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Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation
Michael D Rollins1, Douglas C Barnhart, Richard A Greenberg
1Division of Pediatric Surgery, Primary Children's Medical Center, University of Utah, Salt Lake City, UT 84113, USA. michael.rollins@hsc.utah.edu
Insights
Children with isolated skull fractures (ISF) and a Glasgow coma score (GCS) of 15 can be safely discharged after observation, reducing hospital admissions and costs.
Area of Science:
- Pediatric Traumatology
- Emergency Medicine
- Neurosurgery
Background:
- Management of pediatric isolated skull fractures (ISF) is inconsistent.
- Assessing neurologic deterioration risk in children with GCS 15 and ISF is crucial.
Purpose of the Study:
- To estimate the risk of neurologic deterioration in pediatric patients with ISF and GCS 15.
- To guide decisions on hospital admission for these patients.
Main Methods:
- Retrospective review of pediatric trauma patients with ISF on head CT (2003-2008).
- Exclusion criteria included injury >24h, GCS <15, intracranial pathology, depressed or complex fractures.
- Focus on patients with GCS 15 and ISF.
Main Results:
- 235 pediatric patients with ISF identified; 87% from falls.
- 58 patients discharged from ED after observation (3.3h median); 177 admitted.
- Discharged patients incurred lower costs ($291 vs $1447).
Conclusions:
- Pediatric patients with ISF and GCS 15 can be safely discharged after observation if asymptomatic.
- This approach can significantly reduce unnecessary hospitalizations and associated costs.
- Reliable social environment is a key factor for safe discharge.
Purpose:
The management of children presenting with an isolated skull fracture (ISF) posttrauma is highly variable. We sought to estimate the risk of neurologic deterioration in children with a Glasgow coma score (GCS) 15 and ISF to reduce unnecessary hospital admissions.
Methods:
A retrospective review at a level I pediatric trauma referral center was conducted for patients with ISF on head computed tomography from 2003 to 2008. Patients were excluded for injury greater than 24 hours prior, GCS less than 15, intracranial pathology, significant fracture depression, or complex fractures involving facial bones or skull base.
Results:
A total of 235 patients were identified with an ISF. The median age was 11 months, with falls accounting for 87% of the injuries. One hundred seventy-seven patients were admitted, and 58 patients were discharged from the emergency department after a period of observation (median, 3.3 hours). Median length of stay for those admitted to the hospital was 18.2 hours. One patient developed vomiting following overnight observation and a repeat computed tomography scan demonstrated a small extra-axial hematoma that required no intervention. The mean total costs for patients discharged from the emergency department were $291 vs $1447 for those admitted for observation (P < .001).
Conclusion:
Patients with a presenting GCS of 15 and an ISF can be safely discharged from the emergency department after a short period of observation if they are asymptomatic and have a reliable social environment. This could result in significant savings by eliminating inpatient costs.
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