The turnout of head trauma in children in our emergency department is slightly higher than other published series with the same age distribution [28].
Some children had dynamic criteria for major trauma, while presenting a clinical picture of mild TBI. The emergency doctor promptly assessed the cases and decided examinations and consultations to be requested in a timely manner. The combined experiences of the emergency physician and the neurosurgeon were certainly helpful in making the protocol safe.
The adoption of PECARNE algorithm has allowed realization of a low number of CT scan compared to that reported in the literature.
The challenge of research during these recent years has the objective to develop, on the basis of original studies, decision-making tools composed by a set of clinical variables obtained from the history and clinical examination in order to predict more accurately the risk of a determined outcome (intracranial lesion) and therefore to guide subsequent clinical decisions named "Clinical Decision Rules (CDR)" [29, 30]. These predictive methods are heterogeneous and therefore hardly comparable.
However, the increasing use of brain CT has been accompanied to a growing concern about the radiation risk, to which children are particularly exposed due to the greater sensitivity of their tissues to radiation and for the long life expectancy in which oncogenic damage from radiation can express itself with a demonstrated higher incidence of leukemia, brain tumors and other solid tumors [31–37].
When the risk is very high as in major trauma (risk > 20%), brain CT is always indicated. Hennelly et al. calculated the optimal threshold of benefit of a CT for a risk of intracranial injury equal to 4.8%. In children where the risk approaches or exceeds 5% it is strongly recommended to perform CT first. The use of CT is also strongly recommended in all cases where significant clinical deterioration is evident. On the other hand, there is no indication to perform a CT in children with lower risk
It was observed that only 10% of skull radiographs and CT scans were positive for a skull fracture, requiring hospitalization in half of these patients.
Among the currently available scores that specify the criteria for performing a CT scan in infants with head trauma, the PECARN score can be considered today the most reliable [38–40]. Using the PECARN TBI algorithm we had a low incidence of CT scans compared to that known in the literature [41–43].
The univariate and multivariate analyzes have shown how the protocol is very protective towards younger patients (< 2 years old). Unsurprisingly, the most urgent triage codes (1 and 2) have an increased likelihood of CTs because those patients who had a more complex dynamics or severe symptoms. The risk of bleeding appears greater and for this reason they are more likely to undergo CTs.
We wondered if a protocol that includes observation could contribute to the increase in hospital crowding [7–14, 19, 22, 24, 44, 45].
The adoption of the PECARNE TBI algorithm in our ED did not increase crowding. The access times to the visit are in fact congruent with the Italian ministerial indications and comparable to the others on (Linee di indirizzo nazionali sul triage intraospedaliero Linee di indirizzo nazionali sul triage intraospedaliero A cura di Ministero della salute Anno 2019). Process times were within the 4–6-hour limit recommended by various scientific societies [46, 47]. The boarding rate was very low, and no patients experienced exit blocks. The hospital observation for these patients, with a dedicated observation unit, allows the containment of crowding allowing a net reduction in the number of CT scans performed. A well-organized path with dedicated spaces has allowed effective management that does not increase crowding.
Symptoms, especially for children under 2 years of age, are extremely vague and difficult to pick up. In fact, it emerges that the most frequent symptoms are pain and headache. If the unreliability of anamnestic data in the ED is already known in adults, in cases of pediatric trauma it is even more frequent [48]. There is difficulty of telling the child about the incident and the symptom because they are too young to express themselves or because of fear. It also to get information from accompanying adults who is not always the one who was present at the head injury especially for children of a few months, parental emotionality can prevail.
The majority of mild head injuries in our reality occur in a home or recreational setting.
In more than half of the cases a neurosurgical consultation was requested, while in a few cases radiological examinations were necessary.
The need for hospitalization and surgical intervention was little less than in other cases reported [28]. This data, together with the fact that there have been no ED return visits, we consider that the algorithm is extremely safe. Our hospital has the only Emergency Department in the city and the only one with neurosurgery and CT scans active 24 hours a day; this data further emphasizes the security of the revisit data, albeit retrospective.
The fact that the number of visits to our center was greater than in the cases already mentioned, and the not negligible percentage of patients who leave before the conclusion, could suggest that in our region there is a greater propensity to bring the child with head trauma in the emergency room, perhaps also due to a reduced rapid availability of free-choice pediatrics in the area.