Prevalence of Clinically Important Traumatic Brain Injuries in Children With Minor Blunt Head Trauma and Isolated Severe Injury Mechanisms

Abstract

To determine the prevalence of clinically important traumatic brain injuries (TBIs) with severe injury mechanisms in children with minor blunt head trauma but with no other risk factors from the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules (defined as isolated severe injury mechanisms).Design: Secondary analysis of a large prospective observational cohort study.Setting: Twenty-five emergency departments participating in the PECARN.Patients: Children with minor blunt head trauma and Glasgow Coma Scale scores of at least 14.Intervention: Treating clinicians completed a structured data form that included injury mechanism (severity categories defined a priori).Main Outcome Measures: Clinically important TBIs were defined as intracranial injuries resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for at least 2 nights. We investigated the rate of clinically important TBIs in children with either severe injury mechanisms or isolated severe injury mechanisms.Results: Of the 42 412 patients enrolled in the overall study, 42 099 (99%) had injury mechanisms recorded, and their data were included for analysis. Of all study patients, 5869 (14%) had severe injury mechanisms, and 3302 (8%) had isolated severe injury mechanisms. Overall, 367 children had clinically important TBIs (0.9%; 95% CI, 0.8%-1.0%). Of the 1327 children younger than 2 years with isolated severe injury mechanisms, 4 (0.3%; 95% CI, 0.1%-0.8%) had clinically important TBIs, as did 12 of the 1975 children 2 years or older (0.6%; 95% CI, 0.3%-1.1%). Conclusion:Children with isolated severe injury mechanisms are at low risk of clinically important TBI, and many do not require emergent neuroimaging.

Does implementation of the PECARN rules for minor head trauma improve patient-centered outcomes in a lower resource emergency department: a retrospective cohort study

“…These low incidence rates imply that the majority of head trauma cases encountered in our PED are minor and do not require any imaging. Our results are similar to those of a large US prospective study conducted by Nigrovic et al where only 0.9% of 42,412 patients with minor blunt head trauma had a ciTBI [ 30 ]. They are also comparable to those of a French prospective study by Lorton et al where only 0.6% of 1499 patients with minor head trauma had a ciTBI [ 5 ].…”

“…Interestingly, in the literature, the several studies investigating the impact of PECARN rules on CT scanning rates of pediatric patients with head trauma display different baseline rates of head CT scanning. Whereas our clinical setting is characterized by a lower overall baseline CT scan rate (21.6% vs. 35.3% in the PECARN study) when compared to the US [ 4 , 30 , 33 ], our CT scanning rates seem to be higher than those reported in Europe (5.1 to 8.4%) [ 5 , 20 ]. Compared to the large prospective US study validating the PECARN prediction rules, our study included a higher percentage of children younger than 2 years of age and a lower proportion of cases with severe mechanisms of injury or with high-risk predictor findings for ciTBI, such as signs of altered mental status or of basilar skull fractures [ 4 ].…”

“…Nevertheless, although our baseline rates are comparable to those of a recent QI study conducted in the US, the implementation of PECARN guidelines in our PED had less of an impact on CT use when compared to results reported by Nigrovic et al consisting of a CT scan decrease from 21 to 15% after implementation and down to 9% through individual provider feedback [ 24 ]. Most published studies showing a positive impact from the implementation of the PECARN rules were conducted in developed countries [ 5 , 20 – 22 ], with adequate administrative resources, or conducted specifically as QI projects [ 23 , 30 ]. According to previous studies, a CT rate of less than 15% is achievable for all children with minor blunt head trauma [ 20 , 24 , 25 ].…”

Association of a Guardian's Report of a Child Acting Abnormally With Traumatic Brain Injury After Minor Blunt Head Trauma

“…In prior studies of children with isolated scalp hematomas, 14 isolated vomiting, 15 isolated severe mechanisms of injury, 16 or isolated history of loss of consciousness, 13 the risk of ciTBI was low. As in the present study, however, the prevalence of ciTBI increased when combined with another PECARN TBI predictor.…”

Re-Examining the Brain Injury Guidelines in Pediatric Traumatic Brain Injury: Can Simple Isolated Non-Displaced Skull Fractures be Treated as a BIG-1 Injury?

“…It is also possible that race/ethnicity/socioeconomic status and age may be effect modifiers as they may affect patient outcomes and components of ci-TBI such as the length of hospital stay. 21,22 Given our sample size, we could not analyze these categories separately, thus socioeconomic data were not collected. Additionally, this study captured data through a time period when our institutional policy for ICU admission changed and this could have affected patient outcome, even though ICU admission was not a specific end-point of our study.…”