to determine the incidence of intracranial hemorrhage (ICH) after mild traumatic brain injury (mTBI) in patients aged ≥ 65 years. The secondary aim was to identify risk factors for intracranial lesions and evaluate the need for in-hospital observation in this age group.

METHODS

This observational retrospective single-center study included all patients aged ≥ 65 years who were referred to our clinic for oral and plastic maxillofacial surgery following mTBI over a five-year period. Demographic and anamnesis data, clinical and radiological findings, and treatment were analyzed. Acute and delayed ICH and patient outcomes during hospitalization were evaluated using descriptive statistical analysis. A multivariable analysis was performed to find associations between CT findings and clinical data.

RESULTS

A total of 1,062 patients (55.7% male, 44.2% female) with a mean age of 86.3 years were included in the analysis. Ground-level fall was the most frequent cause of trauma (52.3%). Fifty-nine patients (5.5%) developed an acute traumatic ICH, and 73 intracerebral lesions were radiologically observed. No association was detected between ICH rate and antithrombotic medication (p = 0.4353). The delayed ICH rate was 0.09% and the mortality rate was 0.09%. Significant risk factors for increased ICH were a Glasgow Coma Scale score of < 15, loss of consciousness, amnesia, cephalgia, somnolence, dizziness, and nausea according to multivariable analysis.

CONCLUSION

Our study showed a low prevalence of acute and delayed ICH in older adults with mTBI. The ICH risk factors identified here should be considered when revising guidelines and developing a valid screening tool. Repeat CT imaging is recommended in patients with secondary neurological deterioration. In-hospital observation should be based on an assessment of frailty and comorbidities and not on CT findings alone.

Non-ionizing Imaging for the Emergency Department Assessment of Pediatric Minor Head Trauma

Minor blunt head trauma (MHT) represents a common reason for presentation to the pediatric emergency department (ED). Despite the low incidence of clinically important traumatic brain injuries (ciTBIs) following MHT, many children undergo computed tomography (CT), exposing them to the risk associated with ionizing radiation. The clinical predictions rules developed by the Pediatric Emergency Care Applied Research Network (PECARN) for MHT are validated accurate tools to support decision-making about neuroimaging for these children to safely reduce CT scans. However, a few non-ionizing imaging modalities have the potential to contribute to further decrease CT use. This narrative review provides an overview of the evidence on the available non-ionizing imaging modalities that could be used in the management of children with MHT, including point of care ultrasound (POCUS) of the skull, near-infrared spectroscopy (NIRS) technology and rapid magnetic resonance imaging (MRI). Skull ultrasound has proven an accurate bedside tool to identify the presence and characteristics of skull fractures. Portable handheld NIRS devices seem to be accurate screening tools to identify intracranial hematomas also in pediatric MHT, in selected scenarios. Both imaging modalities may have a role as adjuncts to the PECARN rule to help refine clinicians' decision making for children at high or intermediate PECARN risk of ciTBI. Lastly, rapid MRI is emerging as a feasible and accurate alternative to CT scan both in the ED setting and when repeat imaging is needed. Advantages and downsides of each modality are discussed in detail in the review.

Predicting factors for abnormal brain computed tomography in children with minor head trauma

Background

Deciding whether a cranial Computed Tomography (CT) scan in a patient with minor head trauma (MHT) is necessary or not has always been challenging. Diagnosing Traumatic Brain Injury (TBI) is a fundamental part of MHT managing especially in children who are more vulnerable in terms of brain CT radiation consequences and TBI. Defining some indications to timely and efficiently predict the likelihood of TBI is necessary. Thus, we aimed to determine the impact of clinical findings to predict the need for brain CT in children with MHT.

Methods

In a prospective cohort study, 200 children (2 to 14 years) with MHT were included from 2019 to 2020. The data of MHT-related clinical findings were gathered. The primary and secondary outcomes were defined as a positive brain CT and any TBI requiring neurosurgery intervention, respectively. In statistical analysis, we performed Binary Logistic regression analysis, Fisher’s exact test and independent samples t-test using SPSS V.26.

Results

The mean age of participants was 6.5 ± 3.06 years. Ninety patients underwent brain CT. The most common clinical finding and injury mechanism were headache and falling from height, respectively. The results of brain CTs were positive in seven patients (3.5%). We identified three predicting factors for an abnormal brain CT including headache, decreased level of consciousness, and vomiting.

Conclusion

We showed that repetitive vomiting (≥2), headache, and decreased level of consciousness are predicting factors for an abnormal brain CT in children with MHT.

Comparison of intracranial injury predictability between machine learning algorithms and the nomogram in pediatric traumatic brain injury

OBJECTIVE

The overuse of head CT examinations has been much discussed, especially those for minor traumatic brain injury (TBI). In the disruptive era, machine learning (ML) is one of the prediction tools that has been used and applied in various fields of neurosurgery. The objective of this study was to compare the predictive performance between ML and a nomogram, which is the other prediction tool for intracranial injury following cranial CT in children with TBI.

METHODS

Data from 964 pediatric patients with TBI were randomly divided into a training data set (75%) for hyperparameter tuning and supervised learning from 14 clinical parameters, while the remaining data (25%) were used for validation purposes. Moreover, a nomogram was developed from the training data set with similar parameters. Therefore, models from various ML algorithms and the nomogram were built and deployed via web-based application.

RESULTS

A random forest classifier (RFC) algorithm established the best performance for predicting intracranial injury following cranial CT of the brain. The area under the receiver operating characteristic curve for the performance of RFC algorithms was 0.80, with 0.34 sensitivity, 0.95 specificity, 0.73 positive predictive value, 0.80 negative predictive value, and 0.79 accuracy.

CONCLUSIONS

The ML algorithms, particularly the RFC, indicated relatively excellent predictive performance that would have the ability to support physicians in balancing the overuse of head CT scans and reducing the treatment costs of pediatric TBI in general practice.

PECARN algorithms for minor head trauma: Risk stratification estimates from a prospective PREDICT cohort study

BACKGROUND

The Pediatric Emergency Care Applied Research Network (PECARN) head trauma clinical decision rules informed the development of algorithms that risk stratify the management of children based on their risk of clinically important traumatic brain injury (ciTBI). We aimed to determine the rate of ciTBI for each PECARN algorithm risk group in an external cohort of patients and that of ciTBI associated with different combinations of high- or intermediate-risk predictors.

METHODS

This study was a secondary analysis of a large multicenter prospective data set, including patients with Glasgow Coma Scale scores of 14 or 15 conducted in Australia and New Zealand. We calculated ciTBI rates with 95% confidence intervals (CIs) for each PECARN risk category and combinations of related predictor variables.

RESULTS

Of the 15,163 included children, 4,011 (25.5%) were aged <2 years. The frequency of ciTBI was 8.5% (95% CI = 6.0%-11.6%), 0.2% (95% CI = 0.0%-0.6%), and 0.0% (95% CI = 0.0%-0.2%) in the high-, intermediate-, and very-low-risk groups, respectively, for children <2 years and 5.7% (95% CI = 4.4%-7.2%), 0.7% (95% CI = 0.5%-1.0%), and 0.0% (95% CI = 0.0%-0.1%) in older children. The isolated high-risk predictor with the highest risk of ciTBI was "signs of palpable skull fracture" for younger children (11.4%, 95% CI = 5.3%-20.5%) and "signs of basilar skull fracture" in children ≥2 years (11.1%, 95% CI = 3.7%-24.1%). For older children in the intermediate-risk category, the presence of all four predictors had the highest risk of ciTBI (25.0%, 95% CI = 0.6%-80.6%) followed by the combination of "severe mechanism of injury" and "severe headache" (7.7%, 95% CI = 0.2%-36.0%). The very few children <2 years at intermediate risk with ciTBI precluded further analysis.

CONCLUSIONS

The risk estimates of ciTBI for each of the PECARN algorithms risk group were consistent with the original PECARN study. The risk estimates of ciTBI within the high- and intermediate-risk predictors will help further refine clinical judgment and decision making on neuroimaging.

Gastrointestinal Decompression on Computed Tomography Examination for Patients with Craniocerebral Injury

Objective: Patients with craniocerebral injury usually accompanied by intracranial hypertension and vomiting, which affect the effect of CT scanning. The aim of this study was to discuss the application effects of gastrointestinal decompression on computed tomography (CT) examination for patients with craniocerebral injury. Methods: A total of 80 patients with craniocerebral injury in our hospital were randomly selected and divided into control and observation groups, 40 cases in each group. The observation group was given gastrointestinal decompression before the CT examination, while the control group received routine examination. The success rate of CT examination, CT scanning effect, examination, and complication during scanning were recorded and compared in two groups. Results: The one-time success rate (100.0%) of CT examination was 100.0% (40/40) in the observation group was significantly higher than the rate in the control group (82.5%, P = 0.034). The CT examination clearly showed in the types of craniocerebral injury, the brain tissue injury, the ventricular compression and the midline displacement. The CT examination time of observation group was shorter than that of control group (P < 0.001), while there was no significant difference in the whole examination time spent on both gastrointestinal decompression operation and CT examination between the two groups (P = 0.301). In the observation group, there was only 1 case of retching, and no cases of vomiting or aspiration during scanning. The incidence of various complications in observation group was significantly lesser than the incidence in control group (P = 0.034). Conclusions: Continue gastrointestinal decompression can significantly reduce the incidence of vomiting and other complication in patients with craniocerebral injury during CT examination, reduce the CT examination time, and improve the success rate of one-time scanning.

Head home: a prospective cohort study of a nurse-led paediatric head injury clinical decision tool at a district general hospital

OBJECTIVES

To assess if a nurse-led application of a paediatric head injury clinical decision tool would be safe compared with current practice.

METHODS

All paediatric (<17 years) patients with head injuries presenting to Frimley Park Emergency Department (ED), England from 1 May to 31 October 2018 were prospectively screened by a nurse using a mandated electronic 'Head Injury Discharge At Triage' questionnaire (HIDATq). We determined which patients underwent CT of brain and whether there was a clinically important intracranial injury or re-presentation to the ED. The negative predictive value of the screening tool was assessed. We determined what proportion of patients could have been sent home from triage using this tool.

RESULTS

Of the 1739 patients screened, 61 had CTs performed due to head injury (six abnormal) with a CT rate of 3.5% and 2% re-presentations. Of the entire cohort, 1052 screened negative. 1 CT occurred in this group showing no abnormalities. Of those screened negative, 349 (33%)/1052 had 'no other injuries' and 543 (52%)/1052 had 'abrasions or lacerations'. HIDATq's negative predictive value for CT was 99.9% (95% CI 99.4% to 99.9%) and 100% (95% CI 99.0% to 100%) for intracranial injury. The positive predictive value of the tool was low. Five patients screened negative and re-presented within 72 hours but did not require CT imaging.

CONCLUSION

A negative HIDATq appears safe in our ED. Potentially 20% (349/1739) of all patients with head injuries presenting to our department could be discharged by nurses at triage with adequate safety netting advice. This increases to 50% (543/1739), if patients with lacerations or abrasions were given advice and discharged at triage. A large multicentre study is required to validate the tool.

Characteristics of vomiting as a predictor of intracranial injury in pediatric minor head injury

OBJECTIVES

Vomiting is common in children after minor head injury. In previous research, isolated vomiting was not a significant predictor of intracranial injury after minor head injury; however, the significance of recurrent vomiting is unclear. This study aimed to determine the value of recurrent vomiting in predicting intracranial injury after pediatric minor head injury.

METHODS

This secondary analysis of the CATCH2 prospective multicenter cohort study included participants (0-16 years) who presented to a pediatric emergency department (ED) within 24 hours of a minor head injury. ED physicians completed standardized clinical assessments. Recurrent vomiting was defined as ≥ four episodes. Intracranial injury was defined as acute intracranial injury on computed tomography scan. Predictors were examined using chi-squared tests and logistic regression models.

RESULTS

A total of 855 (21.1%) of the 4,054 CATCH2 participants had recurrent vomiting, 197 (4.9%) had intracranial injury, and 23 (0.6%) required neurosurgical intervention. Children with recurrent vomiting were significantly more likely to have intracranial injury (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.7-3.1), and require neurosurgical intervention (OR, 3.5; 95% CI, 1.5-7.9). Recurrent vomiting remained a significant predictor of intracranial injury (OR, 2.8; 95% CI, 1.9-3.9) when controlling for other CATCH2 criteria. The probability of intracranial injury increased with number of vomiting episodes, especially when accompanied by other high-risk factors, including signs of a skull fracture, or irritability and Glasgow Coma Scale score < 15 at 2 hours postinjury. Timing of first vomiting episode, and age were not significant predictors.

CONCLUSIONS

Recurrent vomiting (≥ four episodes) was a significant risk factor for intracranial injury in children after minor head injury. The probability of intracranial injury increased with the number of vomiting episodes and if accompanied by other high-risk factors, such as signs of a skull fracture or altered level of consciousness.

Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries

The aim of this study was to determine the potential impact of the Pediatric Emergency Care Applied Research Network (PECARN) rules on the CT rate in a large paediatric minor traumatic head injury (MTHI) cohort and compare this with current national Dutch guidelines. This was a planned sub-study of a prospective multicentre observational study that enrolled 1006 children younger than 18 years with MTHI. We calculated the number of recommended CT scans and described trauma-related CT scan abnormalities. The PECARN rules recommended a significantly lower percentage of CT scans in all age categories, namely 101/357 (28.3%) versus 164/357 (45.9%) (p < 0.001) in patients under 2 years of age and 148/623 (23.8%) versus 394/623 (63.2%) (p < 0,001) versus in patients 2 years and older.Conclusion: The projected CT rate can significantly be reduced if the PECARN rules are applied. We therefore advocate that the PECARN guidelines are also implemented in The Netherlands. What is Known: • To guide clinicians whether to perform a CT scan in children with a minor traumatic head injury (MTHI) clinical decision rules has been developed. • The overall CT scan rate in adherence with the Dutch MTHI guidelines is 44%. What is New: • The projected CT rate can significantly be reduced in a Dutch cohort of MTHI if the PECARN rules are applied. • The Dutch national guidelines for MTHI can safely be replaced by the PECARN rules.

Multi-centre study found that strict adherence to guidelines led to computed tomography scans being overused in children with minor head injuries

AIM

Our primary aim was to calculate the head computed tomography (CT) scan rate in children with a minor head injury (MHI) when the Dutch National guidelines were followed in clinical practice. The secondary aim was to determine the incidence of CT abnormalities and the guideline predictors associated with traumatic abnormalities.

METHODS

We performed a multi-centre, prospective observational cross-sectional study in the emergency departments of six hospitals in The Netherlands between 1 April 2015 and 31 December 2016.

RESULTS

Data on 1002 patients were studied and 69% of cases complied with the guidelines. The overall CT rate was 44% and the incidence of traumatic abnormal CT findings was 13%. CT scans were performed in 19% of children under two years of age, 48% of children between two and five years and 63% of children aged six years or more. Multivariate regression analysis for all age categories showed that CT abnormalities were predicted by a Glasgow Coma Scale of less than 15, suspicion of a basal skull fracture, vomiting and scalp haematomas or external lesions of the skull.

CONCLUSION

Strict adherence to the Dutch national guidelines resulted in CT overuse. New guidelines are needed to safely reduce CT scan indications.

Paediatric acute care: Highlights from the Paediatric Acute Care-Advanced Paediatric Life Support Conference, Hobart, 2018

The Paediatric Acute Care Conference (PACC) is an annual conference organised by APLS Australia to advance paediatric acute care topics for clinicians in pre-hospital medicine, EDs, acute paediatrics, intensive care and anaesthesia. The PACC 2018 was held in Hobart, Tasmania. We provide a summary of some of the presentations.