TBI Risk Higher in Children Presenting to the ED 24 Hours After Head Injury

child concussion head injury
child concussion head injury
Delayed presentation to the emergency department longer than 24 hours after head injury in children, although infrequent, may be significantly associated with traumatic brain injury.

Children who present to the emergency department (ED) >24 hours after injury are more likely to suffer from traumatic brain injury (TBI) compared with children who present to the ED within 24 hours, according to the results of a study published in the Annals of Emergency Medicine. Study findings showed that factors potentially predictive of TBI in children who present to the ED longer than 24 hours after injury include suspicion of depressed skull fracture and non-frontal scalp hematoma.

Researchers performed a secondary analysis of the Australasian Pediatric Head Injury Rule Study, obtaining data from children who had presented to the ED longer than 24 hours (n=981) and less than 24 hours (n=18,784) after injury with Glasgow Coma Scale scores of 14 and 15. A total of 10 EDs from New Zealand and Australia provided patient data for analysis.

Predictors of TBI were assessed, with clinically important TBI defined as death, intubation >24 hours, neurosurgery (intracranial pressure monitoring, craniotomy, hematoma evacuation, elevation of depressed skull fracture, dura repair, tissue debridement, and lobectomy), or TBI–related hospital admission ≥2 nights.

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Approximately half (48.5%; n=465) of patients who presented to the ED ≥24 hours had an injury resulting from falls from <1 meter and a smaller percentage of patients (3.8%) had injuries from traffic accidents. Patient symptoms and features associated with presenting >24 hours following injury vs <24 hours of injury included non-frontal scalp hematoma (20.8% vs 18.1%, respectively), headache (31.6% vs 19.9%, respectively), vomiting (30.0% vs 16.3%, respectively), and assault with non-accidental injury concerns (1.4% vs 0.4%, respectively). Almost 4% (n=37) of patients had TBI on computed tomography (CT) scan, including suspicion of depressed skull fracture (0.8%) and intracranial hemorrhage (3.2%). Clinically important TBI occurred in 0.8% of patients and 0.2% of these patients required neurosurgery.

In addition to suspicion of depressed skull fracture, another factor associated with TBI was non-frontal scalp hematoma (odds ratio [OR] 19.0; 95% CI, 8.2-43.9). Non-frontal scalp hematoma was also associated with and possibly predictive of clinically important TBI (OR 11.7; 95% CI, 2.4-58.6), as was suspicion of depressed fracture (OR 19.7; 95% CI, 2.1-182.1).

Study limitations include the secondary analysis nature of an original observational study and the lack of CT scan data in the majority of patients.

“Treating clinicians should evaluate and manage delayed presentations outside of the current head injury clinical decision rule parameters because these rules have not been validated for this subset of patients,” the researchers concluded.


Borland ML, Dalziel SR, Phillips N, et al; Paediatric Research in Emergency Department International Collaborative (PREDICT) Group. Delayed presentations to emergency departments of children with head injury: a PREDICT study [published online January 14, 2019]. Ann Emerg Med. doi:10.1016/j.annemergmed.2018.11.035