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Abstract：
Pediatric traumatic brain injuries (TBIs) are a leading cause of death and disability. The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide a framework for requesting head computed tomography (HCT) after pediatric head trauma (PHT); however, quantitative data are lacking regarding both TBIs found on HCT and justification of the HCT request according to the PECARN guidelines.
To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request.
This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022.
All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines.
Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture.
Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians.
In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.
To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request.
This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022.
All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines.
Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture.
Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians.
In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.
摘要：
■小儿创伤性脑损伤（TBI）是导致死亡和残疾的主要原因。儿科急诊护理应用研究网络（PECARN）指南提供了在小儿头部外伤（PHT）后请求头部计算机断层扫描（HCT）的框架；然而，缺乏关于在HCT上发现的TBI和根据PECARN指南的HCT请求的理由的定量数据。
■要评估类型，频率,以及儿童HCT上TBI的危险因素转诊至接受HCT治疗的急诊科（ED），并评估HCT要求的质量。
■这个多中心，回顾性队列研究纳入了18岁以下接受HCT治疗的PHT患者,这些患者在2020年1月1日至2022年5月31日期间的随诊时间内接受了91例ED.数据在2022年7月至8月之间进行了分析。
■所有具有病理结果的放射学报告均由4位资深放射科医师进行审查。根据PECARN指南，随机抽取了600个由急诊医师填写的HCT请求，以审查检查理由。
■TBI之间的关联，年龄,性别,使用单变量χ2和Cochrane-Armitage检验对格拉斯哥昏迷量表（GCS）进行了调查。多变量逐步二元逻辑回归用于估计颅内出血（ICH）的比值比（ORs），任何类型的骨折,面部骨骨折,头骨穹窿骨折.
■总的来说，纳入5146名患有PHT的HCT儿童(中位[IQR]年龄，11.2[4.7-15.7]岁；5146个男孩中的3245个[63.1%]）。5146例患者中有306例（5.9％）被诊断出ICHs，5146例患者中有674例（13.1％）被诊断出骨折。在多变量分析中，以下变量与ICH相关：GCS评分为8分或更低（OR，5.83；95%CI，1.97-14.60；P<.001），颅外血肿（OR，2.54；95%CI，1.59-4.02；P<.001），颅底骨折（OR，9.32；95%CI，5.03-16.97；P<.001），上颈椎骨折（OR，19.21；95%CI，1.79-143.59；P=.006），和颅骨拱顶骨折(或，35.64；95%CI，24.04-53.83；P<.001）。当在HCT上既未发现颅外血肿也未发现骨折时，显示ICH的OR为0.034（95%CI，0.026-0.045；P<.001）。颅骨穹顶骨折更常见于2岁以下的儿童(多变量OR，6.31；95%CI，4.16-9.66；P<.001；参考：儿童≥12岁），而面部骨骨折在12岁以上的男孩中更常见(多变量OR，26.60；95%CI，9.72-109.96；P<.001；参考：2岁以下儿童）。对于589名可评估儿童中的396名（67.2％）的急诊医师提出的要求，进行HCT的理由未遵循PECARN指南。
■在这项5146名接受PHTHCT的儿童的队列研究中，了解ICHs和骨折的临床和放射学特征的几率可以帮助急诊医师和放射科医师改善图像分析,避免遗漏重大损伤.近三分之二的患者没有实施PECARN规则。
■要评估类型，频率,以及儿童HCT上TBI的危险因素转诊至接受HCT治疗的急诊科（ED），并评估HCT要求的质量。
■这个多中心，回顾性队列研究纳入了18岁以下接受HCT治疗的PHT患者,这些患者在2020年1月1日至2022年5月31日期间的随诊时间内接受了91例ED.数据在2022年7月至8月之间进行了分析。
■所有具有病理结果的放射学报告均由4位资深放射科医师进行审查。根据PECARN指南，随机抽取了600个由急诊医师填写的HCT请求，以审查检查理由。
■TBI之间的关联，年龄,性别,使用单变量χ2和Cochrane-Armitage检验对格拉斯哥昏迷量表（GCS）进行了调查。多变量逐步二元逻辑回归用于估计颅内出血（ICH）的比值比（ORs），任何类型的骨折,面部骨骨折,头骨穹窿骨折.
■总的来说，纳入5146名患有PHT的HCT儿童(中位[IQR]年龄，11.2[4.7-15.7]岁；5146个男孩中的3245个[63.1%]）。5146例患者中有306例（5.9％）被诊断出ICHs，5146例患者中有674例（13.1％）被诊断出骨折。在多变量分析中，以下变量与ICH相关：GCS评分为8分或更低（OR，5.83；95%CI，1.97-14.60；P<.001），颅外血肿（OR，2.54；95%CI，1.59-4.02；P<.001），颅底骨折（OR，9.32；95%CI，5.03-16.97；P<.001），上颈椎骨折（OR，19.21；95%CI，1.79-143.59；P=.006），和颅骨拱顶骨折(或，35.64；95%CI，24.04-53.83；P<.001）。当在HCT上既未发现颅外血肿也未发现骨折时，显示ICH的OR为0.034（95%CI，0.026-0.045；P<.001）。颅骨穹顶骨折更常见于2岁以下的儿童(多变量OR，6.31；95%CI，4.16-9.66；P<.001；参考：儿童≥12岁），而面部骨骨折在12岁以上的男孩中更常见(多变量OR，26.60；95%CI，9.72-109.96；P<.001；参考：2岁以下儿童）。对于589名可评估儿童中的396名（67.2％）的急诊医师提出的要求，进行HCT的理由未遵循PECARN指南。
■在这项5146名接受PHTHCT的儿童的队列研究中，了解ICHs和骨折的临床和放射学特征的几率可以帮助急诊医师和放射科医师改善图像分析,避免遗漏重大损伤.近三分之二的患者没有实施PECARN规则。
