Page 18 - Delaware Medical Journal - October 2016
P. 18
among children has dropped from 27 percent before inclusion of NAIDHC in the trauma system to 19.5 percent subsequently. But our observations do point to opportunities for calibrating intensity of services to severity of injury more precisely.
Several factors may account for the increasing trend in registrations of minor TBI, but, in view of the stability of the rates of moderate and severe TBI, an actual increase in the population- based incidence of mild TBI cannot be one of them. The epoch
of this study coincided with a marked increase in appreciation of for seeking medical attention and for referral to higher levels of care have fallen among members of the public and in the medical
the simultaneous increase in availability of trauma services incorporation of NAIDHC. The step-increase in the registration of mild TBI in 2007 seen in Figure 1 this process. In either case the trend in minor TBI registrations rather than an actual increase in the burden of disease.
Evidence has accumulated to support the management of children with mild TBI without transfer to a higher level of care and most often without admission. Dias and colleagues managed 215 children with mild TBI and CT scans that were negative for intracranial injury in the observation unit of an emergency department.6 Children 24 months of age were excluded from the study, primarily to allow completion of evaluations for abuse. No child suffered neurological Among 827 patients with TBI seen in the emergency department
at Primary Children’s Medical Center in Salt Lake City, 269 (33 percent) were sent home directly, and 285 were managed in an observation unit.7 patients had CT scans: Skull fractures were seen in 109 cases, and various intracranial hemorrhages were present in 35. None of the patients selected for observation suffered neurological deterioration
the principle that admission can be avoided for the great majority
of children with mild TBI. More recently Powell and colleagues reported 350 children with GCS 14 or 15 and isolated skull fractures on CT scan.8 None required neurosurgical intervention (95 percent conducted by the Pediatric Emergency Care Applied Research Network, Holmes et al. reported a negative predictive value for interval 99.97 to 100 percent) among children with GCS 14 or 15 and a negative CT scan.9 White and colleagues at Riley Children’s
Hospital in Indianapolis received 619 pediatric patients with isolated skull fractures in transfer from other institutions. None required preventable if the admission lasted less than 36 hours and if there was no surgical intervention or advanced imaging study.10 This Children’s in Salt Lake City between 2003 and 2013. Head injuries were overrepresented among the preventable transfers.
What do children with mild TBI and their families require of the
is not threatening. Criteria for determining which children with mild TBI need brain imaging have been validated and are widely known and utilized.11,12 Fast MR imaging is available at NAIDHC and at Christiana Care Health System (CCHS), and CT scanning is available at every other hospital emergency department in the region. CT radiation dosing “as low as reasonably achievable” can be prescribed in other settings just as at the children’s medical center.13,14 Brain imaging that establishes the absence of intracranial hemorrhage eliminates any question of neurosurgical intervention.6-9,15 In doubtful cases technology exists for pushing images between hospital picture archiving and communication systems (PACSs) to allow review at the referral center. Telemedicine can make clinical review possible as well. With resolve and cooperation among hospital systems, whether the injured child will need neurosurgical services can be determined in the home community.
Children with mild TBI who have been determined not to have a threatening intracranial injury may still require management of symptoms: analgesics, anti-emetics, and intravenous hydration. These basic, supportive services are available at some but not all hospitals in the DTS. Even at institutions where supportive services are available, medical professionals in home communities may be reluctant to offer them because of concern for possible neurosurgical instability and limited capacity for care of younger children, who are disproportionately represented among non-substantive registrations. These understandable concerns may be addressed by education and close, real time communication with the referral center.
for abuse. Many pediatric trauma programs have adopted guidelines to increase detection of abuse and to eliminate racial and economic disparities in screening, and to serve these purposes guidelines must set a low threshold.16-19 For example, at NAIDHC for every non- ambulatory child with a skull fracture, the Child at Risk Evaluation (CARE) Team must be consulted. Many young children with
mild TBI will be swept up by screening guidelines, and if medical
306
Del Med J | October 2016 | Vol. 88 | No. 10
