ABSTRACT

Introduction:

Questions surround the appropriate emergency department (ED) disposition of children who have sustained blunt head trauma (BHT). Our objective was to identify physician disposition preferences of children with blunt head trauma (BHT) and varying computed tomography (CT) findings.

Methods:

We surveyed pediatric and general emergency physicians (EP), pediatric neurosurgeons (PNSurg), general neurosurgeons (GNSurg), pediatric surgeons (PSurg) and trauma surgeons regarding care of two hypothetical patients: Case 1: a 9-year-old who fell 10 feet and Case 2: an 11-month-old who fell 5 feet. We presented various CT findings and asked physicians about disposition preferences. We evaluated predictors of patient discharge using multivariable regression analysis adjusting for hospital and ED characteristics and clinician experience. Pediatric EPs served as the reference group.

Results:

Of 2,341 eligible surveyed, 715 (31%) responded. Most would discharge children with linear skull fractures (Case 1, 71%; Case 2, 62%). Neurosurgeons were more likely to discharge children with small subarachnoid hemorrhages (Case 1 PNSurg OR 6.87, 95% CI 3.60, 13.10; GNSurg OR 6.54, 95% CI 2.38, 17.98; Case 2 PNSurg OR 5.38, 95% CI 2.64, 10.99; GNSurg OR 6.07, 95% CI 2.08, 17.76). PSurg were least likely to discharge children with any CT finding, even linear skull fractures (Case 1 OR 0.14, 95% CI 0.08, 0.23; Case 2 OR 0.18, 95% CI 0.11, 0.30). Few respondents (<6%) would discharge children with small intraventricular, subdural, or epidural bleeds.

Conclusion:

Substantial variation exists between specialties in reported hospitalization practices of neurologically-normal children with BHT and traumatic CT findings.

INTRODUCTION

Traumatic brain injury (TBI) is a leading cause of death in children older than 1 year of age and a significant cause of morbidity. Between 2002 and 2006 the estimated annual number of TBIs in children less than 15 years of age in the U.S. was approximately 511,000, including approximately 2,200 deaths, 35,000 hospitalizations, and 474,000 emergency department (ED) visits.¹ Cranial computed tomography (CT) is the diagnostic test of choice for evaluating children with blunt head trauma in the ED. Fewer than 10% of these CTs, however, are diagnostic of TBI.^2–9 Furthermore, the implications of small traumatic findings on CT are not clear.^10–12 Therefore, CT should ideally be selectively used with the goal of identifying clinically-important findings

Several large studies have suggested that the presence or absence of certain clinical signs and symptoms are predictive of a TBI requiring acute intervention, such as hospitalization, neurological surgery, or on-going anti-epileptic pharmacotherapy.^{3, 8, 9, 13,14} Studies such as these have caused investigators to question the necessity of identifying children with TBIs that are not clinically important.^10, 11 With newer generation helical CT scanners, TBIs not identified 20 years ago are now being more readily visualized. Furthermore, with more sensitive neuroimaging tools, such as magnetic resonance imaging (MRI) and single-photon emission computed tomography (SPECT) brain perfusion imaging, TBIs not visible on cranial CT are also being identified.^15,16 Considering this rapid pace of technological developments in neuroimaging, future modalities will likely identify even smaller, more subtle TBIs, and challenge current neuroimaging decision rules that focus on TBI identified on cranial CT.

Current clinical practice patterns result in a number of neurologically-normal children with small TBIs undergoing cranial CT and hospitalization for observation despite the lack of need for acute intervention.^3, 9 The potential inefficiency in this practice prompted us to seek the opinion of specialists on what constitutes a clinically-significant TBI on CT scan for the purposes of hospitalization and acute management. Our objective was to identify variations and factors associated with ED disposition of neurologically-normal children with blunt head trauma and different traumatic cranial CT findings. We hypothesized that substantial variation in practice exists among physicians caring for neurologically-normal children with TBIs on CT and that factors associated with this variation can be identified.

METHODS

RESULTS

We distributed 2,799 surveys. Three hundred sixty-seven were ultimately undeliverable. Ninety-one respondents were ineligible to participate in the survey (90 did not care for children younger than 18 years with trauma and one was a nurse practitioner). In total, 715 (31%) of 2,341 eligible participants responded to the survey. Response rates within subspecialty were pediatric emergency medicine 336/878 (38%), general emergency medicine 161/645 (25%), pediatric neurosurgery 58/135 (43%), general neurosurgery 21/203 (10%), pediatric surgery 76/387 (20%), and trauma surgery 48/93 (52%).

Physician and hospital characteristics of respondents are shown in Table 1. Nearly one-half of all participants specialize in PEM. One-third have more than 15 years of practice experience. Most respondents care almost exclusively for pediatric patients. Participants were evenly distributed across the 4 categories representing annual pediatric patient volume. Most respondents practice in urban areas.

Overall patient discharge rates by isolated CT finding for Case 1 and Case 2 are shown in Table 2. Most respondents would discharge patients having isolated linear, non-displaced skull fractures. Up to 1 quarter of respondents would discharge patients with diastatic (widened) skull fractures, depressed skull fractures, or basilar skull fractures. Few respondents would discharge patients with pneumocephalus, small intracerebral hemorrhage, subarachnoid or very small intraventricular hemorrhages, subdural or epidural hematomas. Discharge rates by practice specialty for both cases are reported in Tables 3 and ​and44.

The statistically significant results of the multivariable analyses for the 2 cases are shown in Tables 5and ​and6,6, respectively. Pediatric surgeons were least likely to discharge either patient with various types of skull fractures, and physicians working in children’s hospitals were more likely to discharge Case 1 with a linear skull fracture. In both cases, pediatric neurosurgeons and general neurosurgeons were more likely to discharge patients with small subarachnoid hemorrhages, and for Case 1, they were more likely to discharge patients with small intracerebral hemorrhages. Of note, pediatric neurosurgeons were also substantially more likely to discharge Case 1 with a small epidural hematoma. In general, physicians with fewer than 5 years of experience also had a lower odds ratio of patient discharge with several of the CT findings.

DISCUSSION

Management of children with minor head trauma remains controversial, and there is no clear standard of care. Not only is there debate on which children require imaging, but the appropriate subsequent disposition of these children once the CT results are known is also unclear as there are no specific guidelines. In our survey of specialists caring for these children, we found substantial variation in the reported hospitalization practices of neurologically-normal children with traumatic findings on cranial CT following blunt head trauma, despite the fact that many TBIs identified on CT do not need acute intervention.^{8,9, 18–20} In fact, TBIs needing neurosurgery in children with Glasgow Coma Scale scores of 14-15 are very uncommon.^3,5,8,9 If medical or surgical intervention is not needed, hospitalization may in fact not be necessary, assuming the neurologically-normal child has reliable parents, no suspicion of inflicted injuries (i.e., abuse) and acceptable follow-up.

In the case scenarios presented, while almost two-thirds of the specialists would discharge patients with a linear skull fracture, a substantial number indicated that they would still admit these children for inpatient observation. Several previous studies have suggested that neither an isolated linear skull fracture nor a basilar skull fracture is, by itself, an indication for hospital admission.^21,22Children with isolated skull fractures in the study by Beaudin et al²³ were discharged from the ED or the pediatric ward without complications and could have easily been managed at home after a period of ED observation.

All surveyed specialty groups reported that they were less likely to discharge patients with intracranial hemorrhages (subarachnoid, intraventricular, subdural, epidural or intracerebral hemorrhages) as opposed to those with isolated skull fractures. Although the reasons for this were not elicited in this study, it is known that certain regions of the brain, especially the medial temporal lobe and the posterior fossa, tolerate mass effect poorly. Potential concern for enlargement of even small hemorrhages in the subacute phase of injury probably influences the decision to admit these patients for observation. Interestingly, pediatric EPs were the most likely of all the specialties to discharge patients with traumatic findings on cranial CT from the ED. Neurosurgeons also indicated their willingness to discharge patients with certain CT findings. In previous research, neurosurgeons have suggested that neurosurgical consultation is not necessary in patients with minor TBI findings and normal neurologic status.²⁴

LIMITATIONS

The study has several limitations. We achieved a 31% response rate to our survey. While this compares favorably to many recent surveys, it is unclear to what degree the practice patterns of non-respondents may have differed from those that responded.^25–27 We also cannot be certain that the responses to the hypothetical cases reflect the actual practice patterns of those caring for children with blunt head trauma. Respondents may be more willing to discharge home a theoretical patient than an actual patient. We also surveyed only those specialists working in major pediatric trauma centers and children’s hospitals because we assumed that they care for a large portion of these types of patients and considered these clinicians to be the most knowledgeable about this issue. It is possible that there are other clinicians who care for children with these injuries that did not have the opportunity to respond to our survey, and their practice patterns may differ.

CONCLUSION

Substantial variation exists between specialties in reported hospitalization practices of neurologically-normal children with blunt head trauma and traumatic cranial CT findings. Pediatric neurosurgeons and general neurosurgeons are more willing to discharge patients than are pediatric surgeons, and other important specialty differences are evident as well. Better evidence is needed to guide disposition decision-making in neurologically-normal children with minor, traumatic cranial CT findings.