Factors influencing ED care of young children at-risk for clinically important traumatic brain injury.

OBJECTIVES: Care decisions for young children presenting to the emergency department (ED) with head injury are often challenging (e.g. whether to obtain neuroimaging). We sought to identify factors associated with acute management of children at-risk for clinically important traumatic brain injury (ciTBI) and describe symptom management.

METHODS: Observational evaluation of children, ages 0-4years, presenting to a pediatric ED following minor head injury. Children with ≥1 risk element per the Pediatric Emergency Care Academic Research Network's decision rule were deemed "at-risk" for ciTBI. Clinician surveys regarding their initial clinical management were used to identify three care groups. Nonparametric tests analyzed group differences and logistic regression investigated associations of putative high-risk factors with neuroimaging.

RESULTS: Of 104 children enrolled: (i) 30 underwent neuroimaging, (ii) 59 were observed, and (iii) 15 were discharged following the clinician's initial patient exam. Children with a non-frontal scalp hematoma were more likely to receive immediate neuroimaging and children not acting like themselves per caregiver report were more likely to be initially observed, relative to the other care groups (p≤0.01). Among high-risk factors, altered mental status (OR 5.12, 95% CI 1.8-21.1), presence of ≥3 risk elements of the decision rule (OR 3.5, 95% CI 1.2-10.6), unclear skull fracture on exam (OR 31.3, 95% CI 5.4-593.8), and age<3months (OR 5.3, 95% CI 1.5-21.9) were associated with neuroimaging. No child had ciTBI. TBI symptoms (e.g. vomiting) were infrequently treated.

CONCLUSIONS: ED management varied for young children with similar risk stratification. Investigation of how age in concert with specific risk factors influences medical decision making would advance evidenced-based care.