National Hospital Ambulatory Medical Care Survey ()-United States, 2001-2010 (Emergency Department Visits).You send him home with close parental observation and return precautions and follow-up with his pediatrician. A repeat neurological exam after a few hours in the ED remains normal. You watch him a little longer in the ED and he continues to feed well and to act normally. In an editorial accompanying this article it was even suggested that rapid MRI techniques could be substituted for CT scans in head injured children as this would cut down on radiation and the increased risk of missing skull fractures with rapid MRI was unlikely to be important. The authors concluded that most children with skull fractures could be managed conservatively. The traumatic brain injured patients were more likely to have multiple fractures as well as lower Glascow Coma Scale scores. The non-operative group was more likely to have parietal fractures whereas the operative groups were more likely to have frontal bone fractures. In the non-operative group, falls were the most common mechanism of injury whereas motor vehicle crash and struck in the head by an object were more common mechanisms in the operative patients. 58 patients underwent fracture repair and 67 patients underwent surgery for treatment of traumatic brain injury. ![]() 772 patients were treated non-operatively. A study addressing this very issue looked at 897 pediatric patients presenting with skull fractures from 2000 to 2005. Maybe what we need is a better understanding of which skull fractures are high risk so we can avoid admitting those unlikely to require any intervention. Īs physicians, we are very anxious about skull fractures, as evidenced by the high rate of admissions. No one needed a neurosurgical intervention. ![]() 201, or about 57% were hospitalized, the rest were discharged from the ED. In their sample 350 patients had skull fractures but no other abnormalities identified. Of these, 11,035 were less than 2 years of age. They looked at 43, 904 children with blunt head injury across multiple sites. One of the largest studies of head injury in children is the Pediatric Emergency Care Applied Research Network (PECARN) study. Only one patient required a neurosurgical procedure. 78% of these patients were admitted, 85% discharged the next day and 95% discharged within 2 days. In a multicenter study of management trends in US pediatric EDs, almost 4,000 children younger than 19 years were seen for isolated skull fractures. 77.5 % were admitted for neurological observation and none required a neurosurgical procedure. Their ages ranged from 1 week to 12.4 years. ![]() A retrospective review of pediatric head trauma patients in Chicago, Illinois looked at 71 patients with isolated skull fractures. No patient had a positive neurological exam and none required a neurosurgical intervention. Only 17% were discharged from the ED, the rest were admitted to the hospital floor or placed in 23-hour observation. The median age was 19 months but ages ranged from 2 weeks to 15 years. A retrospective study in Houston, Texas looked at 326 patients with isolated non-displaced linear skull fractures. Most children with isolated linear skull fractures are admitted to the hospital for observation and monitoring. In 2009-2010 it was 2193.8 per 100,000, a 50% increase.Overall, males, ages 0 to 4 years have the highest rates of TBI-related ED visits, hospitalizations and deaths compared to other groups in the US. In 2007-2008, the rate of TBI-related ED visits in this age group was 1374 per 100,000. Children aged 0 to 4 years had the highest rate of any age group. But should we?Īccording to the CDC, the rates of ED visits for traumatic brain injury have increased from 2001-2002 to 2009-2010. ![]() Your resident has phoned in an admission for observation. A head CT was obtained which demonstrates a non-displaced parietal linear skull fracture but no other findings. The boy is an otherwise healthy infant with no significant history. Nothing in the story has raised concerns about non-accidental trauma. He has a left parietal scalp hematoma but no other apparent injuries. He has a normal and non-focal neurological exam. He has fed in the waiting room with no emesis. Several hours have passed since the fall and now he is behaving normally. He cried immediately and vomited a few times. You are examining a 7 month-old baby boy who fell off the changing table onto a hard tiled floor at day care this morning. But given the numbers, it might not make sense to reflexively admit. When children hit their heads it can be scary for parents and providers alike.
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