Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage: Identifying Low-Risk Patients Who May Not Benefit From ICU Admission

Erin Comer Burns, Beech Burns, Craig Newgard, Amber Laurie, Rongwei (Rochelle) Fu, Theresa Graif, Casey S. Ward, Abbie Bauer, David Steinhardt, Laura Ibsen, David M. Spiro

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

BACKGROUND: Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary. OBJECTIVES: To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI). METHODS: We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI. RESULTS: Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%–99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, −0.053–0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample). CONCLUSIONS: A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.

Original languageEnglish (US)
JournalPediatric Emergency Care
DOIs
StateAccepted/In press - Oct 28 2016

Fingerprint

Intracranial Hemorrhages
Traumatic Intracranial Hemorrhage
Intensive Care Units
Critical Care
Pediatrics
Inpatients
Wounds and Injuries
Depressed Skull Fracture
Traumatic Brain Injury
Confidence Intervals
Pediatric Intensive Care Units
Trauma Centers
Neurosurgery
Artificial Respiration
Blood Transfusion
Hospital Emergency Service

ASJC Scopus subject areas

  • Pediatrics, Perinatology, and Child Health
  • Emergency Medicine

Cite this

Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage : Identifying Low-Risk Patients Who May Not Benefit From ICU Admission. / Burns, Erin Comer; Burns, Beech; Newgard, Craig; Laurie, Amber; Fu, Rongwei (Rochelle); Graif, Theresa; Ward, Casey S.; Bauer, Abbie; Steinhardt, David; Ibsen, Laura; Spiro, David M.

In: Pediatric Emergency Care, 28.10.2016.

Research output: Contribution to journalArticle

Burns, Erin Comer ; Burns, Beech ; Newgard, Craig ; Laurie, Amber ; Fu, Rongwei (Rochelle) ; Graif, Theresa ; Ward, Casey S. ; Bauer, Abbie ; Steinhardt, David ; Ibsen, Laura ; Spiro, David M. / Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage : Identifying Low-Risk Patients Who May Not Benefit From ICU Admission. In: Pediatric Emergency Care. 2016.
@article{13f383057baa4c6b8f6c3c69ef764a7d,
title = "Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage: Identifying Low-Risk Patients Who May Not Benefit From ICU Admission",
abstract = "BACKGROUND: Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary. OBJECTIVES: To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI). METHODS: We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI. RESULTS: Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6{\%}; 95{\%} confidence interval, 82.2{\%}–99.9{\%}) from the low-risk group, with a negative likelihood ratio of 0.056 (95{\%} confidence interval, −0.053–0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55{\%} of the sample). CONCLUSIONS: A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.",
author = "Burns, {Erin Comer} and Beech Burns and Craig Newgard and Amber Laurie and Fu, {Rongwei (Rochelle)} and Theresa Graif and Ward, {Casey S.} and Abbie Bauer and David Steinhardt and Laura Ibsen and Spiro, {David M.}",
year = "2016",
month = "10",
day = "28",
doi = "10.1097/PEC.0000000000000950",
language = "English (US)",
journal = "Pediatric Emergency Care",
issn = "0749-5161",
publisher = "Lippincott Williams and Wilkins",

}

TY - JOUR

T1 - Pediatric Minor Traumatic Brain Injury With Intracranial Hemorrhage

T2 - Identifying Low-Risk Patients Who May Not Benefit From ICU Admission

AU - Burns, Erin Comer

AU - Burns, Beech

AU - Newgard, Craig

AU - Laurie, Amber

AU - Fu, Rongwei (Rochelle)

AU - Graif, Theresa

AU - Ward, Casey S.

AU - Bauer, Abbie

AU - Steinhardt, David

AU - Ibsen, Laura

AU - Spiro, David M.

PY - 2016/10/28

Y1 - 2016/10/28

N2 - BACKGROUND: Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary. OBJECTIVES: To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI). METHODS: We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI. RESULTS: Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%–99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, −0.053–0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample). CONCLUSIONS: A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.

AB - BACKGROUND: Pediatric patients with any severity of traumatic intracranial hemorrhage (tICH) are often admitted to intensive care units (ICUs) for early detection of secondary injury. We hypothesize that there is a subset of these patients with mild injury and tICH for whom ICU care is unnecessary. OBJECTIVES: To quantify tICH frequency and describe disposition and to identify patients at low risk of inpatient critical care intervention (CCI). METHODS: We retrospectively reviewed patients aged 0 to 17 years with tICH at a single level I trauma center from 2008 to 2013. The CCI included mechanical ventilation, invasive monitoring, blood product transfusion, hyperosmolar therapy, and neurosurgery. Binary recursive partitioning analysis led to a clinical decision instrument classifying patients as low risk for CCI. RESULTS: Of 296 tICH admissions without prior CCI in the field or emergency department, 29 had an inpatient CCI. The decision instrument classified patients as low risk for CCI when patients had absence of the following: midline shift, depressed skull fracture, unwitnessed/unknown mechanism, and other nonextremity injuries. This clinical decision instrument produced a high likelihood of excluding patients with CCI (sensitivity, 96.6%; 95% confidence interval, 82.2%–99.9%) from the low-risk group, with a negative likelihood ratio of 0.056 (95% confidence interval, −0.053–0.166). The decision instrument misclassified 1 patient with CCI into the low-risk group, but would have impacted disposition of 164 pediatric ICU admissions through 5 years (55% of the sample). CONCLUSIONS: A subset of low-risk patients may not require ICU admission. The proposed decision rule identified low-risk children with tICH who may be observable outside an ICU, although this rule requires external validation before implementation.

UR - http://www.scopus.com/inward/record.url?scp=84992708477&partnerID=8YFLogxK

UR - http://www.scopus.com/inward/citedby.url?scp=84992708477&partnerID=8YFLogxK

U2 - 10.1097/PEC.0000000000000950

DO - 10.1097/PEC.0000000000000950

M3 - Article

C2 - 27798539

AN - SCOPUS:84992708477

JO - Pediatric Emergency Care

JF - Pediatric Emergency Care

SN - 0749-5161

ER -