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Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center
Rebecca A Reynolds1,2, Katherine A Kelly3, Ranbir Ahluwalia1,2
11Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville.
Insights
A new protocol for managing pediatric linear skull fractures safely reduced neurosurgical consultations and hospital admissions. This approach prioritizes consultations for select patients, demonstrating feasibility in a level 1 trauma center.
Area of Science:
- Pediatric Traumatology
- Neurosurgery
- Emergency Medicine
Background:
- Isolated linear skull fractures in children often lack intracranial findings and rarely necessitate urgent neurosurgical intervention.
- A multidisciplinary fracture management protocol was implemented at a level 1 pediatric trauma center to standardize care.
Purpose of the Study:
- To evaluate the safety and efficacy of a new protocol for managing isolated linear skull fractures in pediatric patients.
- To assess the impact of the protocol on neurosurgical consultations and patient outcomes.
Main Methods:
- A retrospective comparison of pediatric patients (<18 years) with linear skull fractures and no intracranial abnormalities on CT scan before and after protocol implementation.
- Data collected included patient demographics, injury mechanisms, neurosurgical consultations, admission rates, and emergency department revisits.
Main Results:
- The post-protocol cohort showed a significant decrease in neurosurgery consultations (86% to 44%) and hospital admissions (52% to 38%).
- There was a notable increase in fractures from falls >3 feet and those with unknown injury mechanisms post-protocol.
- No deaths or inpatient neurosurgical procedures were recorded in either cohort.
Conclusions:
- Protocolizing the management of isolated linear skull fractures is safe and feasible in a high-volume pediatric trauma center.
- The protocol allows for prioritized neurosurgical consultations for higher-risk patients.
- Further research is needed on admission criteria, interfacility transfers, and healthcare costs.
Objective:
Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons-verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy.
Methods:
Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020.
Results:
The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8-25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed.
Conclusions:
Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.
