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Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study
Meredith L Borland1, Stuart R Dalziel2, Natalie Phillips3
1Perth Children's Hospital (formerly Princess Margaret Hospital for Children), Perth, Western Australia, Australia; Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Western Australia, Australia.
Insights
Delayed head injury presentation in children, though uncommon, is linked to traumatic brain injury (TBI). Key signs like nonfrontal scalp hematomas and vomiting indicate increased TBI risk, guiding emergency department evaluations.
Area of Science:
- Pediatric Emergency Medicine
- Neurotrauma
- Clinical Decision Rules
Background:
- Existing clinical decision rules for head-injured children primarily cover presentations within 24 hours of injury.
- A subset of children present to emergency departments more than 24 hours after head injury, necessitating specific evaluation guidelines.
Purpose of the Study:
- To determine the prevalence of traumatic brain injuries (TBIs) in children presenting >24 hours after head injury.
- To identify key symptoms and signs associated with TBI in delayed presentations to guide clinical management.
Main Methods:
- Secondary analysis of the Australasian Paediatric Head Injury Rule Study data.
- Focused on children with first presentations >24 hours post-injury and Glasgow Coma Scale scores of 14-15.
- Examined associations between clinical factors and TBI on computed tomography (CT) and clinically important TBI.
Main Results:
- 5.0% of 19,765 children presented >24 hours after injury; 3.8% had TBI on CT, with 0.8% having clinically important TBI.
- Delayed presentation was associated with nonfrontal scalp hematoma, headache, vomiting, and suspected nonaccidental injury.
- Nonfrontal scalp hematoma and suspicion of depressed skull fracture were significant predictors of TBI on CT and clinically important TBI.
Conclusions:
- Delayed presentation of pediatric head injury, while infrequent, carries a significant association with TBI.
- Clinical evaluation for delayed head injury presentations should prioritize identified risk factors such as nonfrontal scalp hematomas and suspected fractures.
Study Objective:
Existing clinical decision rules guide management for head-injured children presenting 24 hours or sooner after injury, even though some may present greater than 24 hours afterward. We seek to determine the prevalence of traumatic brain injuries for patients presenting to emergency departments greater than 24 hours after injury and identify symptoms and signs to guide management.
Methods:
This was a planned secondary analysis of the Australasian Paediatric Head Injury Rule Study, concentrating on first presentations greater than 24 hours after injury, with Glasgow Coma Scale scores 14 and 15. We sought associations with predictors of traumatic brain injury on computed tomography (CT) and clinically important traumatic brain injury.
Results:
Of 19,765 eligible children, 981 (5.0%) presented greater than 24 hours after injury, and 465 injuries (48.5%) resulted from falls less than 1 m and 37 (3.8%) involved traffic incidents. Features associated significantly with presenting greater than 24 hours after injury in comparison with presenting within 24 hours were nonfrontal scalp hematoma (20.8% versus 18.1%), headache (31.6% versus 19.9%), vomiting (30.0% versus 16.3%), and assault with nonaccidental injury concerns (1.4% versus 0.4%). Traumatic brain injury on CT occurred in 37 patients (3.8%), including suspicion of depressed skull fracture (8 [0.8%]) and intracranial hemorrhage (31 [3.8%]). Clinically important traumatic brain injury occurred in 8 patients (0.8%), with 2 (0.2%) requiring neurosurgery, with no deaths. Suspicion of depressed skull fracture was associated with traumatic brain injury on CT consistently, with the only other significant factor being nonfrontal scalp hematoma (odds ratio 19.0; 95% confidence interval 8.2 to 43.9). Clinically important traumatic brain injury was also associated with nonfrontal scalp hematoma (odds ratio 11.7; 95% confidence interval 2.4 to 58.6) and suspicion of depressed fracture (odds ratio 19.7; 95% confidence interval 2.1 to 182.1).
Conclusion:
Delayed presentation after head injury, although infrequent, is significantly associated with traumatic brain injury. Evaluation of delayed presentations must consider identified factors associated with this increased risk.
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