Cerebral hyperemia and impaired cerebral autoregulation associated with diabetic ketoacidosis in critically ill children

OBJECTIVE: Cerebral edema associated with diabetic ketoacidosis is an uncommon but severe complication of insulin-dependent diabetes mellitus with unclear pathophysiology. We sought to determine whether cerebral edema in patients with diabetic ketoacidosis was related to changes in cerebral blood flow, autoregulation, regional cerebral saturation, or S100B. DESIGN: Prospective case series. SETTING: Pediatric intensive care unit of a tertiary children's hospital. PATIENTS: Six patients with diabetic ketoacidosis and altered mental status, requiring computed tomographic scan of the head. INTERVENTIONS: Study evaluations included: 1) transcranial Doppler evaluations to determine middle cerebral artery flow velocities and cerebral autoregulation, defined by the autoregulatory index, at 6 and 36 hrs; 2) continuous monitoring of regional cerebral oxygenation on the left lateral forehead using near-infrared spectroscopy for the first 24 hrs of admission; 3) serial measurement of S100B as a marker of central nervous system injury; and 4) follow-up head computed tomographic scan. RESULTS: Serial computed tomographic scans showed that four of six patients had changes in brain volume without overt cerebral edema. Initial scans showed narrowing of the third and lateral ventricles when compared with follow-up. There was no difference in middle cerebral artery flow velocities between admission and recovery at 36 hrs, despite Paco2 increasing during treatment. Cerebral flow was normal to increased, despite hypocapnia. Cerebral autoregulation was impaired in five of six patients at 6 hrs and normalized by 36 hrs. Mean regional cerebral oxygenation was measured in five of six patients and decreased linearly with time. Two patients showed maximal regional cerebral oxygenation before returning to baseline. There were no periods of low regional cerebral oxygenation in any patient at any time. No elevation in S100B was found. CONCLUSIONS: We found normal to increased cerebral blood flow, elevated regional cerebral oxygenation, impaired autoregulation, and changes in brain volume in clinically ill pediatric patients with diabetic ketoacidosis. We found no evidence of cerebral ischemia. These findings suggest that the pathophysiology of cerebral edema in diabetic ketoacidosis may involve a transient loss of cerebral autoregulation, allowing a paradoxic increase in cerebral blood flow and the development of vasogenic cerebral edema.     

Necessity of hospital admission for pediatric minor head injury

The objective of this study was to evaluate the need for mandatory hospital admission of all pediatric patients with minor head injury (MHI) and negative computed tomographic (CT) scans for head injury. The study was a retrospective chart review of all patients admitted to a pediatric trauma service over a period of 4 years. MHI was defined as blunt head trauma with a Glasgow Coma Scale (GCS) score of 15 and a nonfocal neurological examination. Only patients < or = 13 years of age and with a negative head CT scan were included, and during hospitalization all patients were observed for delayed complications. A total of 197 patients met the inclusion criteria. The patients' mean age was 7.1 years, with a range of 2 months to 13 years. The most common mechanisms of injury were being struck by a motor vehicle while walking (82 patients), and falling (75 patients). No complications were observed, and although persistent symptoms occurred in 5 patients, they did not delay discharge. We conclude that pediatric patients with MHI and negative CT scans of the head do not require routine admission for observation for delayed complications.     

Is Hospital Admission and Observation Required after a Normal Abdominal Computed Tomography Scan in Children with Blunt Abdominal Trauma?

Objectives: The objective was to determine if hospital admission of children with blunt abdominal trauma for observation of possible intraabdominal injury (IAI) is necessary after a normal abdominal computed tomography (CT) scan in the emergency department (ED). Methods: The authors conducted a prospective observational cohort study of children less than 18 years of age with blunt abdominal trauma who underwent an abdominal CT scan in the ED. Abdominal CT scans were obtained with intravenous contrast but no oral contrast. The decision to hospitalize the patient was made by the attending emergency physician (EP) with the trauma or pediatric surgery teams. An abnormal abdominal CT scan was defined by the presence of any visualized IAI or findings suggestive of possible IAI (e.g., intraperitoneal fluid without solid organ injury). Patients were followed to determine if IAI was later diagnosed and the need for acute therapeutic intervention if IAI was present. Results: A total of 1,295 patients underwent abdominal CT, and 1,085 (84%) patients had normal abdominal CT scans in the ED and make up the study population. Seven‐hundred thirty‐seven (68%) were hospitalized, and 348 were discharged to home. None of the 348 patients discharged home and 2 of the 737 hospitalized patients were identified with an IAI after a normal initial abdominal CT. The IAIs in patients with normal initial CT scans included a 10‐year‐old with a mesenteric hematoma and serosal tear at laparotomy and a 10‐year‐old with a perinephric hematoma on repeat CT. Neither underwent specific therapy. The negative predictive value (NPV) of a normal abdominal CT scan for IAI was 99.8% (95% confidence interval [CI] = 99.3% to 100%). Conclusions: Children with blunt abdominal trauma and a normal abdominal CT scan in the ED are at very low risk of having a subsequently diagnosed IAI and are very unlikely to require a therapeutic intervention. Hospitalization of children for evaluation of possible undiagnosed IAI after a normal abdominal CT scan has a low yield and is generally unnecessary.     

Variation in Utilization of Computed Tomography Scanning for the Investigation of Minor Head Trauma in Children: A Canadian Experience

OBJECTIVES: To compare the utilization rates of CT scans in investigating minor head trauma in children in Canada, to identify the injuries determined by these scans, and to identify clinical findings that are highly associated with its diagnosis and the injury itself. METHODS: A retrospective cohort study involving nine pediatric hospitals in Canada was conducted. A structured data collection method was used. Inclusion criteria included age 16 years or less, history of blunt head trauma, and a Glasgow Coma Scale score (GCS) greater than or equal to 13. Data collected included demographic information, type of injury, relevant clinical information, computed tomography (CT) scan data, and clinical outcome. Clinical findings associated with CT scan and positive CT scan were identified using logistic regression. RESULTS: One thousand one hundred sixty-four children were included in the study. One hundred seventy-one (15%) had a CT scan, of which 60 (35%) were abnormal. There was a significant difference in the rate of ordering of CT scans among the participating hospitals, but no significant difference in the rate of abnormal CT scans. Mechanism of injury, GCS, and loss of consciousness were significantly related to the presence of an abnormal CT scan. CONCLUSIONS: Although there is a significant difference in the utilization of CT scans to investigate minor head trauma in children across Canada, there is no significant difference in the frequency of head injuries in these patients. This suggests that it may be possible to determine clinical criteria that are predictive of a head injury in these patients.     

Failure of the Miller Criteria to Predict Significant Intracranial Injury in Patients with a Glasgow Coma Scale Score of 14 after Minor Head Trauma

Objective: To determine the utility of the Miller criteria (presence of headache, nausea, vomiting, and signs of depressed skull fracture) for predicting the need for CT in patients with minor head trauma and a Glasgow Coma Scale score (GCS) of 14.
Methods: The study was a prospective, consecutive series of all patients undergoing head CT scans with a GCS of 14 following head trauma. A data sheet was completed for all patients prior to obtaining a head CT scan.
Results: 264 patients were entered into the study and 35 patients were found to have traumatic abnormalities on head CT scan. The use of the Miller criteria to select those patients who would require head CT scan would have resulted in missing 17 of the 35 abnormal scans, including 2 patients who required neurosurgical intervention. These 2 patients were markedly intoxicated upon presentation.
Conclusion: The use of the Miller criteria as the only criteria for screening patients with a GCS of 14 after minor head trauma who require a head CT scan is not recommended. While the authors have identified ethanol intoxication as one confounding factor, further refinement of this risk-stratification tool is required.     

Clinically suspected coagulopathy in blunt head trauma

Patients with moderate to severe head injury and abnormal coagulation studies have a significantly higher risk of brain injury. The objective of this study was to determine the association of clinical suspicion of coagulopathy and intracranial injury (ICI) among patients sustaining blunt head trauma, including minor injuries. As part of the NEXUS II blunt head injury study, enrolled patients were prospectively evaluated for ICI and suspicion of coagulopathy. We examined the relationship between suspicion of coagulopathy and the presence of any clinically significant or "therapeutically inconsequential" ICI based on head computed tomography (CT) scan results. The NEXUS II study enrolled 13,728 patients, including 493 with suspicion of coagulopathy. Significant ICI was present in 46 (9.3%; 95% confidence interval [CI] 6.9-12.2) patients with suspected coagulopathy, and in 460 of 9863 (4.7%; 95% CI 4.3-5.1) patients without such suspicion. "Therapeutically inconsequential" findings were found on head CT scan in 74 patients, and 7 of these had suspected coagulopathy. Interventions including intubation, intracranial pressure monitoring, or craniotomy were performed in 5 of these 7 (71%; 95% CI 29-96) individuals, compared with only 3 of 67 (4%; 95% CI 1-12) patients without suspicion of coagulopathy. Initial clinical suspicion of coagulopathy, independent of laboratory confirmation, is associated with a greater prevalence of significant ICI injury after blunt head trauma; it also substantially increases the risk of morbidity despite the presence of an apparent "therapeutically inconsequential" injury. CT scanning of the head should be performed initially based on clinical suspicion of coagulopathy.     

Variation in therapy and outcome for pediatric head trauma patients

OBJECTIVE: This study was undertaken to examine variation in therapies and outcome for pediatric head trauma patients by patient characteristics and by pediatric intensive care unit. Specifically, the study was designed to examine severity of illness on admission to the pediatric intensive care unit, the therapies used during the pediatric intensive care unit stay, and patient outcomes. DATA SOURCES AND SETTING: Consecutive admissions from three pediatric intensive care units were recorded prospectively (n = 5,749). For this study, all patients with an admitting diagnosis of head trauma were included (n = 477). Data collection occurred during an 18-month period beginning in June 1996. All of the pediatric intensive care units were located in children's hospitals, had residency and fellowship training programs, and were headed by a pediatric intensivist. METHODS: Admission severity was measured as the worst recorded physiological derangement during the period 1 yr old (16.1% vs. 6.1%; p = .002). Comparisons by insurance status indicated that observed mortality rates were highest for self-paying patients. However, patient characteristics were not associated with use of therapies or standardized mortality rates after adjustment for patient severity. There was significant variation in the use of paralytic agents, seizure medications, induced hypothermia, and intracranial pressure monitoring on admission across the three pediatric intensive care units. In multivariate models, only the use of seizure medications was associated significantly with reduced mortality risk (odds ratio = 0.17; 95% confidence interval = 0.04-0.70; p = .014). CONCLUSIONS: Therapies and outcomes vary across pediatric intensive care units that care for children with head injuries. Increased use of seizure medications may be warranted based on data from this observational study. Large randomized controlled trials of seizure prophylaxis in children with head injury have not been conducted and are needed to confirm the findings presented here.     

Utility of an Initial D-dimer Assay in Screening for Traumatic or Spontaneous Intracranial Hemorrhage

OBJECTIVE: To evaluate the sensitivity of a D-dimer assay as a screening tool for possible traumatic or spontaneous intracranial hemorrhage. If adequately sensitive, the D-dimer assay may potentially permit omission of a more expensive computed tomography (CT) scan of the head when such hemorrhage is clinically suspected. METHODS: Prospective, consecutive, blinded study of patients (age > 16 years) requiring a CT scan of the head for suspected intracranial hemorrhage over a five-month period at a university, Level I trauma center. All study patients had a serum D-dimer assay obtained prior to their CT scans. Sensitivity and specificity, with 95% confidence intervals (95% CIs), of the enzyme-linked immunosorbent assay (ELISA) D-dimer assay for the detection of intracranial hemorrhage were calculated. RESULTS: Of the 319 patients entered in the study, 25 (7.8%) had a CT scan positive for intracranial hemorrhage. Patients with intracranial hemorrhage were more likely to have a positive D-dimer assay (chi-square = 13.075, p < 0.001). The D-dimer assay had 21 true-positive and four false-negative tests, resulting in a sensitivity of 84.0% (95% CI = 63.7% to 95.5%) and a specificity of 55.8% (95% CI = 55.5% to 55.9%). The four false-negative cases included one small intraparenchymal hemorrhage, one small subarachnoid hemorrhage, one moderate-sized intraparenchymal hemorrhage with mid-line shift, and one large subdural hematoma requiring emergent surgery. CONCLUSIONS: Due to the catastrophic nature of missing an intracranial hemorrhage in the emergency department, the D-dimer assay is not adequately sensitive or predictive to use as a screening tool to allow routine omission of head CT scanning.     

The prognostic value of neuron-specific enolase in head trauma patients

In recent years, in addition to neurological examination and neuroradiologic examinations, attempts have been made to assess the severity of post-traumatic brain injury and to obtain an early idea of patient prognosis using biochemical markers with a high degree of brain tissue specificity. One such enzyme is neuron-specific enolase (NSE). This study investigates the correlation between serum NSE levels, Glasgow Coma Score, and prognosis measured by Glasgow Outcome Scores in head trauma patients. This was a prospective study conducted with 80 trauma patients presenting to the Emergency Department. Patients were divided into four groups. The first group consisted of patients with general body trauma, but no head trauma. The second group had minor head trauma. The third group had moderate head trauma, and the fourth group had severe head trauma. The relationship between subjects' admission NSE levels and admission and discharge Glasgow Coma Scores (GCS) and Glasgow Outcome Scores (GOS) 1 month later was examined. A receiver operating characteristic (ROC) analysis was performed using a serum NSE cutoff level of 20.52 ng/mL and a GOS of 3 or less as the definition of poor neurologic outcome. There was a significant difference in the NSE levels between group 1 (general trauma) and group 3 (moderate head trauma). There was also a statistically significant difference in NSE levels between group 1 (general trauma) and group 4 (severe head trauma) (p < 0.05). There was a statistically significant inverse relationship between NSE levels and GOS as determined within groups 3 (moderate) and 4 (severe head trauma) (p < 0.05). When NSE levels were compared with admission GCS, it was found that GCS fell as NSE levels rose. There was no significant correlation between NSE and GCS within groups 3 (moderate) or 4 (severe). There was a statistically significant correlation within group 2 (mild) (p < 0.05). By ROC analysis, serum NSE was 87% sensitive and 82.1% specific in predicting poor neurologic outcome in the study patients. The area under the curve was 0.931. This study shows that initial serum NSE levels in moderate and severe head trauma patients correlate inversely with GOS 1 month later, but only within the moderate and severe head trauma groups. However, serum NSE was 87% sensitive and 82.1% specific in predicting poor neurologic outcome in all of the study patients. This derived cutoff value now needs to be prospectively validated.     

Utilizing clinical factors to reduce head CT scan ordering for minor head trauma patients

Our study objective was to determine whether simple clinical criteria can be used to safely reduce the number of patients who require cranial computed tomography (CT) scan after sustaining minor head trauma. Awake patients (Glascow Coma Scale = 15) who presented to the emergency department with acute head injury associated with a loss of consciousness were evaluated for clinical predictors of head injury prior to CT scan. The studied risk factors included severe headache, nausea, vomiting, and depressed skull fracture on physical examination. Patients with no risk factors present were compared with patients with one or more risk factors with respect to abnormal CT rate and rate of operative intervention for head injury. Of the 2143 patients entered into the study, 1302 (61%) had no risk factor for head injury, whereas 841 (39%) had one or more risk factors present. A total of 138 (6.4%) of those studied had an abnormal CT scan. This number included 3.7% of those patients with no risk factors vs. 11% in patients with one or more risk factors. The CT scan abnormalities in the no-risk-factor group were not clinically significant. All 5 patients who required operative intervention had at least one of the risk factors present. The use of four simple clinical criteria in minor head trauma patients would allow a 61% reduction in the number of head CT scans performed and still identify all patients who require neurosurgical intervention and the majority of patients with an abnormal CT scan. This method could lead to a large savings in patient charges nationwide. Further studies may be helpful in confirming these findings.     

ED utilization of computed tomography in a poisoned population

The objective of this prospective, analytic study was to identify predictors and describe the demographic and clinical correlates of head computed tomography (CT) evaluation in patients with poisoning or drug overdose and altered mental status. Forty-three patients that were evaluated by head CT and 109 that were not evaluated by head CT were entered into the study at a poison control center. None of the 43 scanned patients had any acute findings on head CT. A logistic regression model yielded 4 predictors that were statistically associated with the ordering of a head CT scan: Glasgow Coma Scale (GCS) < or = 8 (odds ratio [OR]: 2.3; 95% confidence interval [CI] 1.03-5.7); age > or = 41 years (OR 5.3; 95% CI 2.2-13); use of drugs or abuse by history (OR 2.8; 95% CI 1.04-7.6); and witnessed seizure activity (OR 4.8; 95% CI 1.3-17.9). We also tested 2 additional models to identify predictors of hospital admission, 1 with and 1 without CT scan included as a covariate. In the first model, only GCS 相似文献   

Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults with blunt trauma

Objective

The objective of this study is to determine the rate of intra-abdominal injury (IAI) in adults with blunt abdominal trauma after a normal abdominal computed tomographic (CT) scan. We hypothesize that the risk of subsequent IAI is so low that hospital admission and observation for possible IAI are unnecessary.

Methods

We conducted a prospective, observational cohort study of adults (>18 years) with blunt trauma who underwent abdominal CT scanning in the emergency department. Computed tomographic scans were obtained with intravenous contrast but no oral contrast. Abnormalities on abdominal CT included all visualized IAIs or any finding suggestive of possible IAI. Patients were followed up to determine the presence or absence of IAI and the need for therapeutic intervention if IAI was identified.

Results

Of the 3103 patients undergoing abdominal CT, 2734 (88%) had normal CT scans. The median age was 39 years (interquartile range, 26-51 years); and 2141 (78%) were admitted to the hospital. Eight (0.3%; 95% confidence interval, 0.1%-0.6%) were identified with IAIs after normal abdominal CT scans including the following injuries: pancreas (5), liver (4), gastrointestinal (2), and spleen (2). Five underwent therapy at laparotomy. Abdominal CT had a likelihood ratio (+) of 20.9 (95% confidence interval, 17.7-24.8) and likelihood ratio (−) of 0.034 (0.017-0.068).

Conclusion

Adult patients with blunt torso trauma and normal abdominal CT scans are at low risk for subsequently identified IAI. Thus, hospitalization for evaluation of possible IAI after a normal abdominal CT scan is unnecessary in most cases.     

迟发性脑挫裂伤的CT表现及复诊时间

目的:探讨迟发性脑挫裂伤的CT表现及复诊时间。方法:回顾分析152例经2 次以上CT检查证实的迟发性脑挫裂伤的CT首诊时间、首诊CT 表现、CT首次检出脑挫裂伤的时间及表现。结果:伤后24小时内复查CT共检出迟发性脑挫裂伤88例,占57.9%;首诊CT发现伴蛛网膜下腔出血和广泛脑水肿的31例中,27 例日后形成重型或极重型迟发性脑挫裂伤。结论:头部外伤后,应于伤后24小时内复查头部CT,以尽早明确有无迟发性脑挫裂伤。对临床累计昏迷超过30分钟,首诊CT呈现伴有蛛网膜下腔出血的广泛脑水肿者尤应密切随诊。     

重症腹部伤伤员3d内直接护理项目及时数分析

目的分析重症腹部伤伤员3d内护理工作量及护理项目的规律,为未来海战护理人力资源的合理分配、提高急救护理水平提供理论依据。方法采用PRN分类方法统计44名重症腹部伤伤员入院后24、48、72h所接受的护理项目时数,为适应海战的需要,经过临床医疗、护理专家的3轮筛选,将5类27项直接护理项目作为筛选后保留项目。结果腹部伤伤员入院后第1个24h所接受的直接护理时数与第2个24h所接受的直接护理时数在统计学上差异显著(P<0.001),第2个24h与第3个24h所接受的直接护理时数有差异(P<0.05)。结论腹部伤伤员入院后第1d的护理工作量明显大于第2d的护理工作量,第2d的护理工作量大于第3d的护理工作量。     

Low Yield of Paired Head and Cervical Spine Computed Tomography in Blunt Trauma Evaluation

Background

With increased computed tomography (CT) utilization, clinicians may simultaneously order head and neck CT scans, even when injury is suspected only in one region.

Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury

OBJECTIVE:: Intracranial hypertension after severe head injury is associated with case fatality, but there is no sound evidence that monitoring of intracranial pressure (ICP) and targeted management of cerebral perfusion pressure (CPP) improve outcome, despite widespread recommendation by experts in the field. The purpose was to determine the effect of ICP/CPP-targeted intensive care on functional outcome and therapy intensity levels after severe head injury. DESIGN:: Retrospective cohort study with prospective assessment of outcome. SETTING:: Two level I trauma centers in The Netherlands from 1996 to 2001. PATIENTS:: Three hundred thirty-three patients who had survived and remained comatose for >24 hrs, from a total of 685 consecutive severely head-injured adults. INTERVENTIONS:: In center A (supportive intensive care), mean arterial pressure was maintained at approximately 90 mm Hg, and therapeutic interventions were based on clinical observations and computed tomography findings. In center B (ICP/CPP-targeted intensive care), management was aimed at maintaining ICP <20 mm Hg and CPP >70 mm Hg. Allocation to either trauma center was solely based on the site of the accident. MEASUREMENTS AND MAIN RESULTS:: We measured extended Glasgow Outcome Scale after >/=12 months. Patient characteristics were well balanced between the centers. ICP monitoring was used in zero of 122 (0%) and 142 of 211 (67%) patients in centers A and B, respectively. In-hospital mortality rate was 41 (34%) vs. 69 (33%; p = .87). The odds ratio for a more favorable functional outcome following ICP/CPP-targeted therapy was 0.95 (95% confidence interval, 0.62-1.44). This result remained after adjustment for potential confounders. Sedatives, vasopressors, mannitol, and barbiturates were much more frequently used in center B (all p < .01). The median number of days on ventilator support in survivors was 5 (25th-75th percentile, 2-9) in center A vs. 12 (7-19) in center B (p < .001). CONCLUSIONS:: ICP/CPP-targeted intensive care results in prolonged mechanical ventilation and increased levels of therapy intensity, without evidence for improved outcome in patients who survive beyond 24 hrs following severe head injury.     

Identification of Ethanol-intoxicated Patients with Minor Head TVauma Requiring Computed Tomography Scans

Objective: To determine whether clinical parameters and neurologic scores can be used to guide the decision to obtain computed tomography (CT) head scans for ethanol-intoxicated patients with presumed-minor head injuries.
Methods: In a prospective cohort analysis, 107 consecutive adult patients who presented to a county emergency department (ED) with serum ethanol levels >80 mg/dL and minor head trauma were studied. Commonly used clinical variables were determined for each patient. Each patient also underwent an abbreviated neurologic scoring examination and a Glasgow coma scale (GCS) score evaluation at the time of presentation and one hour later, after which a cranial CT scan was done. For purposes of analysis, patients with and patients without intracerebral injuries visible on CT scans of the head were compared.
Results: Nine of 107 patients (8.4%; 95% confidence interval [CI] = 3.9–15.4%) had CT scans that were positive for intracerebral injury. Two patients (1.9%; 95% CI = 0.2–6.6%) needed craniotomy. Five patients had hemotympanum and two patients had bilateral periorbital ecchy-mosis, but CT scans were negative for intracerebral injury in these patients. There was no statistically significant difference between the patients with and without CT scan abnormalities, based on the clinical variables, the GCS scores, or the abbreviated neurologic scoring examinations at presentation or at one hour.
Conclusion: The prevalence of intracerebral injury in CT scans of ethanol-intoxicated patients with minor head injuries was 8.4%. Commonly used clinical parameters and neurologic scores at presentation and one hour later were unable to predict which patients would have intracerebral injuries as evidenced by CT scans. Our low (1.9%) neurosurgical intervention rate supports the need to develop a selective approach to CT scanning in this population.     

Clinical decision instruments for CT scan in minor head trauma

Previous studies have presented conflicting results regarding the predictive value of various clinical symptoms and signs for performing computed tomography (CT) scan in minor head injury. Moreover, despite the presence in the literature of several similar publications regarding whether or not CT should be employed at the time of presentation of minor head injured patients, data regarding delayed CT are limited. The objective of this study was to determine whether high-risk criteria represent a significant indication for initial CT scan in patients with minor head trauma, and whether or not analysis using delayed CT scan is necessary in patients with high-risk criteria before being discharged. Patients presenting to the Emergency Department with minor head trauma between September 1, 2003 and September 1, 2004 were evaluated prospectively. After being divided into two main groups, low- and high-risk, four separate sub-groups based on age were established. Initial spiral CT examination was done within 3 h of trauma on all patients in addition to a delayed control CT scan in those with high-risk criteria between 16 and 24 h after trauma. The difference between the high- and low-risk groups in terms of abnormal CT findings was statistically significant (p < 0.0005). Among high-risk patients there was a significant difference between patients with a Glasgow Coma Scale (GCS) score of 13 or 14 and those with a GCS score of 15 (p < 0.0005). The relationship between vomiting and abnormal CT scan was significant (odds ratio 4.61, 95% confidence interval 2.20-9.64, p = 0.0001), and the relationship between abnormal CT scan and suspected skull fracture was also significant (odds ratio 3.46, 95% confidence interval 1.52-7.91, p = 0.0032). No significant correlations between other high-risk criteria and abnormal CT scan were determined. The difference between initial and delayed CT scans in patients with high-risk criteria was not significant (p = 0.161). Low-risk patients with a GCS score of 15 may be discharged without initial CT scan being performed. Initial CT scan absolutely must be performed, however, on patients with GCS < or = 15 in the event of vomiting or suspected skull fracture, even if isolated. Even though the difference between initial and delayed CT scans in patients with high-risk criteria is not significant, it is our opinion that it is still prudent for delayed CT scan to be performed, particularly on patients whose GCS score does not rise to 15, or decreases.     

Is repeat head CT necessary in patients with mild traumatic intracranial hemorrhage

BackgroundPatients with traumatic intracranial hemorrhage (TIH) frequently receive repeat head CT scans (RHCT) to assess for progression of TIH. The utility of this practice has been brought into question, with some studies suggesting that in the absence of progressive neurologic symptoms, the RHCT does not lead to clinical interventions.MethodsThis was a retrospective review of consecutive patients with CT-documented TIH and GCS ≥ 13 presenting to an academic emergency department from 2009 to 2013. Demographic, historical, and physical exam variables, number of CT scans during admission were collected with primary outcomes of: neurological decline, worsening findings on repeat CT scan, and the need for neurosurgical intervention.ResultsOf these 1126 patients with mild traumatic intracranial hemorrhage, 975 had RHCT. Of these, 54 (5.5% (4.2–7.2 95 CI) had neurological decline, 73 (7.5% 5.9–9.3 95 CI) had hemorrhage progression on repeat CT scan, and 58 (5.9% 4.5–7.6 95 CI) required neurosurgical intervention. Only 3 patients (0.3% 0.1–0.9% 95 CI) underwent neurosurgical intervention due to hemorrhage progression on repeat CT scan without neurological decline. In this scenario, the number of RHCT scans needed to be performed to identify this one patient is 305.ConclusionsRHCT after initial findings of TIH and GCS ≥ 13 leading to a change to operative management in the absence of neurologic progression is a rare event. A protocol that includes selective RHCT including larger subdural hematomas or patients with coagulopathy (vitamin K inhibitors and anti-platelet agents) may be a topic for further study.     

Use of Neuroimaging for Children With Seizure in General and Pediatric Emergency Departments

BackgroundSeizure is a common reason for children to visit the emergency department (ED). Pediatric and general EDs may obtain computed tomography (CT) scans of the head for seizure at different rates.ObjectiveTo compare rates of head CT for pediatric seizure between general and pediatric EDs.MethodsThis was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey for patients <21 years of age presenting to an ED with a chief complaint or diagnosis of seizure between 2006 to 2017. Of these patients, we compared head CT use between general and pediatric EDs among patients with fever, trauma, and co-diagnosis of epilepsy using univariable risk differences and in a multivariable logistic regression model.ResultsMore than 5 (5.4) million (78.8%) and 1.5 million (21.2%) pediatric patients with seizure presented to general and pediatric EDs, respectively. Of those, 22.4% (1.21 million) and 13.2% (192,357) underwent CT scans of the head, respectively, a risk difference of 9.2% (95% confidence interval [CI] 2.3–16.1). General EDs obtained CT scans of the head more often in patients with epilepsy (risk difference 17.9% [95% CI 4.0–31.9]), without fever (12.2% [95% CI 3.1–21.4]), and without trauma (10.6% [95% CI 4.4–16.8]). Presenting to a general ED, being afebrile, or having trauma were associated with head CT with adjusted odds ratios of 1.7 (95% CI 1.0–3.2), 4.9 (95% CI 2.6–9.2), and 2.0 (95% CI 1.2–3.4), respectively. Age, gender, and epilepsy were not associated with head CT among all patients with seizure.ConclusionsChildren with seizure are more likely to undergo CT scans of the head at general EDs compared with pediatric EDs.