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Delay PREDICTs Problems in Pediatric TBI

February 20, 2019

Written by Clay Smith

Spoon Feed
The prevalence of traumatic brain injury (TBI) on CT in children with head injury presenting >24 hours post-injury was 3.8%. Predictors of TBI on CT were suspicion of depressed skull fracture and non-frontal scalp hematoma.

Why does this matter?
Most head injury prediction rules include patients presenting within the first 24 hours. But what about children who show up late? Are they out of danger when they present late, or is there still risk?

Delay PREDICTs problems
When children present with head injury after 24 hours, what is the prevalence of traumatic brain injury on CT? This was a planned subanalysis of a prior pediatric TBI study and focused on the 981 out of 19,765 children who came to the ED >24 hours after the injury. They found the prevalence of TBI on CT was 3.8% compared to just 1.2% for those presenting within 24 hours of injury. Additionally, they found the prevalence of clinically important TBI (ciTBI) to be 0.8%, with 2 children needing neurosurgical intervention. Of the 8 with ciTBI, 6 were reportedly due to fall <1m, a fairly innocuous mechanism. Predictors of TBI on CT were non-frontal scalp hematoma and suspicion of depressed skull fracture. Just 21% of the 981 children had a CT on presentation, but almost all were followed up and did not have a bad neurological outcome or death. However, the rate of CT scanning was higher in those with delayed presentation than those presenting within 24 hours, possibly due to concerns for non-accidental mechanism, though this can’t be confirmed with this dataset. My take is that children with delayed presentation for head injury may be at greater risk for TBI on CT. I plan to scan those with suspicion for depressed skull fracture or with non-frontal scalp hematoma.

Another Spoonful
Don’t Forget the Bubbles did an excellent in-depth review by Tessa Davis, with practical, helpful commentary by Damian Roland and an infographic! Allow FOMO drive you to read this post.

Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study. Ann Emerg Med. 2019 Jan 14. pii: S0196-0644(18)31485-9. doi: 10.1016/j.annemergmed.2018.11.035. [Epub ahead of print]

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Reviewed by Thomas Davis

What are your thoughts?