Ultrasound evaluation of skull fractures in children: a feasibility study.
ABSTRACT The objective of this study was to investigate feasibility and evaluate test characteristics of bedside ultrasound for the detection of skull fractures in children with closed head injury (CHI).
This was a prospective, observational study conducted in a pediatric emergency department of an urban tertiary care children's hospital. A convenience sample of children younger than 18 years were enrolled if they presented with an acute CHI, and a computed tomography (CT) scan was performed. Ultrasound was performed by pediatric emergency medicine physicians with at least 1 month of training in bedside ultrasound. Ultrasound interpretation as either positive or negative for the presence of skull fracture was compared with attending radiologist CT scan dictation. Test characteristics (sensitivity, specificity, and positive and negative predictive values) were calculated.
Forty-six patients were enrolled. The median age was 2 years (range, 2 months to 17 years). Eleven patients (24%) were diagnosed with skull fractures on CT scan. Bedside ultrasound had a sensitivity of 82% (95% confidence interval [CI], 48%-97%), specificity of 94% (95% CI, 79%-99%), positive predictive value of 82% (95% CI, 48%-97%), and negative predictive value of 94% (95% CI, 79%-99%).
Bedside ultrasonography can be used by pediatric emergency medicine physicians to detect skull fractures in children with acute CHI. Larger studies are needed to validate these findings. Future studies should investigate the role of this modality as an adjunct to clinical decision rules to reduce unnecessary CT scans in the evaluation of acute CHI in children.
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ABSTRACT: To determine the accuracy of diagnosing appendicitis in the pediatric population by using graded compression ultrasonography. Retrospective case review. University-affiliated community hospital with an emergency department census of approximately 19,000 pediatric visits per year. Ninety-eight children (age less than 13 years) with clinically suspected appendicitis who had graded compression sonographic studies during the 24-month study period. Medical records were reviewed for patient demographics, presenting signs and symptoms, sonographic findings, surgical results, and hospital course. Patients who did not undergo surgery were followed up by telephone for a minimum of two months. Ninety-eight children (42 boys and 56 girls; age range, 2 to 12 years; mean age, 8.0 years) with clinical signs and symptoms of acute appendicitis were examined sonographically. Of the 26 patients whose appendicitis was verified at surgery, ultrasound was positive in 22, with an overall sensitivity of 85%. Of the 72 patients who did not have appendicitis, ultrasound was negative in 68, with a specificity of 94%. Two patients with false-positive ultrasound went to surgery and were found to have acute ileitis and perforated Meckel's diverticulum. The overall diagnostic accuracy was 91.8% (90 of 98). Use of ultrasound to diagnose acute appendicitis was performed with a sensitivity of 85% and a specificity of 94%. This allows the same accuracy in children as has been reported with adults.Annals of Emergency Medicine 08/1993; 22(7):1125-9. · 4.29 Impact Factor
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ABSTRACT: We evaluate the effect of a modification of the University of California-Davis Pediatric Head Injury Rule on the ability of the decision instrument for pediatric head injury to predict clinically important intracranial injury in an external cohort. We analyzed data prospectively recorded in 1,666 pediatric patients enrolled in the derivation set of the National Emergency X-Radiography Utilization Study II (NEXUS II). Treating physicians at 21 emergency departments recorded the presence or absence of clinical predictors on all patients who received a head computed tomography (CT) scan after experiencing blunt head trauma. Predictors included 3 exact elements of the University of California-Davis Rule (abnormal mental status, signs of skull fracture, and scalp hematoma in children < or = 2 years of age), some with different wording, and 2 modified elements with new definitions (the presence of high-risk vomiting or severe headache, rather than any vomiting or headache). A significant intracranial injury was identified by CT in 138 (8.3%) patients. Sensitivity of the modified instrument to detect significant intracranial injury was 90.4% (95% confidence interval [CI] 85.4% to 95.4%); 13 children with such an injury were misclassified as low risk. Specificity of the modified instrument was 42.7% (95% CI 40.1% to 45.3%). In the NEXUS II cohort, a modified version of the University of California-Davis Rule misclassified a substantial proportion of pediatric patients with clinically important blunt head injury. Although we cannot evaluate the exact University of California-Davis Rule, we demonstrate that using stricter definitions of "headache" and "vomiting" and different wording than in the original study may have unintended or negative consequences. We emphasize the importance of careful attention to precise definitions of clinical predictors when a decision instrument is used.Annals of emergency medicine 04/2007; 49(3):325-32, 332.e1. · 4.23 Impact Factor
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ABSTRACT: Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries. We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules. Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in children < or =2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications. Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children < or =2 years of age), and headache.Annals of Emergency Medicine 10/2003; 42(4):492-506. · 4.29 Impact Factor