Re-evaluating the need for hospital admission and observation of pediatric traumatic brain injury after a normal head CT

Plackett, Timothy P.; Asturias, Sabrina; Tadlock, Matthew D.; Wright, Franklin L.; Ton-That, Hieu; Δημητριάδης, Δημήτριος; Esposito, Thomas J.; Inaba, Kenji

doi:10.1016/j.jpedsurg.2015.03.067

Cited by 14 publications

(9 citation statements)

References 11 publications

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“…Although 5.2% of transfers needed neurosurgical intervention, no such cases were counted among those with isolated, nondisplaced skull fractures or those with negative imaging. It has been previously observed that neurologically intact patients can typically be discharged without hospital admission following observation in the ED after a normal head CT scan 35 or one revealing only an isolated linear skull fracture. 3,39 A review by White et al 47 of 438 patients transferred to a Level I facility for an isolated, linear, nondisplaced skull fracture in the absence of multisystem trauma found that all patients recovered with treatment of symptoms, and none required neurosurgical intervention, leading the authors of that paper to conclude that transfer to a higherlevel trauma facility is not warranted in this population.…”

Section: Discussionmentioning

confidence: 99%

Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center

Mackel

Morel

Winer

et al. 2018

Journal of Neurosurgery: Pediatrics

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OBJECTIVEThe authors reviewed the transfer requests for isolated pediatric traumatic brain injuries (TBIs) at a Level I/II facility with the goal of identifying clinical and radiographic traits associated with potentially avoidable transfers that could be safely managed in a non–tertiary care setting.METHODSThe authors conducted a retrospective study of patients < 18 years of age classified as having TBI and transferred to their Level I tertiary care center over a 12-year period. The primary outcome of interest was identifying potentially avoidable transfers, defined as transfers of patients not requiring any neurosurgical intervention and discharged 1 hospital day after admission.RESULTSOverall, 70.8% of pediatric patients with isolated TBI did not require neurosurgical intervention or monitoring, indicating an avoidable transfer. Potentially avoidable transfers were associated with outside hospital imaging that was negative (86%) or showed isolated, nondisplaced skull fractures (86%) compared to patients with cranial pathology (53.8%, p < 0.001) as well as age ≤ 6 years (81% [negative imaging/isolated, nondisplaced fractures] vs 54% [positive cranial pathology], p < 0.001). The presence of headaches, nonfocal deficits, and loss of consciousness were associated with necessary transfer (p < 0.05). Patients with potentially avoidable transfers underwent frequent repeat CT studies (19.1%) and admissions to the pediatric intensive care unit (55.9%) but at a lower rate than those whose transfers were necessary (p < 0.001). Neurosurgical interventions occurred in 11% of patients with cranial pathology, which accounted for 17.9% of necessary transfers and 5.2% of all transfers.CONCLUSIONSIn the authors’ region, potentially up to 70% of interfacility transfers for pediatric brain trauma in the absence of other systemic injuries warranting surgical intervention may not require neurosurgical intervention and could be managed locally. No patients transferred with isolated, nondisplaced skull fractures or negative CT scans required neurosurgical intervention, and 86% were discharged the day after admission. In contrast, 11% of patients with CT scans indicative of cranial pathology required neurosurgical intervention. Age > 6 years, loss of consciousness, and nonfocal deficits were associated with a greater likelihood of needing a transfer. Further studies are required to clarify which patients can be managed at local institutions, but referring centers should practice overcaution given the potential risks.

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Section: Discussionmentioning

confidence: 99%

Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center

Mackel

Morel

Winer

et al. 2018

Journal of Neurosurgery: Pediatrics

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“…Hospitalization is not necessary for many children with nondisplaced skull fractures [27] and neurologically normal children with isolated linear skull fractures after minor blunt head trauma [28]. Reducing unnecessary hospitalizations can prevent emotional stress, in addition to saving costs for the child's family and the health care system [29][30][31]. This study has several limitations.…”

Section: Discussionmentioning

confidence: 98%

Traumatic skull fractures in children and adolescents: A retrospective observational study

Wang

Zhou

et al. 2018

Injury

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“…The healthcare costs associated with pediatric skull fracture patients with CSF leaks have not been well documented in the literature. 6,21 Traumatic CSF leaks are as-sociated with greater hospital and physician expenditures, both at the index hospitalization and at 90 days. However, since average LOSs were longer in the CSF leak cohort than in the non-CSF leak cohort, it is possible that the difference in costs is largely attributable to prolonged admission, 6,21 especially in the intensive care unit.…”

Section: Discussionmentioning

confidence: 99%

“…6,21 Traumatic CSF leaks are as-sociated with greater hospital and physician expenditures, both at the index hospitalization and at 90 days. However, since average LOSs were longer in the CSF leak cohort than in the non-CSF leak cohort, it is possible that the difference in costs is largely attributable to prolonged admission, 6,21 especially in the intensive care unit. The increased rates of neurosurgical procedures for patients with CSF leaks are also likely contributors to the elevated costs associated with their care.…”

Section: Discussionmentioning

confidence: 99%

Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015

Varshneya¹,

Rodrigues²,

Medress³

et al. 2019

Neurosurgical Focus

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OBJECTIVESkull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.METHODSThe authors queried the MarketScan database (2007–2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.RESULTSThe authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non–CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6–13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2–44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7–5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5–4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).CONCLUSIONSThe authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.

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Re-evaluating the need for hospital admission and observation of pediatric traumatic brain injury after a normal head CT

Cited by 14 publications

References 11 publications

Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center

Secondary overtriage of pediatric neurosurgical trauma at a Level I pediatric trauma center

Traumatic skull fractures in children and adolescents: A retrospective observational study

Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015

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