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Published on: October 17, 2017
Suspected abusive head trauma in children - when do they really need to be transferred to a neurosurgical unit?
Aled Lester1, Zoe James2, Dmitri Sastin2
1Cardiff University School of Medicine, Cardiff, UK.
Insights
Most abusive head trauma (AHT) patients transferred to neurosurgical centers do not require surgery. Transferring AHT patients only when clinically necessary can improve safeguarding investigations and patient care.
Area of Science:
- Paediatric Neurosurgery
- Child Protection
- Forensic Medicine
Background:
- Transferring paediatric patients with suspected abusive head trauma (AHT) to specialized neurosurgical centers can disrupt crucial safeguarding investigations.
- Timely and appropriate transfer is essential, but unnecessary transfers can impede investigations and patient management.
Purpose of the Study:
- To analyze referral patterns of suspected AHT patients to a tertiary paediatric neurosurgical center.
- To inform future transfer decisions for AHT patients, balancing clinical necessity with investigative needs.
Main Methods:
- Retrospective review of suspected AHT patients referred between 2012 and 2021.
- Comparison of surgical rates, intubation, ventilation, radiological findings, and Glasgow Coma Scale (GCS) between transferred and non-transferred patients.
- Calculation of odds ratios for neurosurgical transfer based on clinical and radiological features.
Main Results:
- Of 76 referred patients, 18 were transferred; only one required surgery, while most received supportive care.
- Transferred patients frequently had subdural hematomas (SDHs) and a GCS ≥ 13 at presentation.
- Patients with GCS ≥ 13 and SDHs, bilateral hematomas, or vomiting were significantly more likely to be transferred.
Conclusions:
- The majority of transferred AHT patients do not undergo surgical intervention.
- Transfer should be reserved for cases likely to require surgery, allowing others to remain locally for safeguarding investigations.
- Immediate transfer may not be necessary for AHT patients with GCS ≥ 13 and specific findings (vomiting, SDHs, bilateral hematomas) if emergency surgery is unlikely.
Objectives:
Transferring paediatric patients with suspected abusive head trauma (AHT) to paediatric neurosurgical centres, disrupts safeguarding investigations. Therefore, it is desirable that suspected AHTs are transferred only when clinically necessary. The aim of this study was to describe referral patterns of patients referred to a tertiary paediatric neurosurgical centre with suspected AHT, with the view of informing future transfer of AHT patients.
Design:
A retrospective review was performed of all suspected AHT patients referred to the University Hospital of Wales between 2012 and 2021.
Methods:
Rates of surgery, intubation and ventilation, radiological findings and presenting GCS were compared between referred patients and those transferred for neurosurgical care. Variables were compared between the transferred and the non-transferred groups. For categorical variables, Chi-squared tests were performed, with Fisher's exact test used where the expected count was less than 5. Odds ratios (OR) for neurosurgical transfer with radiological or clinical features at presentation were calculated.
Results:
A total of 76 patients were referred, of which 18 were transferred for neurosurgical care. Of these, six were intubated and ventilated. Only one transferred patient required surgery, with the remainder receiving supportive care. Amongst the transferred group, 77.8% had SDHs and 68.6% had a GCS ≥ 13 at presentation. Patients with a GCS ≥ 13 and SDHs, bilateral haematomas or a history of vomiting were significantly more likely to be transferred (OR = 4.27, 95%CI 1.01-18.00, p = .05).
Conclusions:
Most transferred patients with suspected AHT did not receive surgical intervention. We suggest that patients should be transferred when it is likely that they will require surgery, otherwise they should stay locally in order to complete their safeguarding investigations. Immediate transfer may not be necessary for AHT patients with a GCS ≥ 13 and either vomiting, SDHs or bilateral haematomas, provided they are unlikely to require emergency surgery.
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