Minor Head Injury Research Articles

Indications for Computed Tomography in Older Adult Patients With Minor Head Injury in the Emergency Department.

Older age is a risk factor for intracranial injury after head trauma, and computed tomography (CT) is generally recommended. We aimed to develop a clinical prediction rule for risk stratification to avoid CT head imaging in older adult patients with minor head injury, named Computed Tomography of the Head for the patients at Advanced age (CTHEAD). This was a single-center observational study in Japan that used retrospective chart review data to service a prediction rule that was prospectively validated. Patients aged≥65years who presented to our emergency department with a chief complaint of head trauma and a Glasgow Coma Scale (GCS) of≥13 were eligible. Patients were excluded if they had GCS score<13, anticoagulant therapy, focal neurologic symptoms, posttraumatic seizures, penetrating injury, evident depressed fracture, unknown mechanism, or CT not undertaken. The primary outcome was acute traumatic lesion on head CT. We screened 1,494 patients; 538 were included in the derivation cohort, and 580, in the validation cohort. Multivariable analysis of the derivation group found that high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, and anterograde amnesia were significantly associated with traumatic head findings on CT. A clinical prediction rule was developed from these four risk factors. The negative predictive value (NPV) of the absence of the four components was 95.1% (95% confidence interval [CI]= 92.9% to 96.7%), and the positive predictive value (PPV) of one or more risk factors was 20.6% (95% CI= 17.3% to 24.4%). The rule was validated prospectively with an NPV of zero risk factors of 94.5% (95% CI= 92.4% to 96.1%) and a PPV of one or more risk factors of 15.9% (95% CI= 13.0% to 19.3%). Fifty-three (9.1%) patients in the validation cohort experienced the primary outcome. The results suggest that older adult patients with minor head injury may forgo head CT if they do not have high-risk mechanisms of injury, vomiting, witnessed loss of consciousness, or anterograde amnesia. External validation of this rule is needed.

A-141 An Inclusive Recruitment Strategy Can Help to Improve mTBI Research

Abstract Objective Participant recruitment for mild traumatic brain injury (mTBI) research is challenging due to confounding factors and other documented selection biases. The strict application of typical inclusion and exclusion criteria has raised questions about the generalizability of mTBI research. This study explored the effect of applying commonly employed selection criteria on eligibility for mTBI research. Method Between July and October 2019, a trained research nurse performed a weekly review of a tertiary hospital emergency department treatment registry. Three hundred and eight cases coded as “minor head injury” were identified (Mage = 43.7, SDage = 25.6). The case records underwent formal data extraction. Extracted clinical and demographic data were mapped against commonly applied mTBI research selection parameters. The presence of persistent postconcussion symptoms (PPCS) was established via telephone administration of the Rivermead Postconcussion Symptom Questionnaire, 7–19 days post injury. Results Analysis revealed that 23% of patients met the World Health Organization operational definition of an mTBI. The failure to meet this criterion was primarily due to missing or incomplete information for post-traumatic amnesia. The application of exclusion criteria left just 5.5% of the initial pool eligible for mTBI research. Of these participants, ongoing PPCS could not be established in any individuals. Conclusion Participant recruitment for mTBI research could be improved by establishing a dedicated patient management system that streamlines and augments the quality of vital clinical data. An inclusive recruitment strategy that handles patient heterogeneity using statistical methods as opposed to exclusion from research could enhance the generalisability of mTBI research.

Acil Serviste Minör Pediatrik Kafa Travmasında Hematolojik Belirteçlerin Değerlendirilmesi

Öz. Amaç:Çocukluk yaş grubunda morbidite ve mortalitenin en sık sebebi kafatravmalarıdır. Kafa travması olan çocuklarda beyin tomografisi için çeşitli protokoller tanımlanmıştır. Bunlarda klinik değerlendirmeler ön plana çıktığı için acil servislerde uygunsuz, abartılı hasta şikayetleri veya aşırı iş yükü yoğunluğu nedeniyle beyin tomografisi çekimi için karar vermek zor olabilir. Çalışmamızda minör pediatrik kafa travmalı hastalarda, beyin tomografisi çekimine karar verme aşamasında nötrofil-lenfositoranı ve trombosit-lenfosit oranının yol gösterici olup olamayacağını araştırmayı amaçladık. Materyal ve Metod: Bu retrospektif çalışmaya beyin tomografisi taramalarında patolojisi olan 96 hasta(grup I), yaşı ve cinsiyet bakımından bu gruba denk olan normal sağlıklı ve beyin tomografisi sonucu olan 99 (grup II) çocuk dâhil edildi. Grup 1 medikal ve cerrahi tedavi almalarına göre iki gruba ayrıldı. Hematolojik parametreler rutin laboratuvar yöntemleri ile çalışıldı. Her katılımcıda rutin hematolojik parametreler incelendi. Bulgular: Gruplar karşılaştırıldığında, nötrofil, lökosit, nötrofil-lenfosit oranı ve trombosit-lenfosit oranı grup I’ de grup 2’ye göre anlamlı derecede yüksekti (tümü için p&amp;lt;0.05). Alt grup analizlerinde; grup I’ de cerrahi tedavi gereken hastalarda nötrofil-lenfosit oranı ve trombosit-lenfosit oranı medikal izlem gerektiren hastalara göre istatiksel olarak anlamlı derecede yüksekti (tümü için p&amp;lt;0.05). Receiver operating characteristic analizi nötrofil-lenfosit oranı ve trombosit-lenfosit oranının minor kafatravmasında patoloji ve cerrahiyi öngörmede önemli olabileceğini göstermektedir. Sonuç: Minör kafa travmalarında nötrofil-lenfosit oranı ve trombosit-lenfosit oranının yüksekliği beyin tomografisi çekimi gerekliliği için yol gösterici olabilir. Ek olarak, bu parametreler patoloji saptanması durumunda uygulanacak tedavi yöntemini seçmede de yardımcı olabilir.

Factors associated with avoidable interhospital transfers for children with a minor head injury.

Children with minor head injuries (MHI) are routinely transferred to a pediatric trauma center for definitive care. Unwarranted transfers result in minimal benefit to the patient and add substantially to healthcare costs. The purpose of this study is to explore the factors associated with avoidable interhospital transfers of children with MHI. We conducted a retrospective cohort study of children <18years of age transferred to our pediatric emergency department (PED) for MHI between January 2013 and December 2018. Patients transferred for non-accidental trauma, and those with a history of coagulopathies, underlying neurological conditions, intraventricular shunts and developmental delay were excluded. Transfers were categorized as avoidable if none of the following interventions were required at our PED: procedural sedation, anticonvulsant initiation, subspecialty consultation, intensive care unit admission or hospital admission for ≥2 nights, intubation or operative intervention. We collected demographics, injury mechanism, neuroimaging results, interventions performed and PED disposition. Binary logistic regression was conducted to provide adjusted associations between patient characteristics and the risk of avoidable interhospital transfers. We analyzed 1078 transfers for MHI, of which 450 (42%) transfers were classified as avoidable. Children in the avoidable transfer group tended to be younger, less likely to have experienced loss of consciousness, and more likely to belong to the the group at lowest risk for a clinically important traumatic brain injury (ciTBI). Our multivariable model determined that children less than 2years of age (OR=1.75; 95% CI=1.3-2.37), low-risk group for ciTBI (OR=1.66; 95% CI=1.22-0.1), and a positive head CT at the transferring hospital (OR=0.06; 95% CI=0.02-0.1) were all significantly associated with avoidable transfers. There is a high rate of avoidable transfers in children with MHI. Focused interventions targeting risk factors associated with avoidable transfers may reduce unwarranted interhospital transfers.

Exploring Neuronal Vulnerability to Head Trauma Using a Whole Exome Approach.

Brain injuries are associated with oxidative stress and a need to restore neuronal homeostasis. Mutations in ion channel genes, in particular CACNA1A, have been implicated in familial hemiplegic migraine (FHM) and in the development of concussion-related symptoms in response to trivial head trauma. The aim of this study was to explore the potential role of variants in other ion channel genes in the development of such responses. We conducted whole exome sequencing (WES) on16 individuals who developed a range of neurological and concussion-related symptoms following minor or trivial head injuries. All individuals were initially tested and shown to be negative for mutations in known FHM genes.Variants identified from the WES results were filtered to identify rare variants (minor allele frequency [MAF] <0.01) in genes related to neural processes as well as genes highly expressed in the brain using a combination of in silico prediction tools (SIFT, PolyPhen, PredictSNP, Mutation Taster, and Mutation Assessor). Rare (MAF <0.001) or novel heterozygous variants in 7 ion channel genes were identified in 37.5% (6/16) of the cases (CACNA1I, CACNA1C, ATP10A, ATP7B, KCNAB1, KCNJ10, and SLC26A4), rare variants in neurotransmitter genes were found in 2 cases (GABRG1 and GRIK1), and rare variants in 3 ubiquitin-related genes identified in 4 cases (SQSTM1, TRIM2, and HECTD1).In this study, the largest proportion of potentially pathogenic variants in individuals with severe responses to minor head trauma were identified in genes previously implicated in migraine and seizure-related autosomal recessive neurological disorders. Together with results implicating variants in the hemiplegic migraine genes, CACNA1A and ATP1A2, in severe head trauma response, our results support a role for heterozygous deleterious mutations in genes implicated in neurological dysfunction and potentially increasing the risk of poor response to trivial head trauma.

ROLE OF COMPUTED TOMOGRAPHY IN PATIENT WITH MINOR HEAD INJURY IN TERTIARY CARE HOSPITAL

Aim: Approximately 2 million people sustain traumatic brain injury (TBI) annually in India. A CT scan of the head is the initial choice of radiological investigation to evaluate patients with suspected head injury. The need for neurosurgical intervention is based on the clinical status of the patient and the radiological finding on head CT.&#x0D; Material and Methods: This was a prospective observational study done over a period of 6 months. A total of 201 patients were included in the study. Patients of traumatic brain injury above 15 years of age who were subjected to two or more CT scans of the brain. Patients were followed for a maximum of up to 5 scans. The decision of repeat scan was taken by the treating neurosurgeon. Patients who were taken up for surgery based upon the findings of the first CT scan. Patients who were discharged or who expired after the first CT scan.&#x0D; Results: A total of 201 consequent head injury patients with 2 or more CT scans were studied. 192 were male. The mean age was 38.6 years (Range: 16e80). Road traffic accidents was the most common cause of trauma (134, 67%) followed by fall from height (47, 24%) and assault (17, 10%). Progression of lesion was seen more frequently in mixed lesions (21.8%), followed by SDH (12.5%) and EDH (6.2%).&#x0D; Conclusions: Repeat CT scans were found to be of value in detecting new lesions or enlargement of existing lesions resulting in change of management in a significant proportion of patients.&#x0D; Keywords: Computed Tomography, Minor Head Injury, Tertiary Care Hospital, Traumatic Brain Injury (TBI), Lesions.

Mild head trauma in elderly patients: experience of an emergency department

IntroductionWe evaluated the risk profile of elderly patients who came to the emergency department for mild head trauma. The primary goal was to determine the difference in the incidence of posttraumatic intracranial hemorrhage (ICH) after minor head injury (MHI). The secondary objective was to assess worse outcome, such as: hospitalization rate, rate of re-admission, need of neurosurgery. We also assess the admission process times and length of hospital stay. The ultimate goal was to optimize the diagnostic-observational management of minor head trauma in elderly patients. Material and methodsWe evaluated all patients with MHI who came to our emergency department during 2017 and 2018. All patients underwent computed tomography. ResultsWe enrolled 2325 patients, of whom 1094 were 75 years of age or older. The population was divided into two categories according to age: The “elderly population” was 75 or older, and the younger patients were younger than 75. The elderly population, in comparison with the younger patients, had a higher rate of ICH (12.1% versus 5.1%), a higher hospitalization rate (11.7% versus 5.5%), and a higher rate of readmission within 30 days (6.8% versus 3.2%). The elderly population also had longer admission process times (8 h, 25 min, versus 4 h, 09 min) and longer lengths of hospital stay (9 h, 41 min, versus 5 h, 29 min). Of the younger patients, 92% (versus 41% of the elderly population) did not take any drugs, 6% (versus 39%) were receiving antiplatelet therapy, 1% (versus 13%) took vitamin K antagonists, and 1% (versus 7%) took oral direct-acting anticoagulants. Logistic regression models revealed that a 1-year increase in age raised the risk of bleeding by 2% on average; this finding was statistically significant (odds ratio [OR], 1023/year, p < 0.001). The rate of ICH increased significantly after the age of 75, by 180% (OR, 2.82; p < 0.001). ConclusionsThese data suggest that age is an independent risk factor for ICH, whereby the age of 75 entails a 180% increase in the risk of bleeding.

PENERAPAN SLOW DEEP BREATHING TERHADAP NYERI CKR DI IGD RUMAH SAKIT PKU MUHAMMADIYAH GOMBONG

Background: Minor head injury is a nervous system disorder caused by a violent blow or jolt to the head or body. As a consequence of this accident an individual will be losing his awareness signed by headache and pain. One way to overcome it is by giving nursing actions like slow deep breathing therapy.Purpose: getting the effect of slow deep breathing therapy to decrease the pain of minor head injury patient.Metode: this study was a quasi-experimental design with Pretest–posttest design with control group approach. A group of 40 respondents were recruited applying by consecutive sampling technique. The study was conducted between the period of June 25 to July 25 of 2007. The study instrument used a pain scale named NRS (numerical rating scale).Result: Based on the data presented that adult age group of intervention group was 60%, while in control group was 55%. Most of gender category was male, 70% of intervention and 75% of control group respectively. The result of paired samples t-test exam 1 received value sig.(2-tailed) = 0,000, it means that there was different of mean average of pre-test post-test group. Meanwhile, paired samples t-test exam 2 resulted value sig.(2-tailed) = 0,021 (sig&gt;0,05), it means that there was different of mean average of pre-test post-test group.Conclusion: There was effect of slow deep breathing to decrease the pain of minor head injury patient.

Risk of Intracranial Hemorrhage and Short-Term Outcome in Patients with Minor Head Injury

To examine the occurrence of traumatic intracranial hemorrhage (tICH) and outcome in patients with minor head injury and assess the probable risk factors. Patients with minor head injury who visited our hospital from January 2015 to July 2017 were registered consecutively, and enrolled patients were aged ≥18 years, visited within 24 hours of the injury, and had a Glasgow Coma Scale score of 15 at outpatient clinic or before the injury. Of the 1122 enrolled patients, 55 (4.9%) had tICH. An antiplatelet agent was administered in 114 patients, an anticoagulant agent was administered in 49 patients, and none of them were administered in 948 patients. A multivariate analysis of tICH identified it as a risk factor, showing significant difference between antiplatelet medication (P= 0.0312), fall from stairs (P= 0.0057), traffic accident (P= 0.0117), neurologic symptoms (P= 0.0091), and modified Rankin Scale (mRS) score before trauma (P < 0.0001). We also analyzed association of enlargement of tICH with different parameters and only anticoagulant medication indicated an increased risk (P= 0.0005). Thirty patients (2.6%) were dependent or died at discharge (mRS 3-6). The mRS score before trauma (P < 0.0001), tICH (P < 0.0001), spinal injury (P < 0.0001), and enlargement of intracranial hemorrhage (P= 0.0008) indicated an increased probability of morbidity (mRS 3-6) in multivariate analysis. Antiplatelet and anticoagulant medications were risk factor for tICH and enlargement of tICH in patients with minor head injury, respectively. A pretrauma condition of disability/dependence is an important risk factor for tICH and outcome.

Characteristics of vomiting as a predictor of intracranial injury in pediatric minor head injury.

Vomiting is common in children after minor head injury. In previous research, isolated vomiting was not a significant predictor of intracranial injury after minor head injury; however, the significance of recurrent vomiting is unclear. This study aimed to determine the value of recurrent vomiting in predicting intracranial injury after pediatric minor head injury. This secondary analysis of the CATCH2 prospective multicenter cohort study included participants (0-16 years) who presented to a pediatric emergency department (ED) within 24 hours of a minor head injury. ED physicians completed standardized clinical assessments. Recurrent vomiting was defined as ≥ four episodes. Intracranial injury was defined as acute intracranial injury on computed tomography scan. Predictors were examined using chi-squared tests and logistic regression models. A total of 855 (21.1%) of the 4,054 CATCH2 participants had recurrent vomiting, 197 (4.9%) had intracranial injury, and 23 (0.6%) required neurosurgical intervention. Children with recurrent vomiting were significantly more likely to have intracranial injury (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.7-3.1), and require neurosurgical intervention (OR, 3.5; 95% CI, 1.5-7.9). Recurrent vomiting remained a significant predictor of intracranial injury (OR, 2.8; 95% CI, 1.9-3.9) when controlling for other CATCH2 criteria. The probability of intracranial injury increased with number of vomiting episodes, especially when accompanied by other high-risk factors, including signs of a skull fracture, or irritability and Glasgow Coma Scale score < 15 at 2 hours postinjury. Timing of first vomiting episode, and age were not significant predictors. Recurrent vomiting (≥ four episodes) was a significant risk factor for intracranial injury in children after minor head injury. The probability of intracranial injury increased with the number of vomiting episodes and if accompanied by other high-risk factors, such as signs of a skull fracture or altered level of consciousness.

Impact of Computed Tomography Scans on the Risk of Thyroid Disease in Minor Head Injury Patients: A Population-Based Retrospective Cohort Study.

We investigated the association between head computed tomography (CT) scans and the risk of noncancer thyroid diseases in patients with minor head injury in a Taiwanese healthcare setting. For this retrospective population-based cohort study, the 2009–2013 Longitudinal Health Insurance Database was used to include patients with a minor head injury at admission or emergency visit between 2009 and 2013. Multivariate analysis with a multiple Cox regression model was applied to analyze the data. According to whether a CT scan was conducted within 14 days of admission, patients were divided into a CT scan group (n = 14,041) or a non-CT scan group (n = 34,684). No increased incidence of thyroid diseases was observed in the CT scan group regardless of the number of CT scans performed. The incidence rate ratio for one scan was 1.10 (95% confidence interval: 0.94–1.29) and for two or more scans was 1.09 (95% confidence interval: 0.93–1.28). In conclusion, this population-based cohort study showed that a head CT scan is not associated with increased risk of thyroid disease in patients with minor head injury. The short-term adverse effects on the thyroid could be mild when a regular CT scan is appropriately performed.

Effect of the implementation of a new guideline for minor head injury on computed tomography-ratio and hospitalizations in the Netherlands.

A new nationwide guideline for minor head injury was introduced in the Netherlands in 2010. The effect on computed tomography (CT) ratio and hospital admission ratio after introduction of the guideline is unknown. The aim was to reduce these numbers as part of cost-effective health care. Therefore, we assessed the effect on these variables after introduction of the guideline. We used an interrupted time-series study design. Data selection was done 3 years before (2007-2009) and several years after (2012, 2014, 2015) introduction of the guideline. Data collection was performed for 3880 patients. Introduction of the new guideline was associated with an increase in CT ratio from 24.6% before to 55% after introduction (P < 0.001). This increase is the result of both the new guideline and a secular trend. Besides this, hospital admissions increased from 14.7 to 23.4% (P < 0.001) during the study period. This increase was less clearly associated with the new guideline. After introduction of the guideline there was no significant difference in (intra)cranial traumatic findings (2.6% vs. 3.4%; P = 0.13) and neurosurgical interventions (0.1% vs. 0.2%; P = 0.50). Between 2007 and 2015, a marked increase in CT ratio and hospital admissions has been observed. The increase in CT ratio seems to be caused both by the new guideline and by a secular trend to perform more CT scans. Adaptations to the guideline should be considered to improve patient care and cost-effectiveness in patients with minor head injury.

It's Time to Normalize Observation for Pediatric Minor Head Trauma.

The 2009 PECARN minor head injury clinical decision rule (CDR) represented an important advance in pediatric emergency care.1 For over a decade, it has offered clinicians a proven evidence-based tool to thoughtfully guide neuroimaging for pediatric minor head trauma while dramatically reducing missed clinically important traumatic brain injuries. When appropriately applied it simultaneously limits harmful radiation exposures and better utilizes health care resources. Nonetheless, in spite of the PECARN CDR, neuroimaging of children for minor head trauma in the United States (as studied between the years 2007 and 2015) has not changed appreciably and remains at approximately 30%.2 In this month's issue of AEM, Singh et al.3 describe their experience, with pediatric minor head trauma and the use of a planned observation period prior to making a decision to CT them. This study is similar to a PECARN study published in 2011; this current study, however, was conducted by the PREDICT Collaborative, specifically in New Zealand and Australia, where the CT rates for pediatric minor head trauma are significantly lower than those in the United States (approximately 8%–10%).3, 4 Planned observation led to an 80% lower adjusted odds of CT use. These findings parallel those of the 2011 PECARN study where observed patients odds of CT use was reduced by nearly half.4 While there are clearly numerous factors contributing to the wide differences in CT rates between the United States and other nations, what is clear is the value of observation as an adjunct to medical decision making in minor head trauma. Management of patients in both the high- and the intermediate-risk groups in this study benefitted from planned observation. While all risk groups in the United States could benefit from more pointed clinical decision support tools, near-term research should focus on intermediate-risk groups where clinician comfort levels may vary in how they interpret symptoms. Decisions to perform a medical test, for better or for worse, are steeped in heuristics defined by experiences that may or may not be evidence based. If time can dull our impulses to CT children with minor head trauma, then quality initiatives should support the use of observation to modify current heuristic tendencies. By evaluating numerous patients who improve during their planned observation in the ED, clinicians could potentially learn to shift their medical judgments toward less interventional stances on neuroimaging. Over a decade has passed since the publication of the PECARN CDR and yet, in spite of sound evidence, we are not making significant progress in reducing overall numbers of CT scans for minor pediatric head injury. Studies, now from both PREDICT and PECARN, have demonstrated the effectiveness of planned observation as a means to trim CT rates. As far medical expenses go, observation time is relatively cheap relative to the costs of unnecessary imaging and cancer. If building planned observation time into the PECARN CDR potentiates the diffusion of the tool to a broader audience, we can begin to chip away at our country's unnecessarily high CT rate.

P037: Adherence to the Canadian CT Head Rule in a Nova Scotian emergency and trauma centre

Introduction: Choosing Wisely Nova Scotia (CWNS), an affiliate of Choosing Wisely Canada™ (CWC), aims to address unnecessary care and testing through literature-informed lists developed by various disciplines. CWC has identified unnecessary head CTs among the top five interventions to question in the Emergency Department (ED). Zyluk (2015) determined the Canadian CT Head Rule (CCHR) as the most effective clinical decision rule in adults with minor head injuries. To better understand the current status of CCHR use in Nova Scotia, we conducted a retrospective audit of patient charts at the Charles V. Keating Emergency and Trauma Center, in Halifax, Nova Scotia. Methods: Our mixed methods design included a literature review, retrospective chart audit, and a qualitative audit-feedback component with participating physicians. The chart audit applied the guidelines for adherence to the CCHR and reported on the level of compliance within the ED. Analysis of qualitative data is included here, in parallel with in-depth to contextualize findings from the audit. Results: 302 charts of patients having presented to the surveyed site were retrospectively reviewed. Of the 37 cases where a CT head was indicated as per the CCHR, a CT was ordered 32 (86.5%) times. Of the 176 cases where a CT head was not indicated, a CT was not ordered 155 (88.1%) times. Therefore, the CCHR was followed in 187 (87.8%) of the total 213 cases where the CCHR should be applied. Conclusion: Our study reveals adherence to the CCHR in 87.8% of cases at this ED. Identifying contextual factors that facilitate or hinder the application of CCHR in practice is critical for reducing unnecessary CTs. This work has been presented to the physician group to gain physician engagement and to elucidate enablers and barriers to guideline adherence. In light of the frequency of CT heads ordered EDs, even a small reduction would be impactful.

P062: Characterizing pediatric emergency department discharge communication using PEDICSv2

Introduction: Discharge communication in the pediatric emergency department (ED) is an important aspect of successful transition home for patients and families. The content, process, and pattern of discharge communication in a pediatric ED encounter has yet to be comprehensively explored. The objective of this study was to identify and characterize elements and patterns of discharge communication occurring during pediatric ED visits between health care providers (HCPs) and families. Methods: We analyzed real time video observations (N = 53) of children (0-18) presenting to two Canadian pediatric EDs with fever or minor head injury. We used a revised version of an existing coding scheme, PEDICSv2, to code all encounters. PEDICSv2 includes 32 elements capturing discharge communication. Inter-rater reliability was established with a second coder. Descriptive statistics reflecting the rates of delivery of each communication content element was reported to assess repetition at four stages of the visit (introduction/planning, actions/interventions, diagnosis/home management plan and summary/conclusion). Communication content was analyzed to depict behaviors of individual HCPs and the total communication delivered to the patient and caregiver by the healthcare team. Results: Results show 55.6% of families were asked to repeat their main concern by multiple HCPs during their ED visit. However, only 14.8% of families had comprehension of delivered discharge information assessed by more than one HCP. When involved in care, physicians were the most likely HCP to perform a comprehension assessment. Most of the communication delivered by nursing staff were elements involved in the introduction/planning and action/intervention stages of the visit. Conclusion: Findings indicate that most repetition occurs while eliciting a main concern during the introduction and planning stage of a pediatric ED encounter. In contrast, communication elements focusing on understanding the home management plan are less likely to be repeated by multiple HCPs. Future work focusing on structuring team workflow to minimize repetition during the introduction and planning stage may allow for clearer discharge teaching and more frequent comprehension assessment.

Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries

The aim of this study was to determine the potential impact of the Pediatric Emergency Care Applied Research Network (PECARN) rules on the CT rate in a large paediatric minor traumatic head injury (MTHI) cohort and compare this with current national Dutch guidelines. This was a planned sub-study of a prospective multicentre observational study that enrolled 1006 children younger than 18 years with MTHI. We calculated the number of recommended CT scans and described trauma-related CT scan abnormalities. The PECARN rules recommended a significantly lower percentage of CT scans in all age categories, namely 101/357 (28.3%) versus 164/357 (45.9%) (p < 0.001) in patients under 2 years of age and 148/623 (23.8%) versus 394/623 (63.2%) (p < 0,001) versus in patients 2 years and older.Conclusion: The projected CT rate can significantly be reduced if the PECARN rules are applied. We therefore advocate that the PECARN guidelines are also implemented in The Netherlands.What is Known:• To guide clinicians whether to perform a CT scan in children with a minor traumatic head injury (MTHI) clinical decision rules has been developed.• The overall CT scan rate in adherence with the Dutch MTHI guidelines is 44%.What is New:• The projected CT rate can significantly be reduced in a Dutch cohort of MTHI if the PECARN rules are applied.• The Dutch national guidelines for MTHI can safely be replaced by the PECARN rules.

The importance of skull impact site for minor mechanism head injury requiring neurosurgical intervention.

The most frequent impact sites for head injury patients who require surgical intervention are the temporo-parietal regions. However, most recent guidelines for indication of neuroimaging for head injury sparsely address the impact site as a risk factor. Our purpose was to determine the association between the site of impact in a minor mechanism pediatric head injury and neurosurgical intervention. A retrospective cohort study of head injury patients seen between 2000 and 2016 in a large trauma center was carried out. We looked at all children ages 0-18years who underwent neurosurgical intervention for head traumas. A major mechanism was defined as a fall of >1m, being struck by a fast-flying object, or a motor collision involving an estimated speed of >40kph. All other mechanisms were classified as minor. Out of 533 patients, we excluded patients with non-accidental trauma, patients with a relevant chronic illness, patients with a major mechanism of injury, and patients with missing important data, leaving 43 as the study group. Of the 43 patients with a minor mechanism, none had a site of impact that was outside the temporo-parietal region. We studied one of the largest cohorts of pediatric patients undergoing neurosurgical intervention for a head injury. In our cohort, none of the children who sustained a minor mechanism of injury suffered a site of impact in the occipital or frontal bone regions outside the temple region. These data suggest that injury location should be considered in assessing the need for neuroimaging in minor mechanism head trauma patients.

Uni-hemispheric hyperperfusion in the early postictal state: case report

BackgroundIn the emergency setting of acute ischemic stroke, seizures have been reported in up to 4% of patients. In the absence of arterial occlusion, seizures may also cause abnormalities in CT perfusion in 78% of cases when the time window from onset to imaging is short. Both hyperperfusion and hypoperfusion in the postictal state have been described. Also, though rarely reported, postictal perfusion changes can be uni-hemispheric. In these cases, perfusion maps should be analyzed thoroughly, since perfusion reconstruction software relies heavily on a “normal” contralateral perfusion status.Case presentationA 39-year-old man was found on the ground with a minor head injury. On admission, his reactions were generally slow, but there were no other neurological symptoms, and blood pressure was low. The patient had a history of primary generalized epilepsy and admitted to dropping off his anti-epileptic medication. He was transferred to the radiological department for imaging but shortly before began to experience generalized onset tonic-clonic seizures which were brought under control by intravenous therapy with 10 mg diazepam. After approximately 15 min, a multimodal CT scan was performed, revealing marked changes in the perfusion of the brain hemispheres and posterior fossa, with sharp delimitation at the midline. Blood gas analysis was congruent with respiratory acidosis. Clinically, the patient remained awake without developing any new symptoms. He gradually recovered over the following 3 h and, against our medical recommendation, discharged himself from the hospital.ConclusionsTo the authors’ knowledge, this is the first report of an early postictal state describing sharply delimited uni-hemispheric hyperperfusion and hemispheric alteration of the cerebellum with an equally split rhombencephalon. Surprisingly, these changes were not associated with any focal neurological signs. To prevent misdiagnosis of perfusion alterations in seizures, radiologists and neurologists should be aware of the limitations of CT perfusion maps and software reconstructions. Novel use of CT perfusion reconstruction using peak enhancement helped in identifying the cerebral pathology.

Designing a Multi-Stakeholder Collaboration to Reduce Overuse of Neuroimaging for Minor Head Injury and Atraumatic Headache

Despite recommendations to limit the use of neuroimaging for evaluation of minor head injury and atraumatic headache in children, many children receive unnecessary imaging without clear history or physical exam indications in the emergency department (ED) or other outpatient settings. This overuse of neuroimaging has not previously been explored across clinical settings, nor for the diagnosis of atraumatic headache.We convened a multi-stakeholder design meeting to discuss reasons for overuse of neuroimaging in children and brainstorm potential interventions to reduce overuse. The meeting included didactic sessions on the risks and benefits of neuroimaging and quality improvement methodology. There were also small group discussions of challenges and potential interventions.Participants included ED physicians and nurses, radiologists, Medicaid health plan representatives, a pediatric neurologist, a pediatric primary care provider and a parent. Reasons for overuse included family anxiety and expectations for neuroimaging, pediatric phone triage protocols directing patients to the ED for evaluation, time pressures within primary care and the ED clinics, and reluctance among payers to institute prior authorization for ED-based imaging studies. Several potential interventions were identified and organized into three key driver diagrams: one each for primary care, the ED, and Medicaid health plans.Convening a multi-stakeholder meeting was feasible and resulted in the identification of common reasons for overuse of neuroimaging in children and many potential interventions across clinical settings. Similar multidisciplinary approaches may be helpful for others interested in reducing the overuse of imaging in children.Discussions from a multi-stakeholder meeting with representation from primary care, pediatric emergency departments, and Medicaid health plans resulted in the identification of common reasons for overuse of neuroimaging in children and many potential interventions across clinical settings.

Are Sequential CT Scans Necessary in Patients on Warfarin with a Minor Head Injury and Initial Normal CT of the Brain?

Are Sequential CT Scans Necessary in Patients on Warfarin with a Minor Head Injury and Initial Normal CT of the Brain?