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Published on: June 21, 2019
Characteristics of pediatric patients with traumatic epidural hematomas who can be safely observed: a clinical
Lindsay Call1, Qian Qiu2, Jeffrey Morris3
1Amherst College, 220 South Pleasant Street, Amherst, MA 01002.
Insights
This study validates prediction rules for safe observation of pediatric traumatic epidural hematoma (EDH). Patients with no mass effect, small EDH volume, and no neurological deficits are unlikely to fail observation.
Area of Science:
- Pediatric Traumatology
- Neurosurgery
- Radiology
Background:
- Traumatic epidural hematoma (EDH) in children requires careful management to balance surgical intervention with conservative observation.
- Previous prediction rules for surgical intervention in pediatric EDH have been developed but require external validation in diverse cohorts.
Purpose of the Study:
- To validate existing clinical and radiographic prediction rules for safe observation of pediatric traumatic EDH.
- To assess the applicability of these rules in a distinct patient cohort.
Main Methods:
- Retrospective analysis of pediatric patients with EDH on CT scan at a Level I trauma center.
- Comparison of the internal cohort's characteristics with an external cohort used for rule development.
- Assessment of the external validity of previously established prediction rules.
Main Results:
- 195 pediatric patients with EDH were included; 158 underwent successful observation, while 37 required surgery.
- Surgical cases exhibited significantly larger EDH volume, increased midline shift, and higher rates of mass effect.
- The validated prediction rules demonstrated a positive predictive value of 97.7% and a negative predictive value of 24.5% for successful observation.
Conclusions:
- Previously developed prediction rules for pediatric EDH observation are validated in a distinct cohort.
- Patients with no mass effect, EDH volume <15 mL, and no neurological deficits are strong candidates for safe observation.
- This validation supports the continued use of conservative management strategies for select pediatric EDH cases.
Objective:
The study aimed to validate admission clinical and radiographic features of pediatric patients with traumatic epidural hematoma (EDH) that lead to safe observation.
Methods:
A Level I trauma center radiology and electronic medical record databases were retrospectively queried for pediatric patients with EDH on CT scan between 1/1/2016 and 10/1/2016. Patient imaging, treatment and outcome variables were abstracted. Characteristics of the cohort were compared to an external cohort used to develop prediction rules for surgical intervention. External validity of the prediction rules was assessed.
Results:
195 eligible subjects were included in the study, 37 of which failed observation and required surgery while 158 underwent successful observation. The surgical cohort had significantly thicker (p < .001) and higher volume (p < .001) EDH, increased midline shift (p < .001) and higher likelihood of mass effect (p < .001). There was significantly higher residual neurologic deficit rate (54% vs 23%, p < .001) and hospital mortality (5% vs 0%, p = .035) amongst the surgical group. There were significant differences in patient demographic, clinical and imaging characteristics between the internal and external cohorts. The predictive rules externally developed yielded positive predictive value of 97.7% (95% CI = 93.3-99.5%), negative predictive value of 24.5% (95% CI = 16.2-34.4%), specificity of 88.5% (95% CI = 69.9-97.6%), and sensitivity of 63.8% (95% CI = 56.6-70.5%) for successful observation.
Conclusion:
The current study validates previously developed prediction rules for safe observation of pediatric EDH in a cohort with distinct characteristics from the external cohort. Specifically, patients with no mass effect, EDH volume <15 ml and no neurological deficits are less likely to fail observation.
Advances In Knowledge:
The current study validates prediction rules for safe observation of pediatric EDH in a distinct pediatric cohort that provides further support to conservative management in these circumstances.
