Big for Small; Validating Brain Injury Guidelines in Pediatric Traumatic Brain Injury

Asad Azim, Faisal S. Jehan, Peter Rhee, Terence O’Keeffe, Andrew Tang, Gary Vercruysse, Narong Kulvatunyou, Rifat Latifi, Bellal Joseph

Research output: Research - peer-reviewArticle

Abstract

INTRODUCTION: Brain Injury Guidelines (BIG) were developed to reduce over utilization of Neurosurgical Consultation (NC) as well as CT imaging. Currently, BIG have been successfully applied to adult populations, but the value of implementing these guidelines among pediatric patients remains unassessed. Therefore, the aim of this study was to evaluate the established BIG (BIG-1 category) for managing pediatric traumatic brain injury (TBI) patients with intracranial hemorrhage (ICH) without neurosurgical consultation (No-NC). METHODS: We prospectively implemented the BIG-1 category (normal neurological exam, ICH ≤ 4mm limited to 1 location, no skull fracture) to identify pediatric TBI patients (age ≤ 21years) that were to be managed No-NC. Propensity score matching was performed to match these No-NC patients to a similar cohort of patients managed with NC before the implementation of BIG in a 1:1 ratio for demographics, severity of injury, and type as well as size of ICH. Our primary outcome measure was need for neurosurgical intervention. RESULTS: A total of 405 pediatric TBI patients were enrolled, of which 160 (80: NC and 80: No-NC) were propensity score matched. The mean age was 9.03 ± 7.47 years, 62.1% (n=85) were male, the median Glasgow Coma Scale (GCS) was 15 [13-15], and the median head-abbreviated injury scale (AIS) was 2 [2-3]. A sub-analysis based on stratifying patients by age groups showed a decreased in the use of RHCT (p=0.02) in the No-NC group, with no difference in progression (p=0.34) and the need for neurosurgical intervention (p=0.9) compared to the NC group. CONCLUSION: The BIG can be safely and effectively implemented in pediatric TBI patients. Reducing repeat head CT in pediatric patients has long-term sequelae. Likewise, adhering to the guidelines helps in reducing radiation exposure across all age groups. LEVEL OF EVIDENCE: Therapeutic/care management, level III

LanguageEnglish (US)
JournalJournal of Trauma and Acute Care Surgery
DOIs
StateAccepted/In press - Jun 6 2017

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Brain Injuries
Referral and Consultation
Guidelines
Pediatrics
Traumatic Brain Injury
Intracranial Hemorrhages
Propensity Score
Age Groups
Abbreviated Injury Scale
Skull Fractures
Glasgow Coma Scale
Craniocerebral Trauma
Head
Demography
Outcome Assessment (Health Care)
Wounds and Injuries
Population
Therapeutics
Radiation Exposure

ASJC Scopus subject areas

  • Surgery
  • Critical Care and Intensive Care Medicine

Cite this

@article{f3388981d9ba40ed910ad1b98acf0e59,
title = "Big for Small; Validating Brain Injury Guidelines in Pediatric Traumatic Brain Injury",
abstract = "INTRODUCTION: Brain Injury Guidelines (BIG) were developed to reduce over utilization of Neurosurgical Consultation (NC) as well as CT imaging. Currently, BIG have been successfully applied to adult populations, but the value of implementing these guidelines among pediatric patients remains unassessed. Therefore, the aim of this study was to evaluate the established BIG (BIG-1 category) for managing pediatric traumatic brain injury (TBI) patients with intracranial hemorrhage (ICH) without neurosurgical consultation (No-NC). METHODS: We prospectively implemented the BIG-1 category (normal neurological exam, ICH ≤ 4mm limited to 1 location, no skull fracture) to identify pediatric TBI patients (age ≤ 21years) that were to be managed No-NC. Propensity score matching was performed to match these No-NC patients to a similar cohort of patients managed with NC before the implementation of BIG in a 1:1 ratio for demographics, severity of injury, and type as well as size of ICH. Our primary outcome measure was need for neurosurgical intervention. RESULTS: A total of 405 pediatric TBI patients were enrolled, of which 160 (80: NC and 80: No-NC) were propensity score matched. The mean age was 9.03 ± 7.47 years, 62.1% (n=85) were male, the median Glasgow Coma Scale (GCS) was 15 [13-15], and the median head-abbreviated injury scale (AIS) was 2 [2-3]. A sub-analysis based on stratifying patients by age groups showed a decreased in the use of RHCT (p=0.02) in the No-NC group, with no difference in progression (p=0.34) and the need for neurosurgical intervention (p=0.9) compared to the NC group. CONCLUSION: The BIG can be safely and effectively implemented in pediatric TBI patients. Reducing repeat head CT in pediatric patients has long-term sequelae. Likewise, adhering to the guidelines helps in reducing radiation exposure across all age groups. LEVEL OF EVIDENCE: Therapeutic/care management, level III",
author = "Asad Azim and Jehan, {Faisal S.} and Peter Rhee and Terence O’Keeffe and Andrew Tang and Gary Vercruysse and Narong Kulvatunyou and Rifat Latifi and Bellal Joseph",
year = "2017",
month = "6",
doi = "10.1097/TA.0000000000001611",
journal = "Journal of Trauma and Acute Care Surgery",
issn = "2163-0755",
publisher = "Lippincott Williams and Wilkins",

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T1 - Big for Small; Validating Brain Injury Guidelines in Pediatric Traumatic Brain Injury

AU - Azim,Asad

AU - Jehan,Faisal S.

AU - Rhee,Peter

AU - O’Keeffe,Terence

AU - Tang,Andrew

AU - Vercruysse,Gary

AU - Kulvatunyou,Narong

AU - Latifi,Rifat

AU - Joseph,Bellal

PY - 2017/6/6

Y1 - 2017/6/6

N2 - INTRODUCTION: Brain Injury Guidelines (BIG) were developed to reduce over utilization of Neurosurgical Consultation (NC) as well as CT imaging. Currently, BIG have been successfully applied to adult populations, but the value of implementing these guidelines among pediatric patients remains unassessed. Therefore, the aim of this study was to evaluate the established BIG (BIG-1 category) for managing pediatric traumatic brain injury (TBI) patients with intracranial hemorrhage (ICH) without neurosurgical consultation (No-NC). METHODS: We prospectively implemented the BIG-1 category (normal neurological exam, ICH ≤ 4mm limited to 1 location, no skull fracture) to identify pediatric TBI patients (age ≤ 21years) that were to be managed No-NC. Propensity score matching was performed to match these No-NC patients to a similar cohort of patients managed with NC before the implementation of BIG in a 1:1 ratio for demographics, severity of injury, and type as well as size of ICH. Our primary outcome measure was need for neurosurgical intervention. RESULTS: A total of 405 pediatric TBI patients were enrolled, of which 160 (80: NC and 80: No-NC) were propensity score matched. The mean age was 9.03 ± 7.47 years, 62.1% (n=85) were male, the median Glasgow Coma Scale (GCS) was 15 [13-15], and the median head-abbreviated injury scale (AIS) was 2 [2-3]. A sub-analysis based on stratifying patients by age groups showed a decreased in the use of RHCT (p=0.02) in the No-NC group, with no difference in progression (p=0.34) and the need for neurosurgical intervention (p=0.9) compared to the NC group. CONCLUSION: The BIG can be safely and effectively implemented in pediatric TBI patients. Reducing repeat head CT in pediatric patients has long-term sequelae. Likewise, adhering to the guidelines helps in reducing radiation exposure across all age groups. LEVEL OF EVIDENCE: Therapeutic/care management, level III

AB - INTRODUCTION: Brain Injury Guidelines (BIG) were developed to reduce over utilization of Neurosurgical Consultation (NC) as well as CT imaging. Currently, BIG have been successfully applied to adult populations, but the value of implementing these guidelines among pediatric patients remains unassessed. Therefore, the aim of this study was to evaluate the established BIG (BIG-1 category) for managing pediatric traumatic brain injury (TBI) patients with intracranial hemorrhage (ICH) without neurosurgical consultation (No-NC). METHODS: We prospectively implemented the BIG-1 category (normal neurological exam, ICH ≤ 4mm limited to 1 location, no skull fracture) to identify pediatric TBI patients (age ≤ 21years) that were to be managed No-NC. Propensity score matching was performed to match these No-NC patients to a similar cohort of patients managed with NC before the implementation of BIG in a 1:1 ratio for demographics, severity of injury, and type as well as size of ICH. Our primary outcome measure was need for neurosurgical intervention. RESULTS: A total of 405 pediatric TBI patients were enrolled, of which 160 (80: NC and 80: No-NC) were propensity score matched. The mean age was 9.03 ± 7.47 years, 62.1% (n=85) were male, the median Glasgow Coma Scale (GCS) was 15 [13-15], and the median head-abbreviated injury scale (AIS) was 2 [2-3]. A sub-analysis based on stratifying patients by age groups showed a decreased in the use of RHCT (p=0.02) in the No-NC group, with no difference in progression (p=0.34) and the need for neurosurgical intervention (p=0.9) compared to the NC group. CONCLUSION: The BIG can be safely and effectively implemented in pediatric TBI patients. Reducing repeat head CT in pediatric patients has long-term sequelae. Likewise, adhering to the guidelines helps in reducing radiation exposure across all age groups. LEVEL OF EVIDENCE: Therapeutic/care management, level III

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