TRAUMA ANZJSurg.com
Epidemiology of traumatic head injury from a major paediatric trauma centre in New South Wales, Australia Jeevaka E. Amaranath,* Mahesh Ramanan,† Jessica Reagh,* Eilen Saekang,* Narayan Prasad,* Raymond Chaseling† and Sannappa Soundappan‡ *Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia †Department of Neurosurgery, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia and ‡Douglas Cohen Department of Paediatric Surgery and Trauma, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
Key words epidemiology, paediatric, traumatic head injury. Correspondence Dr Jeevaka E. Amaranath, Unit 7/9-27 Park Avenue, Sydney, NSW 2047, Australia. Email: [email protected] J. E. Amaranath MBBS; M. Ramanan MBBS; J. Reagh MBBS; E. Saekang MBBS; N. Prasad MBBS; R. Chaseling FRACS; S. Soundappan FRACS. Accepted for publication 7 October 2013. doi: 10.1111/ans.12445
Abstract Background: Traumatic brain injury (TBI) is common and is a leading cause of presentations to emergency departments. Understanding the epidemiology of TBI can aid in improving overall management and identifying opportunities for prevention. Currently, there is a paucity of data on paediatric TBI in NSW. The purpose of this study was to determine the demographics, causes, treatment and outcome of TBI at The Children’s Hospital at Westmead (CHW), a large trauma referral paediatric hospital. Methods: A retrospective chart review was conducted of patients admitted to CHW emergency from 2006 to 2011 with a TBI. Patients who presented to the emergency department and had a history of TBI with either symptoms of concussion and/or positive computed tomography (CT) findings of head injury were selected. Information regarding demographics, injury pattern, CT findings, treatment and outcome were retrieved. Results: Over the 6-year period, there were 1489 presentations at the CHW. Of these, 65% were male and 35% were female. The mean age was 7 years. A total of 93% were classified as mild, 1.5% as moderate and 5.5% as severe. Sports and recreational injuries accounted for 26% of all TBI presentations, while motor vehicle accidents (MVAs) accounted for 77% of all TBI deaths. Sixty-two per cent of children underwent a CT brain, and of those, 40% were normal. Conclusion: The majority of TBI are mild in nature, with younger children and males at greatest risk. There was a low rate of operative intervention and a high rate of good outcomes. Many injuries may be preventable with the adaptation of better public health education programmes, particularly in very young children and those related to MVAs.
Introduction Traumatic brain injury (TBI) is common1 and is one of the leading causes of presentations to hospital emergency departments.2,3 The reported incidence of paediatric TBI hospital admissions in the USA is 70 per 100 000 population.1 It is one of the major causes of mortality and morbidity related to childhood trauma,4 and is associated with significant personal, financial and social consequences. Further, a large proportion of childhood TBI occurs due to preventable causes, such as falls, motor vehicle accidents (MVAs) and sports injuries.5 The incidence of paediatric TBI in New South Wales (NSW) has not recently been formally reported; however, data from the NSW ANZ J Surg 84 (2014) 424–428
Department of Health Emergency showed that head injuries constituted 7% of all paediatric presentations to NSW emergency departments from July 2008 to July 2009.6 This places considerable demands on health services, families and the wider community. Epidemiological data enable the identification of those groups at greatest risk, explore causative factors and analyse variables that may predict outcome. The information is then useful in developing preventative strategies and plan for necessary health services. There have been no population-based studies to date in NSW, Australia, that have reviewed the epidemiology of paediatric TBI. The Children’s Hospital at Westmead (CHW) is a paediatric trauma hospital servicing a population of 2.02 million people,7 with © 2014 Royal Australasian College of Surgeons
Epidemiology of traumatic head injury
Methods We conducted a retrospective chart review of patients aged 0–16 years that were admitted to CHW emergency from January 2006 to December 2011 with a TBI. Patients who presented to the emergency department or were transferred directly to the intensive care unit and had a history of TBI with either symptoms of concussion9 and/or positive computed tomography (CT) findings of head injury were selected. We took into account that the definition of concussion varies with the age of the child. For infants, subtle symptoms, such as listlessness, irritability and change in eating or sleeping patterns,10 were included. Whereas for older children, a wider range of symptoms, including headache, amnesia, confusion, dizziness, fatigue, slurred speech, inattentiveness, sensitivity to light and noise, disorders of taste and smell, and co-ordination deficits, were used to define concussion.11 Patients who had trivial head trauma without symptoms of concussion and without a CT scan were excluded. Positive CT findings included skull fracture, extradural haematoma (EDH), subdural haematoma (SDH), subarachnoid haematoma, cerebral contusion and brain oedema. We extracted data on the age, gender, mechanism of injury, Glasgow coma score (GCS), CT findings, surgery and outcome using a computerized hospital medical record database (Cerner Millennium Powerchart Version 2009.06.1.6). We searched the database for TBI cases using International Classification of Diseases 10th revision (ICD-10) codes. We then assessed these cases for potential inclusion. Severity of TBI was classified into mild (GCS 13–15), moderate (GCS 9–12) and severe (GCS 3–8) based on established criteria.12,13 Patient outcomes were measured using the Glasgow outcome scale (GOS)14,15 based on the level of recovery and disability recorded in the medical record at latest follow-up. Standard practice at our institution is to follow-up all patients admitted with TBI at 6–12 weeks after discharge, and then subsequently as indicated. However, it is likely that some patients with mild TBI who were admitted to the Emergency Department but not the Neurosurgery ward would have been discharged with general practitioner follow-up. For these patients, the outcome was recorded at hospital discharge. GOS 4 and 5 were classified as a good outcome, and GOS 1–3 as poor outcome. We entered data into Microsoft Excel and used the Excel ToolPak for basic data analysis including summary statistics and the generation of tables. We used Statistical Analysis Software 9.1 to generate univariate and multivariate logistic regression models to test the effect of various factors on mortality and GOS. We used odds ratios (OR) as the measure of association between these factors and outcomes for categorical variables. We used P < 0.05 as threshold of significance and calculated 95% confidence intervals (CI) for the OR. The chi-squared statistic was calculated to test for differences © 2014 Royal Australasian College of Surgeons
between proportions, and t-test was used without assuming equal variances for differences between means.
Results There were 1489 presentations with head injury meeting the inclusion criteria over the 6-year period from 2006 to 2011. The total number of children was 1441; 1396 with a single presentation, 42 children with two presentations and 3 children with three presentations. The data collection was complete. Of the presentations, 973 (65%) were male and 516 (35%) female. The mean age overall was 7.0 years, while the mean age for males was 7.9 and females was 5.3 (Fig. 1). A total of 28% of presentations were transfers from other hospitals. Of the 422 (28%) patients that were transferred, 11% went onto have an operation. The highest number of presentations was observed in the 0–1 year age group. As demonstrated in Figure 1, there was a strong trend towards increased proportion of boys above the age of 5. Of those under the age of 5, 54% were boys, compared with 74% among children aged 5 and above. This difference of 20% (95% CI: 16–25%) in the proportion of boys between the two groups was highly statistically significant (χ2 = 67.71, df = 3, P < 0.001). The distribution of TBI severity is displayed in Table 1. A total of 1384 (93%) presentations were classified as mild TBI, 23 (1.5%) moderate and 82 (5.5%) severe. Most presentations (98.7%) resulted in a good recovery (GOS 4 and 5). The mortality rate was 0.87% (13
120
100
80
Frequency
approximately 50 000 hospital presentations annually.8 We describe the demographics, causes, radiological findings, treatment, prognostic factors and outcomes of TBI at CHW to inform the planning and delivery of health-care services and public health interventions. We received approval from the Sydney Children’s Hospitals Network Human Research Ethics Committee prior to commencement of this study.
425
60
40
20
0
999.99, P < 0.001) remained significant predictors of mortality after adjustment for other variables.
Discussion We found that TBI was most frequent among children under the age of 1 and more frequent in males in every age group. The age distributions were also fundamentally different among the sexes, with males having a bimodal distribution (peaks at 0–1 and 14–15) and females a positively skewed distribution (peak at 0–1 and long, right-sided tail). This is mainly due to the increased number of sports injuries in teenage males. It is likely that the second peak for males is higher than presented here because many older children (age 15 and above) are treated at adult hospitals. These findings are consistent with previous Australian and international epidemiological study findings.12,16 However, even though the vast majority of these were mild in severity, most were related to falls at home. A better understanding of the high risk at this age group through continual parental © 2014 Royal Australasian College of Surgeons
Epidemiology of traumatic head injury
education-based programmes may reduce the number of admissions seen through emergency.17 This can have a positive impact on both families and hospitals, by reducing the emotional and financial cost of unwanted imaging and the workload on the emergency department. The use of CT imaging in TBI raises some issues due to the attendant radiation exposure and subsequent risks. The increased lifetime risk of developing cancer following radiation exposure is not insignificant18,19 and needs to factored into any decision-making algorithm for the use of CT in children. In our cohort, 62% of children had a CT brain, and of those patients, 40% had normal CT brain findings. Furthermore, the majority of these patients that went on to have a CT brain had mild head injuries and did not require surgical intervention. There is potential to reduce this radiation exposure with more stringent screening of TBI in the emergency department prior to CT scan. However, intracranial injury may occur with only few or subtle signs,20 and at the very young age, examination and clinical findings may be hard to elicit. In addition, it can be argued that a liberal use of CT scanning can prevent morbidity and mortality caused by unrecognized TBI. The current evidence to guide doctors on what constitutes appropriate criteria for obtaining CT scans in children following TBI still remains controversial. However, large multi-centre studies such as those published by Oman et al.,21 along with others, will lay a foundation of evidence and help devise criteria to guide clinicians to distinguish children who are low risk for significant TBI and those that are higher risk requiring CT imaging. The analysis of moderate and severe head injuries found that they accounted for only 7% of the total number of head injuries, but as expected, were associated with all the TBI deaths.22 MVAs were not only the most significant factor in the cause for moderate and severe head injury, but also TBI death. This result is consistent with other Australian and international paediatric-based studies on head trauma.23 It continues to reinforce the need for broadly targeted road safety initiatives, but also identifies the vulnerability children have in and around motor vehicles. The current Australian public policies and regulations relating to reduction in speed limits, school zones and car child restraints are all important measures to help reduce the severity of TBI, but need continuing reinforcement through education and advertising. Education of young and learner drivers should be a priority for governments for the protection of future generations. Sports and recreational injuries were another significant group within our cohort. More than a quarter of all head injuries occurred through sports and recreational injuries. As seen from previous studies, this was predominantly in the adolescent years and dominated by males.12,24 In a study by Crowe et al., in Victoria, it was shown that Australian Rules Football had a high rate of TBI for adolescents. Our study was not designed to look at the different injury patterns among the different sports; however, our results reinforce that appropriate education and preventative measures need to be implemented to reduce TBI from sports and recreational injuries. These steps, along with parental and adolescent public awareness of the risks of sports and recreational head injuries, especially in the teenage years, may help reduce the numbers of TBI in this age group. © 2014 Royal Australasian College of Surgeons
427
The study had some limitations that need to be considered. Firstly, this is a hospital-based study and therefore is not representative of the general population. CHW is the largest paediatric trauma centre in the state25 and hence probably receives more paediatric TBI than the other two paediatric hospitals in the state. However, there is still likely to be a significant number of cases during the study period that would have presented to other hospitals and hence not included in our analysis. For true population estimates, TBI data would also need to be collected from the other two paediatric hospitals in the state of NSW. Being a retrospective chart review, we were limited to the information that was available in the charts, with no scope for collecting additional data. The outcome of some children was assessed at the time of discharge rather than at any specific followup. However, the patients with moderate and severe TBI, who are most likely to suffer from adverse sequelae of TBI, are always followed-up in the Neurosurgery outpatients clinic, and these data were available for this study. Therefore, we feel it is unlikely that significant follow-up information, in terms of GOS, would have been missed in our study. We were, however, unable to comment on long-term neuropsychological and developmental outcomes, which are likely to be of significant importance in paediatric TBI. This represents an opportunity for a prospective, observational study in the future. In conclusion, the majority of traumatic brain injuries are mild in nature, with younger children and males at greatest risk. There is a low rate of operative intervention12,26 and a high rate of good outcomes. This study provides a good starting point for the epidemiology of head injury in NSW and identifies significant opportunities that exist for further studies and public health prevention programmes.
Acknowledgements We would like to acknowledge Patricia Manglick for her assistance in data extraction. We would also like to acknowledge Dr Hasantha Gunasekera for his assistance in reviewing the manuscript.
References 1. Schneier AJ, Shields BJ, Hostetler SG, Xiang H, Smith GA. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 2006; 118: 483–92. 2. Lam WH, Mackersie A. Paediatric head injury: incidence, aetiology and management. Paediatr. Anaesth. 1999; 9: 377–85. 3. Nolan T, Penny M. Epidemiology of non-intentional injuries in an Australian Urban region: results from injury surveillance. J. Paediatr. Child Health 1992; 28: 27–35. 4. Swaminathan A, Levy P, Legome E. Evaluation and management of moderate to severe pediatric head trauma. J. Emerg. Med. 2009; 37: 63–8. 5. Debono P, Agius S, Ansari S. Paediatric head injuries – a review. Adv. Clin. Neurosci. Rehabil. 2011; 10: 30–5. 6. NSW Health. Infants and children: Acute management of Head Injury. NSW Department of Health, 2010. [Cited 30 Jan 2013.] Available from URL: http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011 _024.pdf 7. Premier & Cabinet NSW Government. Demographics. 2011. [Cited 20 Oct 2012.] Available from URL: http://www.westernsydney.nsw.gov.au/ about-western-sydney/demographics/
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8. National Health Performance Authority. Emergency department services. Australian Institute of Health and Welfare, 2011. [Cited 20 Apr 2013.] Available from URL: http://www.myhospitals.gov.au/hospital/ the-childrens-hospital-at-westmead/services 9. Ropper A, Gorson K. Concussion. N. Engl. J. Med. 2007; 356: 166–72. 10. Gerber P, Coffman K. Nonaccidental head injury in infants. Childs Nerv. Syst. 2007; 23: 499–507. 11. AAP, AAFP. Minor head injuries in children. American Academy of Paediatrics, 2009. [Cited 26 Aug 2013.] Available from URL: http:// pediatrics.aappublications.org/content/104/6/1407.full.pdf+html 12. Crowe L, Babl F, Anderson V, Catroppa C. The epidemiology of paediatric head injuries: data from a referral centre in Victoria, Australia. J. Paediatr. Child Health 2009; 45: 346–50. 13. Anderson V, Catroppa C, Morse S, Haritrou F, Rosenfeld J. Functional plasticity or vunerability after early brain injury? Pediatrics 2005; 116: 1374–82. 14. Cooksley D. Paediatric Neurotrauma. In: Cameron P JG, Everitt I, ed. Textbook of Paediatric Emergency Medicine. Sydney: Churchill Livingstone; 2006; 245–255. 15. Jennett B, Snoek J, Bond MR, Brooks N. Disability after severe head injury: observations on the use of Glasgow Outcome Scale. J. Neurol. Neurosurg. Psychiatry 1981; 44: 285–93. 16. Reid SR, Roesler MS, Gaichas AM, Tsai AK. The epidemiology of paediatric traumatic brain injury in Minnesota. Arch. Pediatr. Adolesc. Med. 2001; 155: 784–9.
Amaranath et al.
17. Bass JL, Christoffel KK, Widome M et al. Childhood injury prevention counseling in primary care settings: a critical review of the literature. Pediatrics 1993; 92: 544–50. 18. Kleinerman RA. Cancer risks following diagnositic and therapeutic radiation exposure in children. Radiology 2006; 36: 121–5. 19. Ron E. Cancer risks from medical radiation. Health Phys. 2003; 85: 47–9. 20. Quayle KS, Jaffe DM, Kuppermann N et al. Diagnositc testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? Pediatrics 1997; 95: 11. 21. Oman JA, Cooper RJ, Holmes JF et al. Performance of a decision rule to predict need for computed tomography among children with blunt head trauma. Pediatrics 2006; 117: 238–46. 22. Mitra B, Cameron P, Butt W. Population-based study of paediatric head injury. J. Paediatr. Child Health 2007; 43: 154–9. 23. Berney J, Favier J, Froidevaux A. Paediatric head trauma: influence of age and sex. Childs Nerv. Syst. 1994; 10: 509–16. 24. Tate RL, McDonald S, Lulham JM. Incidence of hospital-treated traumatic brain injury in an Australian community. Aust. N. Z. J. Public Health 1998; 22: 419–23. 25. ITIM. NSWIoTaIM. The NSW Trauma Registry Profile of Serious to Critical Injuries. 2009. [Cited 20 Apr 2013.] Available from URL: http:// www.itim.nsw.gov.au/wiki/Annual_trauma_registry_reports 26. Thiessen M, Woolridge D. Pediatric minor closed head injury. Pediatr. Clin. North Am. 2006; 53: 1–26.
© 2014 Royal Australasian College of Surgeons
Epidemiology of traumatic head injury from a major paediatric trauma centre in New South Wales, Australia Jeevaka E. Amaranath,* Mahesh Ramanan,† Jessica Reagh,* Eilen Saekang,* Narayan Prasad,* Raymond Chaseling† and Sannappa Soundappan‡ *Douglas Cohen Department of Paediatric Surgery, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia †Department of Neurosurgery, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia and ‡Douglas Cohen Department of Paediatric Surgery and Trauma, The Children’s Hospital at Westmead, Sydney, New South Wales, Australia
Key words epidemiology, paediatric, traumatic head injury. Correspondence Dr Jeevaka E. Amaranath, Unit 7/9-27 Park Avenue, Sydney, NSW 2047, Australia. Email: [email protected] J. E. Amaranath MBBS; M. Ramanan MBBS; J. Reagh MBBS; E. Saekang MBBS; N. Prasad MBBS; R. Chaseling FRACS; S. Soundappan FRACS. Accepted for publication 7 October 2013. doi: 10.1111/ans.12445
Abstract Background: Traumatic brain injury (TBI) is common and is a leading cause of presentations to emergency departments. Understanding the epidemiology of TBI can aid in improving overall management and identifying opportunities for prevention. Currently, there is a paucity of data on paediatric TBI in NSW. The purpose of this study was to determine the demographics, causes, treatment and outcome of TBI at The Children’s Hospital at Westmead (CHW), a large trauma referral paediatric hospital. Methods: A retrospective chart review was conducted of patients admitted to CHW emergency from 2006 to 2011 with a TBI. Patients who presented to the emergency department and had a history of TBI with either symptoms of concussion and/or positive computed tomography (CT) findings of head injury were selected. Information regarding demographics, injury pattern, CT findings, treatment and outcome were retrieved. Results: Over the 6-year period, there were 1489 presentations at the CHW. Of these, 65% were male and 35% were female. The mean age was 7 years. A total of 93% were classified as mild, 1.5% as moderate and 5.5% as severe. Sports and recreational injuries accounted for 26% of all TBI presentations, while motor vehicle accidents (MVAs) accounted for 77% of all TBI deaths. Sixty-two per cent of children underwent a CT brain, and of those, 40% were normal. Conclusion: The majority of TBI are mild in nature, with younger children and males at greatest risk. There was a low rate of operative intervention and a high rate of good outcomes. Many injuries may be preventable with the adaptation of better public health education programmes, particularly in very young children and those related to MVAs.
Introduction Traumatic brain injury (TBI) is common1 and is one of the leading causes of presentations to hospital emergency departments.2,3 The reported incidence of paediatric TBI hospital admissions in the USA is 70 per 100 000 population.1 It is one of the major causes of mortality and morbidity related to childhood trauma,4 and is associated with significant personal, financial and social consequences. Further, a large proportion of childhood TBI occurs due to preventable causes, such as falls, motor vehicle accidents (MVAs) and sports injuries.5 The incidence of paediatric TBI in New South Wales (NSW) has not recently been formally reported; however, data from the NSW ANZ J Surg 84 (2014) 424–428
Department of Health Emergency showed that head injuries constituted 7% of all paediatric presentations to NSW emergency departments from July 2008 to July 2009.6 This places considerable demands on health services, families and the wider community. Epidemiological data enable the identification of those groups at greatest risk, explore causative factors and analyse variables that may predict outcome. The information is then useful in developing preventative strategies and plan for necessary health services. There have been no population-based studies to date in NSW, Australia, that have reviewed the epidemiology of paediatric TBI. The Children’s Hospital at Westmead (CHW) is a paediatric trauma hospital servicing a population of 2.02 million people,7 with © 2014 Royal Australasian College of Surgeons
Epidemiology of traumatic head injury
Methods We conducted a retrospective chart review of patients aged 0–16 years that were admitted to CHW emergency from January 2006 to December 2011 with a TBI. Patients who presented to the emergency department or were transferred directly to the intensive care unit and had a history of TBI with either symptoms of concussion9 and/or positive computed tomography (CT) findings of head injury were selected. We took into account that the definition of concussion varies with the age of the child. For infants, subtle symptoms, such as listlessness, irritability and change in eating or sleeping patterns,10 were included. Whereas for older children, a wider range of symptoms, including headache, amnesia, confusion, dizziness, fatigue, slurred speech, inattentiveness, sensitivity to light and noise, disorders of taste and smell, and co-ordination deficits, were used to define concussion.11 Patients who had trivial head trauma without symptoms of concussion and without a CT scan were excluded. Positive CT findings included skull fracture, extradural haematoma (EDH), subdural haematoma (SDH), subarachnoid haematoma, cerebral contusion and brain oedema. We extracted data on the age, gender, mechanism of injury, Glasgow coma score (GCS), CT findings, surgery and outcome using a computerized hospital medical record database (Cerner Millennium Powerchart Version 2009.06.1.6). We searched the database for TBI cases using International Classification of Diseases 10th revision (ICD-10) codes. We then assessed these cases for potential inclusion. Severity of TBI was classified into mild (GCS 13–15), moderate (GCS 9–12) and severe (GCS 3–8) based on established criteria.12,13 Patient outcomes were measured using the Glasgow outcome scale (GOS)14,15 based on the level of recovery and disability recorded in the medical record at latest follow-up. Standard practice at our institution is to follow-up all patients admitted with TBI at 6–12 weeks after discharge, and then subsequently as indicated. However, it is likely that some patients with mild TBI who were admitted to the Emergency Department but not the Neurosurgery ward would have been discharged with general practitioner follow-up. For these patients, the outcome was recorded at hospital discharge. GOS 4 and 5 were classified as a good outcome, and GOS 1–3 as poor outcome. We entered data into Microsoft Excel and used the Excel ToolPak for basic data analysis including summary statistics and the generation of tables. We used Statistical Analysis Software 9.1 to generate univariate and multivariate logistic regression models to test the effect of various factors on mortality and GOS. We used odds ratios (OR) as the measure of association between these factors and outcomes for categorical variables. We used P < 0.05 as threshold of significance and calculated 95% confidence intervals (CI) for the OR. The chi-squared statistic was calculated to test for differences © 2014 Royal Australasian College of Surgeons
between proportions, and t-test was used without assuming equal variances for differences between means.
Results There were 1489 presentations with head injury meeting the inclusion criteria over the 6-year period from 2006 to 2011. The total number of children was 1441; 1396 with a single presentation, 42 children with two presentations and 3 children with three presentations. The data collection was complete. Of the presentations, 973 (65%) were male and 516 (35%) female. The mean age overall was 7.0 years, while the mean age for males was 7.9 and females was 5.3 (Fig. 1). A total of 28% of presentations were transfers from other hospitals. Of the 422 (28%) patients that were transferred, 11% went onto have an operation. The highest number of presentations was observed in the 0–1 year age group. As demonstrated in Figure 1, there was a strong trend towards increased proportion of boys above the age of 5. Of those under the age of 5, 54% were boys, compared with 74% among children aged 5 and above. This difference of 20% (95% CI: 16–25%) in the proportion of boys between the two groups was highly statistically significant (χ2 = 67.71, df = 3, P < 0.001). The distribution of TBI severity is displayed in Table 1. A total of 1384 (93%) presentations were classified as mild TBI, 23 (1.5%) moderate and 82 (5.5%) severe. Most presentations (98.7%) resulted in a good recovery (GOS 4 and 5). The mortality rate was 0.87% (13
120
100
80
Frequency
approximately 50 000 hospital presentations annually.8 We describe the demographics, causes, radiological findings, treatment, prognostic factors and outcomes of TBI at CHW to inform the planning and delivery of health-care services and public health interventions. We received approval from the Sydney Children’s Hospitals Network Human Research Ethics Committee prior to commencement of this study.
425
60
40
20
0
999.99, P < 0.001) remained significant predictors of mortality after adjustment for other variables.
Discussion We found that TBI was most frequent among children under the age of 1 and more frequent in males in every age group. The age distributions were also fundamentally different among the sexes, with males having a bimodal distribution (peaks at 0–1 and 14–15) and females a positively skewed distribution (peak at 0–1 and long, right-sided tail). This is mainly due to the increased number of sports injuries in teenage males. It is likely that the second peak for males is higher than presented here because many older children (age 15 and above) are treated at adult hospitals. These findings are consistent with previous Australian and international epidemiological study findings.12,16 However, even though the vast majority of these were mild in severity, most were related to falls at home. A better understanding of the high risk at this age group through continual parental © 2014 Royal Australasian College of Surgeons
Epidemiology of traumatic head injury
education-based programmes may reduce the number of admissions seen through emergency.17 This can have a positive impact on both families and hospitals, by reducing the emotional and financial cost of unwanted imaging and the workload on the emergency department. The use of CT imaging in TBI raises some issues due to the attendant radiation exposure and subsequent risks. The increased lifetime risk of developing cancer following radiation exposure is not insignificant18,19 and needs to factored into any decision-making algorithm for the use of CT in children. In our cohort, 62% of children had a CT brain, and of those patients, 40% had normal CT brain findings. Furthermore, the majority of these patients that went on to have a CT brain had mild head injuries and did not require surgical intervention. There is potential to reduce this radiation exposure with more stringent screening of TBI in the emergency department prior to CT scan. However, intracranial injury may occur with only few or subtle signs,20 and at the very young age, examination and clinical findings may be hard to elicit. In addition, it can be argued that a liberal use of CT scanning can prevent morbidity and mortality caused by unrecognized TBI. The current evidence to guide doctors on what constitutes appropriate criteria for obtaining CT scans in children following TBI still remains controversial. However, large multi-centre studies such as those published by Oman et al.,21 along with others, will lay a foundation of evidence and help devise criteria to guide clinicians to distinguish children who are low risk for significant TBI and those that are higher risk requiring CT imaging. The analysis of moderate and severe head injuries found that they accounted for only 7% of the total number of head injuries, but as expected, were associated with all the TBI deaths.22 MVAs were not only the most significant factor in the cause for moderate and severe head injury, but also TBI death. This result is consistent with other Australian and international paediatric-based studies on head trauma.23 It continues to reinforce the need for broadly targeted road safety initiatives, but also identifies the vulnerability children have in and around motor vehicles. The current Australian public policies and regulations relating to reduction in speed limits, school zones and car child restraints are all important measures to help reduce the severity of TBI, but need continuing reinforcement through education and advertising. Education of young and learner drivers should be a priority for governments for the protection of future generations. Sports and recreational injuries were another significant group within our cohort. More than a quarter of all head injuries occurred through sports and recreational injuries. As seen from previous studies, this was predominantly in the adolescent years and dominated by males.12,24 In a study by Crowe et al., in Victoria, it was shown that Australian Rules Football had a high rate of TBI for adolescents. Our study was not designed to look at the different injury patterns among the different sports; however, our results reinforce that appropriate education and preventative measures need to be implemented to reduce TBI from sports and recreational injuries. These steps, along with parental and adolescent public awareness of the risks of sports and recreational head injuries, especially in the teenage years, may help reduce the numbers of TBI in this age group. © 2014 Royal Australasian College of Surgeons
427
The study had some limitations that need to be considered. Firstly, this is a hospital-based study and therefore is not representative of the general population. CHW is the largest paediatric trauma centre in the state25 and hence probably receives more paediatric TBI than the other two paediatric hospitals in the state. However, there is still likely to be a significant number of cases during the study period that would have presented to other hospitals and hence not included in our analysis. For true population estimates, TBI data would also need to be collected from the other two paediatric hospitals in the state of NSW. Being a retrospective chart review, we were limited to the information that was available in the charts, with no scope for collecting additional data. The outcome of some children was assessed at the time of discharge rather than at any specific followup. However, the patients with moderate and severe TBI, who are most likely to suffer from adverse sequelae of TBI, are always followed-up in the Neurosurgery outpatients clinic, and these data were available for this study. Therefore, we feel it is unlikely that significant follow-up information, in terms of GOS, would have been missed in our study. We were, however, unable to comment on long-term neuropsychological and developmental outcomes, which are likely to be of significant importance in paediatric TBI. This represents an opportunity for a prospective, observational study in the future. In conclusion, the majority of traumatic brain injuries are mild in nature, with younger children and males at greatest risk. There is a low rate of operative intervention12,26 and a high rate of good outcomes. This study provides a good starting point for the epidemiology of head injury in NSW and identifies significant opportunities that exist for further studies and public health prevention programmes.
Acknowledgements We would like to acknowledge Patricia Manglick for her assistance in data extraction. We would also like to acknowledge Dr Hasantha Gunasekera for his assistance in reviewing the manuscript.
References 1. Schneier AJ, Shields BJ, Hostetler SG, Xiang H, Smith GA. Incidence of pediatric traumatic brain injury and associated hospital resource utilization in the United States. Pediatrics 2006; 118: 483–92. 2. Lam WH, Mackersie A. Paediatric head injury: incidence, aetiology and management. Paediatr. Anaesth. 1999; 9: 377–85. 3. Nolan T, Penny M. Epidemiology of non-intentional injuries in an Australian Urban region: results from injury surveillance. J. Paediatr. Child Health 1992; 28: 27–35. 4. Swaminathan A, Levy P, Legome E. Evaluation and management of moderate to severe pediatric head trauma. J. Emerg. Med. 2009; 37: 63–8. 5. Debono P, Agius S, Ansari S. Paediatric head injuries – a review. Adv. Clin. Neurosci. Rehabil. 2011; 10: 30–5. 6. NSW Health. Infants and children: Acute management of Head Injury. NSW Department of Health, 2010. [Cited 30 Jan 2013.] Available from URL: http://www0.health.nsw.gov.au/policies/pd/2011/pdf/PD2011 _024.pdf 7. Premier & Cabinet NSW Government. Demographics. 2011. [Cited 20 Oct 2012.] Available from URL: http://www.westernsydney.nsw.gov.au/ about-western-sydney/demographics/
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