In addition to today’s resource, please review The PECARN Pediatric Head Trauma Decision Guidelines Toolkit from The California ACEP.
Between 20% and 60% of children presenting to EDs with head injury undergo head CT in the U.S., even though less than 1% of children with GCS of 14 – 15 have an injury that requires any kind of intervention. Using the PECARN head injury prediction rule can significantly improve the value we deliver to our patients by reducing unnecessary CT scans in children, thereby reducing radiation exposure and decreasing costs.
California ACEP has developed a toolkit to facilitate adoption of the evidence-based PECARN algorithm. The toolkit specifically addresses “shared decision making” as a vital part of PECARN, and spells out how observation can be a safe alternative to CT scanning in low-risk patients. We encourage all emergency providers to utilize the California ACEP PECARN toolkit so all pediatric patients with minor head injuries can benefit from the landmark PECARN study.
Today, I review, link to, and excerpt from “Identification of children at very low risk of clinicallyimportant brain injuries after head trauma: a prospective cohort study”. [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. Lancet. 2009 Oct 3;374(9696):1160-70. doi: 10.1016/S0140-6736(09)61558-0. Epub 2009 Sep 14.
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Summary
Background
CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.Methods
We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14–15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights).Findings
We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and 60 (0·1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1175/1175 (100·0%, 95% CI 99·7–100 0) and sensitivity of 25/25 (100%, 86·3–100·0). 167 (24·1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3698/3698 (99·95%, 99·80–99·99) and sensitivity of 61/63 (96·8%, 89·0–99·6). 438 (19.7%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.Interpretation
These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.Funding
The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.Introduction
Traumatic brain injury is a leading cause of death and disability in children worldwide. In the USA, head trauma in individuals aged 18 years and younger results in about 7400 deaths, over 60 000 hospital admissions, and over 600 000 emergency department visits every year.1,2 Children with clinically-important traumatic brain injury (ciTBI) needing acute intervention, especially neurosurgery, should be identified rapidly. CT is the reference standard for emergently diagnosing traumatic brain injuries, although some brain injuries are not seen on CT.3,4 About 50% of children assessed in North American emergency departments for head trauma undergo CT5,6 (Faul M, Centers for Disease Control and Prevention, personal communication). Between 1995 and 2005, CT use more than doubled.6,7 Furthermore, many traumatic brain injuries identified on CT do not need acute intervention, and some are false positives or non-traumatic findings. Clinical studies using abnormal CT findings as the outcome measure for identifying children with traumatic brain injuries might promote excessive CT use. Children with apparently minor head trauma (Glasgow Coma Scale [GCS] scores of 14–15) are the group most frequently assessed. These children commonly undergo neuroimaging and account for 40–60% of those with traumatic brain injuries seen on CT.8–11 Less than 10% of CT scans in children with minor head trauma, however, show traumatic brain injuries. Furthermore, injuries needing neurosurgery are very uncommon in children with GCS scores of 14–15.10–13Reduction of CT use is important because ionising radiation from CT scans can cause lethal malignancies.14–16 The estimated rate of lethal malignancies from CT is between 1 in 1000 and 1 in 5000 paediatric cranial CT scans, with risk increasing as age decreases.14,15 Clear data for CT use, however, are unavailable, therefore resulting in substantial practice variation.17 Previous predictive models8,10,18–20 are limited by small sample sizes, no validation, and/or no independent assessment of preverbal children (<2 years of age). Therefore, creation and validation of accurate, generalisable prediction rules for identifying children at very low risk of ciTBI are needed. A systematic review21 of head CT prediction rules has recently emphasised the need for a large prospective study of children with minor head trauma to derive and validate a precise rule, and has specifically recommended deriving a separate rule for very young children.Our aim was to derive and validate prediction rules for ciTBI to identify children at very low risk of ciTBI after blunt head trauma for whom CT might be unnecessary.
