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Aim: To determine whether it is justified to undertake a computed tomography (CT) examination of the head in children under 1 year of age who present with a bruise, swelling, or laceration of >5 cm following head injury in children presenting to a paediatric accident and emergency (A&E) department in the northwest of England. Further aims were to determine whether there was any justification for performing a CT head examination for children with soft-tissue injuries measuring <5 cm, or for children >1 year with evidence of soft-tissue injury, but without any other concerning feature.Materials and Methods: Children <3 years of age presenting with soft-tissue evidence of head injury between May 2011 and Oct 2014 and who subsequently underwent head CT were retrospectively identified from radiology requests. The CT images and clinical notes were used to identify those with skull fracture or intracranial haemorrhage and to determine whether the child was subsequently admitted or discharged from A&E.Results: Eighty-five CT head examinations met the criteria for inclusion. Of these, 45 examinations demonstrated skull fractures and four examinations identified intracranial haemorrhage. Thirty-eight requests included soft-tissue evidence of head injury as the sole reason indicated for CT head examination. Of these, 22 examinations demonstrated skull fractures and one examination identified intracranial haemorrhage.Conclusion: Soft-tissue evidence of head injury as the sole reason for CT head examination appears to be justified in the present patient population. Furthermore, this study suggests that CT head examination should also be considered for children with soft-tissue injuries of <5 cm and for children aged between 1 and 3 years if identification of a skull fracture would alter the child's management. [ABSTRACT FROM AUTHOR]

Introduction: Compound elevated skull fractures (CESF) are rare traumatic injuries. To date, only 27 cases have been reported. Methods: The authors report three cases of CESF managed at their institute. All were middle-aged males. The mechanism was assault by sharp-edged objects in two and road traffic accident (RTA) in one case. One underwent simple suturing; debridement and decompressive craniectomy was done in the remaining two cases. Good and poor outcomes were noted in one case each, while one died. A literature review was performed to analyse all cases of CESF reported in English literature. Results: Including this one, a total of 30 cases were analysed. Mean age was 25.2 years, of which seven were aged < 18 years. There were 12 mild, five moderate, 11 severe HI cases and two cases were not detailed. Underlying injuries were seen in ~ 2/3 of cases. All, except two cases, underwent definitive surgery in the form of debridement with/without haematoma removal. Good-to-excellent outcomes were noted in 2/3 cases. There were 6/30 (20%) deaths noted. CNS infections and poor admission GCS were associated with increased mortality rates. Conclusions: CESF are rare injuries. Early surgery in the form of debridement with broad-spectrum antibiotic coverage is recommended to prevent infectious complications and improve outcome. Outcome is dependent on three main factors—admission GCS score, intactness of duramater and post-operative CNS infections. [ABSTRACT FROM AUTHOR]

Background: Accurate diagnosis and risk stratification of traumatic brain injury (TBI) at time of presentation remains a clinical challenge. The Head Injury Serum Markers for Assessing Response to Trauma study (HeadSMART) aims to examine blood-based biomarkers for diagnosing and determining prognosis in TBI. Methods: HeadSMART is a 6-month prospective cohort study comparing emergency department patients evaluated for TBI (exposure group) to (1) emergency department patients evaluated for traumatic injury without head trauma and (2) healthy persons. Study methods and characteristics of the first 300 exposure participants are discussed. Results: Of the first 300 participants in the exposure arm, 70% met the American Congress of Rehabilitation Medicine criteria for TBI, with the majority (80.1%) classified as mild TBI. The majority of subjects in the exposure arm had Glasgow Coma Scale scores of 13-15 (98.0%), normal head computed tomography (81.3%) and no prior history of concussion (71.7%). Conclusion: With systematic phenotyping, HeadSMART will facilitate diagnosis and risk-stratification of the heterogeneous group of individuals currently diagnosed with TBI. [ABSTRACT FROM AUTHOR]

For a diagnostic test with continuous measurement, it is often important to construct confidence intervals for the sensitivity at a fixed level of specificity. Bootstrap-based confidence intervals were shown to have good performance as compared to others, and the one by Zhou and Qin (2005) was recommended as the best existing confidence interval, named the BTII interval. We propose two new confidence intervals based on the profile variance method and conduct extensive simulation studies to compare the proposed intervals and the BTII intervals under a wide range of conditions. An example from a medical study on severe head trauma is used to illustrate application of the new intervals. The new proposed intervals generally have better performance than the BTII interval. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the utility of repeat head CT in a large population of patients with non-isolated blunt mild head trauma (MTBI), especially in the presence of intracranial injury. This is a study of a cohort of 478 non-isolated MTBI patients admitted to the High Dependency Unit of the Emergency Department of the University-Hospital of Florence from July 2008 to December 2013. Results of initial and subsequent head CT scans, and indications for repeat head CT scan (routine vs. neurologic change) were recorded. The study population was divided into two subgroups: 28 (6 %) patients with neurological change or persistently reduced GCS (group GCS-) and 450 (94 %) patients with normal or improving GCS (group GCS+). After 6 months from the event, a telephone interview using SF12 questionnaire was conducted. Among GCS- patients, the admission CT scan showed intracranial lesions (ICI) in 16 (57 %) patients; only two patients had a TBI-related neurosurgical intervention. Among GCS+ patients, the first CT scan showed an ICI in 133 patients; in a significant proportion of patients with ICI at the first CT scan, the injury worsened (40/133, 30 %, p < 0.0001). However, no GCS+ patient had any neurosurgical intervention. We observed a significant reduction in both MCS and PCS scores after the injury compared with the previous period. The number of repeat CT scan was high in patients who presented ICI at the first CT scan; however, no patient with ICI and normal or improving GCS score needed a neurosurgical intervention. [ABSTRACT FROM AUTHOR]

The article comments on the feasibility of fast magnetic resonance imaging (MRI) to reduce radiation exposures of children with traumatic brain injuries (TBIs) computed tomography (CT). It references a study which assessed the feasibility and accuracy of fast MRI to diagnose TBIs in children. The use of highly sensitive, validated clinical decision rules in the modality for neuroimaging children with head injuries is discussed.

The Late Intermediate period (LIP, AD 1000-1450) in the South Central Andes is commonly characterized by an increase in violence. Here, we analyse evidence to test whether the population that inhabited the oasis of Pica (Region of Tarapacá, Northern Chile) during LIP was engaged in violent warfare. The analysis of 96 individuals showed a low prevalence of violence-related injuries (N = 6/96). Facial traumas observed on females could be a result of domestic violence, whereas nasal traumas found in males could be interpreted as a result of ritualized combats. One male exhibits a point embedded in his first right rib which is the only injury that can be attributed to open intergroup combat. These findings, combined with the mortuary characteristics of the Pica 8 cemetery, the lack of defensive constructions at the site, the settlement pattern and the iconography, do not support the existence of war at Pica during the LIP. The weapons found at Pica 8 cemetery are elaborately decorated, and many are clearly useless in combat so they were likely not made to be used in open conflicts. In addition, clothes considered to belong to warriors may be alternately interpreted as garments used for ceremonial purpose. Taking into account the belligerent climate in contemporaneous San Pedro de Atacama, we suggest that the Pica population employed ritualized violence as a means of avoiding larger conflicts or war. We propose that male violence in controlled scenarios permitted the sublimation of social inequalities or internal conflicts, and could have been used in order to create and maintain social stability. Copyright © 2015 John Wiley & Sons, Ltd. [ABSTRACT FROM AUTHOR]

Objectives: To assess the impact of positive postoperative CT head during the initial 72 hours on overall clinical course and outcome. Methodology: 157 patients of head trauma who underwent cranial surgery were prospectively included. All patients underwent a repeat head CT during the initial 72 hours or as was indicated by neurological status of the patient. Data was collected about patient demographics, initial CT diagnosis, repeat CT findings, re-operation if performed, GCS at discharge, mortality and outcome in terms of GOS. Data was analysed for impact of positive finding in postoperative CT head and its impact on clinical course and outcome. Results: The overall mean age was 34.25 ±11.59 years with a mean arrival GCS of 9.2 ±2.32. The mean time to first postoperative CT was 21.45 ±9.83 hours. The postoperative CT scan was positive in 29 (18.5%) patients in which 16 (10.2%) cases required re-intervention. Overall mortality was 19 (12.1%), of which 9 (44.1%) had a positive post-operative CT scan and 4 (21.1%) of them underwent a repeat intervention. 2.3% of patients with negative CT were re-operated while 44.8% were re-operated in the positive CT (p <0.0001). Similarly, mortality was 7.8% in the negative CT group while it was 31.0% in the positive CT group (p <0.0001). Conclusions: Positive follow-up CT scan during early post-operative period can affect significantly the clinical course and neurological outcome of patients. [ABSTRACT FROM AUTHOR]

Introduction and objectives: Evaluation of injuries in emergency departments is based on CT scans. The objective of this forensic study is to reveal certain types and location of skull fractures that can escape CT diagnosis. Methods: This study was conducted by retrospective analysis of 115 cases of hospitalized traumatic brain injury autopsied at INML “Mina Minovici” Bucharest during the year 2011. Results and discussions: In 35 cases were discovered that skull fractures have not been highlighted in CT examinations. Undiagnosed skull fractures were predominantly linear fractures. A linear fracture that comes in the plane of a CT slice may not be visualized if is not depressed or separated. Conclusion: Skull fractures were mostly undiagnosed in men, over the age of 50 with serious traumatic brain injury, with a survival period of less than 5 days and with a single CT examination. In 30.43% of studied cases were detected skull fractures that were not diagnosed on CT. The most common was involved the cranial vault from temporal-parietal areas, followed by frontal area, with irradiation in the anterior and medium fossa. A good accuracy of imaging diagnostic was in the occipital region, and in the posterior fossa of the skull base. [ABSTRACT FROM AUTHOR]

Purpose To inform radiologic technologists about which imaging modalities and examinations are best suited for evaluating specific anatomical structures in patients who have sustained a traumatic injury. Methods Two scholarly research databases were searched to identify articles focused on trauma imaging of the head, cervical spine, thorax, abdomen, and pelvis. Articles focused on trauma diagnosis were excluded. Thirty-two articles were selected for analysis. Discussion Physical examination and plain-film radiographs typically are used to assess nasal bone fracures. Computed tomography (CT) can be used to assess zygomaticomaxillary complex, mandibular, and temporal bone fractures. Traumatic brain injuries are difficult to assess, and broad classifications are used. Depending on the severity of cervical spine trauma, plain-film radiographs or CT imaging is adequate, with magnetic resonance imaging used as a means for further evaluation. Trauma to the thorax typically is assessed with radiography and CT, and CT is recommended for assesment of abdominal and pelvic trauma. Conclusion The literature was consistent regarding which examinations to perform to best evaluate suspected injuries to the chest, abdomen, and pelvis. The need for, and correct use of, imaging in evaluating trauma to the head and cervical spine is more controversial. Despite the need for additional research, emergency department care providers should be familiar with the structures most commonly injured during trauma and the role of medical imaging for diagnosis. [ABSTRACT FROM AUTHOR]

Introduction: In Malaysia, motorcyclists continue to outnumber other road users in injuries and deaths. The objective of this study was to determine the association between helmet fixation and helmet type with head injury and severity of head injury among Malaysian motorcyclists.Methods: The study design was a prospective cross-sectional study. The participants involved injured motorcyclists who were admitted in five selected hospitals in Klang Valley, Malaysia. Participants who sustained head injury were selected as the cases while those with injury below the neck (IBN) were selected as the controls. Questionnaire comprising motorcyclist, vehicle, helmet and crash factors was examined. Diagnoses of injuries were obtained from the participants' medical records.Results: The total subjects with head injuries were 404 while those with IBN were 235. Majority of the cases (76.2%) and controls (80.4%) wore the half-head and open-face helmets, followed by the tropical helmets (5.4% and 6.0% of the cases and controls, respectively). Full-face helmets were used by 1.2% of the cases and 4.7% of the controls. 5.7% of the cases and 6.0% of the controls did not wear a helmet. 32.7% of the cases and 77.4% of the controls had their helmets fixed. Motorcyclists with ejected helmets were five times as likely to sustain head injury [adjusted odds ratio, AOR 5.73 (95% CI 3.38-9.73)] and four times as likely to sustain severe head injury [AOR of 4.83 (95% CI 2.76-8.45)]. The half head and open face helmets had AOR of 0.24 (95% CI 0.10-0.56) for severe head injury when compared to motorcyclists who did not wear a helmet.Conclusion: Helmet fixation is more effective than helmet type in providing protection to the motorcyclists. [ABSTRACT FROM AUTHOR]

Despite being underreported, American football boasts the highest incidence of concussion among all team sports, likely due to exposure to head impacts that vary in number and magnitude over the season. This study compared a biological marker of head trauma in American football athletes with non-contact sport athletes and examined changes over the course of a season. Baseline serum neurofilament light polypeptide (NFL) was measured after 9 weeks of no contact and compared with a non-contact sport. Serum NFL was then measured over the course of the entire season at eight time-points coincident with expected changes in likelihood of increased head impacts. Data were compared between starters ( n = 11) and non-starters ( n = 9). Compared with non-starters (mean ± standard deviation) (7.30 ± 3.57 pg•mL−1) and controls (6.75 ± 1.68 pg•mL−1), serum NFL in starters (8.45 ± 5.90 pg•mL−1) was higher at baseline (mean difference; ±90% confidence interval) (1.69; ± 1.96 pg•mL−1 and 1.15; ± 1.4 pg•mL−1, respectively). Over the course of the season, an increase (effect size [ES] = 1.8; p < 0.001) was observed post-camp relative to baseline (1.52 ± 1.18 pg•mL−1), which remained elevated until conference play, when a second increase was observed (ES = 2.6; p = 0.008) over baseline (4.82 ± 2.64 pg•mL−1). A lack of change in non-starters resulted in substantial differences between starters and non-starters over the course of the season. These data suggest that a season of collegiate American football is associated with elevations in serum NFL, which is indicative of axonal injury, as a result of head impacts. [ABSTRACT FROM AUTHOR]

Despite an improved understanding of traumatic head and neck injury mechanisms, the impact tests required by major motorcycle helmet standards have remained unchanged for decades. Development of new test methods must reflect the specific impact loads causing injury in real crashes as well as test criteria appropriate for the observed injury profiles. This study analysed a collection of in-depth crash investigations of fatally injured helmeted riders in the Adelaide metropolitan region between 1983 and 1994 inclusive to review the head and neck injury patterns that resulted from specific types of impact. Inertial brain injury was sustained in 49% of examined cases, most often resulting from facial impacts but also in a large proportion of tangential, run over, and occipital impact cases. Focal brain and brainstem injury was also common (53%) and regularly associated with skull vault (11/12) and skull base fractures (22/31). Prevention of these fractures in impacts outside the area of required protection and in impacts with a straight edge would provide a significant increase in helmeted rider protection. Cervical spinal cord injury was sustained in facial, straight edge, and tangential impacts on the head. Motorcycle helmets are effective for preventing local skull fractures in impacts for which they are designed, whereas other serious injuries such as basilar skull fracture (BSF) and inertial brain injury persist despite helmet protection. Further impact test procedures should be developed for injurious impact types not currently assessed by major helmet standards, in particular facial impacts, and using test criteria based on commonly observed injuries. This study provides the necessary link, from impact load to injury, for guiding impact test development. [ABSTRACT FROM AUTHOR]

When Abusive Head Trauma (AHT) is suspected in a child, a dilated eye examination by an ophthalmologist is an essential part of the medical workup, as the presence and pattern of retinal hemorrhages can have a high positive predictive rate for abusive head injury. This article proposes to review the clinical presentation, pathophysiology, natural history, sequelae, and differential diagnosis of retinal hemorrhages and other ocular lesions associated with AHT. [ABSTRACT FROM AUTHOR]

When cases of suspected abusive head trauma are adjudicated in courts of law, one of the theories often presented by defense experts is that a normal, healthy infant or child suddenly neurologically deteriorates or dies several weeks to months after birth or minor injury because a preceding subdural hematoma spontaneously rebleeds after a minor traumatic event. This article reviews the underlying scientific basis of subdural hematoma rebleeding as it applies to this courtroom theory. [ABSTRACT FROM AUTHOR]

Objective: Indicators for head CT scan defined by the 2007 National Institute for Health and Care Excellence (NICE) guidelines were analysed to identify CT uptake, influential variables and yield.Design: Cross-sectional study.Setting: Hospital inpatient units: England, Wales, Northern Ireland and the Channel Islands.Patients: Children (<15 years) admitted to hospital for more than 4 h following a head injury (September 2009 to February 2010).Interventions: CT scan.Main Outcome Measures: Number of children who had CT, extent to which NICE guidelines were followed and diagnostic yield.Results: Data on 5700 children were returned by 90% of eligible hospitals, 84% of whom were admitted to a general hospital. CT scans were performed on 30.4% of children (1734), with a higher diagnostic yield in infants (56.5% (144/255)) than children aged 1 to 14 years (26.5% (391/1476)). Overall, only 40.4% (984 of 2437 children) fulfilling at least one of the four NICE criteria for CT actually underwent one. These children were much less likely to receive CT if admitted to a general hospital than to a specialist centre (OR 0.52 (95% CI 0.45 to 0.59)); there was considerable variation between healthcare regions. When indicated, children >3 years were much more likely to have CT than those <3 years (OR 2.35 (95% CI 2.08 to 2.65)).Conclusion: Compliance with guidelines and diagnostic yield was variable across age groups, the type of hospital and region where children were admitted. With this pattern of clinical practice the risks of both missing intracranial injury and overuse of CT are considerable. [ABSTRACT FROM AUTHOR]

Wearable inertial sensors measure human head impact kinematics important to the on-going development and validation of head injury criteria. However, sensor specifications have not been scientifically justified in the context of the anticipated field impact dynamics. The objective of our study is to determine the minimum bandwidth and sample rate required to capture the impact frequency response relevant to injury. We used high-bandwidth head impact data as ground-truth measurements, and investigated the attenuation of various injury criteria at lower bandwidths. Given a 10% attenuation threshold, we determined the minimum bandwidths required to study injury criteria based on skull kinematics and brain deformation in three different model systems: helmeted cadaver (no neck), unhelmeted cadaver (no neck), and helmeted dummy impacts (with neck). We found that higher bandwidths are required for unhelmeted impacts in general and for studying strain rate injury criteria. Minimum gyroscope bandwidths of 300 Hz in helmeted sports and 500 Hz in unhelmeted sports are necessary to study strain rate based injury criteria. A minimum accelerometer bandwidth of 500 Hz in unhelmeted sports is necessary to study most injury criteria. Current devices typically sample at 1000 Hz, with gyroscope bandwidths below 200 Hz, which are not always sufficient according to these requirements. With hard contact test conditions, the identified requirements may be higher than most soft contacts on the field, but should be satisfied to capture the worst contact, and often higher risk, scenarios relative to the specific sport or activity. Our findings will help establish standard guidelines for sensor choice and design in traumatic brain injury research. [ABSTRACT FROM AUTHOR]

Background: An ambulance equipped with a computed tomography (CT) scanner, point-of-care laboratory, and telemedicine capabilities (Mobile Stroke Unit [MSU]) has been shown to enable delivery of thrombolysis to stroke patients at the emergency site, thereby significantly decreasing time to treatment. However, the MSU frequently assesses patients with cerebral disorders other than stroke. For some of these disorders, prehospital CT scanning may also be beneficial.Methods: Our institution manages a program investigating prehospital stroke treatment of patients with neurological emergencies. We assessed a patient with head trauma for whom prehospital CT scanning and laboratory tests allowed cause-based triage to the most appropriate hospital. We examined implications of this case for clinical practice in light of a literature review.Results: The MSU was dispatched to assess a 74-year-old woman with suspected head trauma or stroke, found lying on the floor with a left frontal laceration. Her Glasgow Coma Scale score was 13, apart from drowsiness she exhibited no neurologic deficit. A CT scan ruled out intracranial hemorrhage and skull fracture. On the basis of these prehospital diagnostic findings, the patient was taken to the nearest primary care hospital rather than to a trauma center with neurosurgery facilities.Conclusion: Patients with neurologic disorders other than stroke, such as traumatic brain injury, may also benefit from prehospital CT studies. This case report and the results of our analysis of the literature support the potential benefit of prehospital imaging in correctly triaging patients with suspected traumatic brain injury to the appropriate target hospital. [ABSTRACT FROM AUTHOR]

Background: Temporal bone fractures (TBFs) are harbingers of high energy head trauma that can result in a variety of significant complications of the auditory, vestibular, nervous, and vascular systems. Multiple cohort studies have identified the incidence and proper evaluation of these fractures. We hypothesize that these have changed with the advent of modern high resolution computer tomography (CT) imaging.Methods: We performed a retrospective review of all TBFs admitted to an urban level one trauma center between June 1, 2011 and May 31, 2015. A database was compiled including demographics, physical exam findings, imaging performed and results, morphology and directionality of fracture as well as outcomes and follow-up.Results: One hundred thirteen patients were identified, representing 4.7% of skull fractures and 35.9% of skull base fractures. Most were subsequent to falls (41.6%) followed by pedestrian vehicular trauma (19.5%). The majority of TBF patients (67.3%) had additional fractures of the skull and 77.9% of TBF patients also had some kind of intracranial hemorrhage. The morphology of TBF and the overall mortality (7.9%) was consistent with previous reports. The incidence of facial nerve paralysis (1.6%), CSF leak (1.7%), and hearing loss (18.6%) were all lower than previously reported. Trauma imaging was able to identify 98.6% of TBF, calling the utility of routine temporal bone CT imaging into question.Conclusion: TBFs are less common than they once were and though they still carry a mortality rate similar to previously reported cohorts, the incidence of complications among survivors has dramatically improved. Additionally, modern CT imaging is very capable of identifying these injuries and dedicated temporal bone CT may only be of utility in cases where facial nerve injury or vascular injury is suspected.Level Of Evidence: Epidemiologic study, Level III. [ABSTRACT FROM AUTHOR]

Introduction Golf carts are increasingly used off the golf course and are often viewed as innocuous modes of transportation. However, research has shown they can cause significant injuries, particularly to children. Objectives Analyze golf cart related head and neck injuries in children and adults from a national database. Methods The National Electronic Injury Surveillance System (NEISS) was queried for golf cart injuries. The NEISS tracks consumer product related injuries from a sampling of approximately 100 emergency departments across the United States. Age, general diagnosis (concussion, fracture, laceration), body-part injured, disposition (hospitalized, discharged), location injury occurred, and mechanism of injury were analyzed. Results Over an 11-year period, a total of 3433 total patients were identified. There were 1471 children (16 years old or younger), which compromised 42.9% of the cohort. Children were injured at home or on the road 44.7% of the time compared to only 16.6% of adults (p < 0.003). Children injured their head or neck 42.6% of the time compared to 28.6% of adults (p < 0.0001). Adults who were hit by a car while riding a golf cart or were ejected from the golf cart 44.6% of the time compared to 61.7% of children (p < 0.0001). There were 3.9% of children with a face, head, or neck fracture compared to only 2.4% of adults (p = 0.01). Conclusion Children are more vulnerable to golf cart related injuries, specifically to the head and neck. [ABSTRACT FROM AUTHOR]

Objective This study examines clinical characteristics and helmet use of children presenting to the ED with a recreational vehicle (RV)-related head injury (HI). Methods Observational retrospective study of children <18 years presenting with a RV-related HI to the ED of a state-wide paediatric trauma centre in Australia between April 2011 and January 2014. Results In the 647 presentations identified, corresponding to 7.5% (95% CI 7.0-8.1) of all HI presentations, RVs involved were bicycles (36.3%), push scooters (18.5%), motorcycles (18.4%), horses (11.7%), skateboards (11.6%), quadbikes (2.8%) and go-karts (0.6%). Recorded helmet use was the highest in motorcycle, horse and bicycle riders (83.2%, 82.9% and 65.1%, respectively), and the lowest for push scooter (25.8%) and skateboard riders (17.3%). Overall 23% underwent a CT scan, 8.8% had intracranial injuries on CT, 30.6% were admitted, and 2.2% underwent neurosurgery. Push scooter-related HIs were the least severe. Age (in years), riding a motorised vehicle and not wearing a helmet were independently associated with intracranial injuries on CT on multiple logistic regression (OR 1.1, 95% CI 1.0-1.2; OR 2.4, 95% CI 1.3-4.6 and OR 6.0, 95% CI 3.2-11.2, respectively). Conclusions RV-related HIs accounted for a non-negligible proportion of paediatric HIs presenting to the ED and for significant morbidity and use of hospital resources. Interventions such as introduction of mandatory helmet use for off-road motorised vehicle riding and skateboard riding in children, enhanced injury prevention campaigns, and strict adult supervision during motorised vehicle riding may reduce the morbidity and health care costs associated with paediatric RV-related HIs. [ABSTRACT FROM AUTHOR]

Anecdotal experiences raise concerns that abusive head trauma (AHT) is significantly underdiagnosed and perhaps poorly recognized in Latin American settings. With increasing interest in international collaboration in pediatrics, differences in perspectives regarding complex diagnoses should be explored to facilitate a productive exchange of knowledge and ideas. The purpose of this study was to describe the medical literature pertaining to AHT available to physicians who read only in Spanish. In this review, LILACS, SciELO (major Spanish language databases) and Pubmed were searched with appropriate terms and filters in English, Spanish, and Portuguese for Spanish language articles on AHT. Identified articles’ reference lists were then examined for possible additional articles on AHT. All relevant articles were sorted by country and examined for article type and content. Thirty-four unique articles were located for review from 8 of 21 countries. Most of the articles identified were case reports, case series, or educational, and there were no studies regarding overall incidence or prevalence of AHT. Some scientific information contained in the articles varied considerably from that in the English language literature in the areas of etiology and preventive strategies. This survey highlights that the Spanish language literature regarding AHT is sparse and variable. This must be considered when working collaboratively in a global setting. Additionally, identification of this gap presents an opportunity for education and information exchange among global medical communities. [ABSTRACT FROM AUTHOR]

Purpose: High-velocity trauma with acceleration/deceleration forces turns into shear stress over lenticulostriate or anterior choroidal arteries that lead to basal ganglia hemorrhage. Traumatic basal ganglia hematoma has rarely been described in pediatric population. The aim of this study was to present our clinical series of pediatric patients with traumatic basal ganglia hematoma and to analyze the prognostic indicators of traumatic basal ganglia hematoma. Methods: In this retrospective case series, emergency admissions of pediatric patients with traumatic basal ganglia hematoma due to closed head injury were analyzed. Demographic, clinical, and radiographical data of the patients were retrieved from patients' charts and picture archiving and communication system. Results: There were four children with traumatic basal ganglia hematoma (TBGH). All patients were male. Median age was 8 years (range = 7-16 years). Road accident (three) and fall (one) were the causes of the traumas. Basal ganglia hematoma was present on the right side in one patient and on the left side in three patients. Hematoma volumes ranged from 0.9 to 8.94 ml. All patients were treated conservatively. One patient recovered fully; two patients were moderately disabled at their last clinical follow-ups. The last patient with diffuse subarachnoidal hemorrhage and edema died despite all interventions. Conclusions: Traumatic basal ganglia hematomas are unique and different from other kind of intracerebral hematomas. The eloquent nature of basal ganglia makes it more vulnerable to head trauma. Mechanism of injury, energy and velocity of injury are the most important prognostic criteria. Post-traumatic phase of injury should be carefully observed in patients with TBGH, especially when mechanism and velocity of injury are severe and high. [ABSTRACT FROM AUTHOR]

Objective: To investigate whether MRI in emergency radiology can detect (a) additional trauma-related findings after minor head injury (MHI) or (b) structural, non-trauma-related intracranial lesions when trauma biomarker S-100B concentration is raised, or clinical symptoms are unexplained, or both. Methods: 41 patients with MHI were included. Concentrations of S-100B in serum were measured and categorized using an established cut-off at 0.1μgl-1. Intracerebral trauma-related as well as non-trauma-related chronic structural findings (atrophy, microangiopathy and chronic parenchymal defects) were assessed by cranial CT (CCT) and MRI by two independent radiologists (UL and LLG). All CCT and MRI results were compared with biomarker S-100B. Results: Compared with CCT, MRI detected 10 additional lesions. 5 patients had abnormal MRI with a total of 15 trauma-related lesions and showed elevated S-100B concentrations. Although sensitivity of S-100B was 100%, specificity was only 25%. Patients with structural brain lesions showed significantly higher S-100B serum levels (0.50 and 0.14 μg l-1, p = 0.01). Conclusion: Biomarker S-100B has proven its high negative-predictive value to rule out intracranial bleeding in patients after MHI even if MRI is used as imaging modality. Regarding the low specificity of S-100B, structural lesions of the brain parenchyma not related to the acute trauma may be associated with increased serum concentrations of protein S-100B. Advances in knowledge: Biomarker S-100B has a high negative-predictive value to rule out intracranial bleeding after MHI. Biomarker S-100B's low specificity may be associated with non-traumatic brain parenchyma lesions. MRI is superior to CCT in detecting subtle findings in neuroimaging after MHI. Biomarker S-100B can potentially reduce the large number of normal CCT studies after MHI. [ABSTRACT FROM AUTHOR]

Background: The management of minor and moderate head trauma in children differs widely between countries. Presently, there are no existing guidelines for management of these children in Scandinavia. The purpose of this study was to produce new evidence-based guidelines for the initial management of head trauma in the paediatric population in Scandinavia. The primary aim was to detect all children in need of neurosurgical intervention. Detection of any traumatic intracranial injury on CT scan was an important secondary aim.Methods: General methodology according to the Appraisal of Guidelines for Research and Evaluation (AGREE) II and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was used. Systematic evidence-based review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology and based upon relevant clinical questions with respect to patient-important outcomes. Quality ratings of the included studies were performed using Quality Assessment of Diagnostic Accuracy Studies (QUADAS)-2 and Centre of Evidence Based Medicine (CEBM)-2 tools. Based upon the results, GRADE recommendations, a guideline, discharge instructions and in-hospital observation instructions were drafted. For elements with low evidence, a modified Delphi process was used for consensus, which included relevant clinical stakeholders.Results: The guidelines include criteria for selecting children for CT scans, in-hospital observation or early discharge, and suggestions for monitoring routines and discharge advice for children and guardians. The guidelines separate mild head trauma patients into high-, medium- and low-risk categories, favouring observation for mild, low-risk patients as an attempt to reduce CT scans in children.Conclusions: We present new evidence and consensus based Scandinavian Neurotrauma Committee guidelines for initial management of minor and moderate head trauma in children. These guidelines should be validated before extensive clinical use and updated within four years due to rapid development of new diagnostic tools within paediatric neurotrauma. [ABSTRACT FROM AUTHOR]

Background. Images of head CT for the supratentorial compartment are sometimes recommended to be reconstructed with a thickness of 8–10 mm to achieve lesion conspicuity. However, additional images of a thin slice may not be routinely provided for patients with trauma in the emergency room (ER). We investigated the diagnostic sensitivity of a head CT, where axial images were 10 mm thick slices, in cases of linear skull fractures. Methods. Two trauma surgeons retrospectively reviewed head CT with 10 mm slices and skull X-rays of patients admitted to the ER that were diagnosed with a linear skull fracture. All patients had undergone both head CT and skull X-rays (n=410). Result. The diagnostic sensitivity of head CT with a thickness of sequential 10 mm was 89% for all linear skull fractures but only 56% for horizontal fractures. This CT technique with 10 mm slices missed 6% of patients with linear skull fractures. False-negative diagnoses were significantly more frequent for older (≥55 years) than for young (<15 years) individuals (p=0.048). Conclusions. A routine head CT of the supratentorial region for patients in the ER with head injuries requires both thick-slice images to visualize cerebral hemispheres and thin-slice images to detect skull fractures of the cranial vault. [ABSTRACT FROM AUTHOR]

Importance: Adults with apparently minor head trauma (Glasgow Coma Scale [GCS] scores ≥13 who appear well on examination) may have severe intracranial injuries requiring prompt intervention. Findings from clinical examination can aid in determining which adults with minor trauma have severe intracranial injuries visible on computed tomography (CT).Objective: To assess systematically the accuracy of symptoms and signs in adults with minor head trauma in order to identify those with severe intracranial injuries.Data Sources: We performed a systematic search of MEDLINE (1966-2015) and the Cochrane Library to identify studies assessing the diagnosis of intracranial injuries.Study Selection: Studies were included that measured the performance of findings for identifying intracranial injury with a reference standard of neuroimaging or follow-up evaluation. Fourteen studies (range, 431-7955 patients) met inclusion criteria with patients having GCS scores between 13 and 15 and 50% or more older than 18 years.Data Extraction and Synthesis: Three authors independently performed critical appraisal and data extraction.Results: The prevalence of severe intracranial injury (requiring prompt intervention) among the 23,079 patients with minor head trauma was 7.1% (95% CI, 6.8%-7.4%) and the prevalence of injuries leading to death or requiring neurosurgical intervention was 0.9% (95% CI, 0.78%-1.0%). The presence of physical examination findings suggestive of skull fracture (likelihood ratio [LR], 16; 95% CI, 3.1-59; specificity, 99%), GCS score of 13 (LR, 4.9; 95% CI, 2.8-8.5; specificity, 97%), 2 or more vomiting episodes (LR, 3.6; 95% CI, 3.1-4.1; specificity, 92%), any decline in GCS score (LR range, 3.4-16; specificity range, 91%-99%;), and pedestrians struck by motor vehicles (LR range, 3.0-4.3; specificity range, 96%-97%) were associated with severe intracranial injury on CT. Among patients with apparent minor head trauma, the absence of any of the features of the Canadian CT Head Rule (≥65 years; ≥2 vomiting episodes, amnesia >30 minutes, pedestrian struck, ejected from vehicle, fall >1 m, suspected skull fracture, or GCS score <15 at 2 hours) had an LR of 0.04 (95% CI, 0-0.65), lowering the probability of severe injury to 0.31% (95% CI, 0%-4.7%). The absence of all the New Orleans Criteria findings (>60 years, intoxication, headache, vomiting, amnesia, seizure, or trauma above the clavicle) had an LR of 0.08 (95% CI, 0.01-0.84), lowering the probability of severe intracranial injury to 0.61% (95% CI, 0.08%-6.0%).Conclusions and Relevance: Combinations of history and physical examination features in clinical decision rules can identify patients with minor head trauma at low risk of severe intracranial injuries. Certain findings, including signs of skull fracture, GCS score of 13, 2 or more vomiting episodes, decrease in GCS score, and pedestrians struck by motor vehicles, may help identify patients at increased risk of severe intracranial injuries. [ABSTRACT FROM AUTHOR]

Imaging has many uses, but in cases of suspected child abuse, radiographs and CT scans are vital in identifying fractures and head injury that may not be clinically obvious. There are growing concerns about the small but potential adverse effects of radiation, including cancer, in the paediatric population as a result of imaging. The vast majority of general paediatricians undertaking child abuse assessments request skeletal surveys and CT scans, subjecting children to significant amounts of radiation. Informed consent must be taken from parents for these procedures and therefore this paper aims to look at evidence of the dangers of radiation in children and raise awareness among paediatricians. [ABSTRACT FROM AUTHOR]

Aim: To describe children referred for suspected abusive head trauma (AHT) to a hospital child protection team in Auckland, New Zealand.Methods: Comparative review of demographics, histories, injuries, investigations and diagnostic outcomes for referrals under 15 years old from 1991 to 2010.Results: Records were available for 345 children. Referrals increased markedly (88 in the first decade, 257 in the second), but the diagnostic ratio was stable: AHT 60%, accidental or natural 29% and uncertain cause 11%. The probability of AHT was similar regardless of socio-economic status or ethnicity. In children under 2 years old with accidental head injuries (75/255, 29%) or AHT (180/255, 71%), characteristics of particular interest for AHT included no history of trauma (88/98, 90%), no evidence of impact to the head (84/93, 90%), complex skull fractures with intracranial injury (22/28, 79%), subdural haemorrhage (160/179, 89%) and hypoxic ischaemic injury (38/39, 97%). In children over 2 years old, these characteristics did not differ significantly between children with accidental head injuries (21/47, 45%) and AHT (26/47, 55%). The mortality of AHT was higher in children over 2 years old (10/26, 38%) than under 2 years (19/180, 11%).Conclusions: The striking increase in referrals for AHT probably represents increasing incidence. The decision to refer a hospitalised child with a head injury for assessment for possible AHT should not be influenced by socio-economic status or ethnicity. Children over 2 years old hospitalised for AHT are usually injured by mechanisms involving impact and should be considered at high risk of death. [ABSTRACT FROM AUTHOR]

Computed tomography (CT) scanning is an essential diagnostic tool and has revolutionized care of patients in the acute care setting. However, there is widespread agreement that overutilization of CT, where benefits do not exceed possible costs or harms, is occurring. The goal was to seek consensus in identifying and prioritizing research questions and themes that involve the comparative effectiveness of "traditional" CT use versus alternative diagnostic strategies in the acute care setting. A modified Delphi technique was used that included input from emergency physicians, emergency radiologists, medical physicists, and an industry expert to achieve this. [ABSTRACT FROM AUTHOR]

Background: Overuse of computed tomography (CT) for minor head injury continues despite developed and rigorously validated clinical decision rules like the Canadian CT Head Rule (CCHR). Adherence to this sensitive and specific rule could decrease the number of CT scans performed in minor head injury by 35%. But in practice, the CCHR has failed to reduce testing, despite its accurate performance. Objectives: The objective was to identify nonclinical, human factors that promote or inhibit the appropriate use of CT in patients presenting to the emergency department (ED) with minor head injury. Methods: This was a qualitative study in three phases, each with interview guides developed by a multidisciplinary team. Subjects were recruited from patients treated and released with minor head injuries and providers in an urban academic ED and a satellite community ED. Focus groups of patients (four groups, 22 subjects total) and providers (three groups, 22 subjects total) were conducted until thematic saturation was reached. The findings from the focus groups were triangulated with a cognitive task analysis, including direct observation in the ED (>150 hours), and individual semistructured interviews using the critical decision method with four senior physician subject matter experts. These experts are recognized by their peers for their skill in safely minimizing testing while maintaining patient safety and engagement. Focus groups and interviews were audio recorded and notes were taken by two independent note takers. Notes were entered into ATLAS.ti and analyzed using the constant comparative method of grounded theory, an iterative coding process to determine themes. Data were double-coded and examined for discrepancies to establish consensus. Results: Five core domains emerged from the analysis: establishing trust, anxiety (patient and provider), constraints related to ED practice, the influence of others, and patient expectations. Key themes within these domains included patient engagement, provider confidence and experience, ability to identify and manage patient anxiety, time constraints, concussion knowledge gap, influence of health care providers, and patient expectations to get a CT. Conclusions: Despite high-quality evidence informing use of CT in minor head injury, multiple factors influence the decision to obtain CT in practice. Identifying and disseminating approaches and designing systems that help clinicians establish trust and manage uncertainty within the ED context could optimize CT use in minor head injury. [ABSTRACT FROM AUTHOR]

Background: There is no clear consensus regarding radiologic evaluation of head trauma in young children without traumatic brain injury. We conducted a study to develop and validate a clinical decision rule to identify skull fracture in young children with head trauma and no immediate need for head tomography.Methods: We performed a prospective cohort study in 3 tertiary care emergency departments in the province of Quebec. Participants were children less than 2 years old who had a head trauma and were not at high risk of clinically important traumatic brain injury (Glasgow Coma Scale score < 15, altered level of consciousness or palpable skull fracture). The primary outcome was skull fracture. For each participant, the treating physician completed a standardized report form after physical examination and before radiologic evaluation. The decision to order skull radiography was at the physician's discretion. The clinical decision rule was derived using recursive partitioning.Results: A total of 811 patients (49 with skull fracture) were recruited during the derivation phase. The 2 predictors identified through recursive partitioning were parietal or occipital swelling or hematoma and age less than 2 months. The rule had a sensitivity of 94% (95% confidence interval [CI] 83%-99%) and a specificity of 86% (95% CI 84%-89%) in the derivation phase. During the validation phase, 856 participants (44 with skull fracture) were recruited. The rule had a sensitivity of 89% and a specificity of 87% during this phase.Interpretation: The clinical decision rule developed in this study identified about 90% of skull fractures among young children with mild head trauma who had no immediate indication for head tomography. Use of the rule would have reduced the number of radiologic evaluations by about 60%. [ABSTRACT FROM AUTHOR]

The aim of this study was to evaluate the imaging findings of head and neck injuries in patients from the Boston Marathon bombing. A total of 115 patients from the Boston Marathon bombing presenting to four hospitals who underwent imaging to evaluate for head and neck injuries were included in the study. Twelve patients with positive findings on radiography or cross-sectional imaging were included in the final analysis. The radiographic, computed tomography (CT), and magnetic resonance (MR) imaging features of these patients were evaluated for the presence of shrapnel and morphological abnormality. Head and neck injuries were seen in 12 out of 115 patients presenting to the four hospitals. There were secondary blast injuries to the head and neck in eight patients, indicated by the presence of shrapnel on imaging. In the four patients without shrapnel, there were two with subgaleal hematomas, one with facial contusion and one with mastoid injury. There were two patients with subarachnoid hemorrhage, one with brain contusion, one with cerebral laceration, and one with globe rupture. There was frontal bone, nasal bone, and orbital wall fracture in one patient each. Imaging identified 26 shrapnel fragments, 21 of which were ball bearings. Injuries to the head and neck region identified on imaging from the Boston Marathon bombing were not common. The injuries seen were predominantly secondary blast injuries from shrapnel, and did not result in calvarial penetration of the shrapnel fragments. [ABSTRACT FROM AUTHOR]

Over the past 60 years, the diagnosis of abuse in children has been challenged within both the medical and the legal communities. Nowhere has this been more apparent than in the literature addressing abusive head trauma in infants and children. The diagnostic terminology used currently, while more encompassing than terminology used in the past, has contributed to confusion about the strength of scientific evidence for inflicted injuries. Fortunately, a variety of medical disciplines, including pediatrics, emergency medicine, radiology, ophthalmology, pathology, biomechanics, neurosurgery, and neurology, have contributed to an unprecedented growth in our understanding of inflicted head trauma in children. We can now confirm that abusive head trauma does occur, that it is the leading cause of traumatic death in children under 2 years of age, that it has a characteristic clinical presentation and injury pattern, and that it can involve a variety of different injury mechanisms. Awareness of these mechanisms and rigorous efforts to ensure comprehensive clinical assessments will best inform the diagnostic process. Being able to identify abusive head trauma and finding answers to the challenging questions that remain, including how to mitigate damage when a young patient presents with head trauma, will lead ultimately to improvements in both outcomes and prevention. [ABSTRACT FROM AUTHOR]

The article focuses on the impoct of traumatic brain injury (TBI) as a cause of death and morbidity among children, according to the U.S. Centers for Disease Control and Prevention. Topics discussed include the importance of early diagnosis and management of TBI, guidelines regarding the return to normal activities and athletic participation, and use of computed tomography (CT) scanning.

Abusive head trauma is a serious form of child abuse and mostly seen in infants below the age of two years as a result of a strong shaking by the caregiver who aims to stop the infant's crying. Characteristic symptoms include subdural hematomas, encephalopathy, retinal hemorrhages and fractures of the long bones. When physically examined, there are generally no externally visible signs. For this reason, it can be underdiagnosed, if it is not considered in the differential diagnosis. When the information provided from the parents is inconsistent and contradictory with the clinical picture of the patient, this form of abuse must be suspected and retinal hemorrhages should be searched. In this article, two patients who were admitted to our emergency department and diagnosed with physical child abuse are reported. One of these patients had a history of minor head trauma after falling down from the sofa and the other one had a history of breathlessness and loss of consciousness as a result of excessive crying. [ABSTRACT FROM AUTHOR]

Existing helmet sensor technologies are cost prohibitive or limited in capability to comprehensively assess sports-related head injury. Therefore, development of an accurate, fully compatible low-cost pressure-sensitive sensor is warranted. The aim was to develop a piezo-resistive sensor platform for direct measurement of HIC. Using a programmable microcontroller and 30x35 mm sensor, fifty drop tests with a 5 kg mass were conducted using a Kistler force plate with maximum vertical force of 5000 N. The Power function correlation between force-plate-derived peak force and sensor-derived peak resistance was high (r 2 = 0.974) and used to calculate sensor-derived force-time data. Analysis of force-time curves yielded comparable peak forces (R = 0.982) and time to peak forces (R = 0.938), yet sensor-derived impact durations were elevated (R = 0.498). High linear correlation was found between force-plate- and sensor-derived HIC (r 2 = 0.974). The force plate-derived HIC can be directly estimated with sufficient accuracy from sensor-derived force (r 2 = 0.980) and a residual standard deviation of 11% at HIC >100. Overall, results substantiated the piezo-resistive sensor platform for direct HIC measurement and development of a full-scale helmet system. [ABSTRACT FROM AUTHOR]

BACKGROUND AND OBJECTIVES: Abusive head trauma (AHT) may be missed in the clinical setting. Clinical prediction tools are used to reduce variability in practice and inform decision-making. From a systematic review and individual patient data analysis we derived the Predicting Abusive Head Trauma (PredAHT) tool, using multilevel logistic regression to predict likelihood of AHT. This study aims to externally validate the PredAHT tool. METHODS: Consecutive children aged <36 months admitted with an intracranial injury, confirmed as abusive or nonabusive, to 2 sites used in the original model were ascertained. Details of 6 influential features were recorded (retinal hemorrhage, rib and long -bone fractures, apnea, seizures, and head or neck bruising). We estimated the likelihood of an unrecorded feature being present with multiple imputation; analysis included sensitivity, specificity, and area under the curve, with 95% confidence intervals (CIs). RESULTS: Data included 133 non-AHT cases and 65 AHT cases, 97% of children were <24 months old. Consistent with original predictions, when ≥3 features were present in a child <36 months old with intracranial injury, the estimated probability of AHT was >81.5% (95% CI, 63.3-91.8). The sensitivity of the tool was 72.3% (95% CI, 60.4-81.7), the specificity was 85.7% (95% CI, 78.8-90.7), area under the curve 0.88 (95% CI, 0.823-0.926). CONCLUSIONS: When tested on novel data, the PredAHT tool performed well. This tool has the potential to contribute to decision-making in these challenging cases. An implementation study is needed to explore its performance and utility within the child protection process. [ABSTRACT FROM AUTHOR]

Primary objective: Many Veterans involved in recent OEF/OIF conflicts return with reports of having experienced an mTBI. The Veteran’s Affairs (VA) and Department of Defense (DoD) have gone to great lengths to provide information to Veterans regarding possible effects of TBI. Although well intended, this information may possibly have an iatrogenic effect. Conversely, setting positive expectations for recovery from mTBI has been shown to result in decreased symptomatology. Research design: One-way ANOVA and Tukey post-hoc analyses were used to determine whether there were significant differences on reported severity and number of PCS symptoms (NSI) among the three experimental groups (recovery focused information; expectation for persistent symptoms; and no information given). Methods and procedures: Undergraduate students, who were told to imagine they had experienced a military-related TBI, reported varying levels of expected symptoms when given either positive or negative information about symptom expectation. Main outcomes and results: The results indicate that presenting recovery-oriented literature resulted in the lowest report of expected symptoms, whereas presenting no information resulted in the highest report of expected symptoms. Conclusions: Providing Veterans with information regarding a likely positive trajectory of recovery may result in less symptom persistence during rehabilitation. [ABSTRACT FROM PUBLISHER]

Objective: To provide new information on properties of skateboarders who were hospital admitted with head injuries with details of the injuries including region of head impact. Methods: Hospital records of patients aged 15 and older with a skateboard injury admitted to one Level II Trauma Centre during a 10-year period were reviewed. Data on demographic, exposure, severity, diagnostic and clinical factors for patients with head injury (HI) and without HI (N-HI) were compared analytically. Results: While there were no differences for patients with HI and N-HI by age, gender, mechanism of injury or alcohol use, patients with HI were more severely injured. Although significantly more head impacts occurred to the occipital region of the head, haematomas and/or contusions were much more likely to occur in the frontal region of the brain. Acute neurosurgical intervention was needed in 14% of HI skateboarders. Conclusion: Skateboarding is not an innocuous recreational activity, with head injury present in 75% of patients who were hospital-admitted. Pre-hospital treatment protocols should be aware of this growing injured population. Falls while on a skateboard lead to impacts to the back of head with a contra-coup brain injury resulting in severe and sometimes fatal outcomes. The very low prevalence of helmet use among skateboarders with head injuries indicates that greater efforts should be directed toward incentives for their use. [ABSTRACT FROM PUBLISHER]

Background: We sought to investigate the incidence of abdominal injuries in "found down" trauma patients to better understand the value of emergency department (ED) imaging. Found down patients are at high risk for injuries to the head or neck and low risk to the abdomen or pelvis, so imaging with CT of the abdomen/pelvis (AP) or Focused Assessment with Sonography for Trauma (FAST) is of questionable value. Study Design: The trauma registry was queried over a 10-year period ending December 2013 for found down patients. Demographics, CT AP, FAST scans, and injuries were abstracted from the trauma registry and then through a confirmatory chart review. The primary outcome was significant abdominal or pelvis injury, defined as abdomen/pelvis Abbreviated Injury Scale (AIS) ≥ 3 or an abdominal injury that required operative intervention. The secondary outcome was mortality due to abdominal injury. Results: Of the 342 patients who met inclusion criteria, mean Glasgow Coma Scale (GCS) was 11.0, and 189 (60%) of those tested for alcohol were intoxicated. Abdominal imaging included: CT AP only, 88 (57%); FAST only, 37 (24%); and CT AP and FAST, 29 (19%). Neither CT AP nor FAST scan led to a change in treatment and no patient had abdomen/pelvis AIS ≥ 3. Overall mortality was 33 (10%).The 24 trauma deaths were attributed to serious head trauma (n = 16) or traumatic arrest in the ED (n = 8); the 9 medical deaths were due to cerebral vascular accident (n = 5) or sepsis (n = 4). Conclusions: Although patients found down have a high mortality, abdominal injuries identified by imaging are highly unlikely. Efforts should focus on rapidly identifying and treating other causes of mortality, especially trauma to the head and neck, or medical diagnoses such as cerebral vascular accident or sepsis. [ABSTRACT FROM AUTHOR]

Objectives Concussion is the most common type of mild traumatic brain injury for which patients present to the emergency department ( ED). It is critical to understand the contemporary epidemiology of concussion and rates of head computed tomography ( CT) use in head-injured patients to inform education of evidence-based clinical practice guidelines to emergency medicine providers. Methods This was a cross-sectional analysis of the Nationwide Emergency Department Sample ( NEDS) for years 2006 to 2011, representing a stratified probability sample of all U.S. hospital-based EDs. Patients of all ages with concussion diagnoses were included, and those with intracranial hemorrhages or prolonged loss of consciousness were excluded. Descriptive and bivariate statistics were summarized for patient demographics, injury mechanism, Injury Severity Scores ( ISS), and concussion incidence rates, based on U.S. Census Bureau population estimates. Results There were 756,214,762 (weighted) ED visits in the NEDS between 2006 and 2011, of which 0.5% received diagnoses of concussion. The national incidence rate of concussion visits increased 22.6% from 195 visits per 100,000 person-years in 2006 to 239 visits per 100,000 person-years in 2011. The incidence of concussion visits increased by 28.1% from 2006 to 2011 overall (580,573 to 743,994) and within all age group categories. The rate of head CT use in patients diagnosed with concussion increased 35.7% (range = 34.5% to 46.8%) for the entire group from 2006 to 2011 (p < 0.0001). The injury severity of patients' injuries decreased over time (66.4% ISS < 5 in 2006 and 75% in 2011; p < 0.0001), while the proportion of discharged patients increased over time (78.1% in 2006 and 86.6% in 2011; p < 0.0001). Conclusions ED visits for concussions have increased over time, with a corresponding increase in head CT utilization despite a decrease in injury severity. Increased visits may be due to more concussion awareness and recognition of subtle injuries. Evidence-based clinical practice guidelines for neuroimaging in head-injured patients and management of concussion should be reinforced to emergency medicine providers. [ABSTRACT FROM AUTHOR]

Shared decision-making ( SDM), a collaborative process in which patients and providers make health care decisions together, taking into account the best scientific evidence available, as well as the patient's values and preferences, is being increasingly advocated as the optimal approach to decision-making for many health care decisions. The rapidly paced and often chaotic environment of the emergency department ( ED), however, is a unique clinical setting that offers many practical and contextual challenges. Despite these challenges, in a recent survey emergency physicians reported there to be more than one reasonable management option for over 50% of their patients and that they take an SDM approach in 58% of such patients. SDM has also been selected as the topic on which to develop a future research agenda at the 2016 Academic Emergency Medicine consensus conference, 'Shared Decision-making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda' (). In this paper the authors describe the conceptual model of SDM as originally conceived by Charles and Gafni and highlight aspects of the model relevant to the practice of emergency medicine. In addition, through the use of vignettes from the authors' clinical practices, the applicability of SDM to contemporary EM practice is illustrated and the ethical and pragmatic implications of taking an SDM approach are explored. It is hoped that this document will be read in advance of the 2016 Academic Emergency Medicine consensus conference, to facilitate group discussions at the conference. [ABSTRACT FROM AUTHOR]

Objective--To review results of MRI performed within 48 hours after head trauma in dogs and identify associations between MRI findings and outcome. Design--Retrospective case series. Animals--18 dogs that underwent MRI within 48 hours after known head trauma. Procedures--Medical records were reviewed for information on signalment, history, clinical findings, MRI findings, treatment, and outcome. Results--2 dogs were euthanized, 1 died, and 1 had major persistent deficits. The remaining 14 dogs had a good outcome, including 9 that recovered completely and 5 that had minor persistent deficits. The most common MRI abnormalities were intra-axial changes (n = 13) and extra-axial hemorrhage (13). Intra-axial changes were best seen on T2-weighted and fluid attenuation inversion recovery (FLAIR) images. A mass effect was detected in 9 dogs, 6 of which had a midline shift (mean, 2.18 mm). Three dogs had transtentorial herniation, and 2 had transcranial herniation. Extra-axial hemorrhage was best seen on FLAIR images. The most common location was subdural, with subdural extra-axial hemorrhage most often seen on the same side as the injury. Epidural hemorrhage was seen in 2 dogs. The affected area was larger in these dogs than in dogs with subdural hemorrhage. One dog required surgery and the other was euthanized. Conclusions and Clinical Relevance--Results suggested that in dogs with acute (< 48 hours' duration) head trauma,T2-weighted and FLAIR images provided the most diagnostic information. Dogs with injuries affecting the caudal fossa or affecting both the rostral and caudal fossae typically had poorer outcomes. [ABSTRACT FROM AUTHOR]

Background Computed tomography ( CT) utilization has increased rapidly over the past 15 years. CT is the most common source for radiation exposure. Objectives The objective was to measure the effective dose of radiation delivered during routine head and abdominal CT examinations at a children's hospital. Methods This was a retrospective study of emergency department ( ED) patients < 20 years of age who underwent head or abdominal CT scans in 2012 at a single children's hospital. The authors abstracted the dose-length product from the CT scanners and calculated the effective radiation dose delivered. Patient demographics were abstracted from the medical record. The relationship between effective dose and age, patient weight, and reason for examination were evaluated. Results A total of 478 subjects were included: 255 underwent head CT, and 223 underwent abdominal CT. The median age was 8.1 years (interquartile range = 2.71 to 14.40 years) and 56.9% were male. The median effective dose for head CT was 2.68 mSv (95% confidence interval [ CI] = 2.54 to 2.84 mSv) and decreased as age increased. For abdominal CT, the median effective dose was 5.06 mSv (95% CI = 4.58 to 6.03 mSv) and increased as age increased (3.67 to 11.12 mSv, p < 0.001). For abdominal CT, 8% of 5- to 10-year-olds, 28% of those 10 to 15 years, and 60% of patients over age 15 years received effective doses over 10 mSv. Conclusions The amount of radiation delivered to pediatric patients during routine CT examinations of the head and abdomen was low. Regardless, a large proportion of older patients were exposed to elevated effective doses of radiation during abdominal CT. [ABSTRACT FROM AUTHOR]

The article discusses the National Institute for Health and Clinical Excellence (NICE) guidelines on the management of head injury in children, young people and adults in Great Britain. Topics covered include the establishment of computed tomography (CT) scan as the primary imaging modality in head injury in the updated 2007 NICE guidelines, some terminology regarding safeguarding children included in the guideline, and the risk factors of a head injury.

Objective: To analyze the correlation between early-term blood glucose level and prognosis in patients with isolated head trauma. Methods: This study included a total of 100 patients younger than 18 years of age who had isolated head trauma. The admission blood glucose levels of these patients were measured. Age at the time of the incident, sex, mode of occurrence of the trauma, computed tomography findings, and GCSs were recorded. Kruskall Wallis test was used compare of groups. A p value less than 0.05 was considered statistically significant. Results: The median age of the study population was 7 years and the median GCS was 11. There was a significant negative correlation between blood glucose level and GCS (p < 0.05). A significant correlation in the negative direction was observed between GCS and blood glucose level (r = −0.658, p < 0.05). Seventy-seven percent of the patients were admitted to hospital, while 6% died in ED. Conclusion: The results of the present study suggest that hyperglycemia at an early stage and a low GCS may be reliable predictors of the severity of head trauma and prognosis. A higher blood glucose level may be an ominous sign that predicts a poor prognosis and an increased risk of death. [ABSTRACT FROM AUTHOR]

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The article presents a case study of a 5-month-old boy with nonbloody, nonbilious emesis after every meal. Topics discussed include abnormal eye movements and inconsolable fussiness has been reported and was diagnosed with right eye esotropia and bulging fontanelle; computed tomography scan of his head revealed bilateral subdural fluid collections and increased intracranial pressure; and diagnosis of nonaccidental trauma.

The article investigates the role of the triad in medical research of suspected traumatic shaking. It highlights the reviews on the diagnosis of abusive head trauma (AHT) as well as the increasing body of literature concerning the AHT condition. Also emphasized are the significant concerns of medical research methodology, objectivity and transparency.