La guida del Sole 24 Ore al crisis management (Le guide de Il Sole 24 Ore) (Italian Edition)

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The pediatric studies on this topic widely differ for the characteristics of the population included, the severity of the head injury and the final outcome [ — ]. Children with moderate or severe head injury are more likely to undergo a change in management following results of repeated CT scan [ ]. Some authors recommend a repeated CT in the presence of 3 or more intracranial lesions, a mass effect, an intraventricular hemorrhage, an epidural hematoma on initial CT [ ].

An epidural or subdural hematoma, the presence of cerebral edema, intraparenchymal hemorrhage seem to be associated with a higher risk of evolving and a higher likelihood to lead to a change in management, including surgery [ ]. According to several reports stable or clinically improving patients with a GCS of 14—15 and non-surgical intracranial lesions on initial imaging do not need to undergo routine repeated CT, as its results are highly unlikely to lead to a change in management [ , , , — ].

None of these patients required neurosurgery. Conversely, all the three patients who underwent repeated CT because of clinical deterioration showed injury progression and two of them needed neurosurgery [ ]. While one of these patients presented nausea and vomiting the other was reported to be asymptomatic. None of the patients who did not undergo routine repeated CT scans presented neurologic deterioration or signs and symptoms of potential injury progression [ ]. However, all three patients presented a deterioration in their GCS before receiving a repeat CT [ ].

Another study found that only one patient, out of 47 with intracranial injury following head trauma, needed urgent neurosurgery following repeated CT, performed because of developing signs of increased intracranial pressure [ ]. In children with initial CT showing a non-surgical intracranial injury, close clinical monitoring including repeat assessment of neurologic status seems to be the best approach to decide when a repeated CT is necessary [ — ].

The purpose of this statement is to offer guidance on decision-making about the use of skull X-rays as a screening tool for the diagnosis of intracranial injury in children following a minor head trauma.

Jamie Dimon's interview with Il Sole 24 Ore, english version

Historically, in the absence of readily available CT scanners and high-quality clinical decision rules, skull X-ray was used to categorize patients with minor head trauma into high and low risk for traumatic brain injury, based on the detection of a skull fracture. Prospective observational studies and meta-analysis have demonstrated the association of a skull fracture, identified on a skull X-ray, with a significantly higher risk of intracranial injury in both pediatric and adult patients [ — ].

Skull radiographs have the advantages to expose children to less radiations compared with CT and to require no sedation. In addition there is a high likelihood that both junior doctors and qualified emergency physicians may misread skull radiographs when compared with a radiologist [ , , ].

For these reasons skull radiographs have generally been not recommended as a screening tool for intracranial injury when CT is readily available [ 94 , , ]. A retrospective study in the UK monitoring practice following the abolition of skull x-rays on the management of pediatric head injuries in children older than one year of age showed that skull radiographs could safely be abandoned in these patients. Skull X-rays, however, have been recommended by many authors and guidelines in the assessment of young infants with a large isolated scalp hematoma as the sole manifestation of head trauma [ , — ].

These otherwise asymptomatic infants have shown to be at greater risk for skull fracture, and therefore for intracranial injury [ , , , ]. Negative skull radiographs in these patients were proposed to obviate the need to perform a CT scan as the risk for TBI is reduced, although not absent. In the era of high quality clinical prediction rules for pediatric head trauma, and patient centered outcomes, i.

TBI that require acute intervention such as neurosurgery, intensive care or prolonged hospitalization, rather than the sole presence of an intracranial injury on CT, [ 3 , 92 , 93 ] better estimates of the risk of ciTBI are available for asymptomatic infants with isolated scalp hematoma. A recent a priori-planned secondary analysis [ ] of the PECARN head injury rule study [ 3 ] is the largest prospective study including children younger than two years with isolated scalp hematoma.

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A ciTBI occurred in 12 patients 0. Of patients Younger age, non-frontal scalp hematoma location, increased scalp hematoma size, and severe injury mechanism were independently associated with traumatic brain injury on CT. While skull X-rays could be a good diagnostic tool, in expert hands, for the identification and definition of fractures in children with large overlying hematomas, the advent of point-of-care ultrasound is likely to replace skull radiographs for this purpose, as characteristics of the fracture can be better studied.

Point-of-care ultrasound has the advantages of avoding the patient both exposure to radiation, and time spent away from clinical observation and monitoring in the ED. However, skull X-rays maintain a role as part of the skeletal survey in children presenting with suspected non-accidental injury [ 94 , ]. Clinicians should not routinely use trans-fontanelle ultrasound for diagnosing intracranial injuries in infants presenting to the emergency department following a trauma to the head.

The purpose of this statement is to offer guidance on decision-making about the use of trans-fontanelle cerebral ultrasound as a screening tool for the diagnosis of intracranial injury in infants following a minor head trauma. Trans-fontanelle cerebral ultrasound is a bed-side, easy-to-use, and cheap radiation free test that does not require sedation to be properly performed.

Although it is an accurate test to identify neonatal and perinatal brain injuries, the very limited ability to assess peripheral sub-cranial regions makes trans-fontanelle ultrasound inaccurate to identify extra-axial hematomas in infants with head trauma. Of these, 2 patients were diagnosed with intracranial alterations and received a head CT scan that confirmed a small epidural hematoma in both cases, which did not need neurosurgery.

Despite the promising results of this study the GDG agreed that these data were not sufficient to support the use of trans-fontanelle ultrasound in infants with head trauma in the era of PECARN clinical prediction rules. Clinicians may choose to use point-of-care ultrasound for the identification of skull fractures and the definition of their characteristics e. The purpose of these statements is to offer guidance on decision-making about the use of ultrasound in the diagnosis of skull fractures in children following a minor head trauma.

As reported above, under the recommendation on the use of skull x-rays Key Action Statement 9 , skull fractures are inaccurate predictors of the presence of traumatic brain injuries and skull ultrasound should not be used as a screening tool for intracranial injuries, but rather to identify a skull fracture and define its characteristics. Point-of-care ultrasound is increasingly being used in the emergency setting to provide quick bedside information in the assessment of various fractures [ ]. Ultrasound is a safe, quick and non invasive test that does not involve exposure to ionizing radiation and can be performed in the ED, allowing observation and monitoring to continue in a safe environment.

Although current management of pediatric minor head trauma is based on the use of accurate clinical prediction rules to guide the choice on CT or observation, the use of ultrasound may be helpful for the following reasons:. This condition needs to undergo surgical repair that includes resection of the leptomeningeal cyst and degenerated brain tissue, repair of the dural defect, and cranioplasty [ , ]. Various studies investigated the accuracy of skull ultrasound in identifying skull fractures in children following a minor head trauma compared with CT findings gold standard [ — ].

However these studies showed variability with respect to the characteristics of the included population, the level of training of physicians performing the ultrasound, the technique used and the blinding with the results of the CT. Only one study assessed the agreement between physicians with a different level of expertise on ultrasound, finding a good agreement rate [ ]. In summary, point-of-care ultrasound can be used to detect skull fractures in children with minor head trauma by trained providers, however the evidence from available studies is insufficient to recommend its routine use in clinical practice, where the use of selective CT based on accurate clinical prediction rules remains the gold standard [ 3 , ].

The purpose of this statement is to offer guidance on the use of near infrared technology in children presenting to the ED with blunt head trauma as an aid to clinical assessment in the decision-making on whether to order a CT scan. NIRS technology identifies intracranial haematomas by comparing the optical density of infrared light absorption between symmetrical regions in the two sides of the head. The extravascular blood of the haematomas absorbs NIR light more than intravascular blood. This is due to the higher concentration of heme-based proteins, such as hemoglobin in the hematoma compared with normal brain tissue, where blood is contained within vessels.

When a haematoma is present on one side of the brain a difference in light absorption is detected and recorded by the NIRS device. The examination includes a set of four pairs of measurements of four regions of the brain frontal, temporal, parietal, and occipital , where the device is placed in sequence on the left and right side over pre-selected locations. Two studies included a mixed adult and children population [ , ].

However, neither the exact number of children included, nor separate pediatric results were reported. Interpretation and applicability of their results is affected by significant limitations. The study by Coksun et al. The assessors of the index test and reference standard were blind to the results of the other test. The small sample size, the difference in population compared with children presenting to the ED with head trauma and the lack of blinding in performing the NIRS assessment are important limitations to this study. A CT scan was performed in only 18 The main limitation of this study is the small sample size and the low number of CT reference test performed.

The insufficient number of positive CT scans is responsible for the very wide confidence intervals of diagnostic accuracy measures. Intrinsic limitations of NIRS technology to identify traumatic intracranial haemorrhages should also be noted. This affect accurate identification of deep hematomas or contusions, or very small superficial bleedings.

Second, bilateral hematomas cannot be reliably identified by near-infrared technology, as the technique relies on comparison of light absorption between the two hemispheres. Fourth, scalp haematomas are confounding factors for near-infrared technology measurements. Blood contained within a scalp hematoma can alter the difference in optical density and cause a false-positive result.

Furthermore, thick hair may affect examination performance, while cervical collars may limit the ability to carry out the measurements in the occipital pair of locations. NIRS technology is not meant to be used in isolation and may be helpful in selected group of patients. Further research is needed to clarify the possible usefulness of this technology in conjunction with the PECARN algorithms with the purpose of optimizing CT scan use.

ED physicians should favor initial observation over CT scan for children at intermediate-risk of clinically important traumatic brain injury ciTBI according to the age-appropriate PECARN algorithms, especially in the presence of isolated findings. The purpose of this statement is to offer guidance on decision-making on observation as an alternative to CT scan in children presenting to the ED with minor head trauma. This clinical management strategy has the potential to decrease unnecessary CT scans while minimizing the risk of missing a ciTBI.

A secondary analysis of the PECARN head injury parent study showed that clinical observation before CT decision making resulted in a safe and potentially effective strategy to manage a subset of children with minor head trauma [ ]. There was no increase in the rate of significant traumatic brain injuries. The odds of obtaining a CT remained significantly lower in children who were observed even after adjusting for age, factors associated with TBI i. As expected, the rate of CT use was lower for patients whose symptoms improved during the period of observation.

A more recent single-center study on prospectively enrolled children with minor head trauma presenting to a tertiary care ED found that ED observation time was associated with a time-dependent reduction in cranial CT rate in all three PECARN risk groups, with no delay in the diagnosis of ciTBI [ ]. Children whom clinicians chose to observe presented to the ED sooner after their head injury than those who were not observed.

Due to the relatively small number of patients with ciTBI, both studies had limited ability to identify possible uncommon negative outcomes of observation, i. A previous multicenter RCT showed no significant difference in mortality and neurologic disability at three months after injury between patients with minor head trauma who underwent immediate CT versus in-hospital observation. Both group of patients were similarly satisfied with the care received [ ]. A prospective cost effectiveness analysis performed on the data of the same RCT showed that the immediate CT strategy was less expensive than admission for observation [ ].

However, the radiation-induced risk of cancer was not taken into account. While further studies are needed to evaluate the tradeoff in health care costs between observation-associated longer ED stays and a reduced CT rate, observation appears to be the most effective strategy for children at PECARN intermediate risk, for whom the need for cranial CT may not be obvious at the time of initial evaluation.

For this group of patients parental preference should also be taken into account in the clinical decision-making process. However, future work will need to clarify the best method of risk communication to patients and their families with respect to ED decisions on diagnostic imaging. The decision to forgo CT scan after an ED observation period will depend on physician experience, risk tolerance and shared decision making with patients, and their families.

The purpose of this statement is to offer guidance on the duration of clinical observation for children with minor head trauma, whom ED physicians decide to observe prior to CT-scan decision making. Although rarely, children with minor head trauma may present delayed clinical decompensation due to the evolution of their intracranial injury. While observation appears to be an effective strategy to optimize the selection of patients who need to undergo CT scan, its duration should ensure the early identification of patients who may present delayed deterioration.

Although two recent large prospective studies assessed the effectiveness of clinical observation as an alternative to immediate CT scan, neither of them could define an optimal observation period [ , ]. Although none of the children who were observed without receiving a CT returned for a delayed ciTBI, the study was not designed to determine the optimal period of observation before CT decision-making. Due to the small number of ciTBI 8 patients in the overall study population and the lack of a structured clinical follow-up, rare but possible cases of delayed ciTBI may have been missed.

A recent population-based study found that the incidence of delayed diagnosis of intracranial hemorrhage i. This retrospective study included nearly 18, patients presenting with minor blunt head trauma to any ED in the Calgary Health Region, in Canada, over an 8-year study period. Two children had a delayed diagnosis of intracranial hemorrhage associated with deterioration in level of consciousness at the time of diagnosis 0.

Eight children had a delayed diagnosis of intracranial hemorrhage, which was not associated with deterioration in level of consciousness 0. The calculated incidences of delayed diagnosis of intracranial hemorrhage with and without deterioration in level of consciousness were 0. The CT scan performed the following day, when he represented for balance problems, revealed an extradural haematoma that was managed conservatively during his 2-night admission. The GDG agrees this is a reasonable duration to allow symptom progression or resolution in a monitored environment.

While this duration minimizes, but does not eliminate the risk of potentially missing a ciTBI, the GDG highlights the importance of careful discharge instructions to reduce delay to diagnosis after discharge. However, as reported in the accompanying text to KAS 12b, current evidence does not clarify what should be the optimal observation period for children following minor head trauma prior to making a final decision on CT. Children who require observation in the ED following a head trauma should be appropriately monitored by clinical staff who are qualified to deliver care to children.

The purpose of this statement is to offer guidance on the care that should be provided to children requiring observation in the ED following a head trauma. These patients may be observed in the ED for different reasons. Observation prior to CT scan decision making helps better select patients who need a CT scan, based on the evolution of their signs and symptoms. Observation after a CT may obviate inpatient admission in children with persistent symptoms despite a negative CT scan or in patients with small intracranial injuries amenable of conservative treatment according to neurosurgical advice [ , , , , ].

All but one studies retrieved by our search strategy on the assessment of clinical observation were conducted in pediatric EDs [ , , , ].

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Although it is well recognized that the care of pediatric patients, especially younger children, is better provided by healthcare professionals specifically trained in pediatrics, the level of training and availability of trained staff may vary in small centers. The care and monitoring of head injured children by personnel not adequately trained in pediatrics bears the risk for potential delayed recognition of clinical deterioration and is an indication for patient transfer to appropriate pediatric facilities.

Policies, regulations and training requirements to ensure that children who need observation following a head trauma are properly taken care of by clinical staff adequately trained in pediatrics are beyond the scope of these guidelines. Each institution should have local guidelines and protocols in place to provide this service or to transfer patients to the nearest referral facility within the local health system network. Although the frequency of reassessments during observation may vary based on clinical judgment, the GDG advises for the following minimum requirements in children with GCS of Neurological observations should be recorded more frequently in these patients.

While evidence base data on overnight neurologic monitoring are lacking the GDG advises for waking the child up intermittently to assess the neurological status. The use of a dedicated electronic or paper-based observation chart is suggested for proper documentation. In children presenting to the ED following a minor head trauma and with a personal history of neurosurgical intervention other than isolated placement of a ventricular shunt, clinicians may require a neurosurgical consult, considering the type and time of the intervention, to help support CT-scan decision making.

The purpose of this statement is to offer guidance on the request of neurosurgical consultation to support CT scan decision-making in children who present to the ED following a minor blunt head trauma and have a personal history of neurosurgical intervention, other than isolated placement of a ventricular shunt. A history of prior cranial neurosurgical interventions may be intuitively associated with a higher risk of intracranial complications following head trauma. This risk may vary according to the underlying patient condition, the type and time of intervention.

It is generally estimated to be higher in the first weeks or months following a craniotomy. Our search strategy could not identify any relevant paper on the risk of TBI on CT or ciTBI in children with a history of previous neurosurgical intervention, even when no publication date limits were used. The contribution of the patient underlying condition, the type and time of neurosurgical intervention to the risk of intracranial injury may vary widely between patients, making it difficult to define a subgroup of children who can safely avoid CT scan following a minor head trauma.

Considering the broad spectrum of risk variability for intracranial injury in these patients, as well as the different levels of experience and expertise that physicians working in ED may have in caring for these children, the GDG deemed it appropriate to advise for neurosurgical consultation based on clinical judgment, taking into account the clinical factors reported above. ED physicians must discuss with a neurosurgeon the care of all children with traumatic injuries on CT scan excluding uncomplicated isolated linear skull fractures.

The purpose of these statements is to offer guidance on neurosurgical consultation for the management of intracranial injuries in children presenting to the ED following a head trauma. Recent evidence has definitely shown that patients with isolated, uncomplicated linear skull fractures are at extremely low risk of deterioration and need of neurosurgery and may be safely discharged form the ED, thus obviating the need for neurosurgical consultation [ , ]. For children with intracranial injuries on CT scan an urgent neurosurgery consultation is necessary to ensure timely operative management, where appropriate, or to provide advice on the most appropriate monitoring and follow up for the patient.

The intuitive beneficial practice of requesting a neurosurgical consultation in children with traumatic intracranial injuries on CT scan, translated into recommendation in previous pediatric guidelines and has become a standard of care, despite the lack of supporting scientific evidence [ , ]. This recommendation from the NICE guidelines, which provide guidance for both adult and pediatric patients, likely reflects the careful assessment of appropriate neurosurgical resources use for patients most in need of intervention, in organizations with limited neurosurgical availability compared with patient volume.

The largest and most recent multicenter epidemiological study on over 40, children presenting to the ED for head trauma provides useful estimates on the need of neurosurgical intervention in children with traumatic intracranial injuries on CT scan [ 2 ]. Based on these data and considering the increasing availability in Italy of real-time digital imaging system for telemedicine neurosurgical consultation, the GDG enforces the widely recommended practice of requesting a neurosurgical consultation for all head injured children with intracranial injuries on CT scan other than isolated linear skull fractures.

This is justified by the high need for neurosurgery in the low number of children diagnosed with traumatic intracranial injuries on CT. Similarly, when the estimated risk of needing a neurosurgical intervention is very high based on clinical presentation, as in children with severe head trauma, early involvement of the neurosurgeon, even before CT scan is performed, is likely to shorten the time to and optimize the set up for a life-saving neurosurgical intervention if needed.

The importance of early neurosurgical involvement has been demonstrated by the better outcome of severely head injured patients following direct pre-hospital transport to a dedicated trauma center, which constitutes the foundation of modern trauma systems [ — ]. The purpose of these statements is to provide guidance on the transfer of children with head trauma who present to an emergency facility where CT scan is not available.

Even though pre-hospital triage systems aim to directly transport to centers with neurosurgical facilities most of the head injured children [ 1 , , — ], some patients may self-present to other facilities. In addition, patients initially classified as low risk may deteriorate during assessment. In emergency facilities where CT is not available, indications for inter-hospital transfer of children with head trauma strictly reflect indications for CT head performance. Children at higher risk of intracranial injury should be transferred directly to a pediatric center with neurosurgical capability.

ED physicians working in centers with CT capability but without neurosurgery must follow local healthcare system network guidelines for decision-making on transfer of children with moderate-severe head trauma to referral centers. The purpose of this statement is to provide guidance on the transfer of children with moderate-severe trauma who present to centers with CT availability, but without neurosurgery.

As previously noted in these guidelines, in Italy the organization of formal trauma management systems is heterogeneous and fragmented, especially for pediatric trauma patients [ 17 ]. Although field pre-hospital triage aims to directly transport the most severely head injured children to centers with pediatric neurosurgical capability [ ], unstable patients may be diverted to the nearest facility if stabilization cannot be achieved pre-hospital.

In addition, some patients with moderate head trauma may self-present to less specialized hospitals, while some patients initially classified as low risk may deteriorate during assessment. After stabilization, the decision on timing and modality of transfer to the referral center with neurosurgical capability should follow local healthcare system network guidelines. While rapid transfer of the most severely head injured patients to definitive care is the common goal in all systems, each healthcare system network may have different transfer thresholds secondary triage criteria for children with moderate head injury.

Secondary triage criteria should be agreed with referral centers and should be based on the best trade-off between locally available clinical and technical resources, transport-related resources and distance from the closest pediatric neurosurgical facility. Early contact with the referral neurosurgeon is key to optimize the management of these patients. While recognizing the need for more structured and standardized trauma systems for pediatric patients throughout the whole country, the GDG encourages each health system network to adopt and disseminate clear guidelines and protocols for inter-hospital transfer of head injured children to referral centers and stipulate clear interfacility transfer agreements.

Appropriate transfer of injured children is essential as studies have shown that injured children treated at designated pediatric trauma centers have significantly better outcomes than those treated at adult trauma centers or non-trauma centers, with the highest benefit for the most severely injured [ , — ]. Organization of pediatric trauma care delivery into formal trauma systems not only improves survival of severely injured children but also favorably impacts on their functional long term outcome [ , ]. A trauma system is responsible for the entire patient pathway from pre-hospital care, through ED resuscitation and specialist emergency surgical intervention, to reconstruction of injuries and rehabilitation [ ].

The benefits of centralized care of pediatric patients to designated trauma centers likely result from the combined benefits of pediatric medical specialists and healthcare professionals accustomed to dealing with the special needs of children within a continuum of care. Referral or designated pediatric trauma centers function as pediatric hospital hubs within the trauma network and have the responsibility for coordinating the management of severely injured patients within a regional area.

Although pediatric trauma remains the leading cause of death and disability in children older than one year of age, the small numbers of severely injured children make it challenging to retain an appropriate skill set even in tertiary care centers. The refinement and use of pediatric guidelines within each healthcare system network, in addition to pediatric specific trauma training, will help healthcare professionals deliver the best care to pediatric severely injured patients in both referring and referral hospitals.

In centers with CT availability, but without neurosurgery, ED physicians may perform a head CT scan of children with moderate-severe head trauma, after stabilization, only if it does not delay transfer to the definitive care referral center and provided that images are of good quality and can easily be transferred to the referral center. The purpose of this statement is to provide guidance on the timing of head CT imaging in children with moderate-severe head trauma who present to centers with CT availability, but without neurosurgical facility. Early arrival of severely injured patients to an appropriate trauma center has been shown to be associated with improved outcomes [ ].

Centers with no neurosurgical facility should make any effort to reduce delay to definitive care in head injured children who meet local transfer criteria. However, resource availability, transport-related issues, as well as variability in pediatric-specific training, experience, and comfort of ED clinicians working in referring hospitals may lead to delays in transfer [ ]. In addition, while the ATLS course advocates that referring facilities should not obtain adjunctive diagnostic studies of injuries, which the facility does not have the capability to treat [ 6 ], a recent retrospective study showed that delayed transfer of injured children to a level I pediatric trauma center was associated with increased use of CT imaging before transfer [ ].

However, the retrospective nature of the study could not clarify how many CT scans were actually obtained while waiting for a transport team or helicopter, thus being a consequence of a delay in the system, rather than a cause of delay. This practice leads to increased costs, but most importantly to increased risks of cumulative radiation exposure in vulnerable children.

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In order to avoid delays to definitive care of head injured children who meet local transfer criteria, and considering the increased risks and costs associated with the need of repeating CT scans at referral centers, the GDG agreed that these patients may undergo a head CT scan at the referring center only if this does not delay transfer and good quality images can be available for review by the referral neurosurgeon.

In centers with CT availability but without neurosurgery children with minor head trauma should be managed according to the recommendations previously provided in these guidelines for CT scan decision-making KAS 6 and request of neurosurgical consultation KAS The purpose of this statement is to provide guidance on the modality of neurosurgical consultation for children with minor head trauma who are diagnosed with intracranial injury on CT at a center with CT capability but without neurosurgery. Children with minor head trauma have a very low risk of ciTBI [ 3 ] and the great majority can safely be managed in centers with CT scan capability but without neurosurgery.

For patients who undergo a CT scan that shows a traumatic intracranial injury other than an isolated linear skull fracture a neurosurgical consultation with the referral neurosurgical unit is required to guide transfer decisions. Depending on the type and extent of injury some patients will need to be immediately transferred to the referral center for urgent neurosurgical intervention, neurointensive monitoring or high likelihood of deterioration while others may be safely managed in the referring center.

Several observational studies, mostly retrospective and mainly including adult patients have assessed the use of teleradiology for the management of inter-hospital transfer of patients with head trauma [ — ]. Despite the differences in methodological quality, all studies consistently found a beneficial effect of teleradiology in improving decision-making on transfer. The use of teleradiology was associated with a reduced number of unnecessary transfers, with savings in costs and resource utilization, and a reduced number of adverse events during transfer.

Although smartphone and personal digital assistant devices could be used for the electronic transmission of CT images [ , ], the most common image transmission modality are nowadays computerized image transfer systems, which link the referral center to several referring hospitals. This technology is increasingly available for inter-hospital communication in Italy and the GDG encourages its widespread diffusion in the whole country. ED physicians working in centers with CT capability but without neurosurgery should transfer to referral pediatric centers children with minor head trauma who need clinical observation whenever resources for appropriate clinical observation are not available in the referring center.

The purpose of this statement is to provide guidance on the management of children with minor head trauma who need clinical observation in centers with CT availability, but without neurosurgery and lack of appropriate resources for adequate monitoring of these patients. Children with minor head trauma may require monitoring during observation as an alternative to immediate CT scan, for persistent symptoms or personal risk factors despite a negative CT scan, or following discussion with a neurosurgeon for intracranial injuries that can be managed conservatively.

Decision on the destination facility will be guided by neurosurgical advice for patients with positive CT scan amenable of conservative treatment. For patients who have not undergone a CT scan physicians should follow local transfer guidelines to determine the most appropriate referral center. ED physicians working in centers with CT capability but without neurosurgery should transfer to referral pediatric centers, preferably with pediatric neurosurgical capability, children with minor head trauma needing sedation to undergo CT scan, if no skilled staff in pediatric sedation are available at the referring center.

The purpose of this statement is to provide guidance to ED physicians working in centers without skilled staff in pediatric sedation on the management of children with minor head trauma who need sedation to undergo a head CT. Sedation may be required in uncooperative children in order to prevent movement and ensure optimal imaging quality. Children may be uncooperative because of their young age, because of fear and anxiety, for agitation or irritability secondary to their head injury or because of an underlying medical condition e. In the era of high-speed helical CT usage there seems to be a decreasing requirement for pharmacological sedation [ — ].

Sedation of pediatric patients must be performed by trained personnel with specific skills in pediatric monitoring and resuscitation for the potential for life-threatening adverse events [ ]. Centers that do not have the appropriate resources to safely provide sedation to pediatric patients have to transfer these children to a facility where such resources are available.

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Managing Director Bologna Welcome In , he entered Bologna Welcome with over 15 years of experience in marketing, communication and promotion in the meeting sector. He was involved in the development and implementation of tourism promotion strategies. Patrik is now focused on creating digital strategies and on social tourism. Davide Rosi began his experience in the travel sector in …. From until mid,…. He has been acknowledged as a legal aid at the Court of…. David has almost 35 years of experience…. Founder Studio Salerno He is an expert in economics and marketing for education and a web specialist by vocation.

Since , he has been in charge of Tourist Web Marketing, on a national and international level. He creates and manages strategic communication and online promotion plans. He believes without hesitation in the endless economic…. To date, the group has 11 hotels open, quickly turning into the largest hybrid model solution in Europe….

Interaction designer and engineer Arvind Sanjeev is an interaction designer and engineer who also occasionally takes on the lenses of an artist and a futurist. He is originally from Kerala, India and currently based in Sweden. He is described as being a serial innovator at several platforms and was also awarded as the "Most….

General Manager Italy Deliveroo Citizen of the world, a tireless traveller, a lover of communication, creative and a team player: this is how Matteo Sarzana defines himself. He obtained Degree in Communication at the IULM in Milan and is currently the Italian leader of the largest food delivery and logistics group in the world,….

Copywriter, storytelling expert and trainer Francesca was born in , and started writing in She stopped in and resumed when she discovered the web, fell in love with it and decided that she would like to work with online content. She is a book author, works with editorial publications, companies, people and…. Before taking on this role, he was also Sales Team Manager at HomeAway, managing the performance and productivity of the Italian sales team. Before joining HomeAway he worked for BoookingManager. Founder Gr pes Gr pes was created out of the will and the know-how of Letizia Sebregondi, who has been working with passion in the international wine sector for years.

Thanks to this collaboration, she…. Contributor Wired Bborn in Milan in , journalist. He writes about new technologies, politics and society. In , he published "Rivoluzione Artificiale:…. Founder Marketing Arena He has a Degree in Marketing and Communication and he worked in research for two years at Venice International University before starting consultancy collaborations with leading Italian communication and digital marketing agencies.

In , he founded Marketing Arena, a digital strategy and online marketing company. Main areas of interest: measurement of…. And nothing drives me more than marketing great products and companies. Having managed the sales and…. At Ljubljana Tourism is working in Tourism development sector as regional destination organization coordinator of Central Slovenia region.

She coordinates and…. He is interested in how people perceive the world around them. In particular, how our brains manage to process the information from each of our different senses such as smell, taste, sight, hearing,…. Web and social media consultant Paola is also a freelance writer for several food and tourism magazines. She has worked for three years with the editorial staff of donnamoderna. Director of UNI. Lorenzo has spent most of his career in two areas: budget time and tourism, understood in all its forms, not least those specifically related to….

From , she was national councillor at the Italian National Forensic Association the first female doctor to be national councillor…. She left her first career behind to pursue a dream: converting her territory of Brindisi into a sustainable…. During her career, she has worked on several new projects, from print to the web and radio. In she joined Mondadori to…. Previously, he had obtained a Degree…. She is author and co-author of…. With more than 15 years experience working in the fields of tourism and marketing, Wilma is…. In June , the Italian police arrested more than members of the Secondigliano Alliance , the alliance created by the Licciardi , Contini and Mallardo clans, in an anti-Camorra operation.

Among those who were arrested were the wives of the bosses of the Bosti , Mallardo, Licciardi and Contini clans, but also their lieutenants, children, grandchildren and entrepreneurs who worked for the alliance. According to the reports, the drug was found in 19 bags inside a container that arrived from Colombia. The container was headed to Naples but was intercepted in the port of Genoa.

Despite its origins, it presently has secondary ramifications in other Italian regions, like Lombardy , [56] [57] [58] Piedmont [59] [60] and Emilia-Romagna , [61] [62] in connection with the centers of national economic power. According to the police he would be controlling his international drug trafficking business in the country. Although the 'Ndrangheta is considered the most prominent mafia in Belgium, Camorra is also very active in the country.

The port of Antwerp is one of the main gateways by which drugs enter in Europe from South America. The Camorra clans in Belgium deal in international drug trafficking, money laundering , and reinvesting in real estate. The Secondigliano Alliance , a powerful alliance between the Contini clan , the Licciardi clan and the Mallardo clan is active in Brussels.

In , Vittorio Pirozzi, of the Mariano clan, was arrested in his apartment in Brussels. Pirozzi led a bloody war over the control of the Quartieri Spagnoli in the center of Naples in the mids. According to the media, he is an international drug trafficker, was among the most wanted criminals in Italy and sentenced to 15 years in prison. From Santo Domingo, Bardellino controlled a fish flour import-export enterprise, while building a massive cocaine trade from the Caribbean to the countryside of Aversa , passing through Alberto Beneduce, one of the leaders of the clan and friend of Michele Zagaria.

In the country, he lived in a luxurious residence and held the reins of the clan especially for the management of drug trafficking. The Camorra has been present in France since the early s. The locations with the biggest presence of the organization in the country are the French Riviera , Paris and Lyon. Their biggest objective in the country has always been to create contacts for drug trafficking but also money laundering.

Paolo Di Lauro funnelled the proceeds into real estate, buying dozens of flats in Naples, owning shops in France and the Netherlands, as well as businesses importing fur, fake fur and lingerie. In , Antonio Lo Russo, member of the powerful Lo Russo clan and considered the new regent of the clan, and his cousin Carlo Lo Russo were arrested by agents of National Gendarmerie Section de recherches and by Carabinieri when quietly in a bar in Nice.

The clan is accused of extortion , drug trafficking and murder. According to the then Minister of the Interior of France, Bernard Cazeneuve , the arrest of Lo Russo was a hard blow for the organized crime in the country. In Greece, the Camorra clans are most active in the illicit cigarette trade and drug trafficking. The La Torra clan was known to launder money in the country with the help of the former chancellor of Salerno , Cesare Salomone. In June the operation Spaghetti Connection dismantled an international drug network involving the Camorra and the 'Ndrangheta in Abidjan and Tabou.

The police seized 1. This operation was the third of its kind in Ivory Coast in less than three years, but the largest by its magnitude. Six Italians, one French and three Ivorians were arrested. For 20 years, West Africa has become, if not a hub, a very important rebound zone for traffickers. This operation proves that if they thought that Ivory Coast and West Africa could be a sanctuary, they were wrong.

The drug trafficking in the country is said to contribute to the financing of the various jihadist groups in the Sahel , Africa. In the name of this company, he purchased real estates in Campania and Sardinia. Giuseppe Polverino, the leader of the Polverino clan before his arrest, was considered the ' hashish king', due to his monopoly on the importation of hashish from Morocco to Italy via Spain supplying not only all the Camorra clans, but also the 'Ndrangheta , the Sicilian Mafia and the Sacra Corona Unita.

According to one of the pentitos of the clan, Domenico Verde, the hashish was cultivated in the region of Ketama , and arrived by mules in the beginning, but later was modernized and accessible on trucks and cars. On March 18, an Italian, suspected of being one of the leaders of the Mazzarella clan, was arrested in the Ourika region, near Marrakech. He had a pursuant to a red notice issued against him by Interpol in January On May 29, Raffaele Vallefuoco, an important member of the Polverino clan, was arrested in the Rabat region. Vallefuoco is considered one of the biggest drug traffickers in Italy and was included on the list of the 50 most wanted fugitives.

According to Francesco Forgione , the former president of the Antimafia Commission , the Camorra is very active in gambling houses and money laundering in the Netherlands. The Camorra also uses the country to counterfeit clothes, and the clans most involved in this illegal activity are the Licciardi clan , the Di Lauro clan and the Sarno clan. Augusto La Torre , the former leader of the La Torre clan is suspected of having hid hundreds of millions of euros in Dutch banks, as the La Torre clan was very active in the country in the s transporting large cocaine shipments from South America to Naples via the Netherlands.

In , Raffaele Imperiale bought a coffee shop called Rockland Coffee in Amsterdam, where he sold soft drugs and was involved in large scale cocaine trafficking with the Dutch drug trader Rick van de Bunt. Imperiale worked in Amsterdam until In , two stolen Van Gogh paintings from the Van Gogh Museum in Amsterdam in were recovered in a villa near Naples , connected to Raffaele Imperiale, accused of being one of the Camorra's prolific drug barons.

Imperiale was sentenced to 18 years in absentia for drug offenses. In the s, Umberto Ammaturo , a Camorra boss, established a virtual monopoly of cocaine trafficking to Italy from Peru, where he benefited from the protection and collusion of important personalities. The Camorra boss and member of the Mazzarella clan, Saltavore Zazo, was allegedly involved in a large scheme of international cocaine trafficking from Peru to Europe, with the intention to acquire total control of the Port of Callao ; one of his contacts was drug lord Gerald Oropeza, one of the biggest traffickers in Peru.

Camorra clans in Romania deal in money laundering. The Sacco-Bocchetti clan is a subgroup of the Licciardi clan and Manzo took care of the accounting of the clan, and often supervised the supply of drugs from abroad. His businesses in the country are valued at several million euros. According to the journalist Roberto Saviano , Spain after Italy is the European country most entwined with the Camorra.

It is where the Camorra clans established its massive businesses revolving around drug trafficking and money laundering in real estate. Camorra has been in Spain since the s. The most powerful clan acting in the country is the Polverino clan due to the number of people they have installed and because of the potential of their structure.

The presence of the organization in the Costa del Sol is so strong that Camorra bosses refer to it as Costa Nostra' "Our Coast" , according to Italian journalist Roberto Saviano , a specialist on the Naples criminal underworld. Another clan with influence in Spain is the Scissionisti di Secondigliano led by Raffaele Amato nicknamed Lo Spagnolo the Spaniard , because before creating his own clan, he controlled the drug trafficking operation from Galicia to Naples for the Di Lauro clan.

In February , the Spanish police arrested 14 members of the notorious Marranella clan. According to the Guardia Civil , the clan is one of the most important and violent criminal organizations dedicated to the international drug trade and is based in the Costa del Sol. The Camorra has had a presence in Switzerland for more than 50 years, undertaking money laundering but also arms trafficking and drug trafficking. The Casalesi clan is present throughout the country, and according to the investigations into the clan, it has numerous Swiss bank accounts.

In , Ciro Mazzarella, boss of the Mazzarella clan, decided to move to Switzerland, after losing a war between Camorra clans in Naples. From his logistics base in Lugano , he created an enviable economic empire with cigarette smuggling that arrives from Montenegro. Scotland has had its brush with the Camorra. The La Torre Clan's empire was worth hundreds of millions of euros.

Antonio had several legitimate businesses in Aberdeen, whereas his brother Augusto had several illegal businesses there. Augusto would eventually become a pentito in January A fourth Scottish associate made history by becoming the first foreign member of the Camorra and is currently serving a jail sentence in the UK.

It has been reported that he also receives a monthly salary, legal assistance and protection. Saviano alleges that from the s, Italian gangsters ran a network of lucrative businesses in the city as well as many illegal rackets. Saviano said Scotland's third city, with no history of organized crime, was seen as an attractive safe haven away from the violent inter-gang bloodletting that had engulfed their Neapolitan stronghold of Mondragone.

Saviano claims that before the Italian clans arrived, Aberdeen did not know how to exploit its resources for recreation and tourism. He further states that the Italians infused the city with economic energy, revitalised the tourist industry, inspired new import-export activities and injected new vigour in the real-estate sector. It thereby turned Aberdeen into a chic, elegant address for fine dining and important dealings.

The hub of La Torre's UK empire, Pavarotti's restaurant, now under different ownership, was even feted at Italissima, a prestigious gastronomic fair held in Paris. The restaurant was even advertised on the city's local tourist guides. Saviano further claims to have gone to Aberdeen and worked in a restaurant run by Antonio La Torre. The Camorristas operated a system known as "scratch" where they used to step up illegal activities if their legitimate ventures were struggling. If cash was short they had counterfeit notes printed; if capital was needed in a hurry, they sold bogus treasury bonds.

They annihilated the competition through extortions and imported merchandise tax-free. The Camorra were able to run all sort of deals because the local police had virtually no experience in dealing with organized crime. Although they broke the law, there were never any guns or serious violence, due to lack of rivals.

However, the suggestion that the city remains in the grip of mobsters has been strongly denied by leaders of the strong Italian community in Aberdeen.

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Moreover, Giuseppe Baldini, the Italian government's vice-consul in Aberdeen, denies that the Camorra still maintains its presence in Aberdeen. The Camorra existed in the United States between the midth century and early 20th century. They rivaled the defunct Morello crime family for power in New York City. Eventually, they melded with the early Italian-American Mafia groups. Many Camorra members and associates fled the internecine gang warfare and Italian Justice and immigrated to the United States in the s.

According to the Federal Bureau of Investigation :. In the s, the Sicilian Mafia convinced the Camorra to convert their cigarette smuggling routes into drug smuggling routes with the Sicilian Mafia's assistance. Not all Camorra leaders agreed, leading to the Camorra Wars that cost lives. Opponents of drug trafficking lost the war. The Camorra made a fortune in reconstruction after an earthquake ravaged the Campania region in Now it specializes in cigarette smuggling and receives payoffs from other criminal groups for any cigarette traffic through Italy.

The Camorra is also involved in money laundering, extortion, alien smuggling, robbery, blackmail, kidnapping, political corruption, and counterfeiting. It is believed that nearly Camorra affiliates reside in this country, many of whom arrived during the Camorra Wars. In , the Obama administration imposed sanctions on the Camorra as one of four key transnational organized crime groups, along with the Brothers' Circle from Russia, the Yamaguchi-gumi Yakuza from Japan, and Los Zetas from Mexico.

According to the media, there has always been alliances between the Camorra and the 'Ndrangheta members. The operation consisted in transporting the drugs from Venezuela and Colombia, through several European ports including the port of Amsterdam. At the port of Livorno , kilos of cocaine were seized. On May 11, , a criminal alliance between the sinti criminal organization Casamonica clan , members of the Camorra, and affiliates from the 'Ndrangheta 's of Polistena , Taurianova and Melicucco was dismantled by the police.

On March 21, , 19 arrests were made in Rome of alleged members belonging to the Licciardi clan of the Camorra and members of the Filippone 'ndrina and Gallico 'ndrina accused of drug trafficking. Several Camorra clans have lasting relationships with the Cosa Nostra. Prominent elements of the Mafia such as Salvatore Riina , Leoluca Bagarella , Luciano Leggio and Bernardo Provenzano found themselves in contact with Camorra clans such as the Nuvoletta clan , members of the Camorra such as Michele Zaza and Antonio Bardellino , and with other groups that formed the Nuova Famiglia confederation in the s.

This organization operated in various cities of Apulia during the s. According to the pentito Antonio Accurso, the Di Lauro clan has several links to the Sacra Corona Unita in question with regards to drug trafficking. The relationship between the South American drug cartels and the Italian criminal organizations for over 50 years. Giuseppe Gallo called 'o pazz the crazy one , boss of the Limelli-Vangone clan, is said to having contacts with Colombian drug traffickers able to reach agreements for the purchase of large quantities of cocaine, supplying various clans in the Naples area.

According to the Direzione Investigativa Antimafia , the Albanian mafia has alliances with the Mazzarella clan and with the Scissionisti di Secondigliano , both from Naples and with the Serino clan, from Salerno. Roberto Saviano , an expert on the Camorra, spoke of the Albanian mafia as a "no longer foreign mafia" to Italy and stressed that the Albanians and Italians have a "brotherly" relationship with each other. Saviano notes that the Camorra feels great affinity with the Albanian crime families because both organizations are based on family ties.

Some Camorra clans, including the Giuliano clan, once led by Luigi Giuliano , have established business relationships with Chinese criminal gangs , especially in the sector of counterfeiting Italian brands. The Camorra clans imposed the final price of the products and in return they provided the services to get around the controls. In , investigators discovered a scheme between the Camorra and the Chinese gangs. They exported industrial waste from Italy to China that guaranteed million-dollar revenues for both organizations. The industrial waste left Prato in Italy and arrived in Hong Kong.

Among the Camorra clans involved in this alliance were the Casalesi clan , the Fabbrocino clan and the Ascione clan. In the beginning, the Nigerians were not tolerated by the Camorra but in recent times both organizations are making alliances. The relations between the Camorra and Nigerian mafia concern mainly drug trafficking and prostitution.

In particular, Camorra members allowed the Nigeria gangs to organize the trafficking of women in the territory in exchange for a share on the earnings. The Nigerian mafia produces synthetic drugs independently and sells them with the consent of the Camorra. This alliance, however, can change from one moment to another, as the Nigerians have asked to be treated on par with other Italian mafias, for the fact that they are growing both as a military and as an economic force. These bills would then be transported to the Russian Mafia for distribution in 29 post- Eastern Bloc countries and former Soviet republics.

In March , a massive international arms trafficking ring was dismantled by the authorities of Italy and Austria and coordinated by Eurojust. According to the investigations, the alliance between the Camorra and the Austrians lasted for seven years, until the police dismantled the scheme. I dont know any cases, which are so big and where so many weapons have been sold. The new owners are also not "juvenile guarantors" but several members of the Camorra, one of the most dangerous criminal organizations in Europe.

The weapons are believed to have come originally from Eastern Europe taken to Carinthia in Austria with the objective to arrive in Terzigno near Naples. With most of the old Camorra clans decapitated, and their bosses either dead or arrested, the organization is experiencing a rise in youth criminal gangs trying to take their places.

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This phenomenon is called Paranza , which is Camorra terminology, for a criminal group led by youngsters or "small fish". In , Emanuele Sibillo was 18 and considered one of the first young and leading bosses of this new generation. In , he was shot dead by a rival baby gang.

We can clearly see the baby gangs are criminals, or people who want to have criminal careers.