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Published on: August 16, 2019
Applying Pediatric Brain Injury Guidelines at a Level I Adult/Pediatric Safety-Net Trauma Center
Jamie Schwartz1, Marie Crandall2, Albert Hsu2
1College of Medicine, University of Florida, Gainesville, Florida.
Insights
Applying Brain Injury Guidelines (BIG) to children with mild traumatic intracranial hemorrhage (T-ICH) can safely reduce repeat head CTs (RHCT) and neurosurgical consultations (NSC). This approach helps optimize care for pediatric TBI patients.
Area of Science:
- Pediatric Traumatology
- Neurocritical Care
- Clinical Decision Support
Background:
- Pediatric brain injuries, specifically mild traumatic intracranial hemorrhage (T-ICH), are common.
- Current management of pediatric T-ICH is suboptimal, leading to overuse of repeat head CTs (RHCT) and neurosurgical consultations (NSC).
- Brain Injury Guidelines (BIG) offer a standardized framework for TBI management, with potential applicability to pediatric populations.
Purpose of the Study:
- To apply the Brain Injury Guidelines (BIG) to a low-risk pediatric TBI population.
- To evaluate the safety and efficacy of the BIG framework in reducing overutilization of RHCT and NSC in children.
- To determine if BIG can be safely applied to pediatric patients with mild T-ICH.
Main Methods:
- Retrospective chart review of a pediatric trauma registry over four years.
- Application of BIG criteria to identify patients eligible for evaluation of RHCT and neurosurgical intervention (NSG-I).
- Inclusion of patients with minor skull fractures (mSFx) who otherwise met BIG-1 criteria.
Main Results:
- Twenty-eight pediatric patients with low-risk T-ICH were reviewed.
- RHCT was performed in seven patients; only two were clinically indicated.
- No patient meeting BIG-1 criteria (with or without mSFx) required NSG-I.
Conclusions:
- The BIG criteria can be safely applied to children with mild T-ICH, reducing RHCT and NSC.
- Pediatric patients with mSFx meeting BIG-1 criteria can be managed by acute care surgeons.
- Further prospective studies are needed to validate these findings in larger pediatric populations.
Background:
Pediatric brain injuries are common, but current management of patients with mild traumatic intracranial hemorrhage (T-ICH) is suboptimal, often including unnecessary repeat head CT (RHCT) and neurosurgical consultation (NSC). Brain Injury Guidelines (BIG) have been developed to standardize the management of TBI, and recent work suggests they may be applied to children. The aim of this study was to apply BIG to a low-risk pediatric TBI population to further determine whether the framework can be safely applied to children in a way that reduces overutilization of RHCTs and NSC.
Methods:
A retrospective chart review of a Level I Adult and Pediatric Trauma Center's pediatric registry over 4 y was performed. BIG was applied to these patients to evaluate the utility of RHCT and need for neurosurgical intervention (NSG-I) in those meeting BIG-1 criteria. Those with minor skull fracture (mSFx) who otherwise met BIG-1 criteria were also included.
Results:
Twenty-eight patients with low-risk T-ICH met criteria for review. RHCT was performed in seven patients, with only two being prompted by clinical neurologic change/deterioration. NSC occurred in 21 of the cases. Ultimately, no patient identified by BIG-1 ± mSFx required NSG-I.
Conclusions:
Application of BIG criteria to children with mild T-ICH appears capable of reducing RHCT and NSC safely. Additionally, those with mSFx that otherwise fulfill BIG-1 criteria can be managed similarly by acute care surgeons. Further prospective studies should evaluate the application of BIG-1 in larger patient populations to support the generalizability of these findings.
