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Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage: Identifying Low-Risk Patients Who May Not
Erin Comer Burns, Beech Burns1, Craig D Newgard
1Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine.
Insights
A new decision rule can identify children with traumatic intracranial hemorrhage (tICH) who may not need intensive care unit (ICU) admission. This tool helps avoid unnecessary ICU care for low-risk pediatric patients.
Area of Science:
- Pediatric Traumatology
- Neurocritical Care
- Clinical Decision Instruments
Background:
- Pediatric patients with traumatic intracranial hemorrhage (tICH) are often admitted to ICUs for monitoring.
- There's a need to identify mild tICH cases that don't require intensive care.
Purpose of the Study:
- To determine the frequency of tICH in children.
- To describe patient disposition after tICH.
- To identify pediatric patients at low risk for critical care intervention (CCI).
Main Methods:
- Retrospective review of pediatric tICH patients (0-17 years) from 2008-2013.
- Defined CCI to include mechanical ventilation, invasive monitoring, blood products, hyperosmolar therapy, and neurosurgery.
- Developed a clinical decision instrument using recursive partitioning to identify low-risk patients.
Main Results:
- Out of 296 tICH admissions, 29 required inpatient CCI.
- The decision instrument identified low-risk patients based on the absence of midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries.
- The instrument had high sensitivity (96.6%) for excluding patients needing CCI, misclassifying only one patient.
Conclusions:
- A subset of pediatric tICH patients may not require ICU admission.
- The developed decision rule can identify low-risk children suitable for observation outside the ICU.
- External validation is recommended before implementing this decision rule.
Background:
Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary.
Objectives:
To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI).
Methods:
We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI.
Results:
Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%-99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, -0.053-0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample).
Conclusions:
A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.
