Utility of surveillance imaging after minor blunt head trauma

Clinical article

Joshua J. Chern M.D., Ph.D.1,2, Samir Sarda B.S.1, Brian M. Howard M.D.2, Andrew Jea M.D.3, R. Shane Tubbs P.A.-C., Ph.D.4, Barunashish Brahma M.D.1,2, David M. Wrubel M.D.1,2, Andrew Reisner M.D.1,2, and William Boydston M.D.1,2
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  • 1 Pediatric Neurosurgery Associates, Children's Healthcare of Atlanta;
  • | 2 Department of Neurosurgery, Emory University, Atlanta, Georgia;
  • | 3 Department of Neurosurgery, Texas Children's Hospital, Houston, Texas; and
  • | 4 Pediatric Neurosurgery, Children's of Alabama, Birmingham, Alabama
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Object

Nonoperative blunt head trauma is a common reason for admission in a pediatric hospital. Adverse events, such as growing skull fracture, are rare, and the incidence of such morbidity is not known. As a result, optimal follow-up care is not clear.

Methods

Patients admitted after minor blunt head trauma between May 1, 2009, and April 30, 2013, were identified at a single institution. Demographic, socioeconomic, and clinical characteristics were retrieved from administrative and outpatient databases. Clinical events within the 180-day period following discharge were reviewed and analyzed. These events included emergency department (ED) visits, need for surgical procedures, clinic visits, and surveillance imaging utilization. Associations among these clinical events and potential contributing factors were analyzed using appropriate statistical methods.

Results

There were 937 admissions for minor blunt head trauma in the 4-year period. Patients who required surgical interventions during the index admission were excluded. The average age of the admitted patients was 5.53 years, and the average length of stay was 1.7 days; 15.7% of patients were admitted for concussion symptoms with negative imaging findings, and 26.4% of patients suffered a skull fracture without intracranial injury. Patients presented with subdural, subarachnoid, or intraventricular hemorrhage in 11.6%, 9.19%, and 0.53% of cases, respectively. After discharge, 672 patients returned for at least 1 follow-up clinic visit (71.7%), and surveillance imaging was obtained at the time of the visit in 343 instances.

The number of adverse events was small and consisted of 34 ED visits and 3 surgeries. Some of the ED visits could have been prevented with better discharge instructions, but none of the surgery was preventable. Furthermore, the pattern of postinjury surveillance imaging utilization correlated with physician identity but not with injury severity. Because the number of adverse events was small, surveillance imaging could not be shown to positively influence outcomes.

Conclusions

Adverse events after nonoperative mild traumatic injury are rare. The routine use of postinjury surveillance imaging remains controversial, but these data suggest that such imaging does not effectively identify those who require operative intervention.

Abbreviation used in this paper:

ED = emergency department.

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