http://informahealthcare.com/bij ISSN: 0269-9052 (print), 1362-301X (electronic) Brain Inj, Early Online: 1–5 ! 2015 Informa UK Ltd. DOI: 10.3109/02699052.2015.1017005

ORIGINAL ARTICLE

Falls in young children with minor head injury: A prospective analysis of injury mechanisms Nir Samuel1,3, Ron Jacob2,3, Yael Eilon4, Tania Mashiach4, & Itai Shavit1,3 Pediatric Emergency Department, 2Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel, 3Department of Pediatrics, Rambam Health Care Campus, Haifa, Israel, and 4Unit of Medical Statistics, Rambam Health Care Campus, Haifa, Israel

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Abstract

Keywords

Background: Fall is a common mechanism of injury (MOI) in young children and an important risk factor for traumatic brain injury (TBI). Most children who fall have a minor head injury (MHI), defined as a blunt head trauma that occurred in a patient who is conscious and responsive. Objective: To seek a possible association between MOI and injury severity. Methods: A single centre cohort study was conducted. Data were collected on patients aged 0–2 years with MHI. Clinically-significant TBI (csTBI), defined as head injury resulting in death, intubation or neurosurgery, was the primary outcome measure. Traumatic finding on CT scan (TFCT) was the secondary outcome measure. Results: Five hundred and ninety-five patients were analysed. Eight types of falls were identified: from ground-level, down stairs, from a bed, from a changing table, from furniture, from adulthold, from a playground-device and from a stroller/baby-carriage. One patient (0.16%) had csTBI. Thirty-one (5.2%) underwent CT scans, TFCT was diagnosed in 17 (2.8%) patients; 10 (1.7%) linear skull-fractures, two (0.3%) depressed skull-fractures and five (0.8%) intracranial haemorrhages. Regression analysis did not reveal a statistically significant association between any of the MOI and the presence of TFCT. Conclusions: The risk for csTBI was low and no association was found between MOI and injury severity.

Children, fall, head injury, mechanism of injury, paediatric, trauma History Received 11 July 2014 Revised 22 December 2014 Accepted 13 January 2015 Published online 8 May 2015

Abbreviations: ED, Emergency Department; MHI, Minor Head Injury; MOI, Mechanism of Injury; TBI, Traumatic Brain Injury; csTBI, Clinically significant TBI; CT, Computerized Tomography; ICH, Intracranial Haemorrhage; CC, Cerebral Contusion; DF, Depressed Skull Fracture; LF, Linear Skull Fracture; TFCT, Traumatic findings on CT scan

Introduction Fall is a common mechanism of injury (MOI) in young children [1–3]. Many children who fall have a minor head injury (MHI), defined as an isolated blunt trauma to the head that occurred during the past 24 hours in a patient who has a Glasgow Coma Scale (GCS) score of 13–15 in the emergency department (ED) [2]. A major problem with this population of patients is that a small portion of these children may suffer from a traumatic brain injury (TBI) and a minority may need neurosurgical intervention. Another problem is that, in nonverbal children, history is obtained from caregivers and not from the patient [1–3]. In paediatric MHI, the focus of an emerging body of work had been the development of clinical decision rules aimed at minimizing computerized tomography (CT) scans with its inherent risk of ionizing radiation

Correspondence: Dr Itai Shavit, Pediatric Emergency Department, Meyer Children’s Hospital, Rambam Health Care Campus, POB 9602, Haifa 31096, Israel. Tel: +97248542522/1. Fax: +97248543109. E-mail: [email protected]

exposure [1–7]. The PECARN (Pediatric Emergency Care Applied Research Network) decision rule, which was published in 2009, appears to be the most sensitive and specific decision rule [1, 3]. In Israel, in order to standardize the diagnostic approach, the Israeli ministry of health issued in 2006 a consensus policy statement concerning paediatric MHI in the ED. This policy statement was developed by a taskforce of experts in paediatric emergency medicine, paediatric neurosurgery, paediatric trauma and paediatric neurology. The policy statement includes a decision algorithm which indicates when to perform a CT scan in these patients and is intended to serve as a reference for ED physicians (Figure 1) [8]. Addressing anamnestic factors, such as the exact type of fall, is essential when evaluating the risk for severe injury [1, 2]. However, there is a lack of studies investigating MOI in infants and toddlers who fell. The objectives of this study were to explore MOIs in young children who fell and were diagnosed with MHI and to seek a possible association between these mechanisms and the severity of injury.

N. Samuel et al.

Figure 1. Israeli Ministry of Health policy statement on paediatric minor head injury [8].

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Falls in young children with minor head injury

DOI: 10.3109/02699052.2015.1017005

Patients and methods Study design and subjects

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A single centre cohort study was conducted at a paediatric ED of a level-one trauma centre (Rambam Health Care Campus, Haifa, Israel). The project was supported by ‘Safe Kids Israel’, a non-governmental, not-for-profit organization, acting to reduce paediatric injury by promoting injury prevention strategies [9]. During the 2-year study period, from 1 January 2011 until 31 December 2012, research nurses collected data on patients who were admitted to the ED due to MHI (Figure 1) [8]. Patients aged 0–2 years whose parent’s specified ‘fall’ as the mechanism of injury and who were diagnosed with MHI by the ED physicians were included in the analysis. Patients with more than one injury, those who suffered a non-blunt head injury and those referred from another hospital were excluded. The study was approved by the hospital’s institutional review board. Data collection Data were collected 16 hours a day (07:00–23:00) by a research nurse using a designated structured form. Demographic data was recorded with a detailed description of the MOI, height of fall and the surface on which the child landed. The study nurse interviewed the caregivers of the child immediately after triage. She did not intervene with the decision to order a CT scan and did not provide any consultation or recommendation. Three days after ED discharge, the electronic chart of the patient was extracted to determine whether a CT scan was performed and to record its findings. Any information relevant to the outcome was recorded, such as admission to the hospital for more than 24 hours, any development of neurologic impairment and any neurosurgical intervention if needed. The authors also sought any diagnosis or testing for child abuse. Primary outcome measure Clinically significant TBI (csTBI) The presence of one or more of the following was defined as csTBI: death, intubation or neurosurgery [8]. Secondary outcome measure Traumatic findings on CT scan (TFCT) The presence of one or more of the following was defined as a TFCT: intracranial haemorrhage (ICH), depressed skull fracture (DF), linear skull fracture (LF), cerebral contusion or any other intracranial pathology (i.e. cerebral oedema, diffuse axonal injury) [4]. Statistical analysis Logistic regression analysis was used to model the effects of age, height of fall (lower than 1 metre, higher than 1 metre) and mechanism of fall, on the presence of TFCT. These variables were also compared between patients who had TFCT and patients who had normal scans. Chi-squared test, adjusted odds ratio and Fisher’s exact tests were used to assess differences between categorical variables. The unpaired

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student T-test was used for the analysis of differences in the means of continuous variables. All statistics were calculated using StatsDirect statistical software (v2.6.6, StatsDirect Limited, Cheshire, UK).

Results Five hundred and ninety-five patients with fall-related MHI were enrolled, 332 males and 263 females, with a mean age of 13 ± 6 months (Table I). Eight specific mechanisms of falls were identified (Table I). Six patients returned to the hospital by their parents during the 24 hours following the ED visit. One underwent a CT scan, which was normal. None of the other five patients needed a CT scan or admission to the hospital for further evaluation. None of the patients in the analysis was diagnosed with child abuse. csTBI One case of csTBI was recorded; an 18-month old child who needed neurosurgical intervention [2]. A parietotemporal scalp haematoma was noticed on ED presentation and, 1 hour after arrival, a short tonic-clonic seizure appeared. The patient had an urgent CT scan which revealed a DF. The child underwent surgical alignment of the fracture in the operating theatre. None of the other patients required neurosurgical intervention or intubation and all had an uneventful disease course. None were admitted to hospital for a period of more than 24 hours. TFCT Thirty-one of the 595 patients underwent a CT scan. Seventeen patients had TFCT, while 14 had no such finding. Five patients had ICH, two had DF and 10 had LF. Cerebral contusions were presented in one patient with ICH and in one patient with DF (Table II). Nine of the 17 patients who had TFCT were 5 months of age or younger, six patients fell from adult hold and three fell from a baby carriage or stroller. Six of the 17 patients who had TFCT fell from adult hold, two of whom had LF, two had DF and two had ICH. Five of these six patients were 5 months of age or younger (Tables II and III). One patient who fell Table I. Demographic characteristics of children younger than 2 years of age with fall-related minor head injury (n ¼ 595). n Age, months, M ± SD Gender, n (%) Male Female Mechanism of fall From ground level, n (%) Down the stairs, n (%) From a bed, n (%) From a diaper changing table, n (%) From other furniture, n (%) From adult hold, n (%) From a playground device, n (%) From a stroller/baby carriage, n (%) Not observed by a caregiver, n (%) Total, n (%)

13 ± 6 332 (55.8) 263 (44.2) 135 45 146 20 60 37 12 56 84 595

(22.7) (7.6) (24.5) (3.4) (10.1) (6.2) (2) (9.4) (14.1) (100)

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Table II. Patients with positive findings on computerised tomography (CT) scan. Patient

Age (months)

Gender

Height of fall (metres)

1 2 18 4 2 5 8 12 4 8 23 13 17 1 1 2 20

Male Female Male Male Female Male Male Male Male Male Male Female Male Female Male Male Male

51 51 51 51 51 51 51 41 41 51 51 41 51 51 51 51 51

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1 2 3* 4 5 6 7 8 9 10 11 12 13 14 15 16 17

Landing surface

Mechanism of fall

CT findings

Home floor Home floor Home floor Home floor Home floor Home floor Home floor Home floor Home floor Home floor Home floor Home floor Concrete floor Home floor Home floor Home floor Stairs tiles

From adult hold From adult hold From adult hold From adult hold From adult hold From adult hold From parents bed From parents bed From a diaper changing table From a couch From a couch Not observed by a caregiver From a playground device From a baby carriage From a stroller From a baby carriage Down the stairs

LF, ICH ICH, CC DF, CC LF LF DF ICH LF LF, ICH LF LF LF LF LF ICH LF LF

ICH, intracranial haemorrhage; CC, cerebral contusion; DF, depressed skull fracture; LF, linear skull fracture. *Needed neurosurgical intervention.

Table III. Comparison between patients who had a traumatic finding on CT scan (TFCT) and patients with a normal CT scan.

Variable Age, M ± SD, months Male gender, n(%) Height of fall 41 metre, n (%)

Patients with normal scan (n ¼ 14)

Patients with TFCT (n ¼ 17)

OR

95% CI

p-value

11.8 ± 6.1 9 (64) 4 (29)

8.3 ± 7.4 13 (76) 3 (18)

– 1.8 0.53

– 0.37–8.64 0.1–2.94

0.17 0.72 0.77

from adult hold needed neurosurgical intervention. Five patients underwent a CT scan after a ground-level fall. None of these patients had TFCT. Logistic regression analysis did not reveal a statistically significant association between any of the mechanisms of injury and the presence of TFCT. Comparison between patients who had TFCT and patients who had a normal CT scan was statistically not significant.

Discussion Eight mechanisms of falls were identified in this age group: ground-level fall, fall down stairs, fall from a bed, fall from a changing table, fall from furniture, fall from adult hold, fall from a playground device and fall from a stroller or baby carriage. The findings are consistent with previous reports showing a very low rate of clinical deterioration or a need for intervention in children with MHI [1, 2, 4, 10, 11]. In this cohort, all 595 patients had an uneventful disease course, except one who needed neurosurgical intervention (re-alignment of DF). Thirty-one of the 595 patients who had fall-related MHI underwent a CT scan. This relatively low rate of CT scan is in the range of the 8%, as reported in a previous study (Figure 1) [8, 10]. Of the 31 patients who had CT scans, 17 had TFCT. Of these, 10 had isolated LF, which is associated with a low risk for clinical deterioration [12]. No association was found between any of the mechanisms of injury and the presence of

TFCT. Also, when the mechanisms of falls were compared between patients with abnormal scans and patients with normal scans, no differences were found (Table III). However, in seven patients, CT findings revealed a potential risk for clinical deterioration and/or surgical intervention; five had ICH and two had DF. One patient with ICH and one with DF also had cerebral contusions. Of these seven patients, four (57%) fell from adult hold (Table II). Furthermore, all patients who fell from adult hold had TFCT and one needed neurosurgical intervention. Although statistically not significant, these findings suggest that fall from an adult hold is a potential risk for developing csTBI. Diagnosing csTBI in young children with MHI could be difficult. The PECARN decision tree is regarded as the best decision algorithm [1, 3, 10, 11]. This study included 42 412 patients, of whom 10 718 were under the age of 2 years. Two decision trees were established; one for children older than 2 years (verbal) and one for children aged 2 years or younger (non-verbal). The MOI was divided into two categories; mild/ moderate or severe. In the younger age decision tree, falls were classified as severe only if they occurred from a level of 3 feet or more [1]. It is worth mentioning that, in this cohort, five patients who fell from a level of less the 3 feet had CT findings with a potential risk for csTBI (Table II). This finding suggests that clinicians should be especially careful with regard to applying decision rules in the younger age group. This study has several limitations. First, the study sample was relatively small (595 patients with 31 patients who

Falls in young children with minor head injury

DOI: 10.3109/02699052.2015.1017005

underwent CT scans). Second, this was a single centre study, limiting the generalizability of its findings. Third, the physician’s decision to perform a CT scan was based on the Israeli ministry of health practice parameter (Figure 1). This decision algorithm had not been externally validated. Fourth, the study did not include a systematic follow-up of infants who did not have a CT scan.

Conclusions In this cohort of young children with fall-related MHI, eight mechanisms of injury were identified. The risk for csTBI was low and no association was found between MOI and injury severity.

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Declaration of interest The authors report no conflicts of interest. The authors declare that they do not have any financial and personal relationships with other people or organizations that could inappropriately influence (bias) their work. A research grant was provided by ‘Safe Kids Israel’. The sponsors had no role in study design, conduct, data collection, analysis and report. The corresponding author had access to all the data and takes full responsibility for the decision to submit for publication.

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Falls in young children with minor head injury: A prospective analysis of injury mechanisms.

Fall is a common mechanism of injury (MOI) in young children and an important risk factor for traumatic brain injury (TBI). Most children who fall hav...
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