Protocolized management of isolated linear skull fractures at a level 1 pediatric trauma center

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  • 1 Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville;
  • | 2 Surgical Outcomes Center for Kids, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee;
  • | 3 Department of Neurosurgery, University of Washington, Seattle, Washington;
  • | 4 Department of Biostatistics, Vanderbilt University Medical Center, Nashville;
  • | 5 Department of Pediatric Surgery, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville; and
  • | 6 Department of Pediatrics, Division of Emergency Medicine, Monroe Carell Jr. Children’s Hospital at Vanderbilt, Nashville, Tennessee
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OBJECTIVE

Isolated linear skull fractures without intracranial findings rarely require urgent neurosurgical intervention. A multidisciplinary fracture management protocol based on antiemetic usage was implemented at our American College of Surgeons–verified level 1 pediatric trauma center on July 1, 2019. This study evaluated protocol safety and efficacy.

METHODS

Children younger than 18 years with an ICD-10 code for linear skull fracture without acute intracranial abnormality on head CT were compared before and after protocol implementation. The preprotocol cohort was defined as children who presented between July 1, 2015, and December 31, 2017; the postprotocol cohort was defined as those who presented between July 1, 2019, and July 1, 2020.

RESULTS

The preprotocol and postprotocol cohorts included 162 and 82 children, respectively. Overall, 57% were male, and the median (interquartile range) age was 9.1 (4.8–25.0) months. The cohorts did not differ significantly in terms of sex (p = 0.1) or age (p = 0.8). Falls were the most common mechanism of injury (193 patients [79%]). After protocol implementation, there was a relative increase in patients who fell from a height > 3 feet (10% to 29%, p < 0.001) and those with no reported injury mechanism (12% to 16%, p < 0.001). The neurosurgery department was consulted for 86% and 44% of preprotocol and postprotocol cases, respectively (p < 0.001). Trauma consultations and consultations for abusive head trauma did not significantly change (p = 0.2 and p = 0.1, respectively). Admission rate significantly decreased (52% to 38%, p = 0.04), and the 72-hour emergency department revisit rate trended down but was not statistically significant (2.8/year to 1/year, p = 0.2). No deaths occurred, and no inpatient neurosurgical procedures were performed.

CONCLUSIONS

Protocolization of isolated linear skull fracture management is safe and feasible at a high-volume level 1 pediatric trauma center. Neurosurgical consultation can be prioritized for select patients. Further investigation into criteria for admission, need for interfacility transfers, and healthcare costs is warranted.

ABBREVIATIONS

CARE = Child Protection and Well Being; ED = emergency department; IQR = interquartile range; NAT = nonaccidental trauma; TBI = traumatic brain injury.

Illustration from Cinalli et al. (pp 330–341). Printed with permission from © CC Medical Arts.

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