Television-Related Head Injuries in Children: A Secondary Analysis of a Large Cohort Study of Head-Injured Children in the Pediatric Emergency Care Applied Research Network.

OBJECTIVE: The objective of the study was to describe the epidemiology, cranial computed tomography (CT) findings, and clinical outcomes of children with blunt head trauma after television tip-over injuries. METHODS: We performed a secondary analysis of children younger than 18 years prospectively evaluated for blunt head trauma at 25 emergency departments (EDs) in the Pediatric Emergency Care Applied Research Network from June 2004 to September 2006. Children injured from falling televisions were included. Patients were excluded if injuries occurred more than 24 hours before ED evaluation or if neuroimaging was obtained before evaluation. Data collected included age, race, sex, cranial CT findings, and clinical outcomes. Clinically important traumatic brain injuries (ciTBIs) were defined as death from TBI, neurosurgery, intubation for more than 24 hours for the TBI, or hospital admission of 2 nights or more for the head injury, in association with TBI on CT. RESULTS: A total of 43,904 children were enrolled into the primary study and 218 (0.5%; 95% confidence interval [CI], 0.4% to 0.6%) were struck by falling televisions. The median (interquartile range) age of the 218 patients was 3.1 (1.9-4.9) years. Seventy-five (34%) of the 218 underwent CT scanning. Ten (13.3%; 95% CI, 6.6% to 23.2%) of the 75 patients with an ED CT had traumatic findings on cranial CT scan. Six patients met the criteria for ciTBI. Three of these patients died. All 6 patients with ciTBIs were younger than 5 years. CONCLUSIONS: Television tip-overs may cause ciTBIs in children, including death, and the most severe injuries occur in children 5 years or younger. These injuries may be preventable by simple preventive measures such as anchoring television sets with straps.

Prevalence of Brain Injuries and Recurrence of Seizures in Children With Posttraumatic Seizures.

OBJECTIVES: Computed tomography (CT) is often used in the emergency department (ED) evaluation of children with posttraumatic seizures (PTS); however, the frequency of traumatic brain injuries (TBIs) and short-term seizure recurrence is lacking. Our main objective was to evaluate the frequency of TBIs on CT and short-term seizure recurrence in children with PTS. We also aimed to determine the associations between the likelihood of TBI on CT with the timing of onset of PTS after the traumatic event and duration of PTS. Finally, we aimed to determine whether patients with normal CT scans and normal neurological examinations are safe for discharge from the ED. METHODS: This was a planned secondary analysis from a prospective observational cohort study to derive and validate a neuroimaging decision rule for children after blunt head trauma at 25 EDs in the Pediatric Emergency Care Applied Research Network. We evaluated children < 18 years with head trauma and PTS between June 2004 and September 2006. We assessed TBI on CT, neurosurgical interventions, and recurrent seizures within 1 week. Patients discharged from the ED were contacted by telephone 1 week to 3 months later. RESULTS: Of 42,424 children enrolled, 536 (1.3%, 95% confidence interval [CI] = 1.2%-1.4%) had PTS. A total of 466 of 536 (86.9%, 95% CI = 83.8%-89.7%) underwent CT in the ED. TBIs on CT were identified in 72 (15.5%, 95% CI = 12.3%-19.1%), of whom 20 (27.8%, 95% CI = 17.9%-39.6%) underwent neurosurgical intervention and 15 (20.8%, 95% CI = 12.2%-32.0%) had recurrent seizures. Of the 464 without TBIs on CT (or no CTs performed), 457 had recurrent seizure status known, and five (1.1%, 95 CI = 0.4%-2.5%) had recurrent seizures; four of five presented with Glasgow Coma Scale scores < 15. None of the 464 underwent neurosurgical intervention. We found significant associations between likelihood of TBI on CT with longer time until the PTS after the traumatic event (p = 0.006) and longer duration of PTS (p < 0.001). CONCLUSIONS: Children with PTS have a high likelihood of TBI on CT, and those with TBI on CT frequently require neurosurgical interventions and frequently have recurrent seizures. Those without TBIs on CT, however, are at low risk of short-term recurrent seizures, and none required neurosurgical interventions. Therefore, if CT-negative and neurologically normal, patients with PTS may be safely considered for discharge from the ED.

Clinical Presentations and Outcomes of Children With Basilar Skull Fractures After Blunt Head Trauma.

STUDY OBJECTIVE: We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma. METHODS: This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT). RESULTS: Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT. CONCLUSION: Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.

Performance of the Pediatric Glasgow Coma Scale Score in the Evaluation of Children With Blunt Head Trauma.

OBJECTIVE: The objective was to compare the accuracy of the pediatric Glasgow Coma Scale (GCS) score in preverbal children to the standard GCS score in older children for identifying those with traumatic brain injuries (TBIs) after blunt head trauma. METHODS: This was a planned secondary analysis of a large prospective observational multicenter cohort study of children with blunt head trauma. Clinical data were recorded onto case report forms before computed tomography (CT) results or clinical outcomes were known. The total and component GCS scores were assigned by the physician at initial emergency department evaluation. The pediatric GCS was used for children <2 years old and the standard GCS for those ≥2 years old. Outcomes were TBI visible on CT and clinically important TBI (ciTBI), defined as death from TBI, neurosurgery, intubation for more than 24 hours for the head injury, or hospitalization for 2 or more nights for the head injury in association with TBI on CT. We compared the areas under the receiver operating characteristic (ROC) curves between age cohorts for the association of GCS and the TBI outcomes. RESULTS: We enrolled 42,041 patients, of whom 10,499 (25.0%) were <2 years old. Among patients <2 years, 313/3,329 (9.4%, 95% confidence interval [CI] = 8.4% to 10.4%) of those imaged had TBIs on CT and 146/10,499 (1.4%, 95% CI = 1.2% to 1.6%) had ciTBIs. In patients ≥2 years, 773/11,977 (6.5%, 95% CI = 6.0% to 6.9%) of those imaged had TBIs on CT and 572/31,542 (1.8%, 95% CI = 1.7% to 2.0%) had ciTBIs. For the pediatric GCS in children <2 years old, the area under the ROC curve was 0.61 (95% CI = 0.59 to 0.64) for TBI on CT and 0.77 (95% CI = 0.73 to 0.81) for ciTBI. For the standard GCS in older children, the area under the ROC curve was 0.71 (95% CI = 0.70 to 0.73) for TBI on CT scan and 0.81 (95% CI = 0.79 to 0.83) for ciTBI. CONCLUSIONS: The pediatric GCS for preverbal children was somewhat less accurate than the standard GCS for older children in identifying those with TBI on CT. However, the pediatric GCS for preverbal children and the standard GCS for older children were equally accurate for identifying ciTBI.

Comparison of Prediction Rules and Clinician Suspicion for Identifying Children With Clinically Important Brain Injuries After Blunt Head Trauma.

OBJECTIVE: Children with minor head trauma frequently present to emergency departments (EDs). Identifying those with traumatic brain injuries (TBIs) can be difficult, and it is unknown whether clinical prediction rules outperform clinician suspicion. Our primary objective was to compare the test characteristics of the Pediatric Emergency Care Applied Research Network (PECARN) TBI prediction rules to clinician suspicion for identifying children with clinically important TBIs (ciTBIs) after minor blunt head trauma. Our secondary objective was to determine the reasons for obtaining computed tomography (CT) scans when clinical suspicion of ciTBI was low. METHODS: This was a planned secondary analysis of a previously conducted observational cohort study conducted in PECARN to derive and validate clinical prediction rules for ciTBI among children with minor blunt head trauma in 25 PECARN EDs. Clinicians recorded their suspicion of ciTBI before CT as <1, 1-5, 6-10, 11-50, or >50%. We defined ciTBI as 1) death from TBI, 2) neurosurgery, 3) intubation for more than 24 hours for TBI, or 4) hospital admission of 2 nights or more associated with TBI on CT. To avoid overfitting of the prediction rules, we performed comparisons of the prediction rules and clinician suspicion on the validation group only. On the validation group, we compared the test accuracies of clinician suspicion > 1% versus having at least one predictor in the PECARN TBI age-specific prediction rules for identifying children with ciTBIs (one rule for children <2 years [preverbal], the other rule for children >2 years [verbal]). RESULTS: In the parent study, we enrolled 8,627 children to validate the prediction rules, after enrolling 33,785 children to derive the prediction rules. In the validation group, clinician suspicion of ciTBI was recorded in 8,496/8,627 (98.5%) patients, and 87 (1.0%) had ciTBIs. CT scans were obtained in 2,857 (33.6%) patients in the validation group for whom clinician suspicion of ciTBI was recorded, including 2,099/7,688 (27.3%) of those with clinician suspicion of ciTBI of <1% and 758/808 (93.8%) of those with clinician suspicion >1%. The PECARN prediction rules were significantly more sensitive than clinician suspicion >1% of ciTBI for preverbal (100% [95% confidence interval {CI} = 86.3% to 100%] vs. 60.0% [95% CI = 38.7% to 78.9%]) and verbal children (96.8% [95% CI = 88.8% to 99.6%] vs. 64.5% [95% CI = 51.3% to 76.3%]). Prediction rule specificity, however, was lower than clinician suspicion >1% for preverbal children (53.6% [95% CI = 51.5% to 55.7%] vs. 92.4% [95% CI = 91.2% to 93.5%]) and verbal children (58.2% [95% CI = 56.9% to 59.4%] vs. 90.6% [95% CI = 89.8% to 91.3%]). Of the 7,688 patients in the validation group with clinician suspicion recorded as <1%, CTs were nevertheless obtained in 2,099 (27.3%). Three of 16 (18.8%) patients undergoing neurosurgery had clinician suspicion of ciTBI <1%. CONCLUSIONS: The PECARN TBI prediction rules had substantially greater sensitivity, but lower specificity, than clinician suspicion of ciTBI for children with minor blunt head trauma. Because CT ordering did not follow clinician suspicion of <1%, these prediction rules can augment clinician judgment and help obviate CT ordering for children at very low risk of ciTBI.

Traumatic brain injuries and computed tomography use in pediatric sports participants.

BACKGROUND: Childhood sports-related head trauma is common, frequently leading to emergency department (ED) visits. We describe the spectrum of these injuries and trends in computed tomography (CT) use in the Pediatric Emergency Care Applied Research Network. METHODS: This was a secondary analysis of a large prospective cohort of children with head trauma in 25 Pediatric Emergency Care Applied Research Network EDs between 2004 and 2006. We described and compared children 5 to 18 years old by CT rate, traumatic brain injury (TBI) on CT, and clinically important TBI (ciTBI). We used multi-variable logistic regression to compare CT rates, adjusting for clinical severity. Outcomes included frequency of CT, TBIs on CT, and ciTBIs (defined by [a] death, [b] neurosurgery, [c] intubation>24 hours, or [d] hospitalization for ≥2 nights). FINDINGS: A total of 3289 (14%) of 23082 children had sports-related head trauma. Two percent had Glasgow Coma Scale scores less than 14. 53% received ED CTs, 4% had TBIs on CT, and 1% had ciTBIs. Equestrians had increased adjusted odds (1.8; 95% confidence interval [CI], 1.0-3.0]) of CTs; the rate of TBI on CT was 4% (95% CI, 3%-5%). Compared with team sports, snow (adjusted odds ratio, 4.1; 95% CI 1.5-11.4) and nonmotorized wheeled (adjusted odds ratio, 12.8; 95% CI, 5.5-32.4) sports had increased adjusted odds of ciTBIs. CONCLUSIONS: Children with sports-related head trauma commonly undergo CT. Only 4% of those imaged had TBIs on CT. Clinically important TBIs occurred in 1%, with significant variation by sport. There is an opportunity for injury prevention efforts in high-risk sports and opportunities to reduce CT use in general by use of evidence-based prediction rules. What is known about this subject: Pediatric sports-related head injuries are a common and increasingly frequent ED presentation, as is the use of CT in their evaluation. Little is known about TBIs resulting from different types of sports activities in children. What this study adds to existing knowledge: This study broadens the understanding of the epidemiology of Pediatric TBIs resulting from different sports activities through a prospective assessment of frequency and severity of ciTBIs and ED CT use in a large cohort of head-injured children in a network of pediatric EDs.

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.

Headache in traumatic brain injuries from blunt head trauma.

OBJECTIVE: To determine the risk of traumatic brain injuries (TBIs) in children with headaches after minor blunt head trauma, particularly when the headaches occur without other findings suggestive of TBIs (ie, isolated headaches). METHODS: This was a secondary analysis of a prospective observational study of children 2 to 18 years with minor blunt head trauma (ie, Glasgow Coma Scale scores of 14-15). Clinicians assessed the history and characteristics of headaches at the time of initial evaluation, and documented findings onto case report forms. Our outcome measures were (1) clinically important TBI (ciTBI) and (2) TBI visible on computed tomography (CT). RESULTS: Of 27 495 eligible patients, 12 675 (46.1%) had headaches. Of the 12 567 patients who had complete data, 2462 (19.6%) had isolated headaches. ciTBIs occurred in 0 of 2462 patients (0%; 95% confidence interval [CI]: 0%-0.1%) in the isolated headache group versus 162 of 10 105 patients (1.6%; 95% CI: 1.4%-1.9%) in the nonisolated headache group (risk difference, 1.6%; 95% CI: 1.3%-1.9%). TBIs on CT occurred in 3 of 456 patients (0.7%; 95% CI: 0.1%-1.9%) in the isolated headache group versus 271 of 6089 patients (4.5%; 95% CI: 3.9%-5.0%) in the nonisolated headache group (risk difference, 3.8%; 95% CI: 2.3%-4.5%). We found no significant independent associations between the risk of ciTBI or TBI on CT with either headache severity or location. CONCLUSIONS: ciTBIs are rare and TBIs on CT are very uncommon in children with minor blunt head trauma when headaches are their only sign or symptom.

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.

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 children's 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.