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Paediatric mild head injury: is routine admission to a tertiary trauma hospital necessary?
Krishna Tallapragada1, Ratna Soundarya Peddada1, Mark Dexter2
1Department of Neurosurgery, Children's Hospital Westmead, NSW Health, Sydney, New South Wales, Australia.
Insights
Most pediatric mild head injuries with skull fractures or small hematomas do not require surgery and can be safely managed at primary hospitals. Conservative management leads to good outcomes and brief hospital stays for these children.
Area of Science:
- Pediatric neurosurgery
- Trauma care
- Pediatric emergency medicine
Background:
- Children with isolated linear skull fractures have good outcomes and low surgical risk.
- Identifying mild head injury patterns suitable for conservative management is crucial.
- Safe management of low-risk pediatric head injuries in primary hospitals is a key goal.
Purpose of the Study:
- To identify injury patterns in pediatric mild head injury (MHI) suitable for conservative management.
- To assess the safety and feasibility of managing low-risk neurosurgical lesions in primary hospitals.
- To evaluate outcomes for children with MHI and skull fractures or hematomas.
Main Methods:
- Retrospective analysis of 410 children with MHI (Glasgow Coma Scale 13-15) and CT findings (fracture/hematoma).
- Data collected on demographics, clinical presentation, injury mechanism, CT findings, interventions, and outcomes.
- Statistical analysis using Wilcoxon paired test (P<0.05).
Main Results:
- 93% (381/410) of children were managed conservatively.
- Only 4% (18/410) required extradural hematoma evacuation and 3% (11/410) needed fracture repair.
- Two children developed surgical lesions post-admission; 75% with non-surgical lesions discharged within 2 days.
Conclusions:
- Children with small intracranial hematomas and/or skull fractures not requiring surgery need brief inpatient care.
- These patients can be safely managed in primary hospitals, improving cost-effectiveness.
- Enhanced tertiary hospital transfer guidelines can optimize care for deteriorating patients without compromising safety.
Background:
Previous studies have shown that children with isolated linear skull fractures have excellent clinical outcomes and low risk of surgery. We wish to identify other injury patterns within the spectrum of paediatric mild head injury, which need only conservative management. Children with low risk of evolving neurosurgical lesions could be safely managed in primary hospitals.
Methods:
We retrospectively analysed all children with mild head injury (i.e. admission Glasgow coma score 13-15) and skull fracture or haematoma on a head computed tomography scan admitted to Westmead Children's Hospital, Sydney over the years 2009-2014. Data were collected regarding demographics, clinical findings, mechanism of injury, head computed tomography scan findings, neurosurgical intervention, outcome and length of admission. Wilcoxon paired test was used with P value <0.05 considered significant.
Results:
Four hundred and ten children were analysed. Three hundred and eighty-one (93%) children were managed conservatively, 18 (4%) underwent evacuation of extradural haematoma (TBI surgery) and 11 (3%) needed fracture repair surgery. Two children evolved a surgical lesion 24 h post-admission. Only 17 of 214 children transferred from peripheral hospitals needed neurosurgery. Overall outcomes: zero deaths, one needed brain injury rehabilitation and 63 needed child protection unit intervention. Seventy-five percentage of children with non-surgical lesions were discharged within 2 days. Eighty-three percentage of road transfers were discharged within 3 days.
Conclusions:
Children with small intracranial haematomas and/or skull fractures who need no surgery only require brief inpatient symptomatic treatment and could be safely managed in primary hospitals. Improved tertiary hospital transfer guidelines with protocols to manage clinical deterioration could have cost benefit without risking patient safety.
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