J Neurosurg Pediatrics 14:414–417, 2014 ©AANS, 2014

Head injuries following television-related accidents in the pediatric population Clinical article Adam Ross Befeler, M.D., M.S.,1 David J. Daniels, M.D., Ph.D.,1 Susan A. Helms, R.N., M.A.L.S., 2 Paul Klimo Jr., M.D., M.P.H.,1–3 and Frederick Boop, M.D.1–3 1 Department of Neurosurgery, University of Tennessee Health Science Center; 2Le Bonheur Children’s Hospital; and 3Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee

Object. Current data indicate the rate of head injuries in children caused by falling televisions is increasing. The authors describe these injuries and the cost incurred by them. Methods. In a single-institution retrospective review, all children treated for a television-related injury at Le­ Bonheur Children’s Hospital, a Level I pediatric trauma center, between 2009 and 2013 were identified through the institution’s trauma registry. The type, mechanism, and severity of cranial injuries, surgical interventions, outcome, and costs were examined. Results. Twenty-six patients were treated for a television-related injury during the study period. Most injuries (22 cases, 85%) occurred in children aged 2–4 years (mean age 3.3 years), and 19 (73%) of the 26 patients were male. Head injuries occurred in 20 patients (77%); these injuries ranged from concussion to skull fractures and subdural, subarachnoid, and intraparenchymal hemorrhages. The average Glasgow Coma Scale score on admission was 12 (range 7–15), and 3 patients (12%) had neurological deficits. Surgical intervention was required in 5 cases (19%). The majority of patients made a full recovery. There were no deaths. The total cost for television-related injuries was $1.4 million, with an average cost of $53,893 per accident. Conclusions. A high occurrence of head injuries was seen following television-related accidents in young children. This injury is ideal for a public education campaign targeting parents, health care workers, and television manufacturers. (http://thejns.org/doi/abs/10.3171/2014.7.PEDS1433)

Key Words      •      television trauma      •      pediatric neurosurgery      •      television tip-over      • head injury

T

elevision tip-over injuries in children have long been known to be a significant source of pediatric injury and are thought to account for more than 17,000 (estimate) emergency department visits among pediatric patients in the US per year, which is equivalent to 1 injury every 30 minutes.2 Recently, tip-over injury has gained further recognition by the US Consumer Product Safety Commission, being cited third in their list of the top 5 hidden household hazards.10 There has been an increase in television tip-over injuries in children within the US. A large retrospective nationwide study recently found an increase in the rate of injury from 0.85 injuries per 10,000 children in 1990 to 1.66 injuries per 10,000 children in 2007.2 This represents a 2-fold increase in under 2 decades. Additionally, the study found that the most common site of injury was the

Abbreviations used in this paper: ACS = American College of Sur­geons; GCS = Glasgow Coma Scale; ICU = intensive care unit; LBCH = Le Bonheur Children’s Hospital.

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head and neck region (63.3% of injuries).2 One factor that can account for this high prevalence of injuries is the lack of legislation requiring televisions to be sold with anchoring or other securing devices. Prior studies have focused on overall injuries associated with television tip-over in the pediatric population,1,5,6,8,11 but few have specifically focused on neurological injury, outcome, and cost. We undertook this study to investigate neurological injuries in television-related accidents involving children and to analyze the specific injuries, length of hospitalization, outcomes, and cost of care related to treatment of these injuries compared with other common pediatric head injury mechanisms.

Methods

Cases for this single-institution retrospective review were identified from the records of Le Bonheur Children’s Hospital (LBCH), an American College of Surgeons (ACS) Level I Trauma Center serving western Tennessee J Neurosurg: Pediatrics / Volume 14 / October 2014

Pediatric head injuries from TV-related accidents as well as parts of Arkansas, Mississippi, Kentucky, and Missouri with more than 80,000 pediatric emergencies treated per year. Study criteria included the presence of a television-related injury in a patient who was less than 18 years of age at the time of the accident and was seen at LBCH between 2009 and 2013. A television-related injury was defined as an injury acquired from or involving a falling television. These patients were retrospectively identified using our trauma registry and database that tracks all trauma-related admissions of patients seen in the pediatric emergency department. Patients suspected to have been victims of child abuse were excluded. Institutional review board approval was obtained. Patients charts were reviewed, including all emergency department physician and nursing notes, history and physical examination findings, reports of consultations, progress notes, radiology reports, operative and procedural notes, discharge summaries, and follow-up office records, when available, from the neurosurgical outpatient offices. Demographic data for each patient were collected, including age, sex, and race. Clinical and other injuryrelated data collected included date of injury, mechanism of injury, type of television, specific intracranial injuries identified via imaging modalities, initial loss of consciousness, initial Glasgow Coma Scale (GCS) score, presence of neurological deficits, any required operative or procedural interventions, and the final outcome of the injury. All billed charges from the patient’s primary hospital stay were also recorded to assess cost of care. Additional charges for care after discharge or transportation to the hospital were not recorded or included.

Results

Demographic Data and Television Characteristics

Between 2009 and mid-2013, 26 children were treated for a television-induced injury. There were between 3 and 8 injuries treated per year during this period (Fig. 1). The patients came from the catchment region for our Level I trauma center and therefore represented Tennessee (17 patients, 65%), Arkansas (3 patients, 12%), Mississippi (5 patients, 19%), and Missouri (1 patient, 4%). Cathoderay televisions (box televisions) were involved in 24 (92%) of 26 cases of injuries, while flat-screen televisions were involved in the other 2 (8%). The mean patient age at the time of injury was 3.3 years (range 1 month–7 years), and 22 patients (85%) were between the ages of 2 and 4 (Fig. 2). Nineteen (73%) of the patients were male and 7 (27%) were female. Seven patients were identified by their family members or caregiver as white (27%), 17 patients as black (65%), and 2 patients as other (8%). This racial breakdown mirrors the population breakdown in our region according to the 2010 United States Census (63.3% black, 29.4% white).9

Head Injuries and Treatment

Head injury, defined as either a concussion or abnormal findings on head CT occurred in 20 patients (77%). The injuries included skull fractures, concussions, epidural hematomas, subdural hematomas, subarachnoid hemor-

J Neurosurg: Pediatrics / Volume 14 / October 2014

Fig. 1.  Television-related injuries per year of study. TV = television.

rhages, intraparenchymal hemorrhages, and intraventricular hemorrhages (Tables 1 and 2). There were abnormal findings on head CT in 19 patients (73%). Loss of consciousness occurred in 11 patients (42%). The GCS score was abnormal (less than 15) in 13 patients (50%) upon arrival at the hospital. Among the studied patients overall, the mean GCS score was 12 (range 7–15). Four patients (15%) had a neurological deficit upon arrival and all patients (100%) were admitted, at a minimum for observation. Additionally, 3 patients (12%) suffered orthopedic injuries requiring treatment, and 1 patient (4%) suffered an eyelid laceration requiring ophthalmological treatment. Neurosurgical intervention was required in 5 patients (19%), some of whom required more than 1 intervention. Neurosurgical interventions included 1) placement of an intracranial pressure monitor in 3 patients (12%); 2) placement of an external ventricular drain in 2 patients (8%); 3) lumbar puncture in 1 patient (4%); and 4) hemicraniectomy in 3 patients (12%). All patients requiring surgical intervention, including bedside procedures, had an injury involving a cathode-ray television (Figs. 3 and 4). Outcomes and Cost of Treatment

There were no deaths in our study. Twenty-two (85%) of the patients made a full recovery; however, 4 patients (15%) were discharged with neurological deficits. A total of 62 intensive care unit (ICU) days were recorded for the 26 patients, with an average ICU stay of 4.8 days per patient. The length of stay for patients requiring interventions, including bedside procedures, was between 10 and 20 days. The length of stay for patients who did not require any interventions was between 1 and 6 days. The total charges billed by LBCH for these 26 patients between 2009 and 2013 were $1,401,206.70. The mean charge billed per patient was $53,892.56 (range $5,814.00–$250,214.00). Among the patients who had interventions during their hospitalization, including any bedside procedures, the average 415

A. R. Befeler et al. TABLE 1: Head injuries in 26 patients with television-related injuries

Fig. 2.  Age distribution of pediatric patients with television-related injuries. Values on the x axis represent patient age in years.

cost was $182,130.51 (range $134,057.00–$250,214.00). Among the patients who required no interventions during their hospitalization the average cost was $23,359.72 (range $5814.00–$75,605.00).

Discussion

It is tempting to speculate that the increasing trend of television tip-over injuries is related to the increase in flat-screen televisions; however, this was not evident in our findings. In our review, we found that 24 of the 26 injuries were related to cathode-ray televisions. Typically, televisions associated with tip-over injuries in our study were located on the top of a dresser and involved a young child (average age of 3 years) climbing on the dresser or using the dresser to help them elevate to a standing position. The resulting force applied to the dresser from the child resulted in a tip-over and subsequent fall of the television onto the child. In 2 of our cases, tip-over involved a flatscreen television. Despite the fact that flat-screen televisions are lighter than their cathode-ray counterparts, they still have a high capacity for causing serious injuries in children. First, their center of gravity is much higher than that of older cathode-ray televisions, and this could result in increased momentum once a fall is started. Second, if improperly attached to walls or other surfaces (if the television is not properly mounted to wall studs, if mounting brackets are improperly installed by an inexperienced installer, or if the mounting brackets used are not designed for the size and weight of the television), flat-screen televisions can fall on their own or if a child climbs on them. Our study found a high rate of head injuries (77%) in pediatric patients who suffered a television-induced injury. Yahya et al. reported a head injury rate of 89%.11 In concordance with other studies, our study found that the injuries mostly occurred in very young children between 2 and 4 years old; the admission GCS score averaged 12; half the patients had no neurological deficits upon arrival; and 19% of the patients required surgical intervention.11 416

Type of Injury

No. of Cases (%)

concussion skull fractures subarachnoid hemorrhage intraparenchymal hematoma epidural hematoma subdural hematoma no abnormality on imaging

20 (76.9) 17 (65.4) 2 (7.7) 3 (11.5) 4 (15.4) 6 (23.1) 7 (26.9)

These patients were found to have a mean ICU stay of 4.8 days per patient and total hospital stays ranging between 1 day and 20 days. This resulted in a high cost, with an average hospital charge of $53,892.56 (and total expenditures of more than $1.4 million). The cost of treatment was higher in patients requiring interventions ($182,131.00) than in those who did not require interventions ($23,360.00). Other studies have detailed the morbidity and cost due to a specific traumatic mechanism. Larson et al. found an average hospital cost of $14,947.00 in 249 patients with motocross injuries in 2009.4 Killingsworth et al. found an average hospital cost of $14,052.00 in 5292 pediatric patients with all-terrain-vehicle injuries between 1997 and 2000.3 Another study focused on pediatric bicycle injuries in the US in 2003 and found a mean cost of $18,654.00 per hospitalization in 10,700 children who had bicycle accidents.7 Compared with these other mechanisms that may be thought of as having a higher risk for head injuries, television tip-over injuries in our center resulted in significantly higher hospital charges. Furthermore, total injury-related costs would be much higher if other expenditures—such as rehabilitation, follow-up appointments, future operations (for example, post–decompressive craniectomy cranioplasty), and permanent neurological disabilities—were included. This study has several limitations due to its retrospective nature, namely the detail of information that was available in the patient charts.

Conclusions

Our experience has demonstrated that falling teleTABLE 2: Results of neurological assessment following 26 television-related injuries Variable

No. of Cases (%)

head injury/traumatic brain injury loss of consciousness hematocrit abnormality* GCS abnormality† neurological deficit hospital admission

20 (76.9) 11 (42.3) 19 (73.1) 13 (50) 4 (15.4) 26 (100)

*  Abnormal hematocrit was considered less than 31%. †  The overall mean GCS score was 12 (range 7–15).

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Pediatric head injuries from TV-related accidents manufacturers with recommendations to secure cathoderay televisions to dressers or stands and to ensure that flatscreen televisions are properly mounted and out of reach of young children. Acknowledgment The authors wish to thank Andrew J. Gienapp for technical and copy editing, preparation of the manuscript and figures for publishing, and publication assistance with this manuscript. Disclosure

Fig. 3.  Illustrative case involving a 3-year-old girl.  Left: Axial CT image showing a right parietal depressed skull fracture and subdural hematoma due to a television tip-over injury.  Right: 3D reconstruction of head CT showing the injury.

visions can cause serious intracranial injury, affect toddlers disproportionately, and lead to high medical costs. We think that the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Pediatric Section should partner with the American Academy of Pediatrics for a public injury-prevention campaign to target parents, health care workers (family practitioners, pediatricians, emergency room physicians), and television

Fig. 4.  Illustrative case involving a 4-year-old boy.  A: Initial axial CT image showing subarachnoid hemorrhage and cerebral edema from a tip-over injury by a large box television. The patient presented with altered mental status and underwent craniectomy and placement of an external ventricular drain for intractable elevated intracranial pressure.  B: Axial CT image obtained after craniectomy and placement of ventricular drain.  C and D: Subsequent axial diffusion-restriction MR images showing a posterior cerebral artery/posterior inferior cerebellar artery distribution infarction.

J Neurosurg: Pediatrics / Volume 14 / October 2014

No sources of support were received for this study. None of the authors have any financial conflicts of interest to disclose. Author contributions to the study and manuscript preparation include the following. Conception and design: Befeler, Daniels, Helms, Boop. Acquisition of data: Befeler, Daniels, Helms. Analysis and interpretation of data: Klimo, Befeler, Daniels. Drafting the article: Befeler, Daniels. Critically revising the article: Klimo, Befeler. Reviewed submitted version of manuscript: Klimo, Befeler, Daniels, Boop. Study supervision: Klimo. References   1.  Bernard PA, Johnston C, Curtis SE, King WD: Toppled television sets cause significant pediatric morbidity and mortality. Pe­diatrics 102:E32, 1998   2.  De Roo AC, Chounthirath T, Smith GA: Television-related injuries to children in the United States, 1990-2011. Pediatrics 132:267–274, 2013   3.  Killingsworth JB, Tilford JM, Parker JG, Graham JJ, Dick RM, Aitken ME: National hospitalization impact of pediatric allterrain vehicle injuries. Pediatrics 115:e316–e321, 2005   4.  Larson AN, Stans AA, Shaughnessy WJ, Dekutoski MB, Quinn MJ, McIntosh AL: Motocross morbidity: economic cost and injury distribution in children. J Pediatr Orthop 29: 847–850, 2009   5.  Muñiz AE: Craniofacial injuries from television tip-over. Pediatr Emerg Care 28:52–54, 2012   6.  Platt MS, Stanley C: TV tip-over morbidity and mortality in children. J Forensic Sci 56:1364–1367, 2011   7.  Shah S, Sinclair SA, Smith GA, Xiang H: Pediatric hospitalizations for bicycle-related injuries. Inj Prev 13:316–321, 2007   8.  Suresh N, Harini G, Radhika R, Chidambaram B: Head injuries in children resulting from the fall of television. Indian J Pediatr 77:459–460, 2010   9.  US Census Bureau: Memphis (city), Tennessee. State & County QuickFacts. (http://quickfacts.census.gov/qfd/states/ 47/4748000.html) [Accessed July 8, 2014] 10.  US Consumer Product Safety Commission: Top 5 Hidden Hazards in the Home. (http://www.cpsc.gov/PageFiles/ 165163/hidden.pdf) [Accessed July 8, 2014] 11.  Yahya RR, Dirks P, Humphreys R, Rutka JT, Taylor M, Drake JM: Children and television tipovers: a significant and preventable cause of long-term neurological deficits. J Neurosurg 103 (3 Suppl):219–222, 2005 Manuscript submitted January 28, 2014. Accepted July 7, 2014. Portions of this work were presented in e-poster form at the 42nd Annual Meeting of the Joint AANS/CNS Section on Pediatric Neurological Surgery, Toronto, Canada, December 3–6, 2013. Please include this information when citing this paper: published online August 1, 2014; DOI: 10.3171/2014.7.PEDS1433. Address correspondence to: Paul Klimo Jr., M.D., M.P.H., Semmes-Murphey Neurologic & Spine Institute, 6325 Humphreys Blvd., Memphis, TN 38120. email: [email protected].

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Head injuries following television-related accidents in the pediatric population.

Current data indicate the rate of head injuries in children caused by falling televisions is increasing. The authors describe these injuries and the c...
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