Tara Rhine

Clinical predictors of outcome following inflicted traumatic brain injury in children

BACKGROUND The study aimed to determine which acute injury variables were predictors of long-term functional outcome following inflicted traumatic brain injury (iTBI). METHODS A retrospective case review of 35 children with iTBI was performed. After controlling for age at injury and time since injury, the generalized estimation equations method was used to identify acute injury variables that were significantly related to the Glasgow Outcome Scale scores at the initial follow-up assessments. When available, functional sequelae at these and longer-term follow-ups were also examined. RESULTS In bivariate generalized estimation equations analyses, a low Glasgow Coma Scale (GCS) eye component score, a low GCS motor component score, a low GCS verbal component score, need for neurosurgical intervention, seizures in the first week after injury, need for mechanical ventilation for more than 10 days, length of intensive care unit stay of more than 10 days, initial hyperglycemia, and neuroimaging findings of cerebral edema or loss of gray-white matter differentiation were significantly (p ⩽ 0.05) related to having a poor outcome, as defined by their Glasgow Outcome Scale score at the initial follow-up. In multivariable analyses, considering the significant predictors while controlling for age at injury and time since injury, the presence of cerebral edema on neuroimaging (odds ratio, 27.21; 95% confidence interval, 4.40–168.22), and length of intensive care unit stay of more than 10 days (odds ratio, 21.57; 95% confidence interval, 3.09–150.48) were significantly related to having a poor outcome. CONCLUSION Early clinical data following iTBI help predict long-term functional outcome. Further research to support these findings may help delineate acutely after injury which children with iTBI are at risk for a poor prognosis and should be more closely followed up over time. LEVEL OF EVIDENCE Prognostic study, level IV.

Are UCH-L1 and GFAP promising biomarkers for children with mild traumatic brain injury?

Abstract Objectives: To compare serum biomarker levels between children with mild traumatic brain injury (mTBI) and orthopaedic injury (OI), acutely following injury. Secondarily, to explore the association between biomarker levels and symptom burden over 1 month post-injury. Methods: This was a prospective cohort study of children aged 11–16 years who presented to the emergency department within 6 hours of sustaining mTBI or isolated extremity OI. Serum was drawn at the time of study enrollment and levels of ubiquitin carboxyl-terminal hydrolase L1 (UCH-L1) and glial fibrillary acid protein (GFAP) were analysed. Symptom burden was assessed by the Post-Concussion Symptom Scale (PCSS) acutely following injury and at three subsequent time points over 1 month. Results: Twenty-five children with mTBI and 20 children with OI were enrolled. The average age for the overall cohort was 13 (± 1.6) years and the majority were male and injured playing sports. GFAP levels and PCSS scores were significantly higher acutely following mTBI vs OI (p < 0.01). There was not a significant group difference in UCH-L1 levels. Neither GFAP nor UCH-L1 were predictive of PCSS scores over the 1month post-injury. Conclusions: GFAP may be a promising diagnostic tool for children with mTBI. Additional approaches are needed to predict symptom severity and persistence.

A longitudinal examination of postural impairments in children with mild traumatic brain injury: implications for acute testing

Objective: To examine how postural control changes following pediatric mild traumatic brain injury. Setting: Urban pediatric emergency department. Participants: Children 11 to 16 years old who presented within 6 hours of sustaining mild traumatic brain injury. Design: Prospective observational cohort followed for 1 month. Main Measures: Total center of pressure path velocity and path velocity within distinct frequency bands, ranging from moderate to ultralow, were recorded by the Nintendo Wii Balance Board during a 2-legged stance. Measurements were recorded in 2 separate tests with eyes open and closed. The scores of the 2 tests were compared, and a Romberg quotient was computed. Results: Eleven children were followed for 1 month postinjury. The ultralow frequency, which reflects slow postural movements associated with exploring stability boundaries, was lower (p = .02) during the eyes closed stance acutely following injury. The Romberg quotient for this frequency was also significantly lower acutely following injury (p = .007) than at 1 month. Conclusion: Following mild traumatic brain injury, children acutely demonstrate significantly more rigid sway patterns with eyes closed than with eyes open, which were highlighted by the Romberg quotient. The Romberg quotient could allow for accurate identification and tracking of postural instability without requiring knowledge of preinjury balance ability.

Investigating the feasibility and utility of bedside balance technology acutely after pediatric concussion: a pilot study

Objective:To examine postural instability in children acutely after concussion, using the Wii Balance Board (WBB). We hypothesized that children with traumatic brain injury would have significantly worse balance relative to children without brain injury. Design:Prospective case–control pilot study. Setting:Emergency department of a tertiary urban pediatric hospital. Participants:Cases were a convenience sample 11-16 years old who presented within 6 hours of sustaining concussion. Two controls, matched on gender, height, and age, were enrolled for each case that completed study procedures. Controls were children who presented for a minor complaint that was unlikely to affect balance. Interventions:Not applicable. Main Outcome Measures:The participants postural sway expressed as the displacement in centimeters of the center of pressure during a timed balance task. Balance testing was performed using 4 stances (single or double limb, eyes open or closed). Results:Three of the 17 (17.6%) cases were too dizzy to complete testing. One stance, double limbs eyes open, was significantly higher in cases versus controls (85.6 vs 64.3 cm, P = 0.04). Conclusions:A simple test on the WBB consisting of a 2-legged standing balance task with eyes open discriminated children with concussion from non-head-injured controls. The low cost and feasibility of this device make it a potentially viable tool for assessing postural stability in children with concussion for both longitudinal research studies and clinical care. Clinical Relevance:These pilot data suggest that the WBB is an inexpensive tool that can be used on the sideline or in the outpatient setting to objectively identify and quantify postural instability.

Prevalence and trends of the adult patient population in a pediatric emergency department.

Objectives Although pediatric emergency departments (PEDs) generally do not care for adult patients (≥21 years old), adult patients still present to PEDs with short-term complaints. The purpose of this study was to describe trends in the prevalence, the acuity, and the causes of adult patients presenting to a PED. Methods Patients consisted of adults (≥21 years old) seen in a large, urban PED from January 1, 2004, to December 31, 2008. Data were obtained retrospectively from the electronic medical record. Data included demographics, triage acuity, primary codes according to the International Classification of Diseases, 9th Revision, insurance status, referred status, and disposition. Results There were 463,827 patient visits during the study period. Of these visits, 3361 (0.7%) were adult patients, with a mean (SD) age of 27.5 (9) years. During the 5-year study period, overall PED visits increased by 9% (from 85,987 to 93,753), whereas adult patient visits increased 29% (from 605 to 780). Of the adult patients seen, 1898 (55%) were white and 2100 (62%) were female. Moreover, 1465 (44%) were triaged either emergently or to the medical/trauma resuscitation room, 652 (20%) were admitted, and 677 (20%) were transferred to another facility. Of these adult patients, 712 (21%) were referred to our PED by a primary care provider or subspecialist, and 790 (29%) had no insurance. Conclusions Adult visits to a large, urban PED have increased significantly during the past 5 years. Often, these patients have little or no insurance and present with a high acuity. Transitioning adult patients with long-term “pediatric” conditions and further training PED staff on how to care for adult patients are essential.

Investigating the Connection Between Traumatic Brain Injury and Posttraumatic Stress Symptoms in Adolescents

Objective: To identify potentially modifiable individual and social-environmental correlates of posttraumatic stress symptoms (PTSS) among adolescents hospitalized for traumatic brain injury (TBI). Setting: Four pediatric hospitals and 1 general hospital in the United States. Participants: Children ages 11 to 18 years, hospitalized for moderate-severe TBI within the past 18 months. Design: Retrospective cross-sectional analysis. Main Measures: The University of California at Los Angeles (UCLA) Post-traumatic Stress Disorder (PTSD) Reaction Index and the Youth Self-Report (YSR) PTSD subscale. Results: Of 147 adolescents enrolled, 65 (44%) had severe TBI, with an average time since injury of 5.8 ± 4 months. Of the 104 who completed the UCLA-PTSD Reaction Index, 22 (21%) reported PTSS and 9 (8%) met clinical criteria for PTSD. Of the 143 who completed the YSR-PTSD subscale, 23 (16%) reported PTSS and 6 (4%) met clinical criteria for PTSD. In multivariable analyses, having a negative approach to problem solving and depressive symptoms were both associated (P < .001) with higher levels of PTSS based on the UCLA-PTSD Reaction Index (&bgr; = 0.41 and &bgr; = 0.33, respectively) and the YSR-PTSD subscale (&bgr; = 0.33 and &bgr; = 0.40, respectively). Conclusion: Targeting negative aspects of problem solving in youths after brain injury may mitigate PTSS.

Emergency Department Care of Young Children at Risk for Traumatic Brain Injury: What Are We Doing and Do Parents Understand?

Objectives The aims of the study were to describe emergency department (ED) management of young children with head injury and to assess parental comfort level and perceptions of ED care. Methods This was a prospective observational study of children younger than 5 years who presented to a pediatric ED after head injury. Children were eligible if clinical observation was an appropriate ED management option per the Pediatric Emergency Care Academic Research Networks neuroimaging clinical decision rule. Demographics, injury variables, and ED clinician surveys explaining the care provided were collected at time of study enrollment. Parents were subsequently contacted to assess understanding of ED management and comfort with care. Results One hundred four children were enrolled with a mean (standard deviation) age of 1.19 (1.34) years. Thirty (29%) had emergent neuroimaging and 59 (57%) were placed into a period of observation per clinician report. A total of 37 children received a head computed tomography, of which 21 (57%) were normal. Eighty-four parents (81%) completed the phone follow-up. Of these children, there was a significant difference between whether parents and clinicians reported that the child had been clinically observed in the ED (P < 0.0001). Parents of children who did not receive a head CT were more likely to be uncomfortable with the decision to obtain neuroimaging compared with those who did receive a head CT (P = 0.003). Conclusions Parents are not always comfortable with the medical care practices provided and are often unaware of clinical observation when it does occur. Better parent-clinician communication could improve parental understanding and reduce overall discomfort.

Characterizing Hospitalizations for Pediatric Concussion and Trends in Care

BACKGROUND Children hospitalized for concussion may be at a higher risk for persistent symptoms, but little is known about this subset of children. OBJECTIVE Delineate a cohort of children admitted for concussion, describe care practices received, examine factors associated with prolonged length of stay (LOS) or emergency department (ED) readmission, and investigate changes in care over time. DESIGN/SETTING Retrospective analysis of data submitted by 40 pediatric hospitals to the Pediatric Health Information System. PATIENTS Children 0 to 17 years old admitted with a primary diagnosis of concussion from 2007 to 2014. MEASUREMENTS Descriptive statistics characterized this cohort and care practices delivered, logistic regression identified factors associated with a LOS of ≥2 days and ED readmission, and trend analyses assessed changes in care over time. RESULTS Of the 10,729 children admitted for concussion, 68.7% received intravenous pain or antiemetic medications. Female sex, adolescent age, and having government insurance were all associated (P ⩽ .02) with increased odds of LOS ≥ 2 days and ED revisit. Proportions of children receiving intravenous ondansetron (slope = 1.56, P = .001) and ketorolac (slope = 0.61, P < .001) increased over time, and use of neuroimaging (slope = −1.75, P < .001) decreased. CONCLUSIONS Although concussions are usually self-limited, hospitalized children often receive intravenous therapies despite an unclear benefit. Factors associated with prolonged LOS and ED revisit were similar to predictors of postconcussive syndrome. Since there has been an increased use of specific therapeutics, prospective evaluation of their relationship with concussion recovery could lay the groundwork for evidenced-based admission criteria and optimize recovery.

Factors influencing emergency department care of young children at-risk for clinically important traumatic brain injury

Objectives Care decisions for young children presenting to the emergency department (ED) with head injury are often challenging (e.g. whether to obtain neuroimaging). We sought to identify factors associated with acute management of children at‐risk for clinically important traumatic brain injury (ciTBI) and describe symptom management. Methods Observational evaluation of children, ages 0–4 years, presenting to a pediatric ED following minor head injury. Children with ≥1 risk element per the Pediatric Emergency Care Academic Research Networks decision rule were deemed “at‐risk” for ciTBI. Clinician surveys regarding their initial clinical management were used to identify three care groups. Nonparametric tests analyzed group differences and logistic regression investigated associations of putative high‐risk factors with neuroimaging. Results Of 104 children enrolled: (i) 30 underwent neuroimaging, (ii) 59 were observed, and (iii) 15 were discharged following the clinicians initial patient exam. Children with a non‐frontal scalp hematoma were more likely to receive immediate neuroimaging and children not acting like themselves per caregiver report were more likely to be initially observed, relative to the other care groups (p ≤ 0.01). Among high‐risk factors, altered mental status (OR 5.12, 95% CI 1.8–21.1), presence of ≥3 risk elements of the decision rule (OR 3.5, 95% CI 1.2–10.6), unclear skull fracture on exam (OR 31.3, 95% CI 5.4–593.8), and age < 3 months (OR 5.3, 95% CI 1.5–21.9) were associated with neuroimaging. No child had ciTBI. TBI symptoms (e.g. vomiting) were infrequently treated. Conclusions ED management varied for young children with similar risk stratification. Investigation of how age in concert with specific risk factors influences medical decision making would advance evidenced‐based care.