儿童轻微钝性头部外伤后孤立性意识丧失。

Isolated loss of consciousness in children with minor blunt head trauma.

机构信息

Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts.

Department of Emergency Medicine, Howard County General Hospital, Columbia, Maryland.

出版信息

JAMA Pediatr. 2014 Sep;168(9):837-43. doi: 10.1001/jamapediatrics.2014.361.

DOI:10.1001/jamapediatrics.2014.361

PMID:25003654

Abstract

IMPORTANCE

A history of loss of consciousness (LOC) is frequently a driving factor for computed tomography use in the emergency department evaluation of children with blunt head trauma. Computed tomography carries a nonnegligible risk for lethal radiation-induced malignancy. The Pediatric Emergency Care Applied Research Network (PECARN) derived 2 age-specific prediction rules with 6 variables for clinically important traumatic brain injury (ciTBI), which included LOC as one of the risk factors.

OBJECTIVE

To determine the risk for ciTBIs in children with isolated LOC.

DESIGN, SETTING, AND PARTICIPANTS: This was a planned secondary analysis of a large prospective multicenter cohort study. The study included 42 ,412 children aged 0 to 18 years with blunt head trauma and Glasgow Coma Scale scores of 14 and 15 evaluated in 25 emergency departments from 2004-2006.

EXPOSURE

A history of LOC after minor blunt head trauma.

MAIN OUTCOMES AND MEASURES

The main outcome measures were ciTBIs (resulting in death, neurosurgery, intubation for >24 hours, or hospitalization for ≥2 nights) and a comparison of the rates of ciTBIs in children with no LOC, any LOC, and isolated LOC (ie, with no other PECARN ciTBI predictors).

RESULTS

A total of 42 412 children were enrolled in the parent study, with 40 693 remaining in the current analysis after exclusions. Of these, LOC occurred in 15.4% (6286 children). The prevalence of ciTBI with any history of LOC was 2.5% and for no history of LOC was 0.5% (difference, 2.0%; 95% CI, 1.7-2.5). The ciTBI rate in children with isolated LOC, with no other PECARN predictors, was 0.5% (95% CI, 0.2-0.8; 13 of 2780). When comparing children who have isolated LOC with those who have LOC and other PECARN predictors, the risk ratio for ciTBI in children younger than 2 years was 0.13 (95% CI, 0.005-0.72) and for children 2 years or older was 0.10 (95% CI, 0.06-0.19).

CONCLUSIONS AND RELEVANCE

Children with minor blunt head trauma presenting to the emergency department with isolated LOC are at very low risk for ciTBI and do not routinely require computed tomographic evaluation.

摘要

重要性

在因钝器头部外伤而到急诊科就诊的儿童中，意识丧失（LOC）病史通常是进行计算机断层扫描（CT）检查的主要原因之一。CT 检查存在不可忽视的致死性辐射诱导恶性肿瘤风险。儿科急症护理应用研究网络（PECARN）针对临床显著的创伤性脑损伤（ciTBI），制定了 2 个具有 6 个变量的年龄特异性预测规则，其中 LOC 是危险因素之一。

目的

确定单纯 LOC 儿童发生 ciTBI 的风险。

设计、地点和参与者：这是一项对大型前瞻性多中心队列研究的计划二次分析。该研究纳入了 2004-2006 年期间在 25 个急诊科就诊的 42412 名年龄在 0 至 18 岁之间、有钝器头部外伤、格拉斯哥昏迷量表评分为 14 或 15 分的儿童。

暴露因素

轻微钝器头部外伤后出现 LOC 病史。

主要结局和测量指标

主要结局指标为 ciTBI（导致死亡、神经外科手术、插管>24 小时或住院>2 晚）以及比较无 LOC、任何 LOC 和单纯 LOC（即无其他 PECARN ciTBI 预测因素）患儿的 ciTBI 发生率。

结果

在母研究中共有 42412 名儿童入组，排除后当前分析中剩余 40693 名儿童。其中，15.4%（6286 名儿童）出现 LOC。任何 LOC 病史的 ciTBI 发生率为 2.5%，无 LOC 病史的 ciTBI 发生率为 0.5%（差异为 2.0%；95%CI，1.7-2.5）。无其他 PECARN 预测因素的单纯 LOC 患儿的 ciTBI 发生率为 0.5%（95%CI，0.2-0.8；2780 名患儿中有 13 名）。与单纯 LOC 患儿相比，同时存在 LOC 和其他 PECARN 预测因素的患儿，年龄小于 2 岁的 ciTBI 风险比为 0.13（95%CI，0.005-0.72），年龄为 2 岁或以上的患儿的风险比为 0.10（95%CI，0.06-0.19）。