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Critical Emergency Department Interventions and Clinical Deterioration in Children With Nonsevere Traumatic
Pradip P Chaudhari, Susan Durham, Richard G Bachur1
1Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA.
Insights
In children with mild traumatic intracranial hemorrhage (tICH), 13% experienced clinically important tICH. A subset with specific clinical and imaging features showed low risk, aiding in better management decisions.
Area of Science:
- Pediatric Emergency Medicine
- Pediatric Neurosurgery
- Trauma Surgery
Background:
- Practice variation in managing pediatric nonsevere traumatic intracranial hemorrhage (tICH) necessitates better risk stratification.
- Understanding the incidence and timing of critical events in tICH is crucial for clinical decision-making.
Purpose of the Study:
- To determine the rates and timing of clinically important tICH in children.
- To identify clinical and neuroradiographic factors associated with tICH outcomes.
- To inform accurate risk stratification for pediatric tICH management.
Main Methods:
- Retrospective cohort study of 135 children (<18 years) with tICH and initial Glasgow Coma Scale (GCS) > 8.
- Defined clinically important tICH as immediate emergency department (ED) interventions or deterioration within 96 hours.
- Used logistic regression to analyze associations between outcomes and patient characteristics.
Main Results:
- Clinically important tICH occurred in 13.3% of children; 6.7% required immediate ED interventions, and 6.7% deteriorated.
- Most children (93.3%) had an initial GCS ≥ 14, including all who later deteriorated.
- Initial GCS and nonaccidental trauma mechanism were associated with outcomes; a low-risk subgroup was identified.
Conclusions:
- Clinically important tICH affects 13% of children with nonsevere tICH, with 7% deteriorating after initial presentation.
- Children with initial GCS ≥ 14 and specific imaging findings (isolated, nonepidural hemorrhage after accidental injury) represent a low-risk group.
- Findings support refined risk stratification for managing pediatric traumatic intracranial hemorrhage.
Objective:
Substantial practice variation exists in the management of children with nonsevere traumatic intracranial hemorrhage (tICH). A comprehensive understanding of rates and timing of clinically important tICH, including critical interventions and deterioration, along with associated clinical and neuroradiographic characteristics, will inform accurate risk stratification.
Methods:
We conducted a single-center retrospective cohort study of children aged younger than 18 years evaluated in the emergency department (ED) from May 1, 2014 to February 28, 2020 with tICH and initial Glasgow Coma Scale (GCS) score of higher than 8. We determined rates of clinically important tICH after injury and within 96 hours of ED arrival, defined as immediate ED interventions (intubation, hyperosmotic agents, or neurosurgery within 4 hours of arrival) or clinically important deterioration (signs/symptoms with change in management). Associations between outcome and clinical and neuroradiographic characteristics were calculated using individual logistic regression models.
Results:
Our sample included 135 children. Clinically important tICH was observed in 13.3% (n = 18); 9 (6.7%) underwent immediate ED interventions and 9 (6.7%) developed deterioration. Most (93.3%, n = 127) presented with an initial GCS ≥ 14, including all children who later deteriorated. Initial GCS ( P = 0.001) and nonaccidental trauma ( P = 0.024) mechanism were associated with the outcome. None of the 71 (52.6%) children with initial GCS ≥ 14, isolated, nonepidural hemorrhage after accidental injury developed clinically important tICH.
Conclusions:
Clinically important tICH occurred in 13% of children with nonsevere tICH, and 7% of children who did not undergo immediate ED interventions later deteriorated, all of whom had an initial GCS ≥ 14. However, a subgroup of children was identified as low risk based on clinical and neuroradiographic characteristics.
