a b s t r a c t

Background: Childhood sports-related head trauma is common, frequently leading to emergency department (ED) visits. We describe the spectrum of these injuries and trends in computed tomography use in the Pediatric Emergency Care Applied Research Network.

Methods: This was a secondary analysis of a large prospective cohort of children with head trauma in 25 Pediatric Emergency Care Applied Research Network EDs between 2004 and 2006. We described and compared children 5 to 18 years old by CT rate, Traumatic brain injury on CT, and clinically important TBI (ciTBI). We used multi- variable logistic regression to compare CT rates, adjusting for clinical severity. Outcomes included frequency of CT, TBIs on CT, and ciTBIs (defined by [a] death, [b] neurosurgery, [c] intubation N 24 hours, or [d] hospitalization for >=2 nights).

Findings: A total of 3289 (14%) of 23082 children had sports-related head trauma. Two percent had Glasgow Coma Scale scores less than 14. 53% received ED CTs, 4% had TBIs on CT, and 1% had ciTBIs. Equestrians had increased adjusted odds (1.8; 95% confidence interval [CI], 1.0-3.0]) of CTs; the rate of TBI on CT was 4% (95% CI, 3%-5%). Compared with team sports, snow (adjusted odds ratio, 4.1; 95% CI 1.5-11.4) and nonmotorized wheeled (adjusted odds ratio, 12.8; 95% CI, 5.5-32.4) sports had increased adjusted odds of ciTBIs.

Conclusions: Children with sports-related head trauma commonly undergo CT. Only 4% of those imaged had TBIs on CT. Clinically important TBIs occurred in 1%, with significant variation by sport. There is an opportunity for Injury prevention efforts in high-risk sports and opportunities to reduce CT use in general by use of evidence- based prediction rules.

What is known about this subject: Pediatric sports-related head injuries are a common and increasingly frequent ED presentation, as is the use of CT in their evaluation. Little is known about TBIs resulting from different types of sports activities in children.

What this study adds to existing knowledge: This study broadens the understanding of the epidemiology of Pediatric TBIs resulting from different sports activities through a prospective assessment of frequency and severity of ciTBIs and ED CT use in a large cohort of head-injured children in a network of pediatric EDs.

(C) 2015

? Prior presentation: This work was presented in part at the American Academy of Pediatrics Annual Meeting, Boston, MA, October 2011.

* Corresponding author at: Division of Emergency Medicine, ML 2008, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave, Cincinnati OH 45229. Tel.: +1 513 636 7973.

E-mail address: [email protected] (R.M. Ruddy).

¹ Current address: Department of Pediatrics, Ann and Robert H. Lurie Children’s Hospital of Chicago and The Center for Healthcare Studies, Northwestern University, Feinberg School of Medicine, Chicago, IL.

² Current address: Department of Pediatrics, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA.

http://dx.doi.org/10.1016/j.ajem.2015.06.069

0735-6757/(C) 2015

1. Introduction

traumatic brain injury is the leading cause of disability in chil- dren older than 1 year and is a leading cause of death in children [1]. The Centers for Disease Control and Prevention recently estimated that more than 2.6 million children 18 years and younger are treated in emergency departments (EDs) for nonfatal sports- and recreation- related injuries annually, with approximately 6.5% of these injuries being TBIs [2].

Recent work suggests that ED visits for sports-related TBIs are in- creasing. Data from the National Electronic Injury surveillance System-All Injury Program revealed that the number of sports- and recreation-related TBI visits to EDs increased by 62% from 2001 to 2009 [2]. A single-institution study demonstrated that visits to the ED for sports-related TBIs have increased by 92% between 2002 and 2011 [3]. Both multicenter and single-center studies have indicated that al- though there have been significant increases in the numbers of children seeking care for sports-related TBIs, the proportion of admissions to the hospital or treatment for sports-related TBIs has remained relatively constant [2,3].

Most studies of sports-related TBIs have been limited by retrospec- tive assessments, data extraction from administrative data sets, or lack of standardized definitions of Clinical predictors or outcomes [4-6]. Much previous work has also been limited to injuries related to indivi- dual sports using administrative data sets or small samples [7-12]. These limitations make it difficult for clinicians to apply these data to ED management, particularly in assessing the risk associated with particular sports mechanisms.

Computed tomography (CT) remains the reference standard for the emergent evaluation of children with head trauma at risk for TBI. How- ever, there has been substantial variation in CT use across centers and between clinicians [13-17]. Research highlighting the risk of exposure to radiation from CT has prompted efforts to reduce this variability in care by developing prediction rules to decrease inappropriate CT use in children with Blunt head trauma [18-20]. This body of work has not focused, however, on children with sports-related head trauma.

There are little prospective data about the differences in risks and outcomes resulting from head trauma in different sporting activities. In addition, there are few data regarding how different sports-related activities may impact clinician-related patterns of CT use. The objectives of this study were to evaluate the frequency of CT use, TBIs on CT, and prevalence of clinically important TBIs (ciTBIs) by sports category in pediatric sports participants.

1. Methods

We performed a planned secondary analysis of a large prospective observational study of children younger than 18 years with blunt head trauma in the Pediatric Emergency Care Applied Research Network [15]. The study was conducted between 2004 and 2006 in 25 PECARN EDs. The methods of the parent study are described else- where [15], whereas the specific methods relevant to the current ana- lysis are described below. Each participating site’s institutional review board approved the study.

• 1. Inclusion criteria and sports categorization

Patients were included in the current analysis if they were at least 5 years and younger than 18 years old, had sports-related head trauma, and presented to the ED within 24 hours of injury. This analysis included patients with all Glasgow Coma Scale scores who otherwise met enrollment criteria. Review of potential sport Classification systems (ie, contact degree, static and dynamic characteristics, or by organization) was not fruitful. Therefore, we classified sports-related trauma a priori (by consensus of the investigators) into 7 broad groups: Team Sports, Nonteam Organized Sports, Snow, Water, Wheeled (nonmotorized),

Equestrian, and Leisure. The classification was completed on the case re- port forms at time of ED visit by the treating physician. Examples of each are as follows: Team Sport: baseball, football, hockey; Nonteam Orga- nized: cheerleading, gymnastics, wrestling; Snow: ice skating, skiing, sledding, snowboarding; Water: diving or swimming; Wheeled: roller-skating, skateboarding, and scooter (data collection forms did not distinguish bicycle riding into sports categories, so they were excluded); Equestrian: horse or bull riding; and Leisure: playground or yard play. We excluded head trauma as a result of motorized sports. Team Sports were further categorized into 6 subgroups: baseball/ softball, basketball, football, hockey, soccer, and other team sports (field hockey, lacrosse, rugby, and volleyball).

• 1. Clinical data collection and PECARN TBI risk factors

Prospective data collection included patient age, sex, presenting signs and symptoms including GCS scores, other signs of altered mental status (defined by agitation, somnolence, repetitive questioning, or slow response to verbal communication), signs of basilar Skull fractures, and other signs of TBI, such as a history of loss of consciousness or vomiting after the injury, or Severe headache at ED presentation. The published PECARN clinical prediction rule for the older age group in- cluded 5 defined clinical predictors of ciTBI (altered mental status, his- tory of loss of consciousness, history of vomiting, signs of basilar skull fracture, and severe headache at ED presentation) besides severe injury mechanism [15]. Each of these five clinical predictors was assessed in this cohort and adjusted for in the multivariable analyses. cranial CTs were obtained at the discretion of the treating clinicians. If a CT was obtained, the treating physicians were asked to document their main reasons for obtaining the CT.

• 1. Outcomes and definitions

We focused on three primary outcomes: (1) the frequency of CT use,

(2) the frequency of TBI on CT, and (3) the frequency of ciTBI. We de- fined ciTBI as death from TBI, neurosurgical procedure, intubation for at least 24 hours for the TBI, or hospitalization for 2 or more nights due to the head trauma in association with TBI on CT. We defined TBI on CT as any of the following: intracranial hemorrhage or contusion, cerebral edema, traumatic infarction, Diffuse axonal injury, shearing injury, sigmoid sinus thrombosis, Midline shift of intracranial contents or signs of brain herniation, skull diastasis, pneumocephalus, or skull fracture depressed by at least the width of the skull.

• 1. Statistical analysis

We analyzed the data using descriptive statistics with 95% confi- dence intervals (CIs), where appropriate, for categorical variables and median and interquartile range for continuous variables. We compared patients in different sports groups on the basis of presenting clinical features, including all factors in the PECARN TBI prediction rule.

We performed multivariable logistic regression with generalized es- timating equations to compare CT rates between different sports groups. The generalized estimating equations model adjusted for the PECARN clinical predictors of ciTBI and for clustering of CT use by hospi- tal. We also compared rates of ciTBI using exact logistic regression for the sports groups and adjusted for the PECARN clinical risk factors. Cat- egories with no ciTBI (Leisure, Nonteam Organized, and Water Sports) were excluded from that analysis. The rates of ciTBI for the team sports groups were not compared using regression because of low prevalence rates. All PECARN clinical risk factors were entered as dichotomous variables in both regression models. If more than 1 of the 5 PECARN clinical risk factors were missing, then the “any PECARN risk factor” variable was considered missing.

Finally, we determined the ED provider-documented reason for obtaining head CT in the subgroup of patients who had GCS scores of

15 and no signs of abnormal mental status at ED presentation. We per- formed the data analysis using SAS statistical software (version 9.3; SAS Institute, Inc, Cary, NC).

1. Results

There were 43904 children enrolled in the parent study. Thirty pa- tients without presenting GCS documentation and 14 patients without documentation of ciTBI were excluded from analysis a priori. Of the re- maining 23373 (53%) who were at least 5 and younger than 18 years old with complete documentation, 3580 (15%) had sports injuries. Patients were excluded from the sports analysis if we were unable to classify the sport during prospective review (n = 291). The remainder of this analysis focuses on the 3289 (14%) children having categorized sports-related trauma (Figure).

• 1. Patient characteristics

Table 1 describes the characteristics of the cohort including the me- dian age, sex, ED presenting GCS scores, and PECARN risk factors by sport category, with further detail in the Team Sports category. The me- dian age of participants in Team and Nonteam Organized Sports catego- ries was at least 2 years older than that of the other categories. Males predominated in each sport category except in Equestrian Sports. Over- all, 2% (51/3289) had ED GCS scores of less than 14. The ED GCS scores were 15 in more than 90% of patients in each category, with the excep- tion of the Equestrian group, in which 12% of participants had ED GCS scores less than 15. Signs of basilar Skull fractures were uncommon in all groups (<= 2%). Participants in Water Sports had the lowest rate of having any PECARN clinical risk factors at 22%, whereas patients in all other categories had 38% to 60% frequency of exhibiting any PECARN clinical risk factors. Soccer participants had the highest rate of having any PECARN clinical risk factors (61%). When evaluating the Team

43,904 patients enrolled in primary pediatric blunt head trauma study

23,373 (53%) 5 years

of age

20,531 excluded for present analysis 20,487 5 years of age

30 missing GCS

14 missing ciTBI outcome data

3,580 (15%) with

sports injuries

291 excluded due to insufficient information to determine sports categorization

3,289/23,082 (14%)

with sports related trauma

Figure. Patient flow diagram.

Sports category by subgroup, Soccer and Other Team Sports had the largest percentages of female participants (45% and 49%, respectively).

• 1. Cranial CT use, TBI on CT, and ciTBI

The overall rate of cranial CT use in the ED was 1743 of 3289 (53%; 95% CI, 51%-55%) in this sports-related cohort compared with 8152 of 19793 (41%; 95% CI, 41%-42%) of children 5 to 18 years of age in the par- ent nonsport study cohort. There were 69 (4%; 95% CI, 3%-5%) of 1743 children with TBIs on CT in our sports-related cohort compared with 576 (7%; 95% CI, 7%-8%) of 8152 in the similarly aged nonsports parent study cohort. Within the overall sports-related cohort, there were 42 (1%; 95% CI, 0.9%-2%) of 3289 children with ciTBIs. Tables 2A and 2B de- scribe the adjusted odds ratio (AOR) of CT use, TBIs on CT, and ciTBIs for sports group and team sport subgroups after adjusting for the 5 PECARN clinical risk factors. All sports groups except Water, Leisure, and Nonteam Organized Sports had greater rates of CT use compared with the overall nonsport cohort. Water, Leisure, and Nonteam Organized Sports had CT rates similar to the overall nonsport cohort. The rates of TBI on CT in all sports categories were less than 10%, except for Wheeled Sports, which had a 12% rate of TBI on CT. The odds of receiving a CT were 1.8 times greater in the Equestrian group compared with the Team Sports group. The ciTBI rate was greatest in the Wheeled Sports group, but both the Snow Sports and Equestrian groups had adjusted odds of ciTBI higher than the Team Sports group. When evaluating only patients injured in Team Sports, there were similar rates of CT use for each of the subgroups; and the ciTBI rate was less 1% or less for each subgroup (Table 2B). Rates and descriptions of the ciTBI outcomes are listed in Table 3. There was only 1 sports-related death, which was in the Wheeled Sports group. The most common ciTBI outcome was hospi- talization for 2 or more nights due to the TBI, which occurred in 1% or less the patients in all sports categories except Equestrian, Snow, and Wheeled Sports.

Table 5 demonstrates a comparison between patients with TBI on CT

and patients with ciTBI. There was a trend toward lower GCS scores (P value = .07) in the ciTBI group. Similarly, there was a slightly higher percentage of NonTeam Sport participants in the ciTBI group (P value

= .065). Of note, although 3 of the 45 patients with ciTBIs had no PECARN rule factors [15], none required neurosurgery. Two of the 3 resulted from Wheeled Sports (unhelmeted), and one resulted from skiing. They met ciTBI criteria by requiring 2 or more nights of hospitali- zation for their TBIs.

Finally, among patients with GCS scores of 15 and no other docu- mented mental status abnormalities, ED clinicians listed mechanism of injury, headache, and loss of consciousness frequently as influencing the decision to obtain a CT (Table 4). Concerns for skull fractures were reported frequently for patients in both the Wheeled Sports group and in the baseball/softball group. Seven percent to 20% of the patients with- in each mechanism category had request by family, referring physician, or consulting physician identified as an indication for obtaining a CT.

1. Discussion

In this study, we found that sports-related injuries accounted for 14% of all head injuries suffered by children in a large prospective cohort. Equestrian, Snow, and Wheeled Sports accounted for the highest per- centages of ciTBIs, whereas among the Team Sports groups, baseball/ softball was associated with the highest rate of ciTBIs. Admission fre- quency was highest in the Equestrian, Snow, and Wheeled Sports. With- in Wheeled Sports, rollerblading, skateboarding, or scooter use as a mechanism contributed to a rate of hospitalization 10 times that seen in Team Sports (5% vs 0.5%) The decision to hospitalize is the most subjective of the ciTBI criteria. It is possible that practice variation con- tributes to the difference between the sports groups. There is known variation in CT use by provider training background and hospital type within the PECARN TBI cohort [17].

Table 1

Patient characteristics by sports categories

Sport (no. of

Median age

Male %

GCS score % (95% CI) Other signs of altered

Signs of basilar skull

Other PECARN risk

participants)	in years (IQR)	(95% CI)	3-8	9-12	13-14	15	mental status? % (95% CI) fracture+ % (95% CI		) factors? % (95% CI)
Team (1898)	14 (12-16)	81 (80-83)	0.2 (0.1-0.5)	0.4 (0.1-0.8)	3 (3-4)	96 (95-97)	19 (18-21)	0.3 (0.1-0.7)	43 (40-45)
Baseball/softball (339)	12 (10-15)	80 (75-84)	0 (0-1)	0 (0-1)	2 (0.8-4)	98 (96-99)	12 (9-16)	0.9 (0.2-3)	28 (23-33)
Basketball (296)	14 (12-16)	79 (74-84)	0.3 (0-2)	0.3 (0-2)	2 (1-5)	97 (94-99)	16 (12-21)	0.3 (0-2)	46 (40-52)
Football (635)	14 (12-16)	99 (98-99)	0.3 (0-1)	0.5 (0.1-1)	5 (3-6)	95 (93-96)	23 (19-26)	0.2 (0-0.9)	47 (43-51)
Hockey (229)	14 (13-16)	86 (81-91)	0 (0-2)	0.9 (0.1-3)	2 (0.7-5)	97 (94-99)	21 (15-26)	0 (0-2)	42 (36-49)
Soccer (300)	15 (13-16)	55 (50-61)	0.3 (0-2)	0.3 (0-2)	4 (2-7)	95 (92-97)	26 (21-31)	0.3 (0-2)	50 (44-56)
Other (99)	16 (15-17)	51 (40-61)	0 (0-4)	0 (0-4)	2 (0.2-7)	98 (93-100)	10 (5-18)	0 (0-4)	36 (27-47)
Nonteam Org. (173)	14 (12-16)	59 (51-66)	0 (0-2)	0 (0-2)	3 (0.9-7)	97 (93-99)	19 (13-25)	2 (0.4-5)	34 (27-42)
Snow (497)	12 (9-14)	70 (66-74)	0.2 (0-1)	1 (0.3-2)	5 (3-7)	94 (91-96)	25 (21-29)	1 (0.3-2)	55 (50-59)
Water (79)	12 (9-15)	67 (56-77)	0 (0-5)	1 (0-7)	3 (0.3-9)	96 (89-99)	10 (5-19)	1 (0-7)	17 (9-27)
Wheeled (377)	11 (8-13)	77 (72-81)	0.8 (0.2-2)	0.5 (0.1-2)	7 (5-10)	92 (89-94)	22 (18-27)	2 (0.8-4)	41 (36-46)
Equestrian (94)	11 (10-14)	15 (8-24)	0 (0-4)	2 (0.3-7)	10 (4-17)	88 (80-94)	23 (15-33)	1 (0-6)	49 (38-60)
Leisure (171)	11 (8-14)	80 (73-86)	0 (0-2)	0.6 (0-3)	2 (0.4-5)	98 (94-99)	17 (12-23)	0 (0-2)	35 (28-43)

IQR, interquartile range.

* Other signs of altered mental status defined as agitation, somnolence, repetitive questioning, or slow response to verbal communications.

⁺ Signs of basilar skull fracture defined as retroauricular bruising, periorbital bruising, hemotympanum, cerebral spinal fluid otorrhoea, or cerebral spinal fluid rhinorrhea.

^? Other PECARN risk factors defined as loss of consciousness, vomiting, or severe headache.

We also found that despite a low overall rate of ciTBI (1%) among all pediatric sports participants, approximately one-half of children with sports- related blunt head trauma underwent cranial CTs during ED evaluation, varying based on the sport. This is in contradistinction to other published data collected prospectively on high school athletes in which only 21% received cranial CT [21]. This suggests that there may be some sideline screening or other selection factors skewing the popu- lation that presents to an ED for evaluation. We also note that the rate of CT among sports participants was more than 10% higher than that of the nonsports cohort from the same age cohort of the parent observational study, although children with sports-related head trauma had a lower rate of TBIs on CT and similar rates of ciTBIs as the non-sports-related group. This suggests that CTs are being applied with relatively greater frequency and less specificity in the sports group. The current analysis of patients 5 to 18 years old included the full spectrum of GCS scores from the original parent prospective study, not only the patients with GCS scores of 14 or 15 that are included in the PECARN TBI prediction rule [15]. That being said, it is important to note that less than 2% of those in the current study had GCS scores in the ED of less than 14.

Within the sports-injury population, we evaluated the frequency of CT use, TBIs on CT, and ciTBIs by specific sport mechanism. We found, appropriately, that the frequency of obtaining CT scans was somewhat related to sports categories with increased risk of ciTBIs. For example, the highest rate of CT scan use was in the 3 sports with the highest odds of ciTBI (Equestrian, Snow, and Wheeled Sports), with adjusted odds of CT use only higher in the Equestrian-related head trauma group. Equestrian and off-road vehicle sport-related head trauma has been shown in past work to be associated with more severe TBIs than head trauma due to other mechanisms [22]. However, in the current

study, other sports categories, particularly Team Sports, were associated with substantial rates of CT use, with infrequent occurrence of ciTBIs.

It appears that the decision to obtain cranial CTs in this sports cohort was greatly driven by concerns related to the mechanism of injury, in ad- dition to the presence of headache in the ED or history of loss of con- sciousness. Treating physicians also reported that parental or referring/ consulting physician request affected up to 20% of decisions to obtain CTs in those patients with normal mental status examination results. This suggests that there may be substantial potential to decrease inap- propriate CT use in this cohort by application of evidence-based recom- mendations such as those provided by the PECARN prediction rule for this age group [15]. In this cohort participating in sports, application of the prediction rule would have identified 42 of 45 patients with ciTBI and 26 of 29 patients with TBI on CT (but without ciTBI). Not only is CT not recommended for patients who have none of the 6 PECARN variables, but selected patients with isolated PECARN variables such as isolated severe mechanism of injury, Isolated headache, isolated history of loss of consciousness, and isolated history of vomiting have a suffi- ciently low risk of ciTBI that they may be observed for a period of time before deciding whether or not to obtain a CT [23-26]. In addition, it has been previously shown that after adjusting for risk of ciTBI, a period of observation before CT decision making can decrease CT use without increasing the risk of missing TBIs [27]. These strategies may effectively be applied to certain children after sports-related head trauma.

As there have been an increasing number of ED visits for head trau- ma over the past decade, including sports-related head trauma, identi- fying clinical tools for discriminating between children at low and high risk for ciTBI presenting for ED evaluation has become even more pressing [3]. We documented considerable CT use despite overall low

Table 2A

Head CT and ciTBI rates by sports categories

Sport (no. of participants)	Any PECARN risk factor n, % (95% CI)	ED Head CT n, % (95% CI)	Adjusted odds of CT use? (n = 3274)	TBI on CT+ n, % (95% CI)	ciTBI? rate n, % (95% CI)	Adjusted odds of ciTBI? (n = 2854) (AOR; 95% CI)
			(AOR; 95% CI)
Team (1898)	967\1893, 51.1% (48.8%-53.4%)	1010, 53.2% (50.9%-55.5%)	Reference	21\1010, 2.1% (1.3%-3.2%)	9, 0.5% (0.2%-0.9%)	Reference

-?

Nonteam Org. (173)	73\173, 42.2% (34.7%-49.9%)	81, 46.8% (39.2%-54.5%)	0.8 (0.6-1.2)	0\81, 0% (0%-4.5%)	0, 0% (0%-2.1%)
Snow (497)	299\494, 60.5% (56.1%-64.9%)	302, 60.8% (56.3%-65.1%)	1.0 (0.8-1.3)	18\302, 6.0% (3.6%-9.3%)	11, 2.2% (1.1%-3.9%)
Water (79)	17\77, 22.1% (13.4%-33.0%)	23, 29.1% (19.4%-40.4%)	0.6 (0.3-1.3)	0\23, 0% (0%-14.8%)	0, 0% (0%-4.6%)

4.1 (1.5-11.4)

-?

Wheeled (377)	182\376, 48.4% (43.2%-53.6%)	194, 51.5% (46.3%-56.6%)	1.0 (0.7-1.3)	23\194, 11.9% (7.7%-17.3%)	20, 5.3% (3.3%-8.1%)	12.8 (5.5-32.4)
Equestrian (94)	49\91, 53.8% (43.1%-64.4%)	64, 68.1% (57.7%-77.3%)	1.8 (1.0-3.0)	5\64, 7.8% (2.6%-17.3%)	2, 2.1% (0.3%-7.5%)	4.5 (0.5-22.7)
Leisure (171)	65\170, 38.2% (30.9%-46.0%)	69, 40.4% (32.9%-48.1%)	0.7 (0.5-1.0)	2\69, 2.9% (0.4%-10.1%)	0, 0% (0%-2.1%) -?
Nonsports (19793)	7563/19715, 38.4% (37.7%-39.0%)	8152, 41.2% (40.5%-41.9%)		576/8152, 7.1% (6.5%-7.6%)	439, 2.2% (2.0%-2.4%)

Table 2B

Cranial CT and ciTBI rates by team sports categories

Sport (no. of participants)	Any PECARN risk factor n, % (95% CI)	ED head CT n, % (95% CI)	Adjusted odds of CT use? (n = 1893) (AOR; 95% CI)	TBI on CT+ n, % (95% CI)	ciTBI? rate n, % (95% CI)
Baseball/softball (339)	110\338, 32.5% (27.6%-37.8%)	150, 44.2% (38.9%-49.7%)	0.9 (0.7-1.1)	9\150, 6.0% (2.8%-11.1%)	5, 1.5% (0.5%-3.4%)
Basketball (296)	149\295, 50.5% (44.7%-56.4%)	138, 46.6% (40.8%-52.5%)	0.7 (0.5-0.9)	3\138, 2.2% (0.5%-6.2%)	1, 0.3% (0%-1.9%)
Football (635)	365\633, 57.7% (53.7%-61.5%)	369, 58.1% (54.2%-62.0%)	Reference	6\369, 1.6% (0.6%-3.5%)	3, 0.5% (0.1%-1.4%)
Hockey (229)	119\229, 52.0% (45.3%-58.6%)	120, 52.4% (45.7%-59.0%)	0.8 (0.6-1.0)	2\120, 1.7% (0.2%-5.9%)	0, 0% (0%-1.6%)
Soccer (300)	182\299, 60.9% (55.1%-66.4%)	179, 59.7% (53.9%-65.3%)	1.0 (0.8-1.2)	1\179, 0.6% (0%-3.1%)	0, 0% (0%-1.2%)
Other (99)	42\99, 42.4% (32.5%-52.8%)	54, 54.5% (44.2%-64.6%)	1.0 (0.5-1.8)	0\54, 0% (0%-6.6%)	0, 0% (0%-3.7%)

^? There were no patients with ciTBI in the Nonteam Org., Water, or Leisure groups.

* Adjusted for any PECARN risk factor (ref = “No”).

⁺ TBI on CT defined as the presence of any Intracranial bleeding, pneumocephalus, cerebral edema, skull fracture depressed the thickness of skull, or diastasis of the skull.

^? Clinically important TBI defined as Intracranial injury resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for 2 or more nights due to the head trauma.

risk of TBI in many patients with blunt head trauma due to sports me- chanisms. This suggests an area of further exploration as we seek to de- velop tools that allow clinicians to make important treatment and assessment decisions in these patients.

1. Limitations

There are several limitations to our study. Although derived from a large, diverse study sample, the sample size for each individual sport category was somewhat limited. This may have impacted our ability to discern differences in risk of the outcomes between sport categories with great precision. Nevertheless, this is one of the largest prospective studies of this population to date documenting the rates of TBIs and the rates of CT use. Our study also had the potential for misclassification of sport injury category for some patients. We sought to decrease this pos- sibility by using only prospectively obtained information documented by the treating ED physicians for categorization. It is possible that we underestimated the rate of TBI on CT by not obtaining CT scans on all pa- tients. In this observational study, the bedside clinician made a decision as to obtaining a CT. We obtained follow-up on all patients to determine ciTBI, a patient-oriented outcome, which is an acceptable alternative when definitive testing is not feasible or ethical.

1. Conclusion

Computed tomographic scans were obtained more frequently in children with sports-related injuries compared with the non-sport- related parent study group despite a lower overall incidence of CT- positive TBI (4% vs 7%, respectively). Furthermore, just 1% of children in the sports-related groups have ciTBIs. Equestrian, Snow, and Wheeled Sports have significantly higher rates of ciTBIs than other sports categories. After controlling for clinical predictors of ciTBI and clustering of CT use by hospital, we found that CT use was similar across

all mechanisms of sport injury except equestrian sports, which had a higher rate. Emergency department CTs were commonly obtained, however, despite low rates of TBI on CT in many sports groups. These findings suggest that (1) focused injury prevention research exploring the underlying causes of increased ciTBI and injury in equestrian, wheeled, and snow sports activities could benefit children; (2) partici- pants and coaches in these sports should specifically be made aware of increased risks and actively encourage use of protective gear; and

(3) children injured in sports-related activities who undergo ED evaluation should be evaluated using evidence-based prediction rules to decrease unnecessary CT scans and associated radiation risks.

Acknowledgements

Contributors’ statement page Todd Glass and Richard M. Ruddy: Drs Glass and Ruddy conceptualized

and designed the study, participated in data collection, reviewed analyses, and drafted and provided direct oversight of the manuscript.

Michelle Miskin: Ms Miskin carried out the analyses and assisted in interpretation of data, and reviewed and critically revised the manuscript.

Elizabeth R Alpern: Dr Alpern participated in data collection, reviewed analyses, helped draft the manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted.

Marc Gorelick, James Callahan, Lois Lee, Mike Gerardi, Kraig Melville,

and James F Holmes: Dr Gorelick, Dr Callahan, Dr Lee, Dr. Gerardi, Dr Melville, and Dr Holmes participated in data collection, reviewed ana- lyses, and reviewed and revised the manuscript.

Nathan Kuppermann conceptualized and designed the study, obtained grant funding, designed the data collection instruments, coordinated and supervised data collection, reviewed analyses, and helped draft and critically revise the manuscript.

Table 3

Clinically important TBI components? by sports categories

Sport (no. of participants)	Intubation N 24 h for TBI n, % (95% CI)	Neurosurgery n, % (95% CI)	Hospitalized >= 2 nights due to TBI n, % (95% CI)	Death from TBI n, % (95% CI)
Team (1898)	1\1897, 0.1% (0%-0.3%)	2, 0.1% (0%-0.4%)	9\1,897, 0.5% (0.2%-0.9%)	0, 0% (0%-0.2%)
Baseball/softball (339)	0, 0% (0%-1%)	1, 0.3% (0%-2%)	5, 1% (0.5%-3%)	0, 0% (0%-1%)
Basketball (296)	0\295, 0% (0%-1%)	0, 0% (0%-1%)	1, 0.3% (0%-2%)	0, 0% (0%-1%)
Football (635)	1, 0.2% (0%-0.9%)	1, 0.2% (0%-0.9%)	3\634, 0.5% (0.1%-1%)	0, 0% (0%-0.6%)
Hockey (229)	0, 0% (0%-2%)	0, 0% (0%-2%)	0, 0% (0%-2%)	0, 0% (0%-2%)
Soccer (300)	0, 0% (0%-1%)	0, 0% (0%-1%)	0, 0% (0%-1%)	0, 0% (0%-1%)
Other (99)	0, 0% (0%-4%)	0, 0% (0%-4%)	0, 0% (0%-4%)	0, 0% (0%-4%)
Nonteam Org. (173)	0, 0% (0%-2%)	0, 0% (0%-2%)	0, 0% (0%-2%)	0, 0% (0%-2%)
Snow (497)	1, 0.2% (0%-1%)	1, 0.2% (0%-1%)	11, 2% (1%-4%)	0, 0% (0%-0.7%)
Water (79)	0, 0% (0%-5%)	0, 0% (0%-5%)	0, 0% (0%-5%)	0, 0% (0%-5%)
Wheeled (377)	2, 0.5% (0.1%-2%)	2, 0.5% (0.1%-2%)	18, 5% (3%-7%)	1, 0.3% (0%-1%)
Equestrian (94)	0, 0% (0%-4%)	1, 1% (0%-6%)	2, 2% (0.3%-7%)	0, 0% (0%-4%)
Leisure (171)	0, 0% (0%-2%)	0, 0% (0%-2%)	0, 0% (0%-2%)	0, 0% (0%-2%)

* Patients can have more than 1 type of ciTBI.

Table 4

Physician documented reason? for obtaining cranial CTs in patients with initial GCS of 15 and normal mental status by sports category

Sport (no. of participants)?,+	Mechanism	Headache	Loss of consciousness	Vomiting	Amnesia	Mental status	Skull fracture?	RequestedJPY
	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)	n (%)
?Team (668)	238 (36%)	261 (39%)	269 (40%)	95 (14%)	180 (27%)	17 (3%)	53 (8%)	88 (13%)
Baseball/softball (110)	59 (54%)	30 (27%)	31 (28%)	13 (12%)	15 (14%)	4 (4%)	24 (22%)	20 (18%)
Basketball (93)	21 (23%)	36 (39%)	36 (39%)	17 (18%)	24 (26%)	1 (1%)	4 (4%)	10 (11%)
Football (237)	88 (37%)	103 (43%)	102 (43%)	31 (13%)	69 (29%)	3 (1%)	10 (4%)	21 (9%)
Hockey (80)	38 (48%)	34 (43%)	43 (54%)	8 (10%)	28 (35%)	4 (5%)	3 (4%)	9 (11%)
Soccer (104)	20 (19%)	39 (38%)	37 (36%)	22 (21%)	33 (32%)	5 (5%)	9 (9%)	19 (18%)
Other (44)	12 (27%)	19 (43%)	20 (45%)	4 (9%)	11 (25%)	0 (0%)	3 (7%)	9 (20%)
Nonteam Org. (53)	18 (34%)	21 (40%)	16 (30%)	5 (9%)	12 (23%)	2 (4%)	6 (11%)	9 (17%)
Snow (182)	89 (49%)	60 (33%)	76 (42%)	43 (24%)	61 (34%)	7 (4%)	18 (10%)	20 (11%)
Water (15)	7 (47%)	4 (27%)	2 (13%)	3 (20%)	3 (20%)	1 (7%)	2 (13%)	1 (7%)
Wheeled (112)	41 (37%)	28 (25%)	40 (36%)	23 (21%)	30 (27%)	4 (4%)	32 (29%)	14 (13%)
Equestrian (40)	27 (68%)	18 (45%)	9 (23%)	4 (10%)	6 (15%)	2 (5%)	1 (3%)	5 (13%)
Leisure (43)	11 (26%)	15 (35%)	13 (30%)	7 (16%)	9 (21%)	2 (5%)	7 (16%)	7 (16%)

* More than 1 reason for obtaining cranial CT can be listed for each patient.

⁺ Other indications for CT (by broad sports group) included seizure, 0% to 7%; neurological deficit, 0% to 16%; young age, 0% to 5%; other, 13% to 28%; CT indication not provided, 3% to 7%.

^? Other indications for CT (by team sports group) included seizure, 0% to 5%; neurological deficit, 0% to 7%; young age, 0% to 7%; other, 15% to 23%; CT indication not provided, 0% to 4%.

^? Skull fracture defined as a CT indication of clinical evidence of skull fracture, skull fracture on radiography, or scalp hematoma.

^JPY Requested defined as a CT indication of parental anxiety/request, trauma team request, or referring MD request.

All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work. Ms Miskin from the PECARN Data Center and Dr Kuppermann had full access to all the data in the study and take responsibility for the integrity of the data and the accu- racy of the data analysis. In addition, Dr Glass and Dr Ruddy worked closely with Ms Miskin, the PECARN Data Center, and Dr Kuppermann to review the data and each aspect of the analysis.

Conflicts of interest: Dr Todd Glass, Dr Richard M. Ruddy, Dr Elizabeth R Alpern, Dr Marc Gorelick, Dr James Callahan, Dr Lois Lee, Dr Mike Gerardi, Dr Kraig Melville, Ms Michelle Miskin, Dr James F. Holmes, and Dr Nathan Kuppermann have no conflicts of interest relevant to this article to disclose.

Financial disclosure: The authors have no financial relationships relevant to the article to disclose.

Funding: This work was supported by a grant from the Health Resources and Services Administration/Maternal and Child Health Bureau (MCHB), Division of Research, Education, and Training and the Emergency Medical Services of Children (EMSC) Program (R40MC02461).

Pediatric Emergency Care Applied Research Network is supported by the Health Resources and Services Administration/MCHB/EMSC Program through the following cooperative agreements: U03MC00001, U03MC00003, U03MC00006, U03MC00007, U03MC00008, U03MC22684, and U03MC22685.

Prior presentation: This work was presented in part at the Section of Emergency Medicine scientific session in poster format at the American Academy of Pediatrics Annual Meeting, Boston, MA, October 2011.

Participating centers and site investigators are listed below in alpha- betical order: Atlantic Health System/Morristown Memorial Hospital (M. Gerardi); Bellevue Hospital Center (M. Tunik, J. Tsung); Calvert Me- morial Hospital (K. Melville); Children’s Hospital Boston (L. Lee); Chil- dren’s Hospital of Michigan (P. Mahajan); Children’s Hospital of New York-Presbyterian (P. Dayan); Children’s Hospital of Philadelphia (F. Nadel); Children’s Memorial Hospital (E. Powell); Children’s National Medical Center (S. Atabaki, K. Brown); Cincinnati Children’s Hospital Medical Center (T. Glass); DeVos Children’s Hospital (J. Hoyle); Harlem Hospital Center (A. Cooper); Holy Cross Hospital (E. Jacobs); Howard County Medical Center (D. Monroe); Hurley Medical Center (D. Borgialli); Medical College of Wisconsin/Children’s Hospital of Wisconsin (M. Gorelick, S. Bandyopadhyay); St. Barnabas Health Care System (M. Bachman, N. Schamban); SUNY-Upstate Medical Center (J. Callahan); University of California Davis Medical Center (N. Kuppermann, J. Holmes); University of Maryland (R. Lichenstein); University of Michigan (R. Stanley); University of Rochester (M. Badawy, L. Babcock-Cimpello); University of Utah/Primary Chil- dren’s Medical Center (J. Schunk); Washington University/St. Louis

Table 5

Sports-related TBI on CT and ciTBI

	TBI on CT (but no ciTBI) (n = 29)	ciTBI (n = 45)	P value
Team vs Nonteam Sports			.065?
Nonteam Sport	17 (58.6%)	36 (80.0%)
Team Sport	12 (41.4%)	9 (20.0%)
Age in years: median [Q1-Q3] GCS categories	13.0 [9.0-15.0]	13.0 [10.0-15.0]	.846+ .070?
3-8	0 (0.0%)	5 (11.1%)
9-12	0 (0.0%)	3 (6.7%)
13-14	4 (13.8%)	9 (20.0%)
15 Signs of altered mental status?	25 (86.2%)	28 (62.2%)	.009?
No	19 (65.5%)	15 (33.3%)
Yes Any PECARN rule variables [15]	10 (34.5%)	30 (66.7%)	.673?
No	3 (10.3%)	3 (6.7%)
Yes	26 (89.7%)	42 (93.3%)

* Fisher exact test.

⁺ Two-sided Wilcoxon rank sum with normal approximation and continuity correction.

^? Signs of altered mental status defined as GCS score less than 15 or other signs of altered mental status defined by agitation, somnolence, repetitive questioning, or slow response to verbal communications.

Children’s Hospital (K. Quayle, D. Jaffe); Women and Children’s Hospital of Buffalo (K. Lillis).

We acknowledge the efforts of the following individuals participating in PECARN at the time this study was initiated:

PECARN Steering Committee: N. Kuppermann, Chair; E. Alpern, J. Chamberlain, J. M. Dean, M. Gerardi, J. Goepp, M. Gorelick, J. Hoyle,

D. Jaffe, C. Johns, N. Levick, P. Mahajan, R. Maio, K. Melville, S. Miller?, D. Monroe, R. Ruddy, R. Stanley, D. Treloar, M. Tunik, A. Walker. MCHB/EMSC liaisons: D. Kavanaugh, H. Park.

PECARN Data Coordinating Center: M. Dean, R. Holubkov, S. Knight,

A. Donaldson.

Data Analysis and Management Subcommittee: J. Chamberlain, Chair; M. Brown, H. Corneli, J. Goepp, R. Holubkov, P. Mahajan, K. Melville, E. Stremski, M. Tunik.

Grants and Publications Subcommittee: M. Gorelick, Chair; E. Alpern,

J. M. Dean, G. Foltin, J. Joseph, S. Miller?, F. Moler, R. Stanley, S. Teach.

Protocol Concept Review and Development Subcommittee: D. Jaffe, Chair; K. Brown, A. Cooper, J. M. Dean, C. Johns, R. Maio, N. C. Mann, D. Monroe, K. Shaw, D. Teitelbaum, D. Treloar.

Quality Assurance Subcommittee: R. Stanley, Chair; D. Alexander, J. Brown, M. Gerardi, M. Gregor, R. Holubkov, K. Lillis, B. Nordberg, R. Ruddy, M. Shults, A. Walker.

Safety and Regulatory Affairs Subcommittee: N. Levick, Chair; J. Brennan, J. Brown, J. M. Dean, J. Hoyle, R. Maio, R. Ruddy, W. Schalick,

T. Singh, J. Wright.

We thank Rene Enriquez, BS, and Sally Jo Zuspan, RN, MSN, at the PECARN Data Coordinating Center (University of Utah) for their dedica- ted and diligent work; the research coordinators in PECARN, without whose dedication and hard work this study would not have been possi- ble; and all the clinicians around the PECARN who enrolled children in this study.

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^* Deceased.