Department of Surgery, 1371Emory University, Atlanta, GA, USA.
Department of Pediatric Surgery, 547254Mary Bridge Children's Hospital, Tacoma, WA, USA.
Am Surg. 2022 Mar;88(3):447-454. doi: 10.1177/00031348211050804. Epub 2021 Nov 4.
Pediatric traumatic brain injury (TBI) affects about 475,000 children in the United States annually. Studies from the 1990s showed worse mortality in pediatric TBI patients not transferred to a pediatric trauma center (PTC), but did not examine mild pediatric TBI. Evidence-based guidelines used to identify children with clinically insignificant TBI who do not require head CT were developed by the Pediatric Emergency Care Applied Research Network (PECARN). However, which patients can be safely observed at a non-PTC is not directly addressed.
A systematic review of the literature was conducted, focusing on management of pediatric TBI and transfer decisions from 1990 to 2020.
Pediatric TBI patients make up a great majority of preventable transfers and admissions, and comprise a significant portion of avoidable costs to the health care system. Majority of mild TBI patients admitted to a PTC following transfer do not require ICU care, surgical intervention, or additional imaging. Studies have shown that as high as 83% of mild pediatric TBI patients are discharged within 24 hrs.
An evidence-based clinical practice algorithm was derived through synthesis of the data reviewed to guide transfer decision. The papers discussed in our systematic review largely concluded that transfer and admission was unnecessary and costly in pediatric patients with mild TBI who met the following criteria: blunt, no concern for NAT, low risk on PECARN assessment, or intermediate risk on PECARN with negative imaging or imaging with either isolated, nondisplaced skull fractures without ICH and/or EDH, or SDH <0.3 cm with no midline shift.
每年约有 475,000 名美国儿童患有小儿外伤性脑损伤 (TBI)。20 世纪 90 年代的研究表明，未转至儿科创伤中心 (PTC) 的小儿 TBI 患者死亡率更高，但并未研究轻度小儿 TBI。由儿科急症护理应用研究网络 (PECARN) 制定了用于识别不需要头部 CT 的临床意义不显著 TBI 儿童的循证指南。然而，并未直接解决哪些患者可以在非 PTC 安全观察的问题。
对 1990 年至 2020 年的小儿 TBI 管理和转院决策进行了系统文献回顾。
小儿 TBI 患者构成了大量可预防的转院和住院的原因，并且占医疗保健系统可避免成本的很大一部分。大多数在转院后被收入 PTC 的轻度 TBI 患者不需要 ICU 护理、手术干预或额外的影像学检查。研究表明，高达 83%的轻度小儿 TBI 患者在 24 小时内出院。
通过综合审查中讨论的文献数据，得出了一种基于证据的临床实践算法，以指导转院决策。我们的系统综述中讨论的论文大多得出结论，对于符合以下标准的轻度 TBI 小儿患者，转院和入院是不必要且昂贵的：钝性，无 NAT 顾虑，PECARN 评估低风险，或 PECARN 中风险伴阴性影像学或影像学检查显示孤立性、无移位颅骨骨折无 ICH 和/或 EDH，或 SDH<0.3cm 且无中线移位。
