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Head Injury

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Emerg Radiol. 2017 Dec 16
Dose monitoring in pediatric and young adult head and cervical spine CT studies at two emergency duty departments.
Niiniviita H, Kiljunen T, Huuskonen M, Teperi S, Kulmala J

PURPOSE:
As the number of pediatric computed tomography (CT) imaging is increasing, there is a need for real-time radiation dose monitoring and evaluation of the imaging protocols. The aim of this study was to present the imaging data, patient doses, and observations of pediatric and young adult trauma-and routine head CT and cervical spine CT collected by a dose monitoring software.

METHODS:
Patient age, study date, imaging parameters, and patient dose as volume CT dose index (CTDIvol) and dose length product (DLP) were collected from two emergency departments' CT scanners for 2-year period. The patients were divided into four age groups (0-5, 6-10, 11-15, and 16-20 years) for statistical analysis and effective dose determination. The 75th percentile doses were evaluated to be used as local diagnostic reference levels (DRLs).

RESULTS:
Six hundred fifteen trauma head, 318 routine head, and 592 trauma cervical spine CT studies were assessed. All mean CTDIvol values were statistically lower in hospital B (40.3†12.3, 30.03†11.1, and 6.9†3.1 mGy, respectively) than in hospital A (53.0†12.9, 43.2†8.7, and 18.3†7.3 mGy, respectively). Statistically significant differences were observed on scanning length between hospitals and between CTDIvol values when protocol was updated. The 75th percentiles of trauma cervical spine in hospital B can be used as local DRL. Non-optimized protocols were also revealed in hospital A.

CONCLUSION:
Dose monitoring software offers a valuable tool for evaluating the imaging practices and finding non-optimized protocols.

Test Dose (mSv) Equivalent background radiation to have equivalent exposure
Chest x-ray 0.1 10 days
Pelvis x-ray 0.1 10 days
CT head 2 8 months
CT cervical spine 3 1 year
Plain c-spine 0.2 3 weeks
CT chest 7 2 years
CT abdomen/pelvis 10 3 years
CT T&L spine 7 2 years
Plain T&L spine 3 1 year
Millimeter wave scanner (that hands in the air TSA thing at the airport) 0.0001 15 minutes
Scatter from a chest x-ray in trauma bay when standing one meter from the patient 0.0002 45 minutes
Scatter from a chest x-ray in trauma bay when standing three meters from the patient 0.000022 6 minutes

Although there tends to be some disagreement into whether or not radiologic studies are being used more or less frequently, we need to be aware of how much radiation we are exposing our patients to. This study cites software based applications to monitor various levels of radiation during a hospital stay but there are many far less technical guidelines that can be used as well. The table above was presented by Dr. Michael McGonigal(), a trauma surgeon at Regions Hospital in St. Paul.


Ann Emerg Med. 2018 Feb 13.
Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study.
Babl FE, Oakley E, Dalziel SR, Borland ML, Phillips N, Kochar A, Dalton S, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Donath S, Hearps S, Molesworth C, Crowe L, Bressan S, Lyttle MD

STUDY OBJECTIVE:
Three clinical decision rules for head injuries in children (Pediatric Emergency Care Applied Research Network [PECARN], Canadian Assessment of Tomography for Childhood Head Injury [CATCH], and Children's Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE]) have been shown to have high performance accuracy. The utility of any of these in a particular setting depends on preexisting clinician accuracy. We therefore assess the accuracy of clinician practice in detecting clinically important traumatic brain injury.

METHODS:
This was a planned secondary analysis of a prospective observational study of children younger than 18 years with head injuries at 10 Australian and New Zealand centers. In a cohort of children with mild head injuries (Glasgow Coma Scale score 13 to 15, presenting in <24 hours) we assessed physician accuracy (computed tomography [CT] obtained in emergency departments [EDs]) for the standardized outcome of clinically important traumatic brain injury and compared this with the accuracy of PECARN, CATCH, and CHALICE.

RESULTS:
Of 20,137 children, 18,913 had a mild head injury. Of these patients, 1,579 (8.3%) received a CT scan during the ED visit, 160 (0.8%) had clinically important traumatic brain injury, and 24 (0.1%) underwent neurosurgery. Clinician identification of clinically important traumatic brain injury based on CT performed had a sensitivity of 158 of 160, or 98.8% (95% confidence interval [CI] 95.6% to 99.8%) and a specificity of 17,332 of 18,753, or 92.4% (95% CI 92.0% to 92.8%). Sensitivity of PECARN for children younger than 2 years was 42 of 42 (100.0%; 95% CI 91.6% to 100.0%), and for those 2 years and older, it was 117 of 118 (99.2%; 95% CI 95.4% to 100.0%); for CATCH (high/medium risk), it was 147 of 160 (91.9%; 95% CI 86.5% to 95.6%); and for CHALICE, 148 of 160 (92.5%; 95% CI 87.3% to 96.1%).

CONCLUSION:
In a setting with high clinician accuracy and a low CT rate, PECARN, CATCH, or CHALICE clinical decision rules have limited potential to increase the accuracy of detecting clinically important traumatic brain injury and may increase the CT rate.

Even though there are many Clinical Decision Tools to guide practice, clinician experience and judgment continue to be equally important. In this study clinician decision making proved to reduce the number of CT scans obtained.


Ital J Pediatr. 2018 Jan 15;44(1):7
Italian guidelines on the assessment and management of pediatric head injury in the emergency department
Liviana Da Dalt, Niccolo' Parri, Angela Amigoni, Agostino Nocerino, Francesca Selmin, Renzo Manara, Paola Perretta, Maria Paola Vardeu, Silvia Bressan

Objective
We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury.

Methods
These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text.

Conclusions
Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.


Summary of recommendations Initial assessment and stabilization

  1. Clinicians must follow the ABCDE approach according to the ATLS/PALS/EPALS principles for the initial assessment and management of all children with severe head trauma (Evidence Quality: X; Recommendation Strength: Strong Recommendation)

  2. In children presenting to the ED with severe blunt head trauma and with signs of raised intracranial pressure (ICP) administration of hyperosmolar therapy with hypertonic saline should be considered (Evidence Quality: B; Recommendation Strength: Moderate Recommendation)

    1. Clinicians should avoid hyperventilation in children presenting to the ED with signs of ICP following a severe head trauma (Evidence Quality: C; Recommendation Strength: Moderate Recommendation);

    2. In children presenting to the ED with signs of impending cerebral herniation following severe head trauma, clinicians may consider hyperventilation as a temporary measure to rapidly reduce ICP in order to increase the patient chances of undergoing a life-saving intervention (Evidence Quality: D; Recommendation Strength: Weak Recommendation)

  3. In children presenting to the ED with severe blunt head trauma, steroids should not be administered (Evidence Quality: B; Recommendation Strength: Strong Recommendation)

  4. In children presenting with severe blunt head trauma, hypothermia should not be initiated in the ED (Evidence Quality: A; Recommendation Strength: Strong Recommendation)

Diagnosis of clinically important traumatic brain injury

CT scan decision-making


  1. Physicians should perform a head CT in all head injured children presenting to the ED with a GCS < 14 (Evidence Quality: A; Recommendation Strength: Strong Recommendation)

  2. Physicians should use the age-appropriate PECARN algorithms to assist their decision-making about head CT scan in children with a GCS≥14 (Evidence Quality: A; Recommendation Strength: Strong Recommendation).

  3. Physicians should favor initial observation over CT scan for children at intermediate-risk for clinically important traumatic brain injury (ciTBI) according to the age-appropriate PECARN algorithms, especially in the presence of isolated findings (Evidence Quality: A; Recommendation Strength: Strong Recommendation)

In children with ventricular shunt who sustain a minor head trauma and have no PECARN predictors of traumatic brain injury and no other risk factors from history, clinicians should favor initial observation over routine immediate CT scan (Evidence Quality: B; Recommendation Strength: Moderate Recommendation)

Repeat CT scan
Clinicians should avoid routine repeat CT scan in children with GCS 1415 and a non-clinically significant intracranial injury on initial CT. Decision on repeating CT should be based on a careful monitoring of the neurological status and consultation with the neurosurgeon (Evidence Quality: C; Recommendation Strength: Weak Recommendation)

Other imaging
In children presenting to the ED with minor head trauma clinicians should not use skull radiographs as a screening tool for clinically important traumatic brain injuries. (Evidence Quality: B; Recommendation Strength: Strong Recommendation)

  1. Clinicians should not routinely use trans-fontanelle ultrasound for diagnosing intracranial injuries in infants presenting to the emergency department following a trauma to the head (Evidence Quality: D; Recommendation Strength: Weak Recommendation)

  2. Clinicians may choose to use point-of-care ultrasound for the identification of skull fractures and the definition of their characteristics (e.g. depression, diastasis) in children with minor head trauma (Evidence Quality: B; Recommendation Strength: Moderate Recommendation)

Clinicians should not routinely use near-infrared spectroscopy (NIRS) technology devices to screen for intracranial hematomas in the assessment of children presenting to the emergency department following a trauma to the head. (Evidence Quality: C; Recommendation Strength: Weak Recommendation)

Management and disposition

Observation

  1. ED physicians should favor initial observation over CT scan for children at intermediate-risk of clinically important traumatic brain injury (ciTBI) according to the age-appropriate PECARN algorithms, especially in the presence of isolated findings. (Evidence Quality: B; Recommendation Strength: Strong Recommendation)

  2. ED physicians who elect to observe previously-healthy children >3 months of age at PECARN intermediate risk of ciTBI following a minor head trauma, should observe these patients for a minimum of 46 h from the time of injury. (Evidence Quality: C; Recommendation Strength: Weak Recommendation).

  3. ED physicians who elect to observe infants younger than 3 months at PECARN intermediate risk of ciTBI following a minor head trauma should consider to observe them for 24 h. (Evidence Quality: D; Recommendation Strength: Weak Recommendation).

  4. Children who require observation in the ED following a head trauma should be appropriately monitored by clinical staff who are qualified to deliver care to children. (Evidence Quality: D; Recommendation Strength: Weak Recommendation).

  5. ED physicians should not repeat a CT scan and/or hospitalize solely for neurologic observation previously healthy children without intracranial injury on initial head CT, unless persistent symptoms or clinical deterioration occur. (Evidence Quality: A; Recommendation Strength: Strong Recommendation).

Neurosurgical consult

  1. In children presenting to the ED following a minor head trauma and with a personal history of neurosurgical intervention other than isolated placement of a ventricular shunt, clinicians may require a neurosurgical consult, considering the type and time of the intervention, to help support CT-scan decision making. (Evidence Quality: D; Recommendation Strength: Weak Recommendation)

  2. ED physicians must discuss with a neurosurgeon the care of all children with traumatic injuries on CT scan, (excluding uncomplicated isolated linear skull fractures). For children presenting with severe head trauma ED physicians should alert a neurosurgeon as soon as possible, ideally prior to CT scan performance. (Evidence Quality: X; Recommendation Strength: Strong Recommendation).

Inter-hospital transfer

Centers without CT scan

  1. ED physicians working in centers with no CT availability should transfer all children presenting with head trauma and either a GCS<14 or at PECARN high risk for ciTBI to referral pediatric centers with neurosurgical capability. (Evidence Quality: A; Recommendation Strength: Strong Recommendation)

  2. ED physicians working in centers with no CT availability should consider to transfer children at PECARN intermediate risk for ciTBI to referral pediatric centers, preferably with pediatric neurosurgical capability. Decision to transfer should take into consideration the availability of resources for appropriate clinical monitoring, the age of the child (transfer should be preferred in children <3 months) and physician experience. (Evidence Quality: D; Recommendation Strength: Weak Recommendation).

Centers with CT scan but without neurosurgery unit

  1. ED physicians working in centers with CT capability but without neurosurgery must follow local healthcare system network guidelines for decision-making on transfer of children with moderate-severe head trauma to referral centers. Each regional system needs to have guidelines and protocols in place to ensure safe, timely and appropriate inter-hospital transfer of these children. (Evidence Quality: X; Recommendation Strength: Strong Recommendation)

  2. In centers with CT availability, but without neurosurgery, ED physicians may perform a head CT scan of children with moderate-severe head trauma, after stabilization, only if it does not delay transfer to the definitive care referral center and provided that images are of good quality and can easily be transferred to the referral center. (Evidence Quality: D; Recommendation Strength: Weak Recommendation).

  3. In centers with CT availability but without neurosurgery children with minor head trauma should be managed according to the recommendations previously provided in these guidelines for CT scan decision-making (KAS 6) and request of neurosurgical consultation (KAS 13). ED physicians should use teleradiology, whenever available, to discuss with the referral neurosurgical unit the transfer of children with traumatic brain inury on CT. (Evidence Quality: B; Recommendation Strength: Strong Recommendation).

  4. ED physicians working in centers with CT capability but without neurosurgery should transfer to referral pediatric centers children with minor head trauma who need clinical observation whenever resources for appropriate clinical observation are not available in the referring center. (Evidence Quality: X; Recommendation Strength: Strong Recommendation).

  5. ED physicians working in centers with CT capability but without neurosurgery should transfer to referral pediatric centers, preferably with pediatric neurosurgical capability, children with minor head trauma needing sedation to undergo CT scan, if no skilled staff in pediatric sedation are available at the referring center (Evidence Quality: X; Recommendation Strength: Strong Recommendation).

Discharge from the ED

  1. ED physicians should ensure the following criteria are met before previously-healthy children with head trauma are discharged from the ED, either after initial assessment or following a period of observation:
    1. GCS 15
    2. Asymptomatic or significant improvement in symptoms
    3. Normal neurological exam
    4. No suspicion of child abuse
    5. Reliable caregivers and ability to easily return to the ED
    6. No other injuries requiring admission

    For children who have undergone a head CT scan

    1. Normal findings or presence of isolated linear skull fracture
    2. Minor intracranial injuries on CT, based on neurosurgical consultation
    (Evidence Quality: X/A; Recommendation Strength: Strong Recommendation)

  2. ED physicians should give verbal and printed discharge advice to children with head trauma and their caregivers upon discharge from the ED or ED observation unit.

    The advice given should include:
    1. Signs and symptoms that warrant medical review
    2. The recommendation that a responsible adult should monitor the patient for the first 24 h after trauma
    3. Details about the possibility of persistent or delayed symptoms following head trauma and whom to contact if they experience ongoing symptoms
    4. Information about return to school and return to sports for children who sustain a concussion
    The above guidelines have been established to assist clinicians assess and stabilize children who have sustained a head injury. Both the experienced and inexperienced clinician in any type of setting can use these guidelines when caring for these kids.

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