Absence of history in cases of Clinically Important Traumatic Brain

Injury (ciTBI)
Stephen Rohl, DOa, James Burns, MD, MPHa, and Raid Amin, PhDb
a University of Florida Pediatric Residency Program, Pensacola, Florida
b University of West Florida, Pensacola, Florida

Abstract:
The goal of this study is to investigate historical explanation of trauma and if the presence or
absence of history correlates to ciTBI, morbidity, and/or mortality.

Study Design:
This study was a retrospective surveillance study of 89 patients selected at random for head
trauma presenting in patients 0-6 months of age from the Sacred Heart Trauma Registry. Data
was stratified based on two main criteria – if an explanation of head injury was present vs. no
explanation. Chi-square (or when appropriate, Fischer’s exact test) was used to analyze
relationships to compare markers of acuity, suspicion for abusive mechanism, and outcomes.

Results:
Out of the 16 of 89 patients which had no explanation, 81.3% were found to have ciTBI (p
<0.001, Chi-square). Four markers of acuity were selected: “GCS ≤ 8”, “Seizures documented”,
“Apnea on presentation”, and “ICU admission”. For no explanation, 18.7% had a GCS ≤ 8 (p =
0.039, Fischer’s exact test), 56.3% had seizures (p <0.001, Fischer’s exact test), 25% had apnea
on presentation (p = 0.076, Fischer’s exact test), and 81.2% were admitted to ICU (p = 0.029,
Fischer’s exact test). Suspicion for abuse was found in 100% of no explanation cases (p = 0.009,
Fischer’s exact test), and outcomes were unfavorable 56.3% of the time (p = 0.002, Fischer’s
exact test). In comparison, the group with any explanation had lower percentages of all of the
above categories (ciTBI, markers of acuity, abuse suspicion, outcomes).

Conclusion:
When no explanation is given in cases of suspected ciTBI, our study revealed increased
incidence of confirmed ciTBI, increased markers of clinical acuity, higher suspicion for abuse,
and poorer outcomes compared to cases with any explanation. Lack of history should serve as a
strong indicator to evaluate for ciTBI, especially in the infant population.
Introduction:

For the pediatric population, head trauma is one of the most common reasons for presentation

to the emergency department. As such, several guidelines have been developed in order to stratify risk

for severe injury such as the PECARN trial (Kuppermann et al., 2009) in order to reduce radiation

exposure from unnecessary imaging and limit further workup. A number of these commonly used

guidelines, however, have limited effectiveness when there is a questionable mechanism or abusive

head trauma is suspected (Kuppermann et al., 2009; Osmond et al., 2010). Clinically important

traumatic brain injury (ciTBI) within the first year of life can have estimated mortality above 20% with

morbidity seen for two-thirds of the survivors (Parks, Annest, Hill, & Karch, 2019). When mechanisms of

head trauma are compared, abusive head trauma (AHT) represents a significant risk for ciTBI in the

infant population and developing methods of identifying such cases are of great importance to first

responders and physicians.

ciTBI can be difficult to screen for in the infant population, as historical information can

sometimes be either sparse, exaggerated, or in some cases withheld completely. Studies such as Babl et

al. (2018) have called into question the validity of screenings such as PECARN, CATCH, and CHALICE as

limited potential to increase accuracy of detecting ciTBI was demonstrated. A similarity that each of

these tools share is that criteria is based on mostly symptoms and physical exam findings. Our

institution has set out to investigate cases of ciTBI with respect to reported mechanism of injury (Burns

et al. 2016) and markers of abuse and their prevalence in association with ciTBI (Proctor et al., 2018).

Falls with a suspected minor mechanism had a negative correlation with ciTBI while cases concerning for

suspected AHT strongly correlated with ciTBI and death in the Burns et al. study. Proctor et. al found

that cases with ciTBI had a statistically significant higher prevalence of markers for abuse (presence of

non-accidental trauma workup, sheltering by child protective services at discharge, and presence of

retinal hemorrhages).
 Suspicion for abusive mechanisms within both of the prior investigations was associated with

higher incidence of ciTBI which was in keeping with several other publications (Miller Ferguson et al.,

2017; Robertson, Abbe, Pelletier, & Hennes, 2018; Yu et al., 2018). Even with the possibility of

inaccurate history, does the absence of history portend a higher incidence of ciTBI?

The goal of this study is to investigate historical explanation of trauma and if this presence or

absence correlates to ciTBI and therefore higher morbidity and mortality.

Methods:

A retrospective surveillance study was performed on patient charts entered into the Sacred

Heart Trauma Registry. The design of the study was reviewed and approved by the Sacred Heart

Hospital Institutional Review Board. The Sacred Heart Trauma Registry is made up of all encounters for

which a trauma alert was called at the Studer Family Children’s Hospital at Sacred Heart. Such events

are initiated by either EMS or ER staff when there is a concern for severe injury by traumatic mechanism

which may require urgent/emergent evaluation by the hospital trauma team. A specific portion of this

registry was selected from dates between January 1st, 2010 and May 1st, 2017. Charts were included

with any diagnosis related to traumatic brain injury (TBI) in an age range between 0 to ≤ 6 months such

as “unspecified injury/mechanism”, “falls”, and/or “hit by object”. Exclusion criteria included any kind

of penetrating injury and motor-vehicle, pedestrian, bicycle or ATV accidents. Although those

mechanisms can also cause ciTBI, they are easily verifiable mechanisms and our aim is to isolate and

investigate mechanisms with possible uncertainty.

A team of 8 people were trained on the method of chart review to standardize data collection.

Patient information was reviewed from the charts in the Sacred Heart Trauma Registry by each of these

individuals. This included records from the emergency department, admission history and physical

exams, progress notes, radiology reports, order and medication histories, discharge planning notes, and

discharge summaries. Data from each chart was added to the prior collected information table. Forty-
six variables in total comprised the final data entry (per chart), however not all of these were used in

this study.

Data was stratified based on two main criterion – if an explanation of the head injury was

present vs. if no explanation was given at the time of presentation to the Sacred Heart Emergency

Department. Each of these encounters were reviewed for the presence of clinically important traumatic

brain injury (ciTBI) as per PECARN criteria (Kuppermann et al., 2009, Table 1). Based on childhood

traumatic brain injury literature, we selected the following variables as markers of clinical acuity often

seen with ciTBI: “GCS less than or equal to 8”, “Seizures documented”, “Apnea on presentation”, “ICU

admission needed”. Evaluation by Department of Children’s and Families (DCF) was charted as an

indicator of high suspicion for non-accidental trauma (NAT).

Chi-square (or when appropriate, Fischer’s exact test) was used to analyze the relationship of

presenting with explanation vs. presenting with no-explanation using Crosstab 2 x 2 for various clinical

features of the head trauma patients including ciTBI, “GCS less than or equal to 8”, “seizures

documented”, “apnea on presentation”, “ICU admission needed”, and “DCF evaluation (NAT

suspected)”. Medical outcomes for each case were estimated based on the Pediatric Outcome

Performance Category Scale (Pollack et al., 2014, Table 4). This scale was applied based on the

estimated needs of the child, physical exam, and other findings at hospital discharge. The outcomes

were combined into two outcomes: generally favorable (category 1 or 2) vs. moderately to severely

impaired (category 3, 4, 5 or 6). All statistical analysis was performed by Dr. James Burns. Analysis was

further approved by Dr. Raid Amin, statistician.

Results:

Of the total 89 infants ≤ 6 months of age, 73 fell into the category of “presented with an

explanation of mechanism of injury” with 16 being in the category of “no explanation for injury”.
 With regards to mechanism of ciTBI, 19 of the 73 (26.0%) cases of those with an explanation

given were found to have ciTBI while 13 of the 16 cases (81.3%) without an explanation of injury were

found to have ciTBI (p<0.001, Chi-square) (Table 1).

A GCS score of less than or equal to 8 was found in only 2 of the 73 cases with explanation

(2.7%) compared to 3 of the 16 cases with no explanation (18.7%) (p = 0.039 Fischer’s exact test) (Table

2).

Seizures were documented 8 of the 73 cases where any explanation was given (11.0 %) whereas

seizures were found in in 9 of the 16 cases where no explanation was given (56.3%) (p<0.001; Fischer’s

exact test) (Table 2).

Although apnea was seen in 8.2% of the cases (6 of 73) with an explanation, 25.0% (4 of 16) of

the cases with no explanation had apnea; however the p value exceeded 0.05 (p = 0.076, Fischer’s exact

test)(Table 2).

An ICU admission was needed in 37 of 73 patients that had an explanation given (50.7%) vs. 13

of 16 children with no explanation (81.2%). (p = 0.029, Fischer’s exact test)(Table 2).

DCF evaluation was performed in 51 (69.9%) of cases with explanation, while in the no

explanation group it was performed on all 16 cases (100%, p = 0.009, Fischer’s exact test)(Table 3)

The Pediatric Outcome Performance Category Scale (POPCS) was also statistically related to

whether there was an explanation on presentation to the Emergency Department or not: 67 out of 73

(91.8%) of those with an explanation had favorable outcome in category 1 or 2, vs. 9/16 (56.3%) without

an explanation having a favorable outcome on discharge.

Discussion:

Amongst infants ≤ 6 months who presented to our emergency department under a trauma

alert, those lacking explanation had clinically important traumatic brain injury (ciTBI) 81.3% of the time.

Several studies (Fujiwara, Okuyama, & Miyasaka, 2008; Hettler & Greenes, 2003) have also noted
increased incidence of ciTBI and concern for abusive mechanisms with no history given, but did not

provide comparison to cases with explanations given. This rate of ciTBI in the group with any

explanation was found to be just 26%, a significantly lower incidence (p <0.001).

Our markers of clinical acuity included “GCS ≤ 8”, “Seizures documented”, “Apnea on

presentation”, and “ICU admission needed”. An increase in each of these markers of acuity was

expected when no explanation was given. When compared to cases with explanation, individuals with

no explanation presented with lower GCS scores (18.7%, p = 0.039), higher incidences of seizures

(56.3%, p < 0.001), and higher rates of ICU admission (81.2%, p = 0.029). Although there was also a

higher rate of apnea in the no explanation group at 25%, this result was not found to be statistically

significant (p = 0.076). This may be due the n of the no explanation group or the limits of data present in

patient charts. A review by Maguire et al. included apnea as a variable in their evaluation for ciTBI,

which not only was found to be positively correlated with ciTBI, but also an even stronger indicator for

ciTBI when compared to seizures. The stakes of accurately diagnosing ciTBI are high, especially when

abusive mechanisms are expected. One such study showed that when abusive head trauma was missed,

infants re-presented with more significant complications during initial stabilization and admission (Oral,

Yagmur, Nashelsky, Turkmen, & Kirby, 2008). As physicians are evaluating infants in this age range with

head trauma as a mechanism, these symptoms can provide an increased suspicion for ciTBI.

Presence of a Department of Children and Family’s (DCF) report served as an indication of

suspicion for abusive head trauma (AHT) during our chart review process. Both categories of patients

presenting via trauma alert trigger high levels of suspicion in this population. Although many cases with

any explanation were evaluated by DCF, an even greater proportion of the cases without explanation

was evaluated (100%, p = 0.0092). Unfortunately, the Florida Department of Children and Families and

Child Protection Team (CPT) in Pensacola have their own systems of charting that are mostly separate
from any charting system available in this study. Furthermore, the results of these workups often finish

far after hospital discharge. As such, the information available can only assume a concern for abuse.

Pediatric Overall Performance Category is the result of a retrospective cohort study across

multiple sites and children’s hospitals to assess the outcome of pediatric intensive care (Pollack et al.,

2014). When applied across our study population, a higher level of disability was seen in the no

explanation group. 43.8% suffered a degree of moderate to severe impairment compared to just 8.2%

in the explanation category (p = 0.002). ciTBI in these moderate to severe categories can have long

lasting effects. A study of 940 cases of ciTBI over a period from 2000 to 2015 found that 676 out of 940

(72%) had significant disability at 5 years post-injury (Nuño et al., 2018). A lack of mechanism of ciTBI is

associated with both immediate acuity and long-term outcomes

There were several challenges and limitations to the data described above. One of the main

criticisms of the several prior studies related to this topic is the circularity bias that exists. Hӧgberg et al

found a significant overlap between diagnostic criteria of AHT and explanatory variables of AHT. As

there is no gold standard for AHT, abuse can be defined by the same variables that are subsequently

analyzed as variables of abuse. An example of this would be using retinal hemorrhages as an indicator

of AHT, then studying the incidence of AHT with retinal hemorrhages found. This logic is inherently

circular. Although this study is comparing one category of history to another, both sets of criteria can

carry a rejection of caregiver credibility. Further directions of this study could include a ranking system

suggested by Hӧgberg et al to reduce this level of bias. The main source of data, the Sacred Heart

Trauma Registry, also provides limitations. All the cases above presented as trauma alerts, which is

group that has already been selected for more severe concern and suspected mechanism. When

compared to emergency department and PCP visits, this population cannot be considered entirely

representative. The trauma registry is made of a hybrid electronic and paper charting system. As a

result, some relevant information was missing which limited the inclusion of additional variables into
this study. Examples of this include charts with missing data on skull fracture, bruising on exam, or

vomiting.

The most important area for further investigation would be the confirmation of AHT/NAT. Such

work is already underway at our institution in partnership with physicians and leaders from DCF and

CPT. There is a wealth of information in the literature about AHT, its correlation to types of explanation

(none vs any), and strong association with ciTBI in the infant population (Ettaro, Berger, & Songer, 2004;

Shein et al., 2012; Pfeiffer et al.,2018). Confirmed cases of abuse could also be screened against

demographics for potential outreach and insight into prevention within the Pensacola community.

Conclusion:

When no explanation is given in cases of suspected ciTBI, our study revealed increased incidence

of confirmed ciTBI, increased markers of clinical acuity, higher suspicion for abuse, and poorer outcomes

when compared to cases when any explanation was given. A lack of any history should serve as a

strong indicator to evaluate for ciTBI further, especially in the infant population.
Table 1 – Lack of explanation associated with CiTBI (p value obtained via Chi-Square analysis)

CiTBI Not Present CiTBI Present Total

Explanation 54 (74%) 19 (26%) 73
No Explanation 3 (18.7%) 13 (81.3%) 16
Total 57 (64%) 32 (36%) 89
p <0.001

Clinically-important traumatic brain injury (ciTBI)

Defined by any of the following descriptions:
• Death from traumatic brain injury
• Neurosurgical interventions for traumatic brain injury
o Intracranial pressure monitoring
o Elevation of depressed skull fracture
o Ventriculostomy
o Hematoma evacuation
o Lobectomy
o Tissue debridement
o Dura repair
o Other
• Intubation of more than 24 hours for traumatic brain injury
• Hospital admission of 2 nights or more for the traumatic brain injury in association with
traumatic brain injury on CT
• Hospital admission for traumatic brain injury defined by admission for persistent neurological
symptoms or signs such as persistent alteration in mental status, recurrent emesis due to head
injury, persistent severe headache, or ongoing seizure management
Traumatic Brain injury on CT
Defined by any of the following descriptions:
• Intracranial hemorrhage or contusion
• Cerebral edema
• Traumatic infarction
• Diffuse axonal injury
• Shearing injury
• Sigmoid sinus thrombosis
• Midline shift of intracranial contents or signs of brain herniation
• Diastasis of the skull
• Pneumocephalus
• Skull fracture depressed by at least the width of the table of the skull
Table 2 – Markers of Clinical Acuity (p values obtained via Fischer’s Exact Test)

GCS ≥8 GCS ≤8 Total

Explanation 71 (97.3%) 2 (2.7%) 73
No Explanation 13 (81.3%) 3 (18.7%) 16
Total 84 (94.4%) 5 (5.6%) 89
p = 0.039
No seizures Seizures Total
Explanation 65 (89%) 8 (11%) 73
No Explanation 7 (43.7%) 9 (56.3%) 16
Total 72 (80.9%) 17 (19.1%) 89
p < 0.001
No Apnea Apnea Total
Explanation 67 (91.8%) 6 (8.2%) 73
No Explanation 12 (75%) 4 (25%) 16
Total 79 (88.8%) 10 (11.2%) 89
p = 0.076
No ICU admission Admitted to ICU Total
Explanation 36 (49.3%) 37 (50.7%) 73
No Explanation 3 (18.8%) 13 (81.2%) 16
Total 39 (43.8%) 50 (56.2%) 89
p = 0.029

Table 3 – DCF evaluation (NAT suspected; p value obtained via Fischer’s Exact Test)

No DCF evaluation DCF evaluation Total

Explanation 22 (30.1%) 51 (69.9%) 73
No Explanation 0 16 (100%) 16
Total 22 (24.7%) 67 (75.3%) 89
p = 0.009
Table 4 – Pediatric Outcome Performance Category Scale (p value obtained via Fischer’s Exact Test)

Favorable Outcome Moderate – Severe Impairment Total

Explanation 67 (91.8%) 6 (8.2%) 73
No Explanation 9 (56.3%) 7 (43.8%) 16
Total 76 (85.4%) 13 (14.6%) 89
p = 0.002

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