Rachel HeidtIsolated Altered Mental Status and Clinically-Important Traumatic Brain Injury in Children with Minor Blunt Head Trauma
Isolated Altered Mental Status and Clinically-Important Traumatic Brain Injury in Children with Minor Blunt Head Trauma
Rachel Heidt, MD; Nathan Kuppermann, MD, MPH; Daniel Tancredi, PhD
Rachel Heidt, MD; Nathan Kuppermann, MD, MPH; Daniel Tancredi, PhD
Oral Presentation
Oral Presentation
Rachel Heidt.wavBackground: Altered mental status (AMS) in a child with blunt head trauma frequently results in computed tomography (CT) scanning, due to the association of AMS with traumatic brain injury (TBI). However, for mild AMS (Glasgow Coma Scale [GCS] score of 14 or other minor signs of AMS), CT use may or may not be warranted. The Pediatric Emergency Care Applied Research Network (PECARN) derived 2 age-specific prediction rules that include AMS as one of 6 risk factors for clinically-important TBI (ciTBI). We sought to determine ciTBI risks in children <18 years-old with isolated GCS scores of 14 or other minor signs of AMS after minor blunt head trauma.
Background: Altered mental status (AMS) in a child with blunt head trauma frequently results in computed tomography (CT) scanning, due to the association of AMS with traumatic brain injury (TBI). However, for mild AMS (Glasgow Coma Scale [GCS] score of 14 or other minor signs of AMS), CT use may or may not be warranted. The Pediatric Emergency Care Applied Research Network (PECARN) derived 2 age-specific prediction rules that include AMS as one of 6 risk factors for clinically-important TBI (ciTBI). We sought to determine ciTBI risks in children <18 years-old with isolated GCS scores of 14 or other minor signs of AMS after minor blunt head trauma.
Methods: This was a secondary analysis of a large, prospective, multicenter cohort study that included 42,412 children <18 years-old with minor blunt head trauma, defined by GCS scores of 14-15, evaluated at 25 PECARN emergency departments (EDs) from 6/2004 to 9/2006. AMS was defined by one or more of the following: GCS score of 14, agitation, somnolence, repetitive questioning, or slow response to verbal communication. ciTBI was defined by TBI resulting in death, neurosurgery, intubation for >24 hours, or hospitalization for ≥ 2 nights with TBI on CT. We defined isolated AMS by absence of all other PECARN age-specific risk factors. We estimated and compared age-specific ciTBI risk in those with and without isolated AMS, using exact and score confidence limits, respectively. We excluded children missing PECARN risk factor data.
Methods: This was a secondary analysis of a large, prospective, multicenter cohort study that included 42,412 children <18 years-old with minor blunt head trauma, defined by GCS scores of 14-15, evaluated at 25 PECARN emergency departments (EDs) from 6/2004 to 9/2006. AMS was defined by one or more of the following: GCS score of 14, agitation, somnolence, repetitive questioning, or slow response to verbal communication. ciTBI was defined by TBI resulting in death, neurosurgery, intubation for >24 hours, or hospitalization for ≥ 2 nights with TBI on CT. We defined isolated AMS by absence of all other PECARN age-specific risk factors. We estimated and compared age-specific ciTBI risk in those with and without isolated AMS, using exact and score confidence limits, respectively. We excluded children missing PECARN risk factor data.
Results: A total of 4,349 children met criteria for AMS on ED presentation. In those < 2 years-old with isolated AMS, ciTBI was present in 2 of 194 (1.03%; 95% CI 0.13 – 3.67%), compared to 28 of 798 (3.51%; 95% CI: 2.34 – 5.03%) when AMS was non-isolated, a relative risk (RR) of 0.29 (95% CI 0.07 – 1.09). For children 2 to 17 years-old, risks of ciTBI were 15 of 1,051 (1.43%; 95% CI 0.8 – 2.34%) and 98 of 2,306 (4.25%; 95% CI 3.46 – 5.15%) when AMS was isolated vs. non-isolated, respectively [RR 0.34 (95% CI: 0.20 – 0.57)].
Results: A total of 4,349 children met criteria for AMS on ED presentation. In those < 2 years-old with isolated AMS, ciTBI was present in 2 of 194 (1.03%; 95% CI 0.13 – 3.67%), compared to 28 of 798 (3.51%; 95% CI: 2.34 – 5.03%) when AMS was non-isolated, a relative risk (RR) of 0.29 (95% CI 0.07 – 1.09). For children 2 to 17 years-old, risks of ciTBI were 15 of 1,051 (1.43%; 95% CI 0.8 – 2.34%) and 98 of 2,306 (4.25%; 95% CI 3.46 – 5.15%) when AMS was isolated vs. non-isolated, respectively [RR 0.34 (95% CI: 0.20 – 0.57)].
Conclusions: Children with minor blunt head trauma presenting to the ED with GCS scores of 14 or other minor signs of AMS are at non-negligible risk of ciTBI and strong consideration for CT should be given. However, the absence of all other PECARN risk factors is associated with significantly lower risk of ciTBI such that a period of ED observation awaiting normalization of mental status rather than CT may be considered.
Conclusions: Children with minor blunt head trauma presenting to the ED with GCS scores of 14 or other minor signs of AMS are at non-negligible risk of ciTBI and strong consideration for CT should be given. However, the absence of all other PECARN risk factors is associated with significantly lower risk of ciTBI such that a period of ED observation awaiting normalization of mental status rather than CT may be considered.
Resident Statement of Involvement: Idea for project was created in discussion with Dr. Kuppermann. I worked with Dr. Tancredi to do the secondary analysis of the public use data set. I submitted two different variations of the same abstract which were accepted for oral/platform presentation at both PAS and SAEM. I am currently writing a manuscript that we plan to submit to JAMA Pediatrics.
Resident Statement of Involvement: Idea for project was created in discussion with Dr. Kuppermann. I worked with Dr. Tancredi to do the secondary analysis of the public use data set. I submitted two different variations of the same abstract which were accepted for oral/platform presentation at both PAS and SAEM. I am currently writing a manuscript that we plan to submit to JAMA Pediatrics.