Mandatory admission after isolated mild closed head injury in children: Is it necessary?

doi:10.1053/jpsu.2001.20026

Journal of Pediatric Surgery

Volume 36, Issue 1, January 2001, Pages 119-121

Presented at the 31st Annual Meeting of the American Pediatric Surgical Association, Orlando, Florida, May 25-29, 2000.

https://doi.org/10.1053/jpsu.2001.20026 Get rights and content

Abstract

Background/Purpose: Children with closed head injuries diagnosed as concussion alone or concussion with brief loss of consciousness are admitted routinely for observation despite a normal central nervous system finding, negative computed tomography (CT) scan, and a Glasgow Coma Score (GCS) of 15. Recent studies have questioned the necessity of such an admission. The purpose of this study was to review a large pediatric database and study the length of stay as well as any required procedures or complications in these children. The hypothesis was that routine admission is unnecessary in this population. Methods: The National Pediatric Trauma Registry-Phase II was reviewed for the period from October 1988 to January 1996. Entry criteria included age less than 18 and an isolated closed head injury after blunt trauma with an admission GCS of 15. Variables studied included age, gender, mechanism of injury, length of stay, procedures, and outcome. Results: A total of 1,033 children met criteria for this study. The average age was 8.3 years. Males predominated at 61.9%. Falls, sports, and motor vehicle crashes were the most common mechanisms of injury. The average length of stay was 1.19 days, and 60 children were not admitted. A total of 583 children had no procedures performed, whereas 386 received a CT scan, and 148 had x-rays. None required neurosurgical intervention, and all were discharged alive. Conclusion: These findings indicate that routine admission may not be necessary for children with isolated mild closed head injuries with a negative CT scan and a normal neurologic finding and allows for a prospective randomized trial to confirm this. J Pediatr Surg 36:119-121. Copyright © 2001 by W.B. Saunders Company.

Section snippets

Materials and methods

The National Pediatric Trauma Registry-Phase II was reviewed for the period from October 1988 through January 1996. All children under the age of 18 who sustained an isolated closed head injury from blunt trauma and had an admission GCS of 15 were identified. The ICD-9 diagnosis codes of 850.0 and 850.1 were chosen as entry criteria because they represent concussion with no loss of consciousness or with brief loss of consciousness for less than 1 hour, respectively. The registry provided the

Results

After review of the 53,113 children in the National Pediatric Trauma Registry, 1,033 patients were identified as having isolated closed head injuries with an admission GCS of 15. Their average age was 8.34 ± 5.31 years. The majority of children were male—61.9% (2 had no gender recorded). All had an injury severity score of 4 representing their isolated closed head injury with less than a 1-hour loss of consciousness. All had sustained the closed head injury as a result of blunt trauma. Table 1

Discussion

Children who sustain mild closed head injuries represent a large number of evaluations in emergency departments every year. The question of disposition is most difficult when the child appears normal and has no evidence of traumatic injury on imaging studies. Guidelines are being developed for this group of patients. Every child should be evaluated carefully after a head injury, because a high degree of suspicion is necessary to find patients who might have complications. A GCS of 15 on

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The epidemiology of crib-related head injuries: A ten-year nationwide analysis
2023, American Journal of Emergency Medicine
Falls from cribs resulting in head injury are understudied and poorly characterized. The purpose of this study was to advance current understanding of the prevalence, descriptive characteristics of injury victims, and the types of crib fall-related head injuries (CFHI) using queried patient cases from the National Electronic Injury Surveillance System (NEISS) database.
Using the US Consumer Product Safety Commission's System NEISS database, we queried all CFHIs among children from over 100 emergency departments (EDs). Patient information regarding age, race, sex, location of the incident, diagnoses, ED disposition, and sequelae were analyzed. The number of CFHI from all US EDs during each year was also collected from the database.
There were an estimated 54,799 (95% CI: 30,228–79,369) total visits to EDs for CFHIs between 2012 and 2021, with a decrease in incidence of approximately 20% during the onset of the COVID-19 pandemic (2019: 5616 cases, 2020: 4459 cases). The annual incidence of injuries showed no significant trend over the 10-year study period. An available subset of 1782 cases of head injuries from approximately 100 EDs was analyzed, and 1442 cases were included in final analysis. Injuries were sorted into three primary categories: unspecified closed head injury (e.g., closed head injury, blunt head trauma, or traumatic brain injury), concussion, or open head injury and skull fracture. Unspecified closed head injuries were the most common of all head injuries (95.4%, 1376/1442). Open head injuries (14/1442, 0.97%) and concussions 3.6% (52/1442, 3.6%) were rare. Most injuries involved children under the age of 1 (42.6%) compared to children who were 1, 2, 3, or 4-years old. About a fourth of patients had other diagnoses in addition to their primary injury including scalp/forehead hematomas, emesis, and contusions. Female patients were more likely to present with other diagnoses in addition to their primary head injury (Difference: 12.3%, 95% CI: 9.87%–15.4%, p < .0001).
Despite minimum rail height requirements set by the Consumer Safety Product Commission (CPSC), head injuries associated with crib falls are prevalent in the United States. However, most injuries were minor with a vast majority of patients being released following examination and treatment.
Management of skull fractures in children less than 1 year of age
2016, Journal of Pediatric Surgery
Citation Excerpt :
Our algorithm is currently being updated in close collaboration with the ED to ensure better diffusion throughout the institution. Our study is consistent with other single-center studies that have demonstrated that patients with isolated SF can be safety returned home [6,13,16]. We show that 4.4% of patients less than 1 year of age with SF required a neurosurgical procedure, and that 80% of admitted patients were discharged within a day.
Management of skull fracture (SF) in pediatric patients varies from observation in the emergency department (ED) to floor admission. Since 2010, a protocol for admitting children with SF specifically to the trauma service was implemented at our institution. The purpose of our study was to review the management of children with SF younger than 1 year of age.
Retrospective chart review of all patients between 0 and 1 year of age seen in our ED for a SF was done from 2010 to 2013.
A total of 180 patients with a mean age of 4.5 months (1 day–12 months) were identified. Of these, 131 patients (73%) were admitted. Mean length of stay was 1.6 days. Admitted patients had more depressed (21 vs. 8%) and diastatic (43 vs. 14%) fractures. Fifty-seven children had intracranial hemorrhages (32%) but only 8 patients required non-emergent surgery for depressed fractures. Admission to the trauma service increased from none to 76% with phone follow-ups increasing from 12% to 91%.
Instituting a protocol allowed a safer management of patients with SF. Moreover, we argue that asymptomatic infants with isolated SF can be safely discharged home after brief observation in the ED.
Observation for isolated traumatic skull fractures in the pediatric population: Unnecessary and costly
2016, Journal of Pediatric Surgery
Blunt head trauma accounts for a majority of pediatric trauma admissions. There is a growing subset of these patients with isolated skull fractures, but little evidence guiding their management. We hypothesized that inpatient neurological observation for pediatric patients with isolated skull fractures and normal neurological examinations is unnecessary and costly.
We performed a single center 10 year retrospective review of all head traumas with isolated traumatic skull fractures and normal neurological examination. Exclusion criteria included: penetrating head trauma, depressed fractures, intracranial hemorrhage, skull base fracture, pneumocephalus, and poly-trauma. In each patient, we analyzed: age, fracture location, loss of consciousness, injury mechanism, Emergency Department (ED) disposition, need for repeat imaging, hospital costs, intracranial hemorrhage, and surgical intervention.
Seventy-one patients presented to our ED with acute isolated skull fractures, 56% were male and 44% were female. Their ages ranged from 1 week to 12.4 years old. The minority (22.5%) of patients were discharged from the ED following evaluation, whereas 77.5% were admitted for neurological observation. None of the patients required neurosurgical intervention. Age was not associated with repeat imaging or inpatient observation (p = 0.7474, p = 0.9670). No patients underwent repeat head imaging during their index admission. Repeat imaging was obtained in three previously admitted patients who returned to the ED. Cost analysis revealed a significant difference in total hospital costs between the groups, with an average increase in charges of $4,291.50 for admitted patients (p < 0.0001).
Pediatric isolated skull fractures are low risk conditions with a low likelihood of complications. Further studies are necessary to change clinical practice, but our research indicates that these patients can be discharged safely from the ED without inpatient observation. This change in practice, additionally, would allow for huge health care dollar savings.
Do children with blunt head trauma and normal cranial computed tomography scan results require hospitalization for neurologic observation?
2011, Annals of Emergency Medicine
Citation Excerpt :
Neurologic deterioration after a negative CT scan result, however, is rare in adults with minor head trauma evaluated in EDs.12-14 Limited pediatric data also suggest that hospitalization is likely unnecessary for children with minor head trauma and normal CT scan results, although the confidence intervals (CIs) around the point estimates of risk are wide.9,10,15 The objective of this study was to identify the frequency with which children with minor blunt head injury and normal initial CT scan results have either traumatic findings identified on a subsequent neuroimaging study or experience neurologic deterioration resulting in the need for neurosurgery (by determination of the negative predictive value of an initial normal CT scan result for neurosurgical intervention).
Children evaluated in the emergency department (ED) with minor blunt head trauma, defined by initial Glasgow Coma Scale (GCS) scores of 14 or 15, are frequently hospitalized despite normal cranial computed tomography (CT) scan results. We seek to identify the frequency of neurologic complications in children with minor blunt head trauma and normal ED CT scan results.
We conducted a prospective, multicenter observational cohort study of children younger than 18 years with blunt head trauma (including isolated head or multisystem trauma) at 25 centers between 2004 and 2006. In this substudy, we analyzed individuals with initial GCS scores of 14 or 15 who had normal cranial CT scan results during ED evaluation. An abnormal imaging study result was defined by any intracranial hemorrhage, cerebral edema, pneumocephalus, or any skull fracture. Patients with normal CT scan results who were hospitalized were followed to determine neurologic outcomes; those discharged to home from the ED received telephone/mail follow-up to assess for subsequent neuroimaging, neurologic complications, or neurosurgical intervention.
Children (13,543) with GCS scores of 14 or 15 and normal ED CT scan results were enrolled, including 12,584 (93%) with GCS scores of 15 and 959 (7%) with GCS scores of 14. Of 13,543 patients, 2,485 (18%) were hospitalized, including 2,107 of 12,584 (17%) with GCS scores of 15 and 378 of 959 (39%) with GCS scores of 14. Of the 11,058 patients discharged home from the ED, successful telephone/mail follow-up was completed for 8,756 (79%), and medical record, continuous quality improvement, and morgue review was performed for the remaining patients. One hundred ninety-seven (2%) children received subsequent CT or magnetic resonance imaging (MRI); 5 (0.05%) had abnormal CT/MRI scan results and none (0%; 95% confidence interval [CI] 0% to 0.03%) received a neurosurgical intervention. Of the 2,485 hospitalized patients, 137 (6%) received subsequent CT or MRI; 16 (0.6%) had abnormal CT/MRI scan results and none (0%; 95% CI 0% to 0.2%) received a neurosurgical intervention. The negative predictive value for neurosurgical intervention for a child with an initial GCS score of 14 or 15 and a normal CT scan result was 100% (95% CI 99.97% to 100%).
Children with blunt head trauma and initial ED GCS scores of 14 or 15 and normal cranial CT scan results are at very low risk for subsequent traumatic findings on neuroimaging and extremely low risk of needing neurosurgical intervention. Hospitalization of children with minor head trauma after normal CT scan results for neurologic observation is generally unnecessary.
Clinical algorithm and resource use in the management of children with minor head trauma
2007, Journal of Pediatric Surgery
There are no clear guidelines for the management of minor head injury, including the use of skull x-rays and computed tomography (CT) scans of the head. This is reflected in clinical practice by a wide variability in imaging study use and by the fact that some patients are discharged home from the emergency room (ER), whereas others are admitted to the hospital with or without a period of observation before admission. To address this issue, we proposed and applied a new protocol for minor head injury at our institution.
Between January 2004 and December 2005, 417 patients presented to the emergency department at our institution with minor head injury. All of them had fallen from less than 1 m. Every chart was retrospectively evaluated, and pertinent data were extracted.
The mean age of the patients was 9.8 months (2 weeks to 32 months). One hundred fifty-three had a skull x-ray, and 13 had a CT scan of the head. Of the 153 patients who had a skull x-ray, only 15 had a skull fracture. Of these 15 patients, 3 also had a CT scan of the head that confirmed the diagnosis of skull fracture. Of the 13 CT scans that were done, only these 3 were positive. Eleven patients were kept in the ER for 6 hours for close observation, and 5 of these were eventually admitted. Overall, 8 patients were admitted to the hospital for observation. Of these 8 patients, 7 had a skull x-ray, from which 5 were positive. Only 2 of the admitted patients had a CT scan, and they were both positive for a skull fracture. One of the CT also demonstrated a subdural hematoma along with subarachnoid hemorrhage. These 2 patients also had a positive skull x-ray. None of the patients that were admitted had headaches or neurologic impairments. The mean age of the patients admitted was 3.8 months (2 weeks to 12 months). The mean hospital stay was 1.2 days (1-3 days).
Only 10% of the skull x-rays and CT scans were positive for a skull fracture, which led to an admission in half of these patients. The other half was mainly discharged from ER after being observed. Several patients underwent a skull x-ray that we feel was not necessary in the management of their minor head injury. For those who had a head CT scan, only one revealed additional information and none of them had an impact on the final management. Observation in the ER could have been reasonable for most cases.
Pediatric minor closed head injury
2006, Pediatric Clinics of North America

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^☆: Address reprint request to Dennis W. Vane, MD, The University of Vermont College of Medicine, 111 Colchester Ave, Fletcher 4, MCHV Campus, Burlington, VT 05401.

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Mandatory admission after isolated mild closed head injury in children: Is it necessary?☆

Abstract

Section snippets

Materials and methods

Results

Discussion

J Pediat Surg

Pediatric brain injuries: The nature, clinical course, and early outcomes in a defined United States' population

Pediatrics

The epidemiology of urban pediatric neurological trauma: Evaluation of, and implications for, injury prevention programs

Neurosurgery