Prevalence of Clinically Important
Traumatic Brain Injuries in Children
With Minor Blunt Head Trauma and
Isolated Severe Injury Mechanisms
Nigrovic LE, Lee LK, Hoyle J, et al; Traumatic Brain Injury (TBI) Working
Group. Prevalence of clinically important traumatic brain injuries in children
with minor blunt head trauma and isolated severe injury mechanisms.
Arch Pediatr Adolesc Med. Published online December 5, 2011.
doi:10.1001/archpediatrics.2011.1156.
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Introduction
•
Background
– Minor blunt head trauma is a common reason for emergency
department evaluation of children.
– Risk of traumatic brain injury (TBI) is low.
– Severe injury mechanism is a predictor of clinically important TBI in the
Pediatric Emergency Care Applied Research Network (PECARN)
prediction rules.1
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Study Objective
– To determine the prevalence of clinically important TBIs in children with
severe injury mechanisms and no other PECARN predictors.
1. Kuppermann N, Holmes JF, Dayan PS, et al; Pediatric Emergency Care Applied Research
Network (PECARN). Identification of children at very low risk of clinically-important brain
injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.
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Methods
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Study Design
– Secondary analysis of a prospective cohort study.
– Conducted by the PECARN.
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Participants
– Children aged <18 years with minor blunt head trauma.
• Glasgow Coma Score ≥14.
– Excluded patients with trivial trauma, penetrating trauma, comorbidities,
or previous cranial computed tomography (CT).
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Injury Mechanisms
– Severe injury mechanism: motor vehicle collision with patient ejection,
death of another passenger, or rollover; pedestrian or bicyclist without
helmet struck by a motorized vehicle; falls (>3 ft if aged <2 years and
>5 ft if aged ≥2 years); or head struck with high-impact object.
– Isolated severe injury mechanism: severe injury mechanism with no
other PECARN TBI predictors.
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Methods
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Outcome Measure
– Clinically important TBI: TBI resulting in death, neurosurgical
intervention, intubation for >24 hours, or positive CT findings in
association with hospital admission for ≥2 nights for management of
head trauma.
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Data Analysis
– Subgroups by age: <2 years vs ≥2 years of age.
– Rate of clinically important TBI with 95% CI.
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Limitations
– Not all eligible children were enrolled.
– Cranial CT was not performed on all patients.
– Caregivers of children with nonaccidental trauma may not report injury
mechanism accurately.
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Results
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Enrollment
– 42 412 patients (78.3% of the 54 161 eligible patients) were enrolled in
overall cohort study; 42 099 (99%) had an injury mechanism recorded
and were included in this substudy.
• 5869 (14%) had severe injury mechanisms.
• 3302 (8%) had isolated severe injury mechanisms.
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Rates of clinically important TBI in children with isolated severe injury
mechanisms:
– Children aged <2 years: 0.3% (95% CI, 0.1%-0.8%).
– Children aged ≥2 years: 0.6% (95% CI, 0.3%-1.1%).
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Results
Injury mechanism varied by patient age. Overall, children with nonisolated
severe injury mechanisms had higher rates of clinically important TBI.
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Results
Children with isolated severe injury mechanisms had a lower rate of clinically
important TBI than those with severe injury mechanisms and other PECARN
TBI predictors.
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Results
The risk of clinically important TBI
increased for children with severe injury
mechanisms and 1 additional PECARN
TBI predictor.
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Comment
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Risk of clinically important TBI is very low in children with isolated severe
injury mechanisms.
– Clinical observation for development of signs or symptoms of TBI may
be an effective clinical strategy.
•
After careful evaluation and observation without development of signs or
symptoms of TBI, many children with isolated severe injury mechanisms
may not require emergent neuroimaging.
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Contact Information
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If you have questions, please contact the corresponding author:
– Lise E. Nigrovic, MD, MPH, Division of Emergency Medicine, Children’s
Hospital Boston, 300 Longwood Ave, Boston, MA 02115
(lise.nigrovic@childrens.harvard.edu).
Funding/Support
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This work was supported by a grant from the Health Resources and
Services Administration/Maternal and Child Health Bureau (HRSA/MCHB),
Division of Research, Training and Education (DRTE), and the Emergency
Medical Services of Children (EMSC) Program (R40MC02461); the
PECARN is supported by cooperative agreements U03MC00001,
U03MC00003, U03MC00006, U03MC00007, and U03MC00008 from the
EMSC program of the HRSA/MCHB.
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