Short Attention Span Summary
Raccoon Battle
In a large cohort of kids with head injury, 1% had physical exam or CT findings of basilar skull fracture (BSF). Of kids with physical exam findings concerning for BSF, 29% had CT findings to corroborate. Conversely, 31% had CT evidence of BSF and no physical exam findings. Of those with exam, CT, or both, over half had additional intracranial findings on CT. Of those with isolated BSF, normal neurological exam and normal GCS, none had adverse outcomes.
Spoon Feed
If a child has exam findings concerning for BSF, do a head CT. If they have isolated BSF and a completely normal neurological exam after a period of ED observation, they have a low risk of adverse outcome and could be considered for discharge. Personally, I lean toward admission if a BSF is present.
Abstract
Ann Emerg Med. 2016 Oct;68(4):431-440.e1. doi: 10.1016/j.annemergmed.2016.04.058. Epub 2016 Jul 25.
Tunik MG, Powell EC, Mahajan P, Schunk JE, Jacobs E, Miskin M, Zuspan SJ, Wootton-Gorges S, Atabaki SM, Hoyle JD Jr, Holmes JF Jr, Dayan PS, Kuppermann N; Pediatric Emergency Care Applied Research Network (PECARN).
Abstract
STUDY OBJECTIVE:
We describe presentations and outcomes of children with basilar skull fractures in the emergency department (ED) after blunt head trauma.
METHODS:
This was a secondary analysis of an observational cohort of children with blunt head trauma. Basilar skull fracture was defined as physical examination signs of basilar skull fracture without basilar skull fracture on computed tomography (CT), or basilar skull fracture on CT regardless of physical examination signs of basilar skull fracture. Other definitions included isolated basilar skull fracture (physical examination signs of basilar skull fracture or basilar skull fracture on CT with no other intracranial injuries on CT) and acute adverse outcomes (death, neurosurgery, intubation for >24 hours, and hospitalization for ≥2 nights with intracranial injury on CT).
RESULTS:
Of 42,958 patients, 558 (1.3%) had physical examination signs of basilar skull fracture, basilar skull fractures on CT, or both. Of the 525 (94.1%) CT-imaged patients, 162 (30.9%) had basilar skull fracture on CT alone, and 104 (19.8%) had both physical examination signs of basilar skull fracture and basilar skull fracture on CT; 269 patients (51.2%) had intracranial injuries other than basilar skull fracture on CT. Of the 363 (91.7%) CT-imaged patients with physical examination signs of basilar skull fracture, 104 (28.7%) had basilar skull fracture on CT. Of 266 patients with basilar skull fracture on CT, 104 (39.1%) also had physical examination signs of basilar skull fracture. Of the 256 CT-imaged patients who had isolated basilar skull fracture, none had acute adverse outcomes (0%; 95% confidence interval 0% to 1.4%), including none (0%; 95% confidence interval 0% to 6.1%) of 59 with isolated basilar skull fractures on CT.
CONCLUSION:
Approximately 1% of children with blunt head trauma have physical examination signs of basilar skull fracture or basilar skull fracture on CT. The latter increases the risk of acute adverse outcomes more than physical examination signs of basilar skull fracture. A CT scan is needed to adequately stratify the risk of acute adverse outcomes for these children. Children with isolated basilar skull fractures are at low risk for acute adverse outcomes and, if neurologically normal after CT and observation, are candidates for ED discharge.
Copyright © 2016 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.
PMID: 27471139 [PubMed – in process]
