Michelle Miskin

The Effect of Observation on Cranial Computed Tomography Utilization for Children After Blunt Head Trauma

OBJECTIVE: Children with minor blunt head trauma often are observed in the emergency department before a decision is made regarding computed tomography use. We studied the impact of this clinical strategy on computed tomography use and outcomes. METHODS: We performed a subanalysis of a prospective multicenter observational study of children with minor blunt head trauma. Clinicians completed case report forms indicating whether the child was observed before making a decision regarding computed tomography. We defined clinically important traumatic brain injury as an intracranial injury resulting in death, neurosurgical intervention, intubation for longer than 24 hours, or hospital admission for 2 nights or longer. To compare computed tomography rates between children observed and those not observed before a decision was made regarding computed tomography use, we used a generalized estimating equation model to control for hospital clustering and patient characteristics. RESULTS: Of 42 412 children enrolled in the study, clinicians noted if the patient was observed before making a decision on computed tomography in 40 113 (95%). Of these, 5433 (14%) children were observed. The computed tomography use rate was lower in those observed than in those not observed (31.1% vs 35.0%; difference: −3.9% [95% confidence interval: −5.3 to −2.6]), but the rate of clinically important traumatic brain injury was similar (0.75% vs 0.87%; difference: −0.1% [95% confidence interval: −0.4 to 0.1]). After adjustment for hospital and patient characteristics, the difference in the computed tomography use rate remained significant (adjusted odds ratio for obtaining a computed tomography in the observed group: 0.53 [95% confidence interval: 0.43–0.66]). CONCLUSIONS: Clinical observation was associated with reduced computed tomography use among children with minor blunt head trauma and may be an effective strategy to reduce computed tomography use.

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

OBJECTIVE 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.

Emergency department practice variation in computed tomography use for children with minor blunt head trauma.

OBJECTIVE To describe factors associated with computed tomography (CT) use for children with minor blunt head trauma that are evaluated in emergency departments. STUDY DESIGN Planned secondary analysis of a prospective observational study of children <18 years with minor blunt head trauma between 2004 and 2006 at 25 emergency departments. CT scans were obtained at the discretion of treating clinicians. We risk-adjusted patients for clinically important traumatic brain injuries and performed multivariable regression analyses. Outcome measures were rates of CT use by hospital and by clinician training type. RESULTS CT rates varied between 19.2% and 69.2% across hospitals. Risk adjustment had little effect on the differential rate of CT use. In low- and middle-risk patients, clinicians obtained CTs more frequently at suburban and nonfreestanding childrens hospitals. Physicians with emergency medicine (EM) residency training obtained CTs at greater rates than physicians with pediatric residency or pediatric EM training. In multivariable analyses, compared with pediatric EM-trained physicians, the OR for CT use among EM-trained physicians in children <2 years was 1.24 (95% CI 1.04-1.46), and for children >2 years was 1.68 (95% CI 1.50-1.89). Physicians of all training backgrounds, however, overused CT scans in low-risk children. CONCLUSIONS Substantial variation exists in the use of CT for children with minor blunt head trauma not explained by patient severity or rates of positive CT scans or clinically important traumatic brain injuries.

Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation

STUDY OBJECTIVE Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results. METHODS We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention. RESULTS Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%). CONCLUSION Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.

Cranial Computed Tomography Use Among Children With Minor Blunt Head Trauma: Association With Race/Ethnicity

OBJECTIVE To determine if patient race/ethnicity is independently associated with cranial computed tomography (CT) use among children with minor blunt head trauma. DESIGN Secondary analysis of a prospective cohort study. SETTING Pediatric research network of 25 North American emergency departments. PATIENTS In total, 42 412 children younger than 18 years were seen within 24 hours of minor blunt head trauma. Of these, 39 717 were of documented white non-Hispanic, black non-Hispanic, or Hispanic race/ethnicity. Using a previously validated clinical prediction rule, we classified each childs risk for clinically important traumatic brain injury to describe injury severity. Because no meaningful differences in cranial CT rates were observed between children of black non-Hispanic race/ethnicity vs Hispanic race/ethnicity, we combined these 2 groups. MAIN OUTCOME MEASURE Cranial CT use in the emergency department, stratified by race/ethnicity. RESULTS In total, 13 793 children (34.7%) underwent cranial CT. The odds of undergoing cranial CT among children with minor blunt head trauma who were at higher risk for clinically important traumatic brain injury did not differ by race/ethnicity. In adjusted analyses, children of black non-Hispanic or Hispanic race/ethnicity had lower odds of undergoing cranial CT among those who were at intermediate risk (odds ratio, 0.86; 95% CI, 0.78-0.96) or lowest risk (odds ratio, 0.72; 95% CI, 0.65-0.80) for clinically important traumatic brain injury. Regardless of risk for clinically important traumatic brain injury, parental anxiety and request was commonly cited by physicians as an important influence for ordering cranial CT in children of white non-Hispanic race/ethnicity. CONCLUSIONS Disparities may arise from the overuse of cranial CT among patients of nonminority races/ethnicities. Further studies should focus on explaining how medically irrelevant factors, such as patient race/ethnicity, can affect physician decision making, resulting in exposure of children to unnecessary health care risks.

Isolated linear skull fractures in children with blunt head trauma

BACKGROUND AND OBJECTIVE: Children and adolescents with minor blunt head trauma and isolated skull fractures are often admitted to the hospital. The objective of this study was to describe the injury circumstances and frequency of clinically important neurologic complications among children with minor blunt head trauma and isolated linear skull fractures. METHODS: This study was a planned secondary analysis of a large prospective cohort study in children <18 years old with blunt head trauma. Data were collected in 25 emergency departments. We analyzed patients with Glasgow Coma Scale scores of 14 or 15 and isolated linear skull fractures. We ascertained acute neurologic outcomes through clinical information collected during admission or via telephone or mail at least 1 week after the emergency department visit. RESULTS: In the parent study, we enrolled 43 904 children (11 035 [25%] <2 years old). Of those with imaging studies, 350 had isolated linear skull fractures. Falls were the most common injury mechanism, accounting for 70% (81% for ages <2 years old). Of 201 hospitalized children, 42 had computed tomography or MRI repeated; 5 had new findings but none required neurosurgical intervention. Of 149 patients discharged from the hospital, 20 had repeated imaging, and none had new findings. CONCLUSIONS: Children with minor blunt head trauma and isolated linear skull fractures are at very low risk of evolving other traumatic findings noted in subsequent imaging studies or requiring neurosurgical intervention. Hospital admission for neurologically normal children with isolated linear skull fractures after minor blunt head trauma for monitoring is typically unnecessary.

Isolated Loss of Consciousness in Children With Minor Blunt Head Trauma

IMPORTANCE A history of loss of consciousness (LOC) is frequently a driving factor for computed tomography use in the emergency department evaluation of children with blunt head trauma. Computed tomography carries a nonnegligible risk for lethal radiation-induced malignancy. The Pediatric Emergency Care Applied Research Network (PECARN) derived 2 age-specific prediction rules with 6 variables for clinically important traumatic brain injury (ciTBI), which included LOC as one of the risk factors. OBJECTIVE To determine the risk for ciTBIs in children with isolated LOC. DESIGN, SETTING, AND PARTICIPANTS This was a planned secondary analysis of a large prospective multicenter cohort study. The study included 42 ,412 children aged 0 to 18 years with blunt head trauma and Glasgow Coma Scale scores of 14 and 15 evaluated in 25 emergency departments from 2004-2006. EXPOSURE A history of LOC after minor blunt head trauma. MAIN OUTCOMES AND MEASURES The main outcome measures were ciTBIs (resulting in death, neurosurgery, intubation for >24 hours, or hospitalization for ≥2 nights) and a comparison of the rates of ciTBIs in children with no LOC, any LOC, and isolated LOC (ie, with no other PECARN ciTBI predictors). RESULTS A total of 42 412 children were enrolled in the parent study, with 40 693 remaining in the current analysis after exclusions. Of these, LOC occurred in 15.4% (6286 children). The prevalence of ciTBI with any history of LOC was 2.5% and for no history of LOC was 0.5% (difference, 2.0%; 95% CI, 1.7-2.5). The ciTBI rate in children with isolated LOC, with no other PECARN predictors, was 0.5% (95% CI, 0.2-0.8; 13 of 2780). When comparing children who have isolated LOC with those who have LOC and other PECARN predictors, the risk ratio for ciTBI in children younger than 2 years was 0.13 (95% CI, 0.005-0.72) and for children 2 years or older was 0.10 (95% CI, 0.06-0.19). CONCLUSIONS AND RELEVANCE Children with minor blunt head trauma presenting to the emergency department with isolated LOC are at very low risk for ciTBI and do not routinely require computed tomographic evaluation.

Epidemiology of Blunt Head Trauma in Children in U.S. Emergency Departments

Among more than 43,000 children treated in 25 emergency departments for blunt head trauma, traumatic brain injury was identified on CT scan in 7% of the patients. Falls were the most frequent injury mechanism for children under the age of 12 years.

Incidental Findings in Children With Blunt Head Trauma Evaluated With Cranial CT Scans

OBJECTIVE: Cranial computed tomography (CT) scans are frequently obtained in the evaluation of blunt head trauma in children. These scans may detect unexpected incidental findings. The objectives of this study were to determine the prevalence and significance of incidental findings on cranial CT scans in children evaluated for blunt head trauma. METHODS: This was a secondary analysis of a multicenter study of pediatric blunt head trauma. Patients <18 years of age with blunt head trauma were eligible, with those undergoing cranial CT scan included in this substudy. Patients with coagulopathies, ventricular shunts, known previous brain surgery or abnormalities were excluded. We abstracted radiology reports for nontraumatic findings. We reviewed and categorized findings by their clinical urgency. RESULTS: Of the 43 904 head-injured children enrolled in the parent study, 15 831 underwent CT scans, and these latter patients serve as the study cohort. On 670 of these scans, nontraumatic findings were identified, with 16 excluded due to previously known abnormalities or surgeries. The remaining 654 represent a 4% prevalence of incidental findings. Of these, 195 (30%), representing 1% of the overall sample, warranted immediate intervention or outpatient follow-up. CONCLUSIONS: A small but important number of children evaluated with CT scans after blunt head trauma had incidental findings. Physicians who order cranial CTs must be prepared to interpret incidental findings, communicate with families, and ensure appropriate follow-up. There are ethical implications and potential health impacts of informing patients about incidental findings.

Pharmacological sedation for cranial computed tomography in children after minor blunt head trauma

Objective Children evaluated in emergency departments for blunt head trauma (BHT) frequently undergo computed tomography (CT), with some requiring pharmacological sedation. Cranial CT sedation complications are understudied. The objective of this study was to document the frequency, type, and complications of pharmacological sedation for cranial CT in children. Methods We prospectively enrolled children (younger than 18 years) with minor BHT presenting to 25 emergency departments from 2004 to 2006. Data collected included sedation agent and complications. We excluded patients with Glasgow Coma Scale scores of less than 14. Results Of 57,030 eligible patients, 43,904 (77%) were enrolled in the parent study; 15,176 (35%) had CT scans performed or planned, and 527 (3%) received pharmacological sedation for CT. Sedated patients’ characteristics were as follows: median age, 1.7 years (interquartile range, 1.1–2.5 years); male 61%; Glasgow Coma Scale score of 15, 86%; traumatic brain injury on CT, 8%. There were 488 patients (93%) who received 1 sedative. Sedation use (0%–21%) and regimen varied by site. Pentobarbital (n = 164) and chloral hydrate (n = 149) were the most frequently used agents. Sedation complications occurred in 49 patients (9%; 95% confidence interval [CI], 7%–12%): laryngospasm 1 (0.2%; 95% CI, 0%–1.1%), failed sedation 31 (6%; 95% CI, 4%–8%), vomiting 6 (1%; 95% CI, 0.4%–2%), hypotension 13 (4%; 95% CI, 2%–7%), and hypoxia 1 (0.2%; 95% CI, 0%–2%). No cases of apnea, aspiration, or reversal agent use occurred. One patient required intubation. Vomiting and failed sedation were most common with chloral hydrate. Conclusions Pharmacological sedation is infrequently used for children with minor BHT undergoing CT, and complications are uncommon. The variability in sedation medications and frequency suggests a need for evidence-based guidelines.