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Which Clinical Features Distinguish Inflicted from Non-Inflicted Brain Injury? A Systematic Review
The Journal of Emergency Medicine in an attempt to identify characteristics of TDI that are predictive of increased mortality. Researchers reviewed cases from the Level I trauma center and the associated coroner’s office. They identified 254 patients from 20,000 registered patients that had documented TDI. These cases were further divided depending on mechanism: 99 individuals sustained blunt trauma and 155 experienced penetrating trauma. Thirty-three patients did not survive to discharge. Patients who sustained blunt trauma most commonly had left-sided TDI, whereas patients with penetrating trauma had equivalent left- and right-sided TDI. After univariate and multivariate regression analyses, higher injury severity score (ISS) and advanced age were found to be independently associated with a higher risk of mortality in the presence of TDI. The authors conclude that although TDI is a sign of severe trauma, it alone does not seem to be a significant factor in causing mortality. [Morgan Eutermoser, MD, Denver Health Medical Center, Denver, CO] Comment: This very small retrospective study highlights that TDI on its own is an injury that warrants little concern as an important cause of mortality. However, because TDI is almost always associated with high ISS, its presence should serve to alert the emergency physician to be diligent in seeking out associated severe injuries that are frequently found in these patients.
e DIAGNOSTIC EFFICACY OF HANDHELD DEVICES FOR EMERGENCY RADIOLOGIC CONSULTATION. Toomey RJ, Ryan JT, McEntee MF, et al. AJR Am J Roentgenol 2010;194:469 –74. This study evaluated the diagnostic accuracy of two handheld computing devices, the Dell Axim (Dell Inc., Round Rock, TX) personal digital assistant (PDA) and the Apple iPod Touch Device (Apple Inc., Cupertino, CA), compared to secondaryclass liquid crystal display monitors for the diagnosis of orthopedic and intracranial injuries. Each device was tested for each of two types of images, posteroanterior wrist radiographs and slices of a computed tomography (CT) brain scan. Examining radiologists at the American Board of Radiology read 30 wrist or brain images and rated their confidence in their decisions. In the PDA CT brain analysis, scores for the PDA readings were significantly higher than those for monitor readings by all interpreters (p ⱕ 0.01). No statistically significant differences between monitor readings and handheld devices were found for the iPod Touch device or for the PDA wrist images. The authors conclude that handheld devices may show promise in the field of emergency teleconsultation. [Karen Ast, MD, Denver Health Medical Center, Denver, CO] Comment: Handheld devices are carried by an increasingly large number of physicians, but their clinical utility with regard to imaging remains unclear. This study provides early data
273 supporting the use of handheld devices for the display of radiographic images, a tool that may be of particular importance for remote medicine.
e WHICH CLINICAL FEATURES DISTINGUISH INFLICTED FROM NON-INFLICTED BRAIN INJURY? A SYSTEMATIC REVIEW. Maguire S, Pickerd N, Farewell D, et al. Arch Dis Child 2009;94:860 –7. The authors of this publication conducted a systematic review to determine which clinical features distinguish inflicted brain injury (iBI) from non-inflicted brain injury (niBI) in children. They examined comparative observational studies involving children 0 to 18 years of age with intracranial hemorrhage due either to confirmed abuse or confirmed accidental trauma. Fourteen studies, representing 1655 subjects, met their inclusion criteria. Three studies did not include children younger than 3 years of age. Eight of the included studies found that children with inflicted brain injury were generally younger than those with accidental brain injury. Apnea was the most discriminatory feature for iBI, with a positive predictive value (PPV) of 93% (97.5% confidence interval [CI] 0.733– 0.986) and an odds ratio (OR) of 17.062 (97.5% CI 5.018 –58.011, p ⫽ 0.001), but was examined by only two studies. Retinal hemorrhages were strongly associated with iBI, with a PPV of 71% (97.5% CI 0.483– 0.868) and an OR of 3.504 (97.5% CI 1.088 –11.280, p ⫽ 0.03). Rib fractures were associated with inflicted injury, with a PPV of 73% (97.5% CI 0.500 – 0.882) and an OR of 3.027 (97.5% CI 0.716 –12.799), but were noted in relatively few subjects. Seizures and long bone fractures were not significantly associated with one etiology of brain injury compared to the other. Skull fractures were more strongly associated with niBI than iBI, with a PPV for iBI of 44% (97.5% CI 0.223– 0.678), and an OR of 0.852 (97.5% CI 0.316 –2.301, p ⫽ 0.2). Bruising to the head and neck was also more common in niBI, but it was rarely noted in the studies examined. The authors conclude that presence of apnea is the most useful feature for determining likelihood of iBI, but that retinal hemorrhages and rib fractures are also useful signs and should be sought out in the child with a head injury. [Ian Tate, MD, Denver Health Medical Center, Denver, CO] Comment: This article identifies some associated injuries that may help a clinician decide whether or not a pediatric patient’s head trauma is accidental. The epidemiology and presenting symptoms of brain injury vary among age groups of children, however, and this review’s lack of a rigorous analysis by age group limits its applicability. Three of the studies reviewed did not even include children younger than 3 years old, whom the authors themselves acknowledge are at the highest risk for iBI. Nevertheless, this article provides some helpful observations about the discriminatory value of other injuries associated with head trauma and directions for future research.
e DIAGNOSTIC EFFICACY OF HANDHELD DEVICES FOR EMERGENCY RADIOLOGIC CONSULTATION. Toomey RJ, Ryan JT, McEntee MF, et al. AJR Am J Roentgenol 2010;194:469 –74. This study evaluated the diagnostic accuracy of two handheld computing devices, the Dell Axim (Dell Inc., Round Rock, TX) personal digital assistant (PDA) and the Apple iPod Touch Device (Apple Inc., Cupertino, CA), compared to secondaryclass liquid crystal display monitors for the diagnosis of orthopedic and intracranial injuries. Each device was tested for each of two types of images, posteroanterior wrist radiographs and slices of a computed tomography (CT) brain scan. Examining radiologists at the American Board of Radiology read 30 wrist or brain images and rated their confidence in their decisions. In the PDA CT brain analysis, scores for the PDA readings were significantly higher than those for monitor readings by all interpreters (p ⱕ 0.01). No statistically significant differences between monitor readings and handheld devices were found for the iPod Touch device or for the PDA wrist images. The authors conclude that handheld devices may show promise in the field of emergency teleconsultation. [Karen Ast, MD, Denver Health Medical Center, Denver, CO] Comment: Handheld devices are carried by an increasingly large number of physicians, but their clinical utility with regard to imaging remains unclear. This study provides early data
273 supporting the use of handheld devices for the display of radiographic images, a tool that may be of particular importance for remote medicine.
e WHICH CLINICAL FEATURES DISTINGUISH INFLICTED FROM NON-INFLICTED BRAIN INJURY? A SYSTEMATIC REVIEW. Maguire S, Pickerd N, Farewell D, et al. Arch Dis Child 2009;94:860 –7. The authors of this publication conducted a systematic review to determine which clinical features distinguish inflicted brain injury (iBI) from non-inflicted brain injury (niBI) in children. They examined comparative observational studies involving children 0 to 18 years of age with intracranial hemorrhage due either to confirmed abuse or confirmed accidental trauma. Fourteen studies, representing 1655 subjects, met their inclusion criteria. Three studies did not include children younger than 3 years of age. Eight of the included studies found that children with inflicted brain injury were generally younger than those with accidental brain injury. Apnea was the most discriminatory feature for iBI, with a positive predictive value (PPV) of 93% (97.5% confidence interval [CI] 0.733– 0.986) and an odds ratio (OR) of 17.062 (97.5% CI 5.018 –58.011, p ⫽ 0.001), but was examined by only two studies. Retinal hemorrhages were strongly associated with iBI, with a PPV of 71% (97.5% CI 0.483– 0.868) and an OR of 3.504 (97.5% CI 1.088 –11.280, p ⫽ 0.03). Rib fractures were associated with inflicted injury, with a PPV of 73% (97.5% CI 0.500 – 0.882) and an OR of 3.027 (97.5% CI 0.716 –12.799), but were noted in relatively few subjects. Seizures and long bone fractures were not significantly associated with one etiology of brain injury compared to the other. Skull fractures were more strongly associated with niBI than iBI, with a PPV for iBI of 44% (97.5% CI 0.223– 0.678), and an OR of 0.852 (97.5% CI 0.316 –2.301, p ⫽ 0.2). Bruising to the head and neck was also more common in niBI, but it was rarely noted in the studies examined. The authors conclude that presence of apnea is the most useful feature for determining likelihood of iBI, but that retinal hemorrhages and rib fractures are also useful signs and should be sought out in the child with a head injury. [Ian Tate, MD, Denver Health Medical Center, Denver, CO] Comment: This article identifies some associated injuries that may help a clinician decide whether or not a pediatric patient’s head trauma is accidental. The epidemiology and presenting symptoms of brain injury vary among age groups of children, however, and this review’s lack of a rigorous analysis by age group limits its applicability. Three of the studies reviewed did not even include children younger than 3 years old, whom the authors themselves acknowledge are at the highest risk for iBI. Nevertheless, this article provides some helpful observations about the discriminatory value of other injuries associated with head trauma and directions for future research.