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Intracranial Hemorrhage After Blunt Head Trauma in Children with Bleeding Disorders

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Intracranial Hemorrhage After Blunt Head Trauma in Children with Bleeding Disorders Intracranial Hemorrhage after Blunt Head Trauma in Children with Bleeding Disorders Lois K. Lee, MD, MPH, Peter S. Dayan, MD, MSc, Michael J. Gerardi, MD, Dominic A. Borgialli, DO, MPH, Mohamed K. Badawy, MD, James M. Callahan, MD, Kathleen A. Lillis, MD, Rachel M. Stanley, MD, Marc H. Gorelick, MD, MSCE, Li Dong, MSc, Sally Jo Zuspan, RN, MSN, James F. Holmes, MD, MPH, and Nathan Kuppermann, MD, MPH, and the Traumatic Brain Injury Study Group for the Pediatric Emergency Care Applied Research Network (PECARN) Objective To determine computerized tomography (CT) use and prevalence of traumatic intracranial hemorrhage (ICH) in children with and without congenital and acquired bleeding disorders. Study design We compared CT use and ICH prevalence in children with and without bleeding disorders in a mul- ticenter cohort study of 43 904 children <18 years old with blunt head trauma evaluated in 25 emergency depart- ments. Results A total of 230 children had bleeding disorders; all had Glasgow Coma Scale (GCS) scores of 14 to 15. These children had higher CT rates than children without bleeding disorders and GCS scores of 14 to 15 (risk ratio, 2.29; 95% CI, 2.15 to 2.44). Of the children who underwent imaging with CT, 2 of 186 children with bleeding disor- ders had ICH (1.1%; 95% CI, 0.1 to 3.8) , compared with 655 of 14 969 children without bleeding disorders (4.4%; 95% CI, 4.1-4.7; rate ratio, 0.25; 95% CI, 0.06 to 0.98). Both children with bleeding disorders and ICHs had symp- toms; none of the children required neurosurgery. Conclusion In children with head trauma, CTs are obtained twice as often in children with bleeding disorders, although ICHs occurred in only 1.1%, and these patients had symptoms. Routine CT imaging after head trauma may not be required in children without symptoms who have congenital and acquired bleeding disorders. (J Pediatr 2011;158:1003-8). ntracranial hemorrhage (ICH) is a significant and potentially life-threatening Icomplication for children with congenital or acquired bleeding disorders.1-9 There is evidence that these children are at increased risk for sustaining ICH From the Department of Pediatrics, Harvard Medical even after minor blunt head trauma.2,6,10 Studies in children with hemophilia School, Boston, MA (L.L.); Department of Pediatrics, Columbia University College of Physicians and have reported ICH rates of 2% to 16% after head trauma, including some children Surgeons, New York, NY (P.D.); Department of Emergency Medicine, Atlantic Health System, with no signs or symptoms of trauma. The risk of ICH varies with the severity of Morristown Memorial Hospital, Morristown, NJ (M.Gerardi); Department of Emergency Medicine, hemophilia, and children with severe hemophilia (factor level <1%) are at highest University of Michigan School of Medicine and Hurley 2,10-13 risk, from spontaneous and traumatic ICH. Although there are few studies Medical Center, Flint, MI (D.B.); Departments of Emergency Medicine and Pediatrics, University of on the risk of ICH after head trauma in children with von Willebrand disease, they Rochester School of Medicine and Dentistry, Rochester, 2,12,14 NY (M.B.); Departments of Emergency Medicine and seem to be at less risk than children with hemophilia. Pediatrics, SUNY-Upstate Medical University, Syracuse, The risk of ICH in patients with other congenital and acquired bleeding dis- NY (J.C.); Department of Pediatrics and Emergency 1,2,15 Medicine, SUNY-Buffalo School of Medicine and orders is less well described. In patients with immune (idiopathic) thrombo- Biomedical Sciences, Buffalo, NY (K.L.); Department of Emergency Medicine, University of Michigan School of cytopenic purpura (ITP), ICH, including spontaneous and traumatic, is rare, Medicine, Ann Arbor, MI (R.S.); Department of Pediatrics, 1,9,16,17 Medical College of Wisconsin, Milwaukee, WI with a reported incidence of 0.1% to 1.0%. However, the prevention of (M.Gorelick); Department of Pediatrics, University of ICH has been a primary goal in the management of ITP, because ICH risk cor- Utah and PECARN Central Data Management and 1,4,17 Coordinating Center, Salt Lake City, UT (L.D., S.Z.); and relates with the severity of thrombocytopenia. The ICH risk in patients who Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA (J.H., have taken anti-coagulants has only been reported in adults, with differing con- N.K.) 18-22 clusions about the risk of anti-coagulation therapy. List of members of the Traumatic Brain Injury Study Group for the Pediatric Emergency Care Applied Research Network (PECARN) available at www.jpeds. com (Appendix). Supported by a grant from the Health Resources and Services Administration/Maternal and Child Health Bu- reau, Division of Research, Education, and Training, and CT Computerized tomography the Emergency Medical Services of Children program (R40MC02461). The Pediatric Emergency Care Applied ED Emergency department Research Network is supported by cooperative agree- GCS Glasgow Coma Scale ments U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008 from the Emergency ICH Intracranial hemorrhage Medical Services of Children program of the Health Re- ITP Immune (idiopathic) thrombocytopenic purpura sources and Services Administration/Maternal and Child LOC Loss of consciousness Health Bureau, Division of Research. The authors declare no conflicts of interest. PECARN Pediatric Emergency Care Applied Research Network RR Rate ratio 0022-3476/$ - see front matter. Copyright ª 2011 Mosby Inc. All rights reserved. 10.1016/j.jpeds.2010.11.036 1003 THE JOURNAL OF PEDIATRICS www.jpeds.com Vol. 158, No. 6 The objectives of this study were to determine the fre- other 110 were excluded from this study because they did quency of computerized tomography (CT) imaging after not meet the criteria for having a congenital or acquired blunt head trauma in children with bleeding disorders com- bleeding disorder at the time of the head injury. Patients pared with children without bleeding disorders, and the prev- with hemophilia were categorized according to type of factor alence of ICH in these children. deficiency and severity (mild, moderate, or severe). For chil- dren with thrombocytopenia, platelet counts at the time of the ED evaluation were obtained, when available from the Methods medical record. Hospital admission was at the discretion of the treating ED This was an a priori planned substudy conducted as part of physician. To determine the clinical outcomes of the patients a larger prospective cohort study to derive and validate a neu- hospitalized for their head trauma, we performed a medical roimaging decision rule for children after blunt head record review, and data were recorded on a structured case trauma.23 The study was approved by the institutional review report form. For children discharged home from the ED, boards at all participating institutions. Written or verbal con- a follow-up telephone call was conducted by trained research sent for this observational study was obtained at each institu- coordinators between 1 week and 3 months after the ED visit tion as required by their institutional review boards. to determine whether the patient had an unscheduled return The study was conducted in 25 emergency departments visit to a healthcare provider and whether any cranial imag- (EDs) participating in the Pediatric Emergency Care Applied ing was performed after their initial ED visit. When a missed Research Network (PECARN).24,25 Children <18 years old traumatic brain injury was suggested at follow-up, the med- who were evaluated for blunt head trauma resulting from ical records and imaging results were obtained and reviewed, non-trivial mechanisms within 24 hours of injury at any of and the patient’s outcome was recorded. When telephone the participating EDs between June 2004 and September follow-up was not available, we mailed a follow-up survey 2006 were eligible for the main study.23 Congenital or ac- or reviewed the medical record, quality improvement re- quired bleeding disorder was defined as hemophilia, von Wil- ports, trauma registries, or morgue reports at the respective lebrand disease, congenital or acquired thrombocytopenia sites to obtain any missing clinical information.23 (defined as platelet count <150 000/mL), a functional platelet The primary outcomes were rates of CT use and presence disorder, other bleeding disorder, or anti-coagulation therapy of an ICH on CT, as reported by an attending radiologist. (warfarin, heparin, low molecular weight heparin/enoxa- ICHs included epidural hematomas, subdural hematomas, parin, clopidogrel). Patients were excluded from both the intraventricular hemorrhages, cerebral contusions, cerebral/ main study and this substudy when they had: (1) trivial mech- cerebellar hemorrhages, subarachnoid hemorrhages, or trau- anisms of injury (falls from standing height, walking, or run- matic infarctions. ning into stationary object) and (2) no signs or symptoms of head injury besides a scalp laceration or abrasion. Patients Data Analysis were also excluded from both studies when they sustained We tabulated basic descriptive information for children with penetrating trauma, when the injury occurred >24 hours be- and without bleeding disorders for the entire study popula- fore the ED evaluation, when they had a pre-existing neuro- tion. Because all the children with bleeding disorders pre- logical disease, known brain tumor, or history of ventricular sented with Glasgow Coma Scale (GCS) scores of 14 or
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