Brian F Flaherty1, Hannah E Moore2, Jay Riva-Cambrin3, Susan L Bratton4. 1. University of Utah, Department of Pediatrics, Division of Critical Care, Salt Lake City, UT 84108. Electronic address: brian.flaherty@hsc.utah.edu. 2. University of Southern California, Keck School of Medicine, Los Angeles, CA 90033. 3. University of Calgary, Department of Clinical Neurosciences, Section of Neurosurgery, Alberta Children's Hospital, Calgary, AB T3B 6A8. 4. University of Utah, Department of Pediatrics, Division of Critical Care, Salt Lake City, UT 84108.
Abstract
BACKGROUND: Although some pediatric patients with small traumatic epidural hematoma (EDH) are observed without surgical drainage, clinical practice remains variable. OBJECTIVES: Create a prediction rule to identify patients with EDH unlikely to fail hospital observation. METHODS: Retrospective review at a level I pediatric trauma center between 2003 and 2014. Presenting clinical and radiographic features were compared between those successfully to failed observation. RESULTS: Two hundred twenty-two patients with EDH whose initial management strategy was observation were analyzed; 196 (88%) were successfully observed. The group failing observation was more likely to present with altered mental status (RR 18.8; 95% CI 8.7-49.6), has larger median bleed thickness (observed = 5.6mm versus failed observation = 10.9mm, p<0.01), median bleed volume (observed = 2.1ml versus failed observation = 15.7ml, p<0.01), and mass effect (RR 3.7; 95% CI 1.8-7.7). No mass effect, EDH volume<15ml, and no neurologic deficits predicted patients at low risk of failing observation with a positive predictive value of 98% (95% CI 93-99%). There was no difference in median discharge Glasgow outcome scores (5 in both groups, p=0.20). CONCLUSION: Patients with no mass effect and EDH volume <15ml on initial CT scan and no neurologic deficit are at low risk of failing observation. LEVEL OF EVIDENCE: Retrospective cohort level I.
BACKGROUND: Although some pediatric patients with small traumatic epidural hematoma (EDH) are observed without surgical drainage, clinical practice remains variable. OBJECTIVES: Create a prediction rule to identify patients with EDH unlikely to fail hospital observation. METHODS: Retrospective review at a level I pediatric trauma center between 2003 and 2014. Presenting clinical and radiographic features were compared between those successfully to failed observation. RESULTS: Two hundred twenty-two patients with EDH whose initial management strategy was observation were analyzed; 196 (88%) were successfully observed. The group failing observation was more likely to present with altered mental status (RR 18.8; 95% CI 8.7-49.6), has larger median bleed thickness (observed = 5.6mm versus failed observation = 10.9mm, p<0.01), median bleed volume (observed = 2.1ml versus failed observation = 15.7ml, p<0.01), and mass effect (RR 3.7; 95% CI 1.8-7.7). No mass effect, EDH volume<15ml, and no neurologic deficits predicted patients at low risk of failing observation with a positive predictive value of 98% (95% CI 93-99%). There was no difference in median discharge Glasgow outcome scores (5 in both groups, p=0.20). CONCLUSION:Patients with no mass effect and EDH volume <15ml on initial CT scan and no neurologic deficit are at low risk of failing observation. LEVEL OF EVIDENCE: Retrospective cohort level I.
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