Evaluation and Management of Blunt Head Trauma in the Pediatric Clinic.

Head injuries, and specifically blunt head trauma, are common among pediatric patients of all ages. Patients may present to their primary care provider, to urgent care, or to the emergency department after head trauma. Such injuries may occur as a result of a variety of mechanisms, including falls, motor vehicle collisions, or sports injuries. Clinical decision rules exist to help guide the clinician in the initial evaluation of head injury and in determining when head imaging may be indicated. One such guideline that is widely used in the United States is known as the PECARN (Pediatric Emergency Care Applied Research Network) criteria. Pediatricians should also evaluate for the presence of symptoms consistent with concussion that may occur as a result of blunt head trauma and be familiar with the management and sequelae of concussion and head injuries. [Pediatr Ann. 2023;52(8):e279-e281.].

Management of Calcified Cephalohematoma of Infancy: The University of Michigan 25-Year Experience.

BACKGROUND: Cephalohematoma of infancy is the result of a subperiosteal blood collection that usually forms during birth-related trauma. A small proportion of cephalohematomas can calcify over time, causing a permanent calvarial deformity that is only correctable with surgery. The authors present a technique for the excision and reconstruction of calcified cephalohematoma and their management experience over the past 25 years. METHODS: All patients with a diagnosis of calcified cephalohematoma between 1994 and 2019 were identified. Patients were included if the diagnosis was confirmed by a pediatric plastic surgeon or a neurosurgeon. All patients underwent surgical evaluation followed by surgical intervention or observation. Patient demographics and potential risk factors for both surgical and nonsurgical groups were compared using chi-square or Fisher's exact test. Additional data were collected for the surgical cohort. RESULTS: Of 160 infants diagnosed with cephalohematoma, 72 met inclusion criteria. Thirty patients underwent surgical treatment. There was no significant difference in demographics, baseline characteristics, or potential risk factors between the operative and nonoperative groups. Mean age at the time of surgery was 8.6 months. Twenty-one surgical patients (70 percent) required inlay bone grafting. All surgery patients had improvement in calvarial shape. The main risk of surgery was blood loss requiring transfusion [eight patients (26.7 percent)]. Thirteen percent of patients experienced minor complications. CONCLUSIONS: This series of 72 children with calcified cephalohematomas, 30 of whom required surgical intervention, is one of the largest to date. The technique presented herein demonstrated excellent surgical outcomes by restoring normal cranial contours and was associated with a low complication profile. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Blunt cerebrovascular injuries: Outcomes from the American Association for the Surgery of Trauma PROspective Observational Vascular Injury Treatment (PROOVIT) multicenter registry.

BACKGROUND: Administering antithrombotics (AT) to the multiply injured patient with blunt cerebrovascular injury (BCVI) requires a thoughtful assessment of the risk of stroke and death associated with nontreatment. Large, multicenter analysis of outcomes stratified by injury grade and vessel injured is needed to inform future recommendations. METHODS: Nine hundred and seventy-one BCVIs were identified from the PROspective Vascular Injury Treatment registry in this retrospective analysis. Using multivariate analysis, we identified predictors of BCVI-related stroke and death. We then stratified these risks by injury grade and vessel injured. We compared the risk of adverse outcomes in the nontreatment group with those treated with antiplatelet agents and/or anticoagulants. RESULTS: Stroke was identified in 7% of cases. Overall mortality was 12%. Both increased with increasing BCVI grade. Treatment with ATs was associated with lower mortality and was not significantly affected by the choice of agent. Withholding ATs was associated with an increased risk of stroke and/or death across all subgroups (Grade I/II: odds ratio [OR], 4.66; 95% confidence interval [CI], 2.48-8.75; Grade III: OR, 7.0; 95% CI, 2.01-24.5; Grade IV: OR, 4.43; 95% CI, 1.76-11.1) even after controlling for covariates. Predictors of death included more severe trauma, Grade IV injury, and the occurrence of stroke. Arterial occlusion, hypotension, and endovascular intervention were significant predictors of stroke. Patients that experienced a BCVI-related stroke were at a 4.2× increased risk of death. The data set lacked the granularity necessary to evaluate AT timing or dosing regimen, which limited further analysis of stroke prevention strategies. CONCLUSION: Stroke and death remain significant risks for all BCVI grades regardless of the vessel injured. Antithrombotics represent the only management strategy that is consistently associated with a lower incidence of stroke and death in all BCVI categories. In the multi-injured BCVI patient with a high risk of bleeding on anticoagulation, antiplatelet agents are an efficacious alternative. Given the 40% mortality rate in patients who survived their initial trauma and developed a BCVI-related stroke, nontreatment may no longer be a viable option. LEVEL OF EVIDENCE: Epidemiological III; Therapeutic IV.

Blunt and Penetrating Severe Traumatic Brain Injury.

Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.

Managing Craniomaxillofacial Injury Without Inpatient Consult: Outcomes and Patient Cost Savings.

BACKGROUND: We hypothesized that trauma surgeons can safely selectively manage traumatic craniomaxillofacial injuries (CMF) without specialist consult, thereby decreasing the overall cost burden to patients. METHODS: A 4-year retrospective analysis of all CMF fractures diagnosed on facial CT scans. CMF consultation was compared with no-CMF consultation. Demographics, injury severity, and specialty consultation charges were recorded. Penetrating injuries, skull fractures, or patients completing inpatient craniofacial surgery were excluded. RESULTS: 303 patients were studied (124 CMF consultation vs 179 no-CMF consultation), mean age was 47.8 years, with 70% males. Mean Glasgow Coma Scale and Injury Severity Score (ISS) was 14 ± 3.4 and 10 ± 9, respectively. Patients with CMF consults had higher ISS (P < .001) and needed surgery on admission (P < .001), while no-CMF consults had shorter length of stay (P < .002). No in-hospital mortality or 30-day readmission rates were related to no-CMF consult. Total patient charges saved with no-CMF consultation was $26 539.96. DISCUSSION: Trauma surgeons can selectively manage acute CMF injuries without inpatient specialist consultation. Additional guidelines can be established to avoid tertiary transfers for specialty consultation and decrease patient charges.

Nonfatal All-Terrain Vehicle-Related Head and Neck Injuries to Children Treated in US Emergency Departments.

This study investigates children <18 years old with nonfatal all-terrain vehicle (ATV)-related head and neck injuries treated in United States emergency departments by analyzing data from the National Electronic Injury Surveillance System from 1990 to 2014. An estimated 279 391 children received emergency treatment during the 25-year study period. The number of injuries remained relatively constant from 1990 to 1997, increased by 142.9% from 1997 to 2007, and then decreased by 37.4% from 2007 to 2014. The most common diagnoses were concussion/closed head injury (32.6%) and fracture (32.6%); 15.4% of children were admitted. The most common injury mechanisms include ejection (30.0%), crash (18.8%), and rollover (15.8%). Patients who were injured on a street/highway were 1.49 times (95% confidence interval = 1.11-1.99) more likely to be admitted than patients injured at other locations. Although the number of nonfatal ATV-related head and neck injuries decreased during the latter part of the study period, they remain common and can have serious medical outcomes.

Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma.

BACKGROUND: Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy (ATT) and endovascular stents. METHODS: Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI. RESULTS: A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol versus no screening protocol (odds ratio [OR], 4.74; 95% confidence interval [CI], 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR, 12.7; 95% CI, 6.24-25.62; p = 0.003). The use of ATT versus no ATT resulted in a decreased risk of stroke (OR, 0.20; 95% CI, 0.06-0.65; p < 0.0001) and mortality (OR, 0.17; 95% CI, 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to ATT versus ATT alone (OR, 1.63; 95% CI, 0.2-12.14; p = 0.63). CONCLUSION: We recommend using a screening protocol to detect BCVI in blunt polytrauma patients. Among patients with high-risk cervical spine injuries, we recommend screening computed tomography angiography to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a computed tomography angiography to detect BCVI. We recommend the use of ATT in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to ATT in patients with Grade II or III BCVIs. LEVEL OF EVIDENCE: Guidelines, Level III.

Resident-Sensitive Quality Measures in the Pediatric Emergency Department: Exploring Relationships With Supervisor Entrustment and Patient Acuity and Complexity.

PURPOSE: This study explores the associations between resident-sensitive quality measures (RSQMs) and supervisor entrustment as well as between RSQMs and patient acuity and complexity for encounters in the pediatric emergency department (PED) in which residents are caring for patients. METHOD: Pediatric residents rotating through Cincinnati Children's Hospital Medical Center PED as well as supervising pediatric emergency medicine faculty and fellows were recruited during the 2017-2018 academic year for the purpose of collecting the following data from the residents' patient encounters for 3 illnesses (acute asthma exacerbation, bronchiolitis, and closed head injury [CHI]): supervisor entrustment decision rating, RSQMs relevant to the care provided, and supervisor patient acuity and complexity ratings. To measure the association of RSQM composite scores with the other variables of interest, mixed models were used. RESULTS: A total of 83 residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with CHI. Entrustment decision ratings were positively associated with asthma RSQM composite scores (beta coefficient = 0.03; P < .001). There was no significant association between RSQM composite scores and entrustment decision ratings for bronchiolitis or CHI. RSQM composite scores were significantly higher when acuity was also higher and significantly lower when acuity was also lower for both asthma (P < .001) and bronchiolitis (P = .01). However, RSQM composite scores were almost identical between levels of acuity for CHI (P = .94). There were no significant differences in RSQM composite scores when complexity varied. CONCLUSION: This study found limited associations between RSQM composite scores and entrustment decision ratings but offers insight into how RSQMs could be used for the purposes of resident assessment and feedback.

Initial Implementation of Resident-Sensitive Quality Measures in the Pediatric Emergency Department: A Wide Range of Performance.

PURPOSE: A lack of quality measures aligned with residents' work led to the development of resident-sensitive quality measures (RSQMs). This study sought to describe how often residents complete RSQMs, both individually and collectively, when they are implemented in the clinical environment. METHOD: During academic year 2017-2018, categorical pediatric residents in the Cincinnati Children's Hospital Medical Center pediatric emergency department were assessed using RSQMs for acute asthma exacerbation (21 RSQMs), bronchiolitis (23 RSQMs), and closed head injury (19 RSQMs). Following eligible patient encounters, all individual RSQMs for the illnesses of interest were extracted from the health record. Frequencies of 3 performance classifications (opportunity and met, opportunity and not met, or no opportunity) were detailed for each RSQM. A composite score for each encounter was calculated by determining the proportion of individual RSQMs performed out of the total possible RSQMs that could have been performed. RESULTS: Eighty-three residents cared for 110 patients with asthma, 112 with bronchiolitis, and 77 with closed head injury during the study period. Residents had the opportunity to meet the RSQMs in most encounters, but exceptions existed. There was a wide range in the frequency of residents meeting RSQMs in encounters in which the opportunity existed. One closed head injury measure was met in all encounters in which the opportunity existed. Across illnesses, some RSQMs were met in almost all encounters, while others were met in far fewer encounters. RSQM composite scores demonstrated significant range and variation as well-asthma: mean = 0.81 (standard deviation [SD] = 0.11) and range = 0.47-1.00, bronchiolitis: mean = 0.62 (SD = 0.12) and range = 0.35-0.91, and closed head injury: mean = 0.63 (SD = 0.10) and range = 0.44-0.89. CONCLUSIONS: Individually and collectively, RSQMs can distinguish variations in the tasks residents perform across patient encounters.

A secondary analysis to inform a clinical decision rule for predicting skull fracture and intracranial injury in children under age 2.

The purpose of this study was to identify factors associated with the risk of closed head injury (CHI) in children under age 2 years with suspected minor head injuries based on age-appropriate, or near age-appropriate, mental status on an exam. The study was a secondary data analysis of a public-use dataset from the largest prospective, multicenter pediatric head injury study found in the current literature. An existing, validated clinical decision rule was examined using a sample of 3,329 children under age 2 to determine whether it, or the individual variables within it, could be utilized alone, or in conjunction with other variables to accurately predict the risk of underlying CHI in this sample. Results indicated that the keys to an accurate triage assessment for children under age 2 with suspected minor head injuries include the ability to identify the specific skull region injured, the ability to assess for the presence and size of any scalp hematoma, the ability to identify signs of altered mental status in this age group, and having access to accurate information regarding the child's age and the details of the injury mechanism. The findings from this study add to the body of knowledge regarding what factors are associated with CHI in children under age 2 with suspected minor head injuries and could be used to inform age-specific recommendations for children under age 2 in triage, educational resources, and national trauma criteria.

Desmopressin is a transfusion sparing option to reverse platelet dysfunction in patients with severe traumatic brain injury.

BACKGROUND: Platelet dysfunction (PD) is an independent predictor of mortality in patients with severe traumatic brain injury (sTBI). Platelet transfusions (PLTs) have been shown to be an effective treatment strategy to reverse platelet inhibition. Their use is contingent on availability and may be associated with increased cost and transfusion-related complications, making desmopressin (DDAVP) attractive. We hypothesized that DDAVP would correct PD similarly to PLTs in patients with sTBI. METHODS: This retrospective study evaluated all blunt trauma patients admitted to an urban, level 1 trauma center from July 2015 to October 2016 with sTBI (defined as head abbreviated injury scale [AIS] ≥3) and PD (defined as adenosine diphosphate [ADP] inhibition ≥60% on thromboelastography) and subsequently received treatment. Per our institutional practice, patients with sTBI and PD are transfused one unit of apheresis platelets to reverse inhibition. During a platelet shortage, we interchanged DDAVP for the initial treatment. Patients were classified as receiving DDAVP or PLT based on the initial treatment. RESULTS: A total of 57 patients were included (DDAVP, n = 23; PLT, n = 34). Patients who received DDAVP were more severely injured (injury severity score, 29 vs. 23; p = 0.045), but there was no difference in head AIS (4 vs. 4, p = 0.16). There was no difference between the two groups in admission platelet count (244 ± 68 × 10/µL vs. 265 ± 66 × 10/µL, p = 0.24) or other coagulation parameters such as prothrombin time, partial thromboplastin time, or international normalized ratio. Before treatment, both groups had similar ADP inhibition as measured by thromboelastography (ADP, 86% vs. 89%, p = 0.34). After treatment, both the DDAVP and PLT groups had similar correction of platelet ADP inhibition (p = 0.28). CONCLUSION: In patients with severe traumatic brain injury and PD, DDAVP may be an alternative to PLTs to correct PD. LEVEL OF EVIDENCE: Therapeutic, level IV.

Pre-treatment with microRNA-181a Antagomir Prevents Loss of Parvalbumin Expression and Preserves Novel Object Recognition Following Mild Traumatic Brain Injury.

Mild traumatic brain injury (mTBI) can result in permanent impairment in memory and learning and may be a precursor to other neurological sequelae. Clinical treatments to ameliorate the effects of mTBI are lacking. Inhibition of microRNA-181a (miR-181a) is protective in several models of cerebral injury, but its role in mTBI has not been investigated. In the present study, miR-181a-5p antagomir was injected intracerebroventricularly 24 h prior to closed-skull cortical impact in young adult male mice. Paw withdrawal, open field, zero maze, Y maze, object location and novel object recognition tests were performed to assess neurocognitive dysfunction. Brains were assessed immunohistologically for the neuronal marker NeuN, the perineuronal net marker wisteria floribunda lectin (WFA), cFos, and the interneuron marker parvalbumin. Protein quantification was performed with immunoblots for synaptophysin and postsynaptic density 95 (PSD95). Fluorescent in situ hybridization was utilized to localize hippocampal miR-181a expression. MiR-181a antagomir treatment reduced neuronal miR-181a expression after mTBI, restored deficits in novel object recognition and increased hippocampal parvalbumin expression in the dentate gyrus. These changes were associated with decreased dentate gyrus hyperactivity indicated by a relative reduction in PSD95 and cFos expression. These results suggest that miR-181a inhibition may be a therapeutic approach to reduce hippocampal excitotoxicity and prevent cognitive dysfunction following mTBI.

Reduction in Head Computed Tomography Ordering in Pediatric Emergency Patients: Effect of National Publication and Local Availability of Urgent Neurology Appointments.

OBJECTIVE: The objective of this study was to evaluate the effect of the Pediatric Emergency Care Applied Research Network (PECARN) blunt head trauma guidelines and implementation of urgent neurology follow-up (UNF) appointments on an observed decline in head computed tomography (CT) use for pediatric emergency department (PED) patients presenting with headache, seizure, and trauma. METHODS: Patients ages 0 to 18 years presenting to and discharged from an urban tertiary care PED with chief complaint of trauma, headache, and seizure between 2007 and 2013 were retrospectively included. The total number of head CTs obtained in the trauma, headache, and seizure groups was compared before and after the publication of the PECARN guidelines in 2009 and the implementation of urgent UNF within a week from PED discharge in 2011, respectively. RESULTS: Between 2007 and 2013, 24,434 encounters were identified with 2762 head CTs performed. Analysis demonstrated a decline in pediatric head CTs for trauma (odds ratio [OR], 2.0; 95% confidence interval [CI], 1.8-2.2) after the publication of the PECARN study on blunt head trauma, for headache (OR, 1.4; 95% CI, 1.1-1.8) and seizure (OR, 1.9; 95% CI, 1.4-2.6) with UNF. However, cross comparison (headache and seizure with PECARN and trauma with UNF) also demonstrated similar significant declines. CONCLUSIONS: The decline in head CTs observed at our institution demonstrated a strong linear relationship, yet cannot be solely attributed to the PECARN blunt head trauma study or the implementation of UNF.

Implementation of a Clinical Decision Support System for Children With Minor Blunt Head Trauma Who Are at Nonnegligible Risk for Traumatic Brain Injuries.

STUDY OBJECTIVE: To determine the effect of providing risk estimates of clinically important traumatic brain injuries and management recommendations on emergency department (ED) outcomes for children with isolated intermediate Pediatric Emergency Care Applied Research Network clinically important traumatic brain injury risk factors. METHODS: This was a secondary analysis of a nonrandomized clinical trial with concurrent controls, conducted at 5 pediatric and 8 general EDs between November 2011 and June 2014, enrolling patients younger than 18 years who had minor blunt head trauma. After a baseline period, intervention sites received electronic clinical decision support providing patient-level clinically important traumatic brain injury risk estimates and management recommendations. The following primary outcomes in patients with one intermediate Pediatric Emergency Care Applied Research Network risk factor were compared before and after clinical decision support: proportion of ED computed tomography (CT) scans, adjusted for age, time trend, and site; and prevalence of clinically important traumatic brain injuries. RESULTS: The risk of clinically important traumatic brain injuries was known for 3,859 children with isolated findings (1,711 at intervention sites before clinical decision support, 1,702 at intervention sites after clinical decision support, and 446 at control sites). In this group, pooled CT proportion decreased from 24.2% to 21.6% after clinical decision support (odds ratio 0.86; 95% confidence interval 0.73 to 1.01). Decreases in CT use were noted across intervention EDs, but not in controls. The pooled adjusted odds ratio for CT use after clinical decision support was 0.73 (95% confidence interval 0.60 to 0.88). Among the entire cohort, clinically important traumatic brain injury was diagnosed at the index ED visit for 37 of 37 (100%) patients before clinical decision support and 32 of 33 patients (97.0%) after clinical decision support. CONCLUSION: Providing specific risks of clinically important traumatic brain injury through electronic clinical decision support was associated with a modest and safe decrease in ED CT use for children at nonnegligible risk of clinically important traumatic brain injuries.

Traumatic Posterior Fossa Subdural Hemorrhage: A Multicenter, Retrospective Cohort Study.

BACKGROUND: Traumatic posterior fossa subdural hemorrhage (SDH) is a rare subtype of subdural hemorrhage in head injuries. Existing data on its pathophysiology and outcome are currently limited; therefore, the condition is not yet fully understood. The present study aimed to determine the incidence, outcome, and prognostic factors for traumatic posterior fossa SDH. METHODS: We performed a retrospective cohort study using the nationwide trauma registry Japan Trauma Data Bank. We identified adult patients (i.e., aged ≥18 years) who had posterior fossa SDH after blunt head trauma from 2004 to 2015. The primary endpoint was in-hospital mortality. We compared patients with and without posterior fossa SDH and adjusted for confounders using a multivariate logistic regression model. RESULTS: A total of 75,838 patients had blunt head injuries. Of these, 266 (0.35%) had posterior fossa SDH, and 177 (median age, 69 years; interquartile range, 55-76) were eligible for analysis. The distribution of the Glasgow Coma Scale (GCS) score was bimodal, and the median score was 14 (interquartile range, 9-15). The mortality rate was 16.9% (95% confidence interval [CI], 11.7%-23.3%). A large posterior fossa SDH (>30 cm3; >1 cm thick), low GCS score on arrival, and the presence of a skull fracture were significantly associated with mortality, with an adjusted odds ratio of 4.51 (95% CI, 1.46-13.9), 0.82 (95% CI, 0.73-0.92), and 4.59 (95% CI, 1.52-13.9), respectively. CONCLUSIONS: Traumatic posterior fossa SDH was extremely rare in our data set. Mortality correlated with the size of the SDH, GCS score on admission, and the presence of a skull fracture.

[Diseases as a 'Stumbling Block' - a Case of Multimorbidity in Clinical Practice]. / Vorerkrankungen als «Stolperstein¼ ­ ein Fall von Multimorbidität in der Klinik.

Diseases as a `Stumbling Block` - a Case of Multimorbidity in Clinical Practice Abstract. Here we report on a 83 year-old patient with cardiac syncope and consecutive traumatic brain injury with intracranial haemorrhage receiving anticoagulation for recurrent pulmonary embolism: a 'medical dilemma' due to the syncope with consecutive traumatic event and the underlying condition. A pre-existing underlying cardiac disease was identified as the cause of the syncope and the intracranial haemorrhage was most likely due to oral anticoagulation for recurrent pulmonary embolisms. The intracranial bleeding inhibited an optimal management of the underlying cardiac condition and the patient deceased shortly thereafter.

Neuroimaging of brain trauma.

PURPOSE OF REVIEW: The purpose of this review is to provide an update on advanced neuroimaging techniques in traumatic brain injury (TBI). We will focus this review on recent literature published within the last 18 months and the advanced neuroimaging techniques of perfusion imaging and diffusion tensor imaging (DTI). RECENT FINDINGS: In the setting of a moderate or severe acute closed head injury (Glasgow Coma Scale <13), the most appropriate neuroimaging study is a noncontrast computed tomography (CT) scan. In the setting of mild TBI, the indication for neuroimaging can be determined using the New Orleans Criteria or Canadian CT Head Rules or National Emergency X-Ray Utilization Study-II clinical criteria. Two advanced neuroimaging techniques that are currently being researched in TBI include perfusion imaging and DTI. Perfusion CT has a higher sensitivity for detecting cerebral contusions than noncontrast CT examinations. DTI is a sensitive at detecting TBI at the group level (TBI-group versus control group), but there is insufficient evidence to suggest that DTI plays a clinical role for diagnosing mild TBI at the individual patient level. SUMMARY: Future research in advanced neuroimaging techniques including perfusion imaging and DTI may improve the accuracy of the diagnosis and prognosis as well as improve the management of TBI.

Vomiting With Head Trauma and Risk of Traumatic Brain Injury.

OBJECTIVES: To determine the prevalence of traumatic brain injuries in children who vomit after head injury and identify variables from published clinical decision rules (CDRs) that predict increased risk. METHODS: Secondary analysis of the Australasian Paediatric Head Injury Rule Study. Vomiting characteristics were assessed and correlated with CDR predictors and the presence of clinically important traumatic brain injury (ciTBI) or traumatic brain injury on computed tomography (TBI-CT). Isolated vomiting was defined as vomiting without other CDR predictors. RESULTS: Of the 19 920 children enrolled, 3389 (17.0%) had any vomiting, with 2446 (72.2%) >2 years of age. In 172 patients with ciTBI, 76 had vomiting (44.2%; 95% confidence interval [CI] 36.9%-51.7%), and in 285 with TBI-CT, 123 had vomiting (43.2%; 95% CI 37.5%-49.0%). With isolated vomiting, only 1 (0.3%; 95% CI 0.0%-0.9%) had ciTBI and 2 (0.6%; 95% CI 0.0%-1.4%) had TBI-CT. Predictors of increased risk of ciTBI with vomiting by using multivariate regression were as follows: signs of skull fracture (odds ratio [OR] 80.1; 95% CI 43.4-148.0), altered mental status (OR 2.4; 95% CI 1.0-5.5), headache (OR 2.3; 95% CI 1.3-4.1), and acting abnormally (OR 1.86; 95% CI 1.0-3.4). Additional features predicting TBI-CT were as follows: skull fracture (OR 112.96; 95% CI 66.76-191.14), nonaccidental injury concern (OR 6.75; 95% CI 1.54-29.69), headache (OR 2.55; 95% CI 1.52-4.27), and acting abnormally (OR 1.83; 95% CI 1.10-3.06). CONCLUSIONS: TBI-CT and ciTBI are uncommon in children presenting with head injury with isolated vomiting, and a management strategy of observation without immediate computed tomography appears appropriate.

Effect of Telenursing on Outcomes of Provided Care by Caregivers of Patients With Head Trauma After Discharge.

Telenursing is a suitable tool for increasing health-related awareness of the caregivers for a better home care. But its efficacy may be affected by several factors. Considering the important complications of head trauma injury and high rate of readmission, we aimed to assess the effect of telenursing on care provided by the family members of patients with head trauma.This randomized controlled trial investigated 72 patients with head trauma, who were randomly allocated to intervention and control groups (36 patients in each group). The caregivers in both groups were provided with 1-hr face-to-face training session on patients' home care and educational booklets. The patients in the intervention group were followed up every week through phone calls by the telenurse for 12 weeks, who recorded the patient's status, as well. Caregivers in the intervention group could call the telenurse any time they desired. The health status of the control group was followed once by a phone call after 12 weeks. Data on patients' readmission and pressure ulcer (based on Norton's scale) rate and time were compared between the groups and analyzed using SPSS software, version 19. Thirty-three patients with a mean ± SD age of 31.12 ± 10.83 years were studied in the control group and 35 patients with a mean ± SD age of 34.11 ± 12.34 years in the intervention group (p = .098). None of the patients in the intervention group were readmitted, whereas 2 patients in the control group were readmitted s(p = .139). Risk of pressure ulcer did not differ between the groups (p = .583). Telenursing had no significant effect in readmission and decubitus prevention for patients with head trauma. Considering the chronic nature of the illness, a longer follow-up period is deemed necessary for an accurate conclusion.

Relationship of Coagulopathy and Platelet Dysfunction to Transfusion Needs After Traumatic Brain Injury.

BACKGROUND: Coagulopathy and platelet dysfunction commonly develop after traumatic brain injury (TBI). Thromboelastography (TEG) and platelet function assays (PFAs) are often performed at the time of admission; however, their roles in assessing post-TBI coagulopathy have not been investigated. We hypothesized that compared to blunt TBI, penetrating TBI would (1) demonstrate greater coagulopathy by TEG, (2) be associated with abnormal PFA results, and (3) require more blood product transfusions. METHODS: We performed a retrospective study of patients admitted to the neuroscience intensive care unit of a level 1 trauma center from 2013 to 2015 with head Abbreviated Injury Scale ≥3. Patients were compared by mechanism of injury (blunt vs. penetrating). Admission demographics, injury characteristics, and laboratory parameters were evaluated. VerifyNow® Aspirin and P2Y12 tests were used for platelet function analysis. RESULTS: Five hundred and thirty-four patients were included in the analysis. There were no differences between groups in platelet count or international normalized ratio; however, patients with penetrating TBI were more coagulopathic by TEG, with all of the TEG parameters being significantly different except for R time. Patients with penetrating head trauma were not more likely than their blunt counterparts to have abnormal PFA results, and PFA results did not correlate with any TEG parameter in either group. The penetrating cohort received more units of blood products in the first 4 and 24 h than the blunt cohort. CONCLUSIONS: Patients presenting with penetrating TBI demonstrated increased coagulopathy compared to those with blunt TBI as measured by TEG and need for transfusion. PFA results did not correlate with TEG findings in this population.