My name is Becca Reynolds and I'm a neurosurgery resident at Vanderbilt University Medical Center. Today I'm going to talk about protocolization of isolated linear skull fracture management at a level one trauma center. Skull fracture management varies nationwide. In a study by Mannix et al in 2013, they published a wide variability in admission rates of children with isolated linear skull fractures across the country. Anywhere from 20 percent to nearly 99 percent of children were admitted at individual facilities based upon which facility they were and where in the country they were located. This wide variability caught our center's interests and made us take a look one step further. In 2019 in JNS Pediatrics we published a study looking at reasons for admission of these children and predictors of bounce back. The reasons for admission are printed here. We found that approximately a quarter of children were admitted for PO challenge or nausea and vomiting. A quarter were admitted for care consultation or non-accidental trauma workup. A quarter were admitted for young age and a quarter were admitted for other unclear reasons moving forward. So based on the information that was found in that study, we created an evidence-based isolated linear skull fracture protocol. We used fracture location, window since the time of injury, and zofran used. Zofran use in our study that was previously done was a single predictor of ED bounce back within 72 hours. As such, we included it as one of the major criteria for children to be admitted versus discharged home. So the problem assessed in this study was unnecessary hospital admissions. The objective was to assess the safety and efficacy of a multidisciplinary fracture management protocol. The efficacy was assessed to determine if there was indeed a decrease in admissions by implementing this protocol and the safety was to determine if there was no change in 72 hour ED revisits or at least there was no increase. The methods of the protocol was implemented in July 2019. There was one year of post-protocol analysis and two years prior of pre-protocol analysis and these two cohorts were compared. Children under 18 years old who presented to our pediatric trauma center were included. It was a retrospective study so they had to have an ICD-10 code for linear skull fracture. Children were included who had acute intracranial findings such as pneumocephalus or hemorrhage. Children who had a depressed skull fracture were excluded as well as those with multiple traumatic findings. The results were interesting. There was a significant decrease in neurosurgical consultation from 86 percent to 44 percent. There was no significant change in trauma consultation. Interestingly there was an increase in care consultation which is the NIT workup as well as social work consultation as well. These two things go hand in hand and this is likely secondary to increased suspicion of providers looking for a concern for child abuse history or non-accidental trauma in this patient population. The primary outcomes of interest were admission and ED revisits. There was a statistically significant decrease in admission rate from 52 percent to 38 percent at our facility. There was a trend towards decrease in fewer ED revisits from four percent to one percent however this was not statistically significant. There were no mortalities and no neurosurgical procedures performed in patient stay. The median ED length of stay was six hours. As such from this study we can conclude that protocolization is both safe and feasible. Neurosurgical consultation can be prioritized in the process of children presenting with isolated linear skull fractures and further investigation into criteria for admission the true necessity of inter-facility transfer and health care costs is warranted to better understand the ramifications of this protocol. These are my references and our team that was involved in this study. I'd like to thank all involved and I'd be happy to take any questions.

neurosurgery resident

linear skull fracture

trauma center

admission rates

evidence-based protocol