{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,3,12]],"date-time":"2026-03-12T08:28:50Z","timestamp":1773304130662,"version":"3.50.1"},"reference-count":24,"publisher":"Journal of Neurosurgery Publishing Group (JNSPG)","issue":"6","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["PED"],"published-print":{"date-parts":[[2017,6]]},"abstract":"<jats:sec><jats:title>OBJECTIVE<\/jats:title><jats:p>Approximately 475,000 children are treated for traumatic brain injury (TBI) in the US each year; most are classified as mild TBI (Glasgow Coma Scale [GCS] Score 13\u201315). Patients with positive findings on head CT, defined as either intracranial hemorrhage or skull fracture, regardless of severity, are often transferred to tertiary care centers for intensive care unit (ICU) monitoring. This practice creates a significant burden on the health care system. The purpose of this investigation was to derive a clinical decision rule (CDR) to determine which children can safely avoid ICU care.<\/jats:p><\/jats:sec><jats:sec><jats:title>METHODS<\/jats:title><jats:p>The authors retrospectively reviewed patients with mild TBI who were \u2264 16 years old and who presented to a Level 1 trauma center between 2008 and 2013. Data were abstracted from institutional TBI and trauma registries. Independent covariates included age, GCS score, pupillary response, CT characteristics, and Injury Severity Score. A composite outcome measure, ICU-level care, was defined as cardiopulmonary instability, transfusion, intubation, placement of intracranial pressure monitor or other invasive monitoring, and\/or need for surgical intervention. Stepwise logistic regression defined significant predictors for model inclusion with p &lt; 0.10. The authors derived the CDR with binary recursive partitioning (using a misclassification cost of 20:1).<\/jats:p><\/jats:sec><jats:sec><jats:title>RESULTS<\/jats:title><jats:p>A total of 284 patients with mild TBI were included in the analysis; 40 (14.1%) had ICU-level care. The CDR consisted of 5 final predictor variables: midline shift &gt; 5 mm, intraventricular hemorrhage, nonisolated head injury, postresuscitation GCS score of &lt; 15, and cisterns absent. The CDR correctly identified 37 of 40 patients requiring ICU-level care (sensitivity 92.5%; 95% CI 78.5\u201398.0) and 154 of 244 patients who did not require an ICU-level intervention (specificity 63.1%; 95% CI 56.7\u201369.1). This results in a negative predictive value of 98.1% (95% CI 94.1\u201399.5).<\/jats:p><\/jats:sec><jats:sec><jats:title>CONCLUSIONS<\/jats:title><jats:p>The authors derived a clinical tool that defines a subset of pediatric patients with mild TBI at low risk for ICU-level care. Although prospective evaluation is needed, the potential for improved resource allocation is significant.<\/jats:p><\/jats:sec>","DOI":"10.3171\/2017.2.peds16419","type":"journal-article","created":{"date-parts":[[2017,4,7]],"date-time":"2017-04-07T14:03:16Z","timestamp":1491573796000},"page":"668-674","source":"Crossref","is-referenced-by-count":17,"title":["Medical necessity of routine admission of children with mild traumatic brain injury to the intensive care unit"],"prefix":"10.3171","volume":"19","author":[{"given":"Jared D.","family":"Ament","sequence":"first","affiliation":[{"name":"Departments ofNeurological Surgery,"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Krista N.","family":"Greenan","sequence":"additional","affiliation":[{"name":"Departments ofNeurological Surgery,"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Patrick","family":"Tertulien","sequence":"additional","affiliation":[{"name":"Departments ofNeurological Surgery,"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Joseph M.","family":"Galante","sequence":"additional","affiliation":[{"name":"Trauma Surgery, and"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Daniel K.","family":"Nishijima","sequence":"additional","affiliation":[{"name":"Emergency Medicine, University of California Davis Medical Center, Sacramento, California"}],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Marike","family":"Zwienenberg","sequence":"additional","affiliation":[{"name":"Departments ofNeurological Surgery,"}],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1754","reference":[{"issue":"3 Suppl","key":"b1-peds16419","series-title":"Neurosurgery","doi-asserted-by":"publisher","first-page":"S25","DOI":"10.1227\/01.NEU.0000210365.36914.E3","article-title":"Surgical management of traumatic parenchymal lesions.","volume":"58","author":"Bullock MR,","year":"2006","unstructured":"Bullock MR, Chesnut R, Ghajar J, Gordon D, Hartl R, Newell DW, : Surgical management of traumatic parenchymal lesions.. Neurosurgery 58:3 SupplS25\u2013S46, Si\u2013Siv, 200610.1227\/01.NEU.0000210365.36914.E3"},{"key":"b2-peds16419","series-title":"J Neurotrauma","first-page":"451","article-title":"Guidelines for the management of severe traumatic brain injury","volume":"17","author":"Bullock RM,","year":"2000","unstructured":"Bullock RM, Chesnut RM, Clifton G, Ghajar J, Marion DW, Narayan RK, : Guidelines for the management of severe traumatic brain injury. J Neurotrauma 17:451\u2013553, 2000"},{"key":"b3-peds16419","series-title":"J Neurotrauma","doi-asserted-by":"publisher","first-page":"1040","DOI":"10.1089\/neu.2005.22.1040","article-title":"Clinical elements that predict outcome after traumatic brain injury: a prospective multicenter recursive partitioning (decision-tree) analysis","volume":"22","author":"Brown AW,","year":"2005","unstructured":"Brown AW, Malec JF, McClelland RL, Diehl NN, Englander J, Cifu DX: Clinical elements that predict outcome after traumatic brain injury: a prospective multicenter recursive partitioning (decision-tree) analysis. J Neurotrauma 22:1040\u20131051, 200510.1089\/neu.2005.22.104016238482"},{"key":"b4-peds16419","series-title":"J Trauma","doi-asserted-by":"publisher","first-page":"69","DOI":"10.1097\/00005373-198801000-00010","article-title":"The Injury Severity Score revisited","volume":"28","author":"Copes WS,","year":"1988","unstructured":"Copes WS, Champion HR, Sacco WJ, Lawnick MM, Keast SL, Bain LW: The Injury Severity Score revisited. J Trauma 28:69\u201377, 1988312370710.1097\/00005373-198801000-00010"},{"key":"b5-peds16419","series-title":"J Am Coll Surg","doi-asserted-by":"publisher","first-page":"216","DOI":"10.1016\/j.jamcollsurg.2004.02.030","article-title":"Mortality prediction of head Abbreviated Injury Score and Glasgow Coma Scale: analysis of 7,764 head injuries","volume":"199","author":"Demetriades D,","year":"2004","unstructured":"Demetriades D, Kuncir E, Murray J, Velmahos GC, Rhee P, Chan L: Mortality prediction of head Abbreviated Injury Score and Glasgow Coma Scale: analysis of 7,764 head injuries. J Am Coll Surg 199:216\u2013222, 200410.1016\/j.jamcollsurg.2004.02.03015275876"},{"issue":"5 Suppl","key":"b6-peds16419","series-title":"J Neurosurg","first-page":"365","article-title":"Utility of serial computed tomography imaging in pediatric patients with head trauma","volume":"105","author":"Durham SR,","year":"2006","unstructured":"Durham SR, Liu KC, Selden NR: Utility of serial computed tomography imaging in pediatric patients with head trauma. J Neurosurg 105:5 Suppl365\u2013369, 200617328259"},{"key":"b7-peds16419","series-title":"Pediatr Neurosurg","doi-asserted-by":"publisher","first-page":"249","DOI":"10.1159\/000445904","article-title":"Traumatic brain injury in children: Role of CDRs-PECARN as a clinical predictive resource for evaluation of intracranical lesions and neuropsychiatric outcomes","volume":"51","author":"Ferrara P,","year":"2016","unstructured":"Ferrara P, Basile MC, Dell'Aquila L, Vena F, Coppo E, Chiaretti A, : Traumatic brain injury in children: Role of CDRs-PECARN as a clinical predictive resource for evaluation of intracranical lesions and neuropsychiatric outcomes. Pediatr Neurosurg 51:249\u2013252, 201610.1159\/00044590427193444"},{"key":"b8-peds16419","series-title":"J Neurol Neurosurg Psychiatry","doi-asserted-by":"publisher","first-page":"346","DOI":"10.1136\/jnnp.52.3.346","article-title":"Ischaemic brain damage is still common in fatal non-missile head injury","volume":"52","author":"Graham DI,","year":"1989","unstructured":"Graham DI, Ford I, Adams JH, Doyle D, Teasdale GM, Lawrence AE, : Ischaemic brain damage is still common in fatal non-missile head injury. J Neurol Neurosurg Psychiatry 52:346\u2013350, 1989292641910.1136\/jnnp.52.3.346"},{"key":"b9-peds16419","series-title":"Stat Med","doi-asserted-by":"publisher","first-page":"143","DOI":"10.1002\/sim.4780030207","article-title":"Regression modelling strategies for improved prognostic prediction","volume":"3","author":"Harrell FE Jr,","year":"1984","unstructured":"Harrell FE Jr, Lee KL, Califf RM, Pryor DB, Rosati RA: Regression modelling strategies for improved prognostic prediction. Stat Med 3:143\u2013152, 1984646345110.1002\/sim.4780030207"},{"key":"b10-peds16419","series-title":"J Neurotrauma","doi-asserted-by":"publisher","first-page":"1025","DOI":"10.1089\/neu.2005.22.1025","article-title":"Predicting outcome after traumatic brain injury: development and validation of a prognostic score based on admission characteristics","volume":"22","author":"Hukkelhoven CW,","year":"2005","unstructured":"Hukkelhoven CW, Steyerberg EW, Habbema JD, Farace E, Marmarou A, Murray GD, : Predicting outcome after traumatic brain injury: development and validation of a prognostic score based on admission characteristics. J Neurotrauma 22:1025\u20131039, 200510.1089\/neu.2005.22.102516238481"},{"key":"b11-peds16419","series-title":"Am Surg","doi-asserted-by":"publisher","first-page":"1162","DOI":"10.3171\/sup.1991.75.1s.0s28","article-title":"Utility of neurosurgical consultation for mild traumatic brain injury.","volume":"72","author":"Huynh T,","year":"2006","unstructured":"Huynh T, Jacobs DG, Dix S, Sing RF, Miles WS, Thomason MH: Utility of neurosurgical consultation for mild traumatic brain injury.. Am Surg 72:1162\u20131165, n1166\u2013n1167, 20061721681310.3171\/sup.1991.75.1s.0s28"},{"key":"b12-peds16419","series-title":"Ann Emerg Med","doi-asserted-by":"publisher","first-page":"714","DOI":"10.1016\/j.annemergmed.2008.08.021","article-title":"Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting","volume":"52","author":"Jagoda AS,","year":"2008","unstructured":"Jagoda AS, Bazarian JJ, Bruns JJ Jr, Cantrill SV, Gean AD, Howard PK, : Clinical policy: neuroimaging and decisionmaking in adult mild traumatic brain injury in the acute setting. Ann Emerg Med 52:714\u2013748, 200810.1016\/j.annemergmed.2008.08.02119027497"},{"key":"b13-peds16419","series-title":"J Head Trauma Rehabil","doi-asserted-by":"publisher","first-page":"229","DOI":"10.1097\/00001199-200505000-00006","article-title":"The incidence of traumatic brain injury among children in the United States: differences by race","volume":"20","author":"Langlois JA,","year":"2005","unstructured":"Langlois JA, Rutland-Brown W, Thomas KE: The incidence of traumatic brain injury among children in the United States: differences by race. J Head Trauma Rehabil 20:229\u2013238, 20051590882310.1097\/00001199-200505000-00006"},{"issue":"Suppl","key":"b14-peds16419","series-title":"J Neurosurg","first-page":"S28","article-title":"The outcome of severe closed head injury","volume":"75","author":"Marshall LF,","year":"1991","unstructured":"Marshall LF, Gautille T, Klauber MR, Eisenberg HM, Jane JA, Luerssen TG, : The outcome of severe closed head injury. J Neurosurg 75:SupplS28\u2013S36, 1991"},{"key":"b15-peds16419","series-title":"J Neurotrauma","doi-asserted-by":"publisher","first-page":"359","DOI":"10.1089\/neu.2014.3453","article-title":"Intraventricular hemorrhage on initial computed tomography as marker of diffuse axonal injury after traumatic brain injury","volume":"32","author":"Mata-Mbemba D,","year":"2015","unstructured":"Mata-Mbemba D, Mugikura S, Nakagawa A, Murata T, Kato Y, Tatewaki Y, : Intraventricular hemorrhage on initial computed tomography as marker of diffuse axonal injury after traumatic brain injury. J Neurotrauma 32:359\u2013365, 20152502636610.1089\/neu.2014.3453"},{"key":"b16-peds16419","series-title":"Injury","doi-asserted-by":"publisher","first-page":"1827","DOI":"10.1016\/j.injury.2011.07.020","article-title":"A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission","volume":"43","author":"Nishijima DK,","year":"2012","unstructured":"Nishijima DK, Shahlaie K, Echeverri A, Holmes JF: A clinical decision rule to predict adult patients with traumatic intracranial haemorrhage who do not require intensive care unit admission. Injury 43:1827\u20131832, 20122183944410.1016\/j.injury.2011.07.020"},{"key":"b17-peds16419","series-title":"BMJ","doi-asserted-by":"publisher","first-page":"425","DOI":"10.1136\/bmj.39461.643438.25","article-title":"Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients","volume":"336","author":"Perel P,","year":"2008","unstructured":"Perel P, Arango M, Clayton T, Edwards P, Komolafe E, Poccock S, : Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 336:425\u2013429, 200810.1136\/bmj.39461.643438.2518270239"},{"key":"b18-peds16419","series-title":"BMC Med Inform Decis Mak","doi-asserted-by":"publisher","first-page":"38","DOI":"10.1186\/1472-6947-6-38","article-title":"Systematic review of prognostic models in traumatic brain injury","volume":"6","author":"Perel P,","year":"2006","unstructured":"Perel P, Edwards P, Wentz R, Roberts I: Systematic review of prognostic models in traumatic brain injury. BMC Med Inform Decis Mak 6:38, 200610.1186\/1472-6947-6-3817105661"},{"key":"b19-peds16419","series-title":"N Engl J Med","doi-asserted-by":"publisher","first-page":"1945","DOI":"10.1056\/NEJMc1407902","article-title":"Epidemiology of blunt head trauma in children in U.S. emergency departments","volume":"371","author":"Quayle KS,","year":"2014","unstructured":"Quayle KS, Powell EC, Mahajan P, Hoyle JD Jr, Nadel FM, Badawy MK, : Epidemiology of blunt head trauma in children in U.S. emergency departments. N Engl J Med 371:1945\u20131947, 201410.1056\/NEJMc140790225390756"},{"key":"b20-peds16419","series-title":"Fundamentals of Biostatistics","author":"Rosner B:","year":"2011","unstructured":"Rosner B: Fundamentals of Biostatistics ed 7Boston, Brooks\/Cole, Cengage Learning, 2011"},{"key":"b21-peds16419","series-title":"Am J Surg","doi-asserted-by":"publisher","first-page":"338","DOI":"10.1016\/j.amjsurg.2003.12.015","article-title":"Value of repeat cranial computed axial tomography scanning in patients with minimal head injury","volume":"187","author":"Sifri ZC,","year":"2004","unstructured":"Sifri ZC, Livingston DH, Lavery RF, Homnick AT, Mosenthal AC, Mohr AM, : Value of repeat cranial computed axial tomography scanning in patients with minimal head injury. Am J Surg 187:338\u2013342, 200410.1016\/j.amjsurg.2003.12.01515006561"},{"key":"b22-peds16419","series-title":"Crit Care Med","doi-asserted-by":"publisher","first-page":"633","DOI":"10.1097\/00003246-199903000-00048","article-title":"Guidelines for intensive care unit admission, discharge, and triage","volume":"27","author":"Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine","year":"1999","unstructured":"Task Force of the American College of Critical Care Medicine, Society of Critical Care Medicine: Guidelines for intensive care unit admission, discharge, and triage. Crit Care Med 27:633\u2013638, 199910.1097\/00003246-199903000-0004810199547"},{"key":"b23-peds16419","series-title":"Eur J Neurol","doi-asserted-by":"publisher","first-page":"191","DOI":"10.1111\/j.1468-1331.2011.03581.x","article-title":"Mild traumatic brain injury","volume":"19","author":"Vos PE,","year":"2012","unstructured":"Vos PE, Alekseenko Y, Battistin L, Ehler E, Gerstenbrand F, Muresanu DF, : Mild traumatic brain injury. Eur J Neurol 19:191\u2013198, 20122226018710.1111\/j.1468-1331.2011.03581.x"},{"key":"b24-peds16419","series-title":"J Neurosurg","doi-asserted-by":"publisher","first-page":"549","DOI":"10.3171\/2011.11.JNS111092","article-title":"Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury?","volume":"116","author":"Washington CW,","year":"2012","unstructured":"Washington CW, Grubb RL Jr: Are routine repeat imaging and intensive care unit admission necessary in mild traumatic brain injury?. J Neurosurg 116:549\u2013557, 20122219609610.3171\/2011.11.JNS111092"}],"container-title":["Journal of Neurosurgery: Pediatrics"],"original-title":[],"link":[{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-pediatr\/19\/6\/article-p668.xml","content-type":"text\/html","content-version":"vor","intended-application":"text-mining"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-pediatr\/19\/6\/article-p668.xml","content-type":"text\/html","content-version":"vor","intended-application":"syndication"},{"URL":"https:\/\/thejns.org\/downloadpdf\/journals\/j-neurosurg-pediatr\/19\/6\/article-p668.xml","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2023,4,15]],"date-time":"2023-04-15T13:06:15Z","timestamp":1681563975000},"score":1,"resource":{"primary":{"URL":"https:\/\/thejns.org\/view\/journals\/j-neurosurg-pediatr\/19\/6\/article-p668.xml"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2017,6]]},"references-count":24,"journal-issue":{"issue":"6"},"URL":"https:\/\/doi.org\/10.3171\/2017.2.peds16419","relation":{},"ISSN":["1933-0707","1933-0715"],"issn-type":[{"value":"1933-0707","type":"print"},{"value":"1933-0715","type":"electronic"}],"subject":[],"published":{"date-parts":[[2017,6]]}}}