Department of Neurosurgery, Washington University School of Medicine in St Louis, St Louis, Missouri.
Department of Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri.
JAMA Pediatr. 2017 Apr 1;171(4):342-349. doi: 10.1001/jamapediatrics.2016.4520.
The appropriate treatment of children with mild traumatic brain injury (mTBI) and intracranial injury (ICI) on computed tomographic imaging remains unclear. Evidence-based risk assessments may improve patient safety and reduce resource use.
To derive a risk score predicting the need for intensive care unit observation in children with mTBI and ICI.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective analysis of the prospective Pediatric Emergency Care Applied Research Network (PECARN) head injury cohort study included patients enrolled in 25 North American emergency departments from 2004 to 2006. We included patients younger than 18 years with mTBI (Glasgow Coma Scale [GCS] score, 13-15) and ICI on computed tomography. The data analysis was conducted from May 2015 to October 2016.
The primary outcome was the composite of neurosurgical intervention, intubation for more than 24 hours for TBI, or death from TBI. Multivariate logistic regression was used to predict the outcome. The C statistic was used to quantify discrimination, and model performance was internally validated using 10-fold cross-validation. Based on this modeling, the Children's Intracranial Injury Decision Aid score was created.
Among 15 162 children with GCS 13 to 15 head injuries who received head computed tomographic imaging in the emergency department, 839 (5.5%) had ICI. The median ages of those with and without a composite outcome were 7 and 5 years, respectively. Among those patients with ICI, 8.7% (n = 73) experienced the primary outcome, including 8.3% (n = 70) who had a neurosurgical intervention. The only clinical variable significantly associated with outcome was GCS score (odds ratio [OR], 3.4; 95% CI, 1.5-7.4 for GCS score 13 vs 15). Significant radiologic predictors included midline shift (OR, 6.8; 95% CI, 3.4-13.8), depressed skull fracture (OR, 6.5; 95% CI, 3.7-11.4), and epidural hematoma (OR, 3.4; 95% CI, 1.8-6.2). The model C statistic was 0.84 (95% CI, 0.79-0.88); the 10-fold cross-validated C statistic was 0.83. Based on this modeling, we developed the Children's Intracranial Injury Decision Aid score, which ranged from 0 to 24 points. The negative predictive value of having 0 points (ie, none of these risk factors) was 98.8% (95% CI, 97.3%-99.6%).
Lower GCS score, midline shift, depressed skull fracture, and epidural hematoma are key risk factors for needing intensive care unit-level care in children with mTBI and ICI. Based on these results, the Children's Intracranial Injury Decision Aid score is a potentially novel tool to risk stratify this population, thereby aiding management decisions.
对于在计算机断层扫描成像中发现有轻度创伤性脑损伤（mTBI）和颅内损伤（ICI）的儿童，适当的治疗方法仍不清楚。基于证据的风险评估可能会提高患者安全性并减少资源使用。
制定一个风险评分，以预测 mTBI 和 ICI 儿童需要重症监护病房观察的情况。
设计、设置和参与者：这是对前瞻性儿科急诊护理应用研究网络（PECARN）头部损伤队列研究的回顾性分析，纳入了 2004 年至 2006 年期间在北美 25 个急诊部门入组的患者。我们纳入了年龄小于 18 岁的 mTBI（格拉斯哥昏迷量表[GCS]评分 13-15）和计算机断层扫描发现有 ICI 的患者。数据分析于 2015 年 5 月至 2016 年 10 月进行。
主要结果是神经外科干预、因 TBI 而插管超过 24 小时或 TBI 死亡的综合结果。多变量逻辑回归用于预测结果。C 统计量用于量化判别能力，10 倍交叉验证用于内部验证模型性能。基于该模型，创建了儿童颅内损伤决策辅助评分。
在急诊科接受头部计算机断层扫描成像的 15162 名 GCS 评分为 13-15 的头部受伤儿童中，有 839 名（5.5%）有 ICI。有和无复合结果的患者中位年龄分别为 7 岁和 5 岁。在这些有 ICI 的患者中，8.7%（n=73）出现了主要结果，其中 8.3%（n=70）接受了神经外科干预。唯一与结果显著相关的临床变量是 GCS 评分（比值比[OR]，3.4；95%CI，1.5-7.4，GCS 评分为 13 与 15 相比）。显著的放射学预测因素包括中线移位（OR，6.8；95%CI，3.4-13.8）、凹陷性颅骨骨折（OR，6.5；95%CI，3.7-11.4）和硬膜外血肿（OR，3.4；95%CI，1.8-6.2）。模型 C 统计量为 0.84（95%CI，0.79-0.88）；10 倍交叉验证 C 统计量为 0.83。基于该模型，我们制定了儿童颅内损伤决策辅助评分，范围为 0 至 24 分。得分为 0 分（即没有这些危险因素）的阴性预测值为 98.8%（95%CI，97.3%-99.6%）。
较低的 GCS 评分、中线移位、凹陷性颅骨骨折和硬膜外血肿是 mTBI 和 ICI 儿童需要重症监护病房级护理的关键危险因素。基于这些结果，儿童颅内损伤决策辅助评分是一种有潜力的新型工具，可以对该人群进行风险分层，从而辅助管理决策。
