Perth Children's Hospital (formerly Princess Margaret Hospital for Children), Perth, Western Australia, Australia; Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, Western Australia, Australia.
Starship Children's Health and the Liggins Institute, University of Auckland, Auckland, New Zealand.
Ann Emerg Med. 2019 Jul;74(1):1-10. doi: 10.1016/j.annemergmed.2018.11.035. Epub 2019 Jan 14.
Existing clinical decision rules guide management for head-injured children presenting 24 hours or sooner after injury, even though some may present greater than 24 hours afterward. We seek to determine the prevalence of traumatic brain injuries for patients presenting to emergency departments greater than 24 hours after injury and identify symptoms and signs to guide management.
This was a planned secondary analysis of the Australasian Paediatric Head Injury Rule Study, concentrating on first presentations greater than 24 hours after injury, with Glasgow Coma Scale scores 14 and 15. We sought associations with predictors of traumatic brain injury on computed tomography (CT) and clinically important traumatic brain injury.
Of 19,765 eligible children, 981 (5.0%) presented greater than 24 hours after injury, and 465 injuries (48.5%) resulted from falls less than 1 m and 37 (3.8%) involved traffic incidents. Features associated significantly with presenting greater than 24 hours after injury in comparison with presenting within 24 hours were nonfrontal scalp hematoma (20.8% versus 18.1%), headache (31.6% versus 19.9%), vomiting (30.0% versus 16.3%), and assault with nonaccidental injury concerns (1.4% versus 0.4%). Traumatic brain injury on CT occurred in 37 patients (3.8%), including suspicion of depressed skull fracture (8 [0.8%]) and intracranial hemorrhage (31 [3.8%]). Clinically important traumatic brain injury occurred in 8 patients (0.8%), with 2 (0.2%) requiring neurosurgery, with no deaths. Suspicion of depressed skull fracture was associated with traumatic brain injury on CT consistently, with the only other significant factor being nonfrontal scalp hematoma (odds ratio 19.0; 95% confidence interval 8.2 to 43.9). Clinically important traumatic brain injury was also associated with nonfrontal scalp hematoma (odds ratio 11.7; 95% confidence interval 2.4 to 58.6) and suspicion of depressed fracture (odds ratio 19.7; 95% confidence interval 2.1 to 182.1).
Delayed presentation after head injury, although infrequent, is significantly associated with traumatic brain injury. Evaluation of delayed presentations must consider identified factors associated with this increased risk.
现有的临床决策规则指导受伤后 24 小时或更短时间内出现的颅脑损伤患儿的治疗，尽管有些患儿可能在受伤后 24 小时后出现。我们旨在确定受伤后 24 小时以上就诊于急诊科的患儿颅脑损伤的发生率，并确定指导治疗的症状和体征。
这是对澳大利亚儿科头部损伤规则研究的一项计划中的二次分析，主要针对受伤后 24 小时以上的首次就诊，格拉斯哥昏迷评分 14 分和 15 分。我们旨在寻找与 CT 预测的创伤性脑损伤和临床显著的创伤性脑损伤相关的症状和体征。
在 19765 名合格的儿童中，981 名（5.0%）在受伤后 24 小时以上就诊，465 名（48.5%）受伤是从小于 1 米的高处坠落引起的，37 名（3.8%）涉及交通事故。与受伤后 24 小时内就诊相比，受伤后 24 小时以上就诊的显著相关特征为非额部头皮血肿（20.8%比 18.1%）、头痛（31.6%比 19.9%）、呕吐（30.0%比 16.3%）和有虐待性非意外损伤的可疑情况（1.4%比 0.4%）。37 名患者（3.8%）在 CT 上发现创伤性脑损伤，包括怀疑颅骨凹陷性骨折（8 [0.8%]）和颅内出血（31 [3.8%]）。8 名患者（0.8%）发生临床显著的创伤性脑损伤，其中 2 名（0.2%）需要神经外科治疗，无死亡病例。怀疑颅骨凹陷性骨折与 CT 上发现创伤性脑损伤一致，唯一其他显著因素是非额部头皮血肿（比值比 19.0；95%置信区间 8.2 至 43.9）。临床显著的创伤性脑损伤也与非额部头皮血肿（比值比 11.7；95%置信区间 2.4 至 58.6）和怀疑颅骨凹陷性骨折（比值比 19.7；95%置信区间 2.1 至 182.1）相关。
颅脑损伤后延迟就诊虽然少见，但与创伤性脑损伤显著相关。对延迟就诊的评估必须考虑到与这种风险增加相关的已确定因素。
