Original Article
Clinical observation: A safe alternative to radiology in infants with mild traumatic brain injury
Observación clínica: una alternativa segura a la radiología en lactantes con traumatismo craneoencefálico leve
David Muñoz-Santanach, Victoria Trenchs Sainz de la Maza, Sara Maya Gallego, Adriana Cuaresma González, Carles Luaces Cubells
Corresponding author
Servicio de Urgencias, Hospital Sant Joan de Déu Barcelona, Esplugues de Llobregat, Barcelona, Spain
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"titulo" => "Clinical observation: A safe alternative to radiology in infants with mild traumatic brain injury" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "164" "paginaFinal" => "169" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "David Muñoz-Santanach, Victoria Trenchs Sainz de la Maza, Sara Maya Gallego, Adriana Cuaresma González, Carles Luaces Cubells" "autores" => array:5 [ 0 => array:2 [ "nombre" => "David" "apellidos" => "Muñoz-Santanach" ] 1 => array:2 [ "nombre" => "Victoria" "apellidos" => "Trenchs Sainz de la Maza" ] 2 => array:2 [ "nombre" => "Sara" "apellidos" => "Maya Gallego" ] 3 => array:2 [ "nombre" => "Adriana" "apellidos" => "Cuaresma González" ] 4 => array:4 [ "nombre" => "Carles" "apellidos" => "Luaces Cubells" "email" => array:1 [ 0 => "cluaces@hsjdbcn.org" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Servicio de Urgencias, Hospital Sant Joan de Déu Barcelona, Esplugues de Llobregat, Barcelona, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Observación clínica: una alternativa segura a la radiología en lactantes con traumatismo craneoencefálico leve" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2235 "Ancho" => 1811 "Tamanyo" => 353777 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the management of mild head trauma in children aged less than 2 years in the hospital where the study was conducted (A: until July 2013; B: from July 2013).</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">CSF, cerebrospinal fluid; CT, computed tomography; Fx, fracture; HT, head trauma; NSur: neurosurgery; Paed, paediatrics ward; PICU, paediatric intensive care unit; TBI, traumatic brain injury.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Head trauma (HT) is one of the main causes of morbidity and mortality in children in developed countries.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1–3</span></a> Approximately 3%–5% of paediatric visits to primary care centres and emergency departments (EDs) are due to HT, which are mild in 90% of cases.<a class="elsevierStyleCrossRefs" href="#bib0175"><span class="elsevierStyleSup">1,2</span></a> There are still several points of controversy in the management of HT,<a class="elsevierStyleCrossRef" href="#bib0190"><span class="elsevierStyleSup">4</span></a> one of which is the role of skull radiography. Historically, the presence of a skull fracture has been considered a risk factor for traumatic brain injury (TBI),<a class="elsevierStyleCrossRefs" href="#bib0180"><span class="elsevierStyleSup">2,3,5</span></a> although the absence of the former does not rule out the latter. It is estimated that about 2% of children with HT may present with a skull fracture, a prevalence that increases in children aged less than 2 years,<a class="elsevierStyleCrossRefs" href="#bib0200"><span class="elsevierStyleSup">6–8</span></a> which is why skull radiography is still recommended in Spain for specific cases of young children with mild HT.<a class="elsevierStyleCrossRefs" href="#bib0215"><span class="elsevierStyleSup">9,10</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In 2013 we conducted a study in our ED<a class="elsevierStyleCrossRef" href="#bib0225"><span class="elsevierStyleSup">11</span></a> that included 800 children aged 2 years or less with mild HT and found a low prevalence of TBI in this group of patients that was independent of the concomitant presence of skull fracture. With the aim of reducing exposure to radiation in these children, and in the awareness that skull radiography was no longer a recommended practice in the guidelines of countries with ample experience in the management of these patients,<a class="elsevierStyleCrossRefs" href="#bib0230"><span class="elsevierStyleSup">12–16</span></a> the protocol for the management of mild HT in our hospital was updated in July of the same year. The main change consisted in replacing skull radiography in children aged less than 2 years with mild HT and moderate risk of TBI by inpatient observation, with performance of head computed tomography (CT) in case of unfavourable progression. <a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> shows the protocol in place until July 2013 (1A) and the protocol that has been applied since (1B).<a class="elsevierStyleCrossRefs" href="#bib0255"><span class="elsevierStyleSup">17,18</span></a></p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The primary objective of this study was to assess whether the implementation of the new protocol led to a reduction in the ability to detect TBI in the initial ED visit, and the secondary objective was to determine the changes in the requests for imaging tests and in hospital admissions that have occurred.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0020" class="elsevierStylePara elsevierViewall">We conducted a study in the ED of an urban tertiary care maternity and children's hospital with 264 paediatric beds that serves patients aged 0–18 years. The hospital serves a catchment area of 1<span class="elsevierStyleHsp" style=""></span>800<span class="elsevierStyleHsp" style=""></span>000 inhabitants and receives an average of 280 emergency visits a day.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The study had a retrospective, observational descriptive design. We established 2 study periods based on the introduction of the new HT protocol: period 1 (pre-implementation) from November 1, 2011 to October 30, 2012; and period 2 (post-implementation) from November 1, 2013 to October 30, 2014.</p><p id="par0030" class="elsevierStylePara elsevierViewall">We searched electronic health records and selected ED discharge summaries for patients managed in the periods under study with a discharge diagnosis of HT (SEUP code 850.9).<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">19</span></a> We included cases of mild HT (modified Glasgow Coma Scale for infants ≥14 points)<a class="elsevierStyleCrossRef" href="#bib0270"><span class="elsevierStyleSup">20</span></a> in which the traumatic event had occurred within less than 24<span class="elsevierStyleHsp" style=""></span>h. We excluded children with HT in the context of polytrauma, patients referred to the hospital that had already undergone imaging tests, and repeat visits considered part of the same episode.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We collected the following data for each visit: age; sex; mechanism of injury; score in the modified Glasgow Coma Scale for infants; risk of TBI (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>); diagnosis of skull fracture and/or TBI; performance of skull radiography, transfontanellar ultrasound and/or CT in the ED; patient destination after ED and outcome. We calculated the length of stay in the ED as the time elapsed between patient arrival and discharge, and length of hospital stay as the time elapsed between patient arrival to the ED and discharge from hospital.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">We defined TBI as any finding secondary to HT in a neuroimaging test interpreted by a radiologist, with the exception of skull fracture. We defined clinically-important traumatic brain injury (ciTBI) as injury resulting in the death of the patient, indication of neurosurgery, mechanical ventilation lasting more than 24<span class="elsevierStyleHsp" style=""></span>h, inotropic support or hospital admission lasting 2 or more nights due to HT.<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">14</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">To determine the outcome of each patient, we reviewed the clinical notes entered during hospitalisation through discharge. For children that were discharged home from the ED, we reviewed the hospital's records as well as the linked Catalonia health system primary care records to identify potential complications of HT documented in subsequent visits.</p><p id="par0050" class="elsevierStylePara elsevierViewall">We entered and processed the collected data in a Microsoft Access database. We tabulated data for quantitative and categorical variables. Data were subsequently analysed using SPSS version 20.0 for Windows (IBM Corp, Armonk, NY, USA). We have described quantitative variables as means or medians and categorical variables as percentages. We used statistical tests to analyse the distribution of data (Kolmogorov–Smirnov) and to compare quantitative data (Student's <span class="elsevierStyleItalic">t</span>, Mann–Whitney <span class="elsevierStyleItalic">U</span>) and qualitative data (chi square, contingency tables, Fisher's exact test). We calculated 95% confidence intervals (CIs) for proportions using the Wilson method. We considered <span class="elsevierStyleItalic">P</span>-values of less than .05 statistically significant.</p><p id="par0055" class="elsevierStylePara elsevierViewall">The study was approved by the Ethics Committee of the hospital.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0060" class="elsevierStylePara elsevierViewall">We included 1,543 visits; 807 (52.3%) in period 1 and 736 (47.7%) in period 2. We did not find significant differences between the two periods under study in patient age, sex, mechanism of injury, modified Glasgow Coma Scale for infants score during assessment at the ED, and risk of TBI (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0065" class="elsevierStylePara elsevierViewall">During period 1, skull fracture was diagnosed in 35 infants (4.3%; 95% CI, 3.1%–6%), TBI in 3 (0.4%; 95% CI, 0.1%–1.0%) and ciTBI in 2 (0.3%; 95% CI, 0.07%–0.9%) compared to skull fracture in 4 infants (0.5%; 95% CI, 0.2%–1.4%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001), TBI in 2 (0.3%; 95% CI, 0.07%–1.0%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1) and ciTBI in 1 (0.1%; 95% CI, 0.02%–0.8%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">=</span><span class="elsevierStyleHsp" style=""></span>1) in period 2. Clinically important TBI was diagnosed based on hospitalisation lasting more than 48<span class="elsevierStyleHsp" style=""></span>h in all cases, as no children required ventilatory or haemodynamic support or underwent neurosurgery.</p><p id="par0070" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a> compares the management of these patients as regards imaging tests and hospital admission during the 2 periods. In patients admitted to hospital, the median length of stay was 36.4<span class="elsevierStyleHsp" style=""></span>h in period 1 (interquartile range [IQR], 17.8–46.3) and 15.7<span class="elsevierStyleHsp" style=""></span>h in period 2 (IQR, 12.9–19.6) (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001). In patients discharged home from the ED, the median length of stay in the ED was 1.8<span class="elsevierStyleHsp" style=""></span>h in period 1 (IQR, 0.8–3.2) and 2<span class="elsevierStyleHsp" style=""></span>h in period 2 (IQR, 1.2–3.7) (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic"><</span><span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleItalic">.</span>001).</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0075" class="elsevierStylePara elsevierViewall">Thirteen patients (1.6%) made a repeat visit to the ED in period 1, compared to three (0.4%) in period 2, and complications from HT were diagnosed in none.</p><p id="par0080" class="elsevierStylePara elsevierViewall">All patients with mild HT had good outcomes. No cases of TBI were detected in any of the children discharged home from the ED at a later time.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">The results of our study show that the new protocol for the management of mild HT in children aged less than 2 years implemented in the ED is beneficial for both the patient and the health system. On the one hand, we found that the ability to detect TBI did not change significantly with the new protocol. On the other hand, there was a significant reduction in the number of radiographs and head ultrasound examinations and the percentage of patients admitted to hospital, as well as the associated lengths of stay. All of the above resulted in a decreased exposure to radiation for the patients and less inconvenience for their families, as well as lower costs for the health system. It is well known that ionising radiation is carcinogenic and that children are particularly sensitive to it, with a risk that is twice or three times that of the general population, so it is particularly important for the use of radiology techniques to be justified and optimised in paediatrics.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> Physicians generally have limited knowledge of the doses involved in the radiology tests that they request, and some surveys have found that physicians often underestimate the radiation dose and its associated risks.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">21–24</span></a> The new protocol introduced in our hospital helped eliminate nearly all exposure due to skull radiographs and limits the use of brain CT, which is the diagnostic test that is most concerning in terms of radioprotection.<a class="elsevierStyleCrossRefs" href="#bib0275"><span class="elsevierStyleSup">21,25,26</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">As we noted above, the reason skull radiography used in the management of children with HT in emergency settings is the increased risk of TBI in the event of a skull fracture; however, the limitations of radiography must be taken into account: it is difficult to interpret, has a low sensitivity for the diagnosis of TBI, and subjects children to a significant dose of ionising radiation.<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">21</span></a> Due to these limitations, most current guidelines<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">14–16</span></a> do not include radiography in the management of paediatric HT save for specific instances, such as the radiological assessment of young children when child abuse is suspected.<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">27</span></a> Consistent with these international guidelines,<a class="elsevierStyleCrossRefs" href="#bib0240"><span class="elsevierStyleSup">14–16</span></a> the new protocol for HT uses clinical criteria to assess the risk of TBI and determine the approach to its management. Thus, patients with mild HT and moderate risk of TBI, who would have undergone skull radiography under the previous protocol, are now kept under observation in the ED until at least 6<span class="elsevierStyleHsp" style=""></span>h have passed since the traumatic event. The study we present here demonstrates that observation is an adequate alternative to determine which patients are eligible for a brain CT scan, as the proportion of detected cases of TBI was similar in both periods, with no significant increase in the number of CT scans or evidence of delays in diagnosis. In this regard, it is also worth noting that the change in protocol did not result in a substantial increase in ED length of stay. This finding is probably due to the fact that while it may not have been explicitly included in the previous protocol, children with HT were also kept under observation. As for the length of stay in the ED of children not admitted to hospital, it is important to consider that they were kept under observation until at least 6<span class="elsevierStyleHsp" style=""></span>h had elapsed from the traumatic event, so that length of stay was also influenced by the time elapsed between the event and the ED visit.</p><p id="par0095" class="elsevierStylePara elsevierViewall">The reduction in the number of skull radiographs was associated to a decrease in the number of cases of skull fracture that were diagnosed. The latter was probably due to nondetection of fractures rather than their absence, as the samples in both periods were similar in terms of age and mechanisms of injury. The risk associated with failing to diagnose a skull fracture in this context is low, as fractures heal spontaneously in most cases.<a class="elsevierStyleCrossRefs" href="#bib0310"><span class="elsevierStyleSup">28,29</span></a> A small proportion of skull fractures can progress to a growing skull fracture, a rare complication that occurs in 1% of cases, mostly in patients with neurologic manifestations or a palpable fracture<a class="elsevierStyleCrossRefs" href="#bib0320"><span class="elsevierStyleSup">30,31</span></a> that would be identified by brain CT.</p><p id="par0100" class="elsevierStylePara elsevierViewall">We found that the percentage of hospital admissions decreased by more than 60% and the length of hospitalisation by nearly 24<span class="elsevierStyleHsp" style=""></span>h in period 2. This is probably due to a reduced detection of skull fractures, which were the reason for admitting most young children with mild HT to hospital. Current data show that when detected, most cases of linear nondisplaced skull fractures in children do not require hospital admission and that observation in the ED is sufficiently safe.<a class="elsevierStyleCrossRefs" href="#bib0315"><span class="elsevierStyleSup">29,32–34</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">The main limitation of this study is its retrospective design, due to which we were unable to determine the mechanism of injury in all cases, and cannot rule out the possibility of inaccuracies in the clinical manifestations or physical examination findings recorded in the ED discharge summaries. Furthermore, we did not have data on the time elapsed between the traumatic event and the visit to the ED, so we could not determine the total number of hours of observation from the moment of HT. Another limitation is that we do not know the number of skull fractures that may have gone unnoticed in period 2 due to omitting skull radiography. However, we must take into account that we also cannot be certain that all skull fractures were diagnosed in period 1, as skull radiographs were not made in approximately 50% of patients. Another aspect to consider is that not all children underwent a CT scan, so it is possible, although very unlikely, that TBI or a growing skull fracture was subsequently diagnosed in some of the patients discharged home from the ED. We did not find any cases with complications in our review of additional visits by these patients to the hospital and of the Catalonia public health system records, so it would be reasonable to assume that they all had favourable outcomes.</p><p id="par0110" class="elsevierStylePara elsevierViewall">To conclude, we would like to state that clinical observation as an alternative to skull radiography enables a decrease in the number of imaging tests and hospital admissions in young children with mild HT without diminishing reliability in diagnosing TBI. This option helps reduce radiation exposure in patients and make more rational use of health resources.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conflict of interests</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflict of interests to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres888153" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec874124" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres888152" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec874123" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conflict of interests" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-07-04" "fechaAceptado" => "2016-09-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec874124" "palabras" => array:4 [ 0 => "Head trauma" 1 => "Infant" 2 => "Radiography" 3 => "Emergency department" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec874123" "palabras" => array:4 [ 0 => "Traumatismo craneal" 1 => "Lactante" 2 => "Radiografía" 3 => "Urgencias" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Objective</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The protocol for the management of mild cranioencephalic trauma in the emergency department was changed in July 2013. The principal innovation was the replacement of systematic skull <span class="elsevierStyleSmallCaps">X</span>-ray in infants with clinical observation. The aims of this study were to determine whether there was (1) a reduction in the ability to detect traumatic brain injury (TBI) in the initial visit to Emergency, and (2) a change in the number of requests for imaging tests and hospital admissions.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methodology</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">This was a retrospective, descriptive, observational study. Two periods were established for the study: Period 1 (1/11/2011–30/10/2012), prior to the implementing of the new protocol, and Period 2 (1/11/2013–30/10/2014), following its implementation. The study included visits to the emergency department by children ≤2 years old for mild cranioencephalic trauma (Glasgow Scale modified for infants ≥14) of ≤24<span class="elsevierStyleHsp" style=""></span>h onset.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">A total of 1,543 cases were included, of which 807 were from Period 1 and 736 from Period 2. No significant differences were observed as regards sex, age, mechanism, or risk of TBI. More cranial fractures were detected in Period 1 than in Period 2 (4.3% vs 0.5%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001), without significant changes in the detection of TBI (0.4% vs 0.3%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1). However, there were more cranial <span class="elsevierStyleSmallCaps">X</span>-rays (49.7% vs 2.7%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001) and more ultrasounds (2.1% vs 0.4%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001) carried out, and also fewer hospital admissions (8.3% vs 3.1%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001). There were no significant differences in the number of computerised tomography scans carried out (2% vs 3%; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.203).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The use of clinical observation as an alternative to cranial radiography leads to a reduction in the number of imaging tests and hospital admissions of infants with mild cranioencephalic trauma, without any reduction in the reliability of detecting TBI. This option helps to lower the exposure to radiation by the patient, and is also a more rational use of hospital resources.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methodology" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Objetivo</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">En julio 2013 se cambió el protocolo de manejo del traumatismo craneoencefálico leve en urgencias, siendo la principal novedad la sustitución sistemática de las radiografías craneales en lactantes por la observación clínica. Los objetivos son determinar si este cambio ha implicado: 1) una disminución en la capacidad de detección de lesiones intracraneales (LIC) en la visita inicial de urgencias y 2) cambios en la solicitud de pruebas de imagen e ingresos.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Metodología</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Estudio retrospectivo, descriptivo-observacional. Se establecen 2 periodos: periodo 1 (1/11/2011-30/10/2012), preimplantación nuevo protocolo, y periodo 2 (1/11/2013-30/10/2014), postimplantación. Se incluyen las consultas por traumatismo craneoencefálico leve a urgencias (escala Glasgow modificada para lactantes<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>14) de<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>24<span class="elsevierStyleHsp" style=""></span>h de evolución de niños<span class="elsevierStyleHsp" style=""></span>≤<span class="elsevierStyleHsp" style=""></span>2años.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Se incluyen 1.543 casos, 807 del periodo 1 y 736 del periodo 2, sin observarse diferencias significativas en sexo, edad, mecanismo y riesgo de LIC. En el periodo 1 se diagnostican más fracturas craneales que en el periodo 2 (4,3 vs. 0,5%; p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001) sin cambios significativos en la detección de LIC (0,4 vs. 0,3%; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>1). Asimismo, se realizan más radiografías de cráneo (49,7 vs. 2,7%; p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001), más ecografías (2,1 vs. 0,4%; p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001) e ingresan más casos (8,3% vs 3,1%; p<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>0,001). No se hallan diferencias significativas en las tomografías computarizadas realizadas (2 vs. 3%; p<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,203).</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">La observación clínica como alternativa a la radiografía craneal permite reducir las pruebas de imagen y los ingresos en los lactantes con traumatismo craneoencefálico leve sin disminuir la fiabilidad diagnóstica de LIC. Esta opción permite la reducción de irradiación al paciente y un uso más racional de los recursos sanitarios.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Metodología" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Muñoz-Santanach D, Trenchs Sainz de la Maza V, Maya Gallego S, Cuaresma González A, Luaces Cubells C. Observación clínica: una alternativa segura a la radiología en lactantes con traumatismo craneoencefálico leve. An Pediatr (Barc). 2017;87:164–169.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Previous presentation: the results of this study were presented at the XX Meeting of the Sociedad Española de Urgencias de Pediatría, receiving the award to the best oral communication in the meeting.</p>" ] ] "multimedia" => array:4 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2235 "Ancho" => 1811 "Tamanyo" => 353777 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Algorithm for the management of mild head trauma in children aged less than 2 years in the hospital where the study was conducted (A: until July 2013; B: from July 2013).</p> <p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">CSF, cerebrospinal fluid; CT, computed tomography; Fx, fracture; HT, head trauma; NSur: neurosurgery; Paed, paediatrics ward; PICU, paediatric intensive care unit; TBI, traumatic brain injury.</p>" ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0060" class="elsevierStyleSimplePara elsevierViewall"><span class="elsevierStyleItalic">Source</span>: Trenchs and Muñoz-Santanach<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">18</span></a>.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " rowspan="6" align="left" valign="top">Low risk</td><td class="td" title="table-entry " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Modified Glasgow coma scale for infants 15 points \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Normal neurologic assessment \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Absence of sighs of skull fracture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Absence of associated symptoms \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Mild traumatic mechanism \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Absence of occipital, parietal or temporal cephalohaematoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="8" align="left" valign="top">Moderate risk</td><td class="td" title="table-entry " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Loss of consciousness lasting less than 5<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>History of vomiting \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Moderate–severe headache or abnormal behaviour as reported by caregiver \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Violent mechanism (motor vehicle accident with ejection of patient, death of another passenger, vehicle rollover, falls from heights >90<span class="elsevierStyleHsp" style=""></span>cm, head struck by high-impact object) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Occipital, parietal or temporal cephalohaematoma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Convulsions immediately after trauma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Coagulopathy \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Patient with cerebrospinal fluid shunt \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " rowspan="9" align="left" valign="top">High risk</td><td class="td" title="table-entry " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Loss of consciousness longer than 5<span class="elsevierStyleHsp" style=""></span>min \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Modified Glasgow coma scale for infants <15 points \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Signs of basal skull fracture (haemotympanum, Battle's sign, periorbital ecchymosis) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Palpable fracture \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Penetrating trauma \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Altered level of consciousness (agitation, somnolence, repetitive questions, amnesia, slowed speech) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Focal neurologic deficits \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Seizures after symptom-free interval \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">•<span class="elsevierStyleHsp" style=""></span>Suspected child abuse \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1501003.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Criteria to assess risk of traumatic brain injury in children aged less than 2 years with mild head trauma.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">HT, head trauma; TBI, traumatic brain injury.</p><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Continuous variables are expressed as median (interquartile range) and qualitative variables as absolute frequency (percentage).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Characteristic \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 1 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>807) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 2 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>736) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Age (months)</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.0 (7.5–17.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.5 (7.1–17.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.752 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Male sex</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">430 (53.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">386 (52.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.742 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Documented HT mechanism</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">782 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">672 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Mechanism of fall \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">703 (89.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">587 (87.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.126 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Glasgow 15 in ED</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">807 (100%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">734 (99.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.227 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Risk of TBI</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.133 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Low \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">408 (50.6%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">405 (55%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Moderate \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">396 (49.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">326 (44.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>High \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (0.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5 (0.7%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1501004.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Epidemiological and clinical characteristics of children aged less than 2 years with mild head trauma managed at the emergency department during the two periods.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">CT, computed tomography.</p><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Continuous variables are expressed as median (interquartile range) and qualitative variables as absolute frequency (percentage).</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 1 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>807) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Period 2 (<span class="elsevierStyleItalic">n</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>736) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleItalic">Imaging test</span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Skull radiograph \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">401 (49.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20 (2.7) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Head CT scan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">16 (2.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">22 (3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.203 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleHsp" style=""></span>Head ultrasound \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">17 (2.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3 (0.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.003 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " colspan="4" align="left" valign="top"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top"><span class="elsevierStyleItalic">Hospital admission</span> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">67 (8.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">23 (3.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1501002.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Imaging tests performed in the emergency department during both periods.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:34 [ 0 => array:3 [ "identificador" => "bib0175" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mild traumatic brain injury" "autores" => array:1 [ 0 => array:2 [ "colaboracion" => "European Federation of Neurological Societies" "etal" => false ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1111/j.1468-1331.2011.03581.x" "Revista" => array:6 [ "tituloSerie" => "Eur J Neurol" "fecha" => "2012" "volumen" => "19" "paginaInicial" => "191" "paginaFinal" => "198" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22260187" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0180" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:1 [ "referenciaCompleta" => "Faul M, Xu L, Wald MM, Coronado VG. 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Benifla" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00381-016-3175-2" "Revista" => array:3 [ "tituloSerie" => "Childs Nerv Syst" "fecha" => "2016" "paginaInicial" => "21" ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23412879/0000008700000003/v2_201708291341/S2341287917301291/v2_201708291341/en/main.assets" "Apartado" => array:4 [ "identificador" => "26005" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Original Articles" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23412879/0000008700000003/v2_201708291341/S2341287917301291/v2_201708291341/en/main.pdf?idApp=UINPBA00005H&text.app=https://analesdepediatria.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341287917301291?idApp=UINPBA00005H" ]
| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 4 | 11 | 15 |
| 2024 October | 57 | 45 | 102 |
| 2024 September | 49 | 41 | 90 |
| 2024 August | 73 | 60 | 133 |
| 2024 July | 47 | 43 | 90 |
| 2024 June | 54 | 24 | 78 |
| 2024 May | 44 | 37 | 81 |
| 2024 April | 53 | 24 | 77 |
| 2024 March | 35 | 27 | 62 |
| 2024 February | 35 | 26 | 61 |
| 2024 January | 26 | 24 | 50 |
| 2023 December | 30 | 24 | 54 |
| 2023 November | 40 | 29 | 69 |
| 2023 October | 36 | 23 | 59 |
| 2023 September | 18 | 17 | 35 |
| 2023 August | 30 | 24 | 54 |
| 2023 July | 40 | 29 | 69 |
| 2023 June | 29 | 27 | 56 |
| 2023 May | 50 | 22 | 72 |
| 2023 April | 31 | 13 | 44 |
| 2023 March | 65 | 29 | 94 |
| 2023 February | 50 | 15 | 65 |
| 2023 January | 43 | 23 | 66 |
| 2022 December | 70 | 33 | 103 |
| 2022 November | 66 | 28 | 94 |
| 2022 October | 63 | 46 | 109 |
| 2022 September | 52 | 35 | 87 |
| 2022 August | 51 | 51 | 102 |
| 2022 July | 62 | 52 | 114 |
| 2022 June | 35 | 44 | 79 |
| 2022 May | 59 | 46 | 105 |
| 2022 April | 58 | 38 | 96 |
| 2022 March | 65 | 51 | 116 |
| 2022 February | 45 | 39 | 84 |
| 2022 January | 68 | 45 | 113 |
| 2021 December | 63 | 49 | 112 |
| 2021 November | 57 | 47 | 104 |
| 2021 October | 109 | 81 | 190 |
| 2021 September | 31 | 36 | 67 |
| 2021 August | 22 | 38 | 60 |
| 2021 July | 32 | 33 | 65 |
| 2021 June | 41 | 35 | 76 |
| 2021 May | 48 | 46 | 94 |
| 2021 April | 92 | 73 | 165 |
| 2021 March | 62 | 38 | 100 |
| 2021 February | 47 | 22 | 69 |
| 2021 January | 46 | 21 | 67 |
| 2020 December | 52 | 23 | 75 |
| 2020 November | 47 | 22 | 69 |
| 2020 October | 88 | 24 | 112 |
| 2020 September | 60 | 27 | 87 |
| 2020 August | 125 | 18 | 143 |
| 2020 July | 129 | 20 | 149 |
| 2020 June | 61 | 14 | 75 |
| 2020 May | 54 | 22 | 76 |
| 2020 April | 30 | 17 | 47 |
| 2020 March | 43 | 16 | 59 |
| 2020 February | 50 | 30 | 80 |
| 2020 January | 37 | 12 | 49 |
| 2019 December | 45 | 37 | 82 |
| 2019 November | 62 | 24 | 86 |
| 2019 October | 41 | 15 | 56 |
| 2019 September | 35 | 25 | 60 |
| 2019 August | 34 | 20 | 54 |
| 2019 July | 39 | 39 | 78 |
| 2019 June | 21 | 18 | 39 |
| 2019 May | 42 | 20 | 62 |
| 2019 April | 73 | 33 | 106 |
| 2019 March | 45 | 14 | 59 |
| 2019 February | 42 | 23 | 65 |
| 2019 January | 62 | 30 | 92 |
| 2018 December | 46 | 36 | 82 |
| 2018 November | 104 | 47 | 151 |
| 2018 October | 127 | 16 | 143 |
| 2018 September | 73 | 20 | 93 |
| 2018 August | 4 | 0 | 4 |
| 2018 July | 1 | 0 | 1 |
| 2018 June | 3 | 0 | 3 |
| 2018 May | 9 | 0 | 9 |
| 2018 April | 23 | 0 | 23 |
| 2018 March | 25 | 0 | 25 |
| 2018 February | 12 | 0 | 12 |
| 2018 January | 33 | 0 | 33 |
| 2017 December | 29 | 0 | 29 |
| 2017 November | 37 | 0 | 37 |
| 2017 October | 16 | 0 | 16 |
| 2017 August | 0 | 9 | 9 |
| 2017 July | 0 | 9 | 9 |
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