Isolated, nondisplaced skull fractures (ISFs) are a common result of pediatric head trauma. They rarely require surgical intervention; however, many patients with these injuries are still admitted to the hospital for observation. This retrospective study investigates predictors of vomiting and ondansetron use following pediatric ISFs and the role that these factors play in the need for admission and emergency department (ED) revisits.
The authors identified pediatric patients (< 18 years old) with a linear ISF who had presented to the ED of a single tertiary care center between 2008 and 2018. Patients with intracranial hemorrhage, significant fracture displacement, or other traumatic injuries were excluded. Outcomes included vomiting, ondansetron use, admission, and revisit following ED discharge. Both univariable and multivariable analyses were used to determine significant predictors of each outcome (p < 0.05).
Overall, 518 patients were included in this study. The median patient age was 9.98 months, and a majority of the patients (59%) were male. The most common fracture locations were parietal (n = 293 [57%]) and occipital (n = 144 [28%]). Among the entire patient cohort, 124 patients (24%) had documented vomiting, and 64 of these patients (52%) received ondansetron. In a multivariable analysis, one of the most significant predictors of vomiting was occipital fracture location (OR 4.05, p < 0.001). In turn, and as expected, both vomiting (OR 14.42, p < 0.001) and occipital fracture location (OR 2.66, p = 0.017) were associated with increased rates of ondansetron use. A total of 229 patients (44%) were admitted to the hospital, with vomiting as the most common indication for admission (n = 59 [26%]). Moreover, 4.1% of the patients had ED revisits following initial discharge, and the most common reason was vomiting (11/21 [52%]). However, in the multivariable analysis, ondansetron use at initial presentation (and not vomiting) was the sole predictor of revisit following initial ED discharge (OR 5.05, p = 0.009).
In this study, older patients and those with occipital fractures were more likely to present with vomiting and to be treated with ondansetron. Additionally, ondansetron use at initial presentation was found to be a significant predictor of revisits following ED discharge. Ondansetron could be masking recurrent vomiting in ED patients, and this should be considered when deciding which patients to observe further or discharge.
ABBREVIATIONSCARE = Child Protection and Well-Being; ED = emergency department; ISF = isolated, nondisplaced skull fracture; NAT = nonaccidental trauma; PO = per os.
Correspondence Jonathan Dallas: Vanderbilt University School of Medicine, Nashville, TN. firstname.lastname@example.org.INCLUDE WHEN CITING Published online December 13, 2019; DOI: 10.3171/2019.9.PEDS19203.Disclosures This research was supported in part by the Surgical Outcomes Center for Kids at Monroe Carell Jr. Children’s Hospital at Vanderbilt and through the Section for Surgical Sciences at Vanderbilt University Medical Center.
BressanSMarchettoLLyonsTWMonuteauxMCFreedmanSBDa DaltL: A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children. Ann Emerg Med71:714–724.e22018
BressanS, MarchettoL, LyonsTW, MonuteauxMC, FreedmanSB, Da DaltL, : A systematic review and meta-analysis of the management and outcomes of isolated skull fractures in children. 71:714–724.e2, 2018)| false
HarrisPATaylorRThielkeRPayneJGonzalezNCondeJG: Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform42:377–3812009
HarrisPA, TaylorR, ThielkeR, PayneJ, GonzalezN, CondeJG: Research electronic data capture (REDCap)—a metadata-driven methodology and workflow process for providing translational research informatics support. 42:377–381, 2009)| false
RollinsMDBarnhartDCGreenbergRAScaifeERHolstiMMeyersRL: Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. J Pediatr Surg46:1342–13462011
RollinsMD, BarnhartDC, GreenbergRA, ScaifeER, HolstiM, MeyersRL, : Neurologically intact children with an isolated skull fracture may be safely discharged after brief observation. 46:1342–1346, 2011)| false
WilliamsDCRussellWSAndrewsALSimpsonKNBascoWTJrTeufelRJII: Management of pediatric isolated skull fractures: a decision tree and cost analysis on emergency department disposition strategies. Pediatr Emerg Care34:403–4082018
WilliamsDC, RussellWS, AndrewsAL, SimpsonKN, BascoWTJr, TeufelRJII: Management of pediatric isolated skull fractures: a decision tree and cost analysis on emergency department disposition strategies. 34:403–408, 2018)| false