Applying Pediatric Brain Injury Guidelines at a Level I Adult/Pediatric Safety-Net Trauma Center

Highlights

• Mild pediatric TBI defined by Brain Injury Guideline (BIG)-1 can be safely managed by acute care surgeons.

• Adding minor skull fracture to BIG-1 does not appear to alter its safety.

• Adhering to BIG-1 may reduce unnecessary neurosurgical consultations and repeat head computed tomography.

Abstract

Background

Pediatric brain injuries are common, but current management of patients with mild traumatic intracranial hemorrhage (T-ICH) is suboptimal, often including unnecessary repeat head CT (RHCT) and neurosurgical consultation (NSC). Brain Injury Guidelines (BIG) have been developed to standardize the management of TBI, and recent work suggests they may be applied to children. The aim of this study was to apply BIG to a low-risk pediatric TBI population to further determine whether the framework can be safely applied to children in a way that reduces overutilization of RHCTs and NSC.

Methods

A retrospective chart review of a Level I Adult and Pediatric Trauma Center's pediatric registry over 4 y was performed. BIG was applied to these patients to evaluate the utility of RHCT and need for neurosurgical intervention (NSG-I) in those meeting BIG-1 criteria. Those with minor skull fracture (mSFx) who otherwise met BIG-1 criteria were also included.

Results

Twenty-eight patients with low-risk T-ICH met criteria for review. RHCT was performed in seven patients, with only two being prompted by clinical neurologic change/deterioration. NSC occurred in 21 of the cases. Ultimately, no patient identified by BIG-1 ± mSFx required NSG-I.

Conclusions

Application of BIG criteria to children with mild T-ICH appears capable of reducing RHCT and NSC safely. Additionally, those with mSFx that otherwise fulfill BIG-1 criteria can be managed similarly by acute care surgeons. Further prospective studies should evaluate the application of BIG-1 in larger patient populations to support the generalizability of these findings.

Introduction

Traumatic brain injury (TBI) is a common problem in the pediatric population, with an estimated 435,000 annual emergency room visits, 37,000 hospitalizations, and 2685 deaths.¹ Evaluation often involves computed tomography (CT) imaging to assess for traumatic intracranial hemorrhage (T-ICH) or skull fracture. Frequently, those with T-ICH receive repeat head CT (RHCT) and neurosurgical consultation (NSC) as part of their care.^2,3 However, in those with mild T-ICH, RHCT, and NSC may represent an inappropriate use of resources, which has implications for both the healthcare system and individual patient health and safety.4, 5

Due to the high demand placed on neurosurgical teams, as well as the desire to limit ionizing radiation in children, there is a need to reconsider the use of RHCT and routine NSC in the management of pediatric patients with minor T-ICH. To restructure the approach to care of this population with TBI, stratification criteria have been developed to identify the appropriate care plan for a patient based on their history, radiographic images, and physical exam findings. These criteria, known as the Brain Injury Guidelines (BIG),¹ have been developed and successfully applied in the treatment of low-risk pediatric T-ICH at a Level I trauma center (L-1 TC).⁴ Additionally, evidence has demonstrated the safety of deferring NSC and RHCT in isolated linear skull fractures in pediatric patients.6, 7, 8, 9

In the present study, we sought to validate the BIG criteria with the addition of minor skull fracture (mSFx) at a Level I adult and pediatric safety-net trauma center in terms of the criteria's efficacy and ability to reduce the need for NSC and RHCT. We hypothesized that retrospective application of the BIG-1 category to pediatric patients with mild TBI involving ICH with or without mSFx would demonstrate that these patients could be successfully managed by acute care surgeons (ACS) while reducing the unnecessary use of NSC and RHCT.