Evren EKİNGEN, Mehmet Kubilay GÖKÇE, Özlem GÜLER, Hakan HAKKOYMAZ, Ali İhsan KİLCİ, Cebrail ÖZTÜRK, Murat TEPE

Acil Serviste Görev Yapan Hekimlerin Minör Kafa Travmalı Çocuk Hastalara Yaklaşımı

Amaç: Bu çalışmada acil servis hekimlerinin kafa travmalı çocuk hastalardaki tomografi kullanımlarını, klinik karar verme kurallarını (KKK) ne kadar uyguladıklarını ve tomografi kullanım kararının verilmesinde rol oynayan etmenleri araştırmayı amaçladık. Gereç ve Yöntem: Ülkemizdeki çeşitli hastanelerin acil servislerinde farklı statülerde görev yapan hekimlere 19 soruluk anketimiz uygulandı. Bulgular: Çalışmamıza 306 hekim katıldı. Minör kafa travmalı çocuk hastalardaki tomografi kullanım oranlarını hekimlerin 103’ü %10 ve altında, 60’ı %11-25 arasında, 39’u %26-50 arasında ve 104’ü %50 ve üzerinde olarak belirtti. Katılımcıların %39,5’i bilgisayarlı tomografi (BT) kararı verirken KKK’yi uyguladığını, %42,8’i kendi klinik tecrübelerine göre, %6,2’si konsültan önerisiyle karar verdiğini belirtti. Hekimlerin %36,6’sı BT çekmediği için tehdit ve hakarete uğradığını, %6,9’u sözlü ve fiziksel saldırıya maruz kaldığını ifade etti. Tomografi kullanımındaki artışın nedenini katılımcıların %56,2’si malpraktis korkusu, %22,2’si aile baskısı, %8,2’si yoğun çalışma ortamında hastayı hızlı sonuçlandırma olarak tanımladı. Sonuç: Hekimlerin KKK’yi uygulama oranlarının düşük ve tomografi çekme oranlarının yüksek olduğu izlenmiştir. Bunun nedenleri arasında medikolegal endişeler, ailelerin baskısı ve acil servisteki hasta yoğunluğu ilk üç sırayı almıştır

Emergency Physicians’ Approach to Minor Head Trauma in Pediatric Patients

Objectives: To investigate the use of tomography in children with head trauma by emergency department physicians, the frequency of their applying clinical decision-making rules (CDMRs), and the factors playing a role in the decision of tomography use. Materials and Methods: Our 19 question-survey was applied to physicians working in different statuses in the emergency departments of various hospitals in our country. Results: Three hundred and six physicians participated in our study. The rate of tomography use in pediatric patients with minor head trauma was reported by physicians as follows: One hundred and three physicians stated as 10% or less, 60 as between 11% and 25%, 39 as between 26% and 50%, and 104 as 50% or more. 39.5% of the participants stated that they applied CDMRs when making a computed tomography (CT) decision, 42.8% stated that they decided according to their clinical experience, 6.2% stated that they made the decision with the recommendation of a consultant. 36.6% of the physicians stated that they were threatened and insulted for not performing a CT scan and 6.9% stated that they were subjected to verbal and physical attacks. The reason for the increase in tomography use was defined as the fear of malpractice by 56.2%, family pressure by 22.2% and desire to conclude the patients quickly in a busy working environment by 8.2% participants. Conclusion: It was observed that the rate of application of CDMRs by physicians was low and the rate of tomography use was high. Medico-legal concerns, the pressure of families, and patient overcrowdedness in the emergency room took the top three places among the reasons for this.

PDF

___

1. Marin JR, Weaver MD, Barnato AE, et al. Variation in emergency department head computed tomography use for pediatric head trauma. Acad Emerg Med. 2014;21:987-995.
2. Azim A, Jehan FS, Rhee P, et al. Big for small: Validating brain injury guidelines in pediatric traumatic brain injury. J Trauma Acute Care Surg. 2017;83:1200-1204.
3. Durgun HM, Tektas E, Zengin Y, et al. Are pediatric emergency care applied research network rules (PECARN) sufficient for computed cranial tomography decision in pediatric patients with mild head trauma? J Clin Exp Invest. 2016;7:35-40.
4. Singh N, Singhal A. Challenges in minor TBI and indications for head CT in pediatric TBI-an update. Childs Nerv Syst. 2017;33:1677-1681.
5. Atabaki SM, Hoyle JD Jr, Schunk JE, et al. Comparison of Prediction Rules and Clinician Suspicion for Identifying Children With Clinically Important Brain Injuries After Blunt Head Trauma. Acad Emerg Med. 2016;23:566-575.
6. Oakley E, May R, Hoeppner T, et al. Computed tomography for head injuries in children: Change in Australian usage rates over time. Emerg Med Australas. 2017;29:192-197.
7. Blackwell CD, Gorelick M, Holmes JF, et al. Pediatric head trauma: changes in use of computed tomography in emergency departments in the United States over time. Ann Emerg Med. 2007;49:320-324.
8. Atmış A, Tolunay O, Çelik T, et al. Dilemma in Pediatric Head Trauma: Is Cranial Computed Tomography Necessary or Not in Minor Head Traumas? J Pediatr Emerg Intensive Care Med. 2016;3:27-31.
9. Abouzeid A, Shaban M, Emam T, et al. Evaluation of Computed tomography (CT) scan ordering in children with mild head injury at Emergency Department at Suez Canal University Hospital. Int J Surg Med. 2018;4:7-12.
10. Osmond MH, Klassen TP, Wells GA, et al. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010;182:341-348.
11. Burns EC, Grool AM, Klassen TP, et al. Scalp Hematoma Characteristics Associated With Intracranial Injury in Pediatric Minor Head Injury. Acad Emerg Med. 2016;23:576-583.
12. Da Dalt L, Parri N, Amigoni A, et al. Italian guidelines on the assessment and management of pediatric head injury in the emergency department. Ital J Pediatr. 2018;44:7.
13. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374:1160-1170.
14. Stein SC. Minor head injury: 13 is an unlucky number. J Trauma. 2001;50:759-760.
15. Di F, Gao Q, Xiang J, et al. Clinical Practice Experiences in Diagnosis and Treatment of Traumatic Brain Injury in Children: A Survey among Clinicians at 9 Large Hospitals in China. PLoS One. 2015;10:e0142983.
16. Kocyigit A, Serinken M, Ceven Z, et al. A strategy to optimize CT use in children with mild blunt head trauma utilizing clinical risk stratification; could we improve CT use in children with mild head injury? Clin Imaging. 2014;38:236-240.
17. Eagles D, Stiell IG, Clement CM, et al. International survey of emergency physicians’ priorities for clinical decision rules. Acad Emerg Med. 2008;15:177-182.
18. Özan E, Ataç GK. Computed tomography use in minor head injury: attitudes and practices of emergency physicians, neurosurgeons, and radiologists in Turkey. Ulus Travma Acil Cerrahi Derg. 2018;24:121-128.