Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice

Characteristics of Intracranial Injuries in Pediatric Patients Following Blunt Head Trauma

OBJECTIVES

Pediatric head trauma is a frequent reason for presentation to the emergency department. Despite this, there are few reports on specific characteristics and injury patterns in head injured children. The goal of this study was to evaluate head injury patterns in children with blunt head injury and their prevalence by age group.

METHODS

This is a planned secondary analysis of the NEXUS II Head CT validation study. Consecutive patients with blunt head trauma were enrolled between 2006 and 2015. Demographics and criteria from 2 clinical decision instruments (NEXUS and Canadian Head CT rules) were gathered at the time of enrollment. We abstracted and cataloged injuries for pediatric patients based on radiologist report. Frequencies of injuries and severity were analyzed by developmental age group.

RESULTS

A total of 1018 pediatric patients were enrolled, 128 (12.6%) of whom had an injury on computed tomography scan. Median age was 11.9 (Interquartile range 4.5-15.5) for all patients and 12 (4.8-15.5) for injured patients. Of injured patients, 49 (38.3%) had a significant injury, and 27 (21.1%) received an intervention. Teenagers had the highest rate of significant injury (50%) and intervention (30%). Injuries were most frequently noted in the temporal (46.1%), frontal (45.3%), and parietal (45.3%) regions. Subarachnoid hemorrhage (29.7%) and subdural hematoma (28.9%) were the most common injuries observed.Intraparenchymal hemorrhage and cerebral edema were more prevalent in older age groups. The most common injury mechanism overall was fall from height (24.7%). Motor vehicle accidents and nonmotorized wheeled vehicle accidents were more common in older patients.

CONCLUSIONS

Serious injuries requiring intervention were rarely encountered in pediatric patients experiencing blunt head trauma. Mechanisms of injury, type of injury, and rates of intervention varied between developmental age groups.

Computed Tomography Utilization in the Management of Children with Mild Head Trauma

This study demonstrates the trend of computed tomography (CT) usage for children with mild traumatic brain injury (mTBI) in the context of the initiation of the Safe CT Imaging Collaborative Initiative to promote the Pediatric Emergency Care Applied Research Network (PECARN) rules at the acute care hospitals in New Jersey. We used administrative databases of 10 children's and 59 general hospitals to compare CT rates before 2014-2015, during 2016, and after the initiation of the program (2017-2019). The CT usage rates at baseline and the end of surveillance in children's hospitals (19.2% and 14.2%) were lower than in general hospitals (36.7% and 21.0%), p < 0.0001. The absolute mean difference from baseline to the end of surveillance in children's hospitals was 5.1% compared to a high of 9.7% in general hospitals, medium-high with 13.2%, and 14.0% in a medium volume of pediatric patients (p < 0.001-0.0001). The time-series model demonstrates a positive trend of CT reduction in pediatric patients with mTBI within four years of the program's implementation (p < 0.03-0.001). The primary CT reduction was recorded during the year of program implementation. Regression analysis revealed the significant role of a baseline CT usage rate in predicting the level of CT reduction independent of the volume of pediatric patients and type of hospital.

Traumatic Brain Injury: Contemporary Challenges and the Path to Progress

Traumatic brain injury (TBI) remains a leading cause of death and disability worldwide, and its incidence is increasing [...].

Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence

The increasing attendance of paediatric emergency departments has become a serious health issue. To reduce an elevated burden of medical errors, inevitably caused by a high level of stress exerted on emergency physicians, we propose potential areas for improvement in regular paediatric emergency departments. In an effort to guarantee the demanded quality of care to all incoming patients, the workflow in paediatric emergency departments should be sufficiently optimised. The key component remains to implement one of the validated paediatric triage systems upon the patient's arrival at the emergency department and fast-tracking patients with a low level of risk according to the triage system. To ensure the patient's safety, emergency physicians should follow issued guidelines. Cognitive aids, such as well-designed checklists, posters or flow charts, generally improve physicians' adherence to guidelines and should be available in every paediatric emergency department. To sharpen diagnostic accuracy, the use of ultrasound in a paediatric emergency department, according to ultrasound protocols, should be targeted to answer specific clinical questions. Combining all mentioned improvements might reduce the number of errors linked to overcrowding. The review serves not only as a blueprint for modernising paediatric emergency departments but also as a bin of useful literature which can be suitable in the paediatric emergency field.

Comparison of severity scales for acute bronchiolitis in real clinical practice

Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing in-hospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, M-WCAS, Respiratory Severity Score, Respiratory Clinical Score, Respiratory Score and Bronchiolitis risk of admission score) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) and the odds ratio (OR) for a relevant outcome were calculated in each scale. Also, the best cut-off point was estimated according to the Youden index, and its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P₂₅-P₇₅ 2.6-7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. A score ≤ 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7-96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV).   Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. However, the PERN scale might be more useful to select patients at low risk of a severe outcome. What is Known: • Several clinical scales are used to assess the severity of bronchiolitis. Nevertheless, none of them seems to be better than others. What is New: • This is the first study comparing different bronchiolitis scales in a real clinical scenario. None of the nine scales compared performed better than the other. However, the PERN scale might be more useful to select patients at low risk of relevant outcomes.

Sustaining the gains: Reducing unnecessary computed tomography scans in pediatric trauma patients

BACKGROUND/PURPOSE

"Pan-scanning" pediatric blunt trauma patients leads to exposure to harmful radiation and increased healthcare costs without improving outcomes. We aimed to reduce computed tomography (CT) scans that are not indicated (NI) by imaging guidelines for injured children.

METHODS

In July 2017, our Pediatric Trauma Center prospectively implemented validated imaging guidelines to direct CT imaging for trauma activations and consultations for children younger than 16 years old with blunt traumatic injuries. Patients with suspected physical abuse, CT imaging prior to arrival, penetrating mechanism, and instability precluding CT imaging were excluded. We compared CT scanning rates for pre-implementation (01/2016-06/2017) and post-implementation (07/2017-08/2021) time periods. Guideline compliance was evaluated by chart review and sustained through iterative process improvement cycles.

RESULTS

During the pre-implementation era, 61 patients underwent 171 CT scans of which 87 (51%) scans were not indicated by guidelines. Post-implementation, 363 patients had 531 scans and only 134 (25%) CTs were not indicated. Total CTs performed declined after initiation of guidelines (2.80 vs 1.46 scans/patient, p<0.0001). Total NI CTs declined (1.41 vs 0.37 NI scans/patient, p<0.0001) reflected in significant reductions in all anatomic regions: head, cervical spine, chest, and abdomen/pelvis. Charges related to NI scans decreased from $1,490.31/patient to $408.21/patient, saving $218,000 in charges. Based on prior utilization, 146 children were spared excessive radiation with no clinically significant missed injuries since guideline implementation.

CONCLUSIONS

Quality improvement and implementation science methodologies to enhance compliance with imaging guidelines for children with blunt injuries can significantly reduce unnecessary CT scanning without compromising care. This practice reduces harmful radiation exposure in a sensitive patient population and may save healthcare systems money and resources.

Machine learning versus traditional methods for the development of risk stratification scores: a case study using original Canadian Syncope Risk Score data

Artificial Intelligence and machine learning (ML) methods are promising for risk-stratification, but the added benefit over traditional statistical methods remains unclear. We compared predictive models developed using machine learning (ML) methods to the Canadian Syncope Risk Score (CSRS), a risk-tool developed with logistic regression for predicting serious adverse events (SAE) after emergency department (ED) disposition for syncope. We used the prospective multicenter cohort data collected for CSRS development at 11 Canadian EDs over an 8-year period to develop four ML models to predict 30-day SAE (death, arrhythmias, MI, structural heart disease, pulmonary embolism, hemorrhage) after ED disposition. The CSRS derivation and validation cohorts were used for training and testing, respectively, and the 43 variables used included demographics, medical history, vital signs, ECG findings, blood tests and the diagnostic impression of the emergency physician. Performance was assessed using the area under the receiver-operating-characteristics curve (AUC) and calibration curves. Of the 4030 patients in the training set and 3819 patients in the test set overall, 286 (3.6%) patients suffered 30-day SAE. The AUCs for model validation in test data were CSRS 0.902 (0.877-0.926), regularized regression 0.903 (0.877-0.928), gradient boosting 0.914 (0.894-0.934), deep neural network 0.906 (0.883-0.929), simplified gradient boosting 0.904 (0.881-0.927). The AUCs and calibration slopes for the ML models and CSRS were similar. Two ML models used fewer predictors than the CSRS but matched its performance. Overall, the ML models matched the CSRS in performance, with some models using fewer predictors.

Comparison of Same and Different Level Height Falls on Subsequent Midline Shift in Pediatric Traumatic Brain Injury

OBJECTIVES

Up to 44% of pediatric traumatic brain injury occurs as a result of a fall. We hypothesized that a fall from height is associated with higher risk for subsequent midline shift in pediatric traumatic brain injury compared with a fall from same level.

METHODS

The Pediatric Trauma Quality Improvement Program 2016 was queried for kids younger than 16 years with an injury in the abbreviated injury scale for the head after a fall. Patients with midline shift were identified. A logistic regression model was used for analysis.

RESULTS

The risk of a midline shift was lower in those with a fall from a height (odds ratio, 0.64; 95% confidence interval, 0.46-0.91, P = 0.01). In kids older than 4 years, there was no association between the level of height of the fall and subsequent midline shift (P = 0.62). The risk for midline shift in kids younger than 4 years after a fall from same level was lower (odds ratio, 0.40; 95% confidence interval, 0.24-0.67; P = 0.001).

CONCLUSIONS

In kids with traumatic brain injury, trauma activations due to falls from the same level are associated with a 2.5-fold higher risk of subsequent midline shift, compared with falling from height.

Effectiveness of a Simulation Curriculum on Clinical Application: A Randomized Educational Trial

INTRODUCTION

The use of simulation to develop clinical reasoning and medical decision-making skills for common events is poorly established. Validated head trauma rules help identify children at low risk for clinically important traumatic brain injury and guide the need for neuroimaging. We predicted that interns trained using a high-fidelity, immersive simulation would understand and apply these rules better than those trained using a case-based discussion. Our primary outcomes were to determine the effectiveness of a single targeted intervention on an intern's ability to learn and apply the rules.

METHODS

This was a prospective randomized controlled trial. Interns were randomized to participate in either a manikin-based simulation or a case discussion. Knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool were assessed both under testing conditions using standardized vignettes and in clinical encounters. In both settings, interns completed a validated assessment tool to test their knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool when assessing patients with head injury.

RESULTS

Under testing conditions, both being in the simulation group and shorter time from training were independently associated with higher score under testing conditions using standardized vignettes (P = 0.038 and P < 0.001), but not with clinical encounters.

CONCLUSIONS

Interns exposed to manikin-based simulation training demonstrated performance competencies that are better than those in the case discussion group under testing conditions using standardized vignettes, but not in real clinical encounters. This study suggests that information delivery and comprehension may be improved through a single targeted simulation-based education.

Imaging for Pediatric Blunt Abdominal Trauma With Different Prediction Rules: Is the Outcome the Same?

BACKGROUND

Computerized tomography (CT) of the abdomen and pelvis is the standard imaging modality to diagnose intra-abdominal injury (IAI). Clinicians must weigh the risk-benefit of CT compared with the degree of clinical suspicion for an IAI. Pediatric Emergency Care Applied Research Network (PECARN), Streck, and blunt abdominal trauma in children (BATiC) prediction rules have been published to help guide evaluation of these patients. Pediatric Emergency Care Applied Research Network uses history and physical examination findings, whereas Streck and BATiC use examination plus laboratory and imaging findings. At the time of the study, there was not a protocol that was more routinely sited. Our goal was to compare these different prediction rules.

METHODS

This was a retrospective electronic chart review of all children younger than 18 years presenting for either level 1 or 2 trauma activations at our pediatric emergency department (ED) between June 1, 2015, to June 30, 2017. Charts were manually reviewed for a mechanism concerning for abdominal trauma, and demographic data, history and physical examination findings, laboratory and imaging results per prediction rules, and revisits in 7 days were collected.The prediction rules were applied to all charts that had all data necessary. For study purposes, a score of zero for PECARN and Streck, and score of ≤5 for modified BATiC (mBATiC) were defined as "low risk." Patients with no CT, negative CT, and no new injury found on revisit were classified as "no IAI identified," and patients with positive CT or revisit with injury found as "IAI identified." The results were compared via Fisher exact test.

RESULTS

A total of 249 patients met the inclusion criteria with a median age of 12 years. Of the low-risk patients, 119 (98.7%) of 121 in PECARN group, 21 (100%) of 21 in Streck, and 48 (85.7%) of 56 in mBATiC group had no IAI identified. None of the low-risk patients required any intra-abdominal intervention. No missed IAI was identified during revisit review. Negative predictive values of all 3 rules were significant for PECARN, Streck, and mBATiC (98.35%, 100%, and 85.71%, respectively). Overall, 27 patients had positive CT results for IAI.

CONCLUSIONS

The PECARN and Streck rules have high negative predictive values to predict low-risk patients who do not require CT. When laboratory studies are not obtained, PECARN is an effective means of excluding IAI for low-risk patients. When laboratory tests were obtained, the Streck rule performed well. Overall, the results are similar to the past individual studies done on each individual rule. History and physical examination findings are of high importance in pediatric trauma. This study supports limited imaging when no abnormal findings are present in children with blunt torso trauma. This is the only study found in the literature that has compared 3 different prediction rules.

Validation of Pediatric Emergency Care Applied Research Network (PECARN) rule in children with minor head trauma

The Pediatric Emergency Care Applied Research Network (PECARN) rule is commonly used for predicting the need for computed tomography (CT) scans in children with mild head trauma. The objective of this study was to validate the PECARN rule in Korean children presenting to the pediatric emergency department (PED) with head trauma. This study was a multicenter, retrospective, observational cohort study in two teaching PEDs in Korea between August 2015 and August 2016. In this observational study, 448 patients who visited PEDs were included in the final analysis. Risk stratification was performed with clinical decision support software based on the PECARN rule, and decisions to perform CT scans were subsequently made. Patients were followed-up by phone call between 7 days and 90 days after discharge from the PED. The sensitivity and specificity were analyzed. The sensitivity was 100% for all age groups, and no cases of clinically important traumatic brain injury (ciTBI) were identified in the very-low-risk group. CT scans were performed for 14.7% of patients in this study and for 33.8% in the original PECARN study. The PECARN rule successfully identified low-risk patients, and no cases of ciTBI were missed despite the reduced proportion of patients undergoing CT scans.

How to fix the Merit-based Incentive Payment System (MIPS) in emergency medicine

In this issue of Academic Emergency Medicine, Gettel et al. report participation and performance of emergency clinicians in 2018's Merit-based Incentive Payment System (MIPS). MIPS is an enormous government program that assesses U.S. clinicians on several factors and makes payment adjustments for Medicare fee for service patients based on those results. MIPS performance is assessed in variable ways based on clinical specialty.

A Pilot Study to Reduce Computed Tomography Utilization for Pediatric Mild Head Injury in the Emergency Department Using a Clinical Decision Support Tool and a Structured Parent Discussion Tool

INTRODUCTION

The American College of Emergency Physicians embarked on the "Choosing Wisely" campaign to avoid computed tomographic (CT) scans in patients with minor head injury who are at low risk based on validated decision rules. We hypothesized that a Pediatric Mild Head Injury Care Path could be developed and implemented to reduce inappropriate CT utilization with support of a clinical decision support tool (CDST) and a structured parent discussion tool.

METHODS

A quality improvement project was initiated for 9 weeks to reduce inappropriate CT utilization through 5 interventions: (1) engagement of leadership, (2) provider education, (3) incorporation of a parent discussion tool to guide discussion during the emergency department (ED) visit between the parent and the provider, (4) CDST embedded in the electronic medical record, and (5) importation of data into the note to drive compliance. Patients prospectively were enrolled when providers at a pediatric and a freestanding ED entered data into the CDST for decision making. Rate of care path utilization and head CT reduction was determined for all patients with minor head injury based on International Classification of Diseases, Ninth Revision codes. Targets for care path utilization and head CT reduction were established a priori. Results were compared with baseline data collected from 2013.

RESULTS

The CDST was used in 176 (77.5%) of 227 eligible patients. Twelve patients were excluded based on a priori criteria. Adherence to recommendations occurred in 162 (99%) of 164 patients. Head CT utilization was reduced from 62.7% to 22% (odds ratio, 0.17; 95% confidence interval, 0.12-0.24) where CDST was used by the provider. There were no missed traumatic brain injuries in our study group.

CONCLUSION

A Pediatric Mild Head Injury Care Path can be implemented in a pediatric and freestanding ED, resulting in reduced head CT utilization and high levels of adherence to CDST recommendations.

Accuracy of PECARN decision rule in minor blunt head trauma in pediatric emergency department: A meta-analysis

BACKGROUND

Paediatric Emergency Care Applied Research Network (PECARN) is a useful Clinical Decision Support Tool (CDST) to identify traumatic brain injuries and reduce the use of head computed tomography (CT) scans among paediatric patients. The present Meta-analysis aims to evaluate the diagnostic accuracy of the PECARN rule from 2009 to 2020 in children with a very low risk of blunt head trauma.

METHODS

A detailed search was conducted from the databases of Medline (via PubMed), Cinahl (via Ebsco), Scopus, Web of Sciences, from 2009 till the end of December 2020 using the keywords like decreased use of CT scan, blunt head trauma (BHT) combined with accuracy, PECARN OR CDST. Studies showing the diagnostic accuracy of the PECARN rule in children younger than 18 years of age with minor BHT were included.

RESULTS

Thirteen studies were included in the present analysis. Pooled sensitivity of 0.08, (95% confidence interval of 0.074-0.087), pooled specificity of 0.20 (95% CI of 0.196-0.213) and diagnostic odds ratio of 0.004 (95% CI of 0.000-0.1666) was in <2 years of age. The overall sensitivity of 0.07, specificity of 0.66, and the diagnostic odds ratio of 0.54 (95% CI of 0.10-2.78) were seen in ≥2 years of age. Overall sensitivity of 0.13 (95% CI 0.12-0.14), specificity of 0.81 (95% CI 0.80-0.82) and diagnostic odds ratio of 0.79 (95% CI of 0.08-7.71) was in 0-18 years of age.

CONCLUSION

The present analysis indicates the PECARN decision tool as an accurate CDST in low-risk minor BHT cases in children below two years of age and can become a valuable tool in reducing Head CT scan overuse in paediatric emergency departments.

Trends in Head Computed Tomography Utilization in Children Presenting to Emergency Departments After Traumatic Head Injury

OBJECTIVES

Although closed head injuries occur commonly in children, most do not have a clinically important traumatic brain injury (ciTBI) and do not require neuroimaging. We sought to determine whether the utilization of computed tomography of the head (CT-H) in children presenting to an emergency department (ED) with a closed head injury changed after publication of validated clinical prediction rules to identify children at risk of ciTBI by the Pediatric Emergency Care Applied Research Network (PECARN).

METHODS

We used the nationwide ED sample (2008-2013) to examine children visiting an ED after a mild closed head injury. Multiple patient and hospital characteristics were assessed.

RESULTS

Of the 4,552,071 children presenting to an ED with a mild closed head injury, 1,181,659 (26.0%) underwent CT-H. Care was most commonly received at metropolitan teaching hospitals (43.5%) and varied markedly by geographic region. Overall, there were no significant changes in the nationwide rates of CT-H utilization in the period immediately after publication of the PECARN prediction rules. However, compared with metropolitan teaching hospitals, CT-H utilization increased significantly for patients treated at nonteaching hospitals and at nonmetropolitan hospitals.

CONCLUSIONS

There was no overall reduction in CT-H utilization after publication of the 2009 PECARN prediction rules. However, patients treated at metropolitan teaching hospitals were significantly less likely to undergo CT-H after 2009, suggesting some penetration of the PECARN tool in that setting. Further research should study patterns of CT-H utilization in nonteaching hospitals and nonmetropolitan hospitals to assess challenges for adoption of validated pediatric ciTBI prediction rules.

Atypical teratoid rhabdoid tumor in the cerebellum of a 7-year-old boy presenting with headache after a fall

A 7-year-old boy presented to a community emergency department (ED) after sustaining a minor fall. Although he was found to have a normal neurologic examination, additional history revealed the patient had been having mild intermittent headaches and dizziness in the months preceding the fall. The emergency clinicians ordered neuroimaging, which demonstrated a right cerebellar mass, ultimately diagnosed as atypical rhabdoid/teratoid tumor. Atypical rhabdoid/teratoid tumor is a rare, aggressive brain tumor with a poor prognosis. The objectives of this case report are to emphasize the importance of detailed history with pediatric head trauma, in particular on reassessment, and to discuss briefly the epidemiology and management of atypical teratoid rhabdoid tumor.

Missed intracranial injuries are rare in emergency departments using the PECARN head injury decision rules

PURPOSE

The PECARN head trauma (HT) prediction rules have been developed to guide computed tomography-related decision-making for children with minor HT (mHT). There are currently limited data on the rate of unscheduled revisits to emergency departments (EDs), and initially missed intracranial injuries, in children with mHT initially assessed using the PECARN rules. This study aimed to fill this gap in knowledge.

METHODS

Clinical charts of children assessed for mHT over a 5-year period at two EDs that implemented the PECARN rules in Italy and France were reviewed retrospectively. Children who returned to EDs for mHT-related, or potentially related complaints, within 1 month of initial assessment were included.

RESULTS

The total number of children with mHT presenting for the first time to the EDs of both sites was 11,749. Overall, 180 (1.5%) unscheduled revisits to the EDs occurred for mHT-related or potentially related complaints. Twenty-three of these 180 patients underwent neuroimaging, and seven had an intracranial injury (including one ischemic stroke). Of these, three were hospitalized and none needed neurosurgery or intensive care.

CONCLUSION

Unscheduled revisits for mHT in EDs using the PECARN rules were very uncommon. Initially missed intracranial injuries were rare, and none needed neurosurgery or intensive care.

The importance of skull impact site for minor mechanism head injury requiring neurosurgical intervention

PURPOSE

The most frequent impact sites for head injury patients who require surgical intervention are the temporo-parietal regions. However, most recent guidelines for indication of neuroimaging for head injury sparsely address the impact site as a risk factor. Our purpose was to determine the association between the site of impact in a minor mechanism pediatric head injury and neurosurgical intervention.

METHOD

A retrospective cohort study of head injury patients seen between 2000 and 2016 in a large trauma center was carried out. We looked at all children ages 0-18 years who underwent neurosurgical intervention for head traumas. A major mechanism was defined as a fall of >1 m, being struck by a fast-flying object, or a motor collision involving an estimated speed of >40 kph. All other mechanisms were classified as minor.

RESULTS

Out of 533 patients, we excluded patients with non-accidental trauma, patients with a relevant chronic illness, patients with a major mechanism of injury, and patients with missing important data, leaving 43 as the study group. Of the 43 patients with a minor mechanism, none had a site of impact that was outside the temporo-parietal region.

CONCLUSION

We studied one of the largest cohorts of pediatric patients undergoing neurosurgical intervention for a head injury. In our cohort, none of the children who sustained a minor mechanism of injury suffered a site of impact in the occipital or frontal bone regions outside the temple region. These data suggest that injury location should be considered in assessing the need for neuroimaging in minor mechanism head trauma patients.

Impact of routine S100B protein assay on CT scan use in children with mild traumatic brain injury

OBJECTIVES

To evaluate the impact of implementing a modified Pediatric Emergency Care Applied Research Network (PECARN) rule including the S100B protein assay for managing mild traumatic brain injury (mTBI) in children.

METHODS

A before-and-after study was conducted in a paediatric emergency department of a French University Hospital from 2013 to 2015. We retrospectively included all consecutive children aged 4 months to 15 years who presented mTBI and were at intermediate risk for clinically important traumatic brain injury (ciTBI). We compared the proportions of CT scans performed and of in-hospital observations before (2013-2014) and after (2014-2015) implementation of a modified PECARN rule including the S100B protein assay.

RESULTS

We included 1,062 children with mTBI (median age 4.5 years, sex ratio [F/M] 0.73) who were at intermediate risk for ciTBI: 494 (46.5%) during 2013-2014 and 568 (53.5%) during 2014-2015. During 2014-2015, S100B protein was measured in 451 (79.4%) children within 6 h after mTBI. The proportion of CT scans and in-hospital observations significantly decreased between the two periods, from 14.4 to 9.5% (p=0.02) and 73.9-40.5% (p<0.01), respectively. The number of CT scans performed to identify a single ciTBI was reduced by two-thirds, from 18 to 6 CT scans, between 2013-2014 and 2014-2015. All children with ciTBI were identified by the rules.

CONCLUSIONS

The implementation of a modified PECARN rule including the S100B protein assay significantly decreased the proportion of CT scans and in-hospital observations for children with mTBI who were at intermediate risk for ciTBI.

Does implementation of the PECARN rules for minor head trauma improve patient-centered outcomes in a lower resource emergency department: a retrospective cohort study

BACKGROUND

Managing children with minor head trauma remains challenging for physicians who evaluate for the need for computed tomography (CT) imaging for clinically important traumatic brain injury (ciTBI) identification. The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules were adopted in our pediatric emergency department (PED) in December 2013 to identify children at low risk for ciTBI. This study aimed to evaluate this implementation's impact on CT rates and clinical outcomes.

METHODS

Retrospective cohort study on pediatric patients with head trauma presenting to the PED of the American University of Beirut Medical Center in Lebanon. Participants were divided into pre- (December 2012 to December 2013) and post-PECARN (January 2014 to December 2016) groups. Patients were further divided into < 2 and ≥ 2 years and stratified into groups of low, intermediate and high risk for ciTBI. Bivariate analysis was conducted to determine differences between both groups.

RESULTS

We included 1362 children of which 425 (31.2%) presented pre- and 937 (68.8%) presented post-PECARN rules implementation with 1090 (80.0%) of low, 214 (15.7%) of intermediate and 58 (4.3%) of high risk for ciTBI. CTs were ordered on 92 (21.6%) pre- versus 174 (18.6%) patients post-PECARN (p = 0.18). Among patients < 2 years, CT rates significantly decreased from 25.2% (34/135) to 16.5% (51/309) post-PECARN (p = 0.03), and dropped in all risk groups but only significantly for low risk patients from 20.7% (24/116) to 11.4% (30/264) (p = 0.02). There was no significant decrease in CT rates in patients ≥2 years (20% pre (58/290) vs 19.6% post (123/628), p = 0.88). There was no increase in bounce back numbers, nor in admission rates or positive CT findings among bounce backs.

CONCLUSIONS

PECARN rules implementation did not significantly change the overall CT scan rate but reduced the CT scan rate in patients aged < 2 years at low risk of ciTBI. The implementation did not increase the number of missed ciTBI.

ACR Appropriateness Criteria® Head Trauma-Child

Head trauma is a frequent indication for cranial imaging in children. The majority of accidental pediatric head trauma is minor and sustained without intracranial injury. Well-validated pediatric-specific clinical decision guidelines should be used to identify very low-risk children who can safely forgo imaging. In those who require acute imaging, CT is considered the first-line imaging modality for suspected intracranial injury because of the short duration of the examination and its high sensitivity for acute hemorrhage. MRI can accurately detect traumatic complications, but often necessitates sedation in children, owing to the examination length and motion sensitivity, which limits rapid assessment. There is a paucity of literature regarding vascular injuries in pediatric blunt head trauma and imaging is typically guided by clinical suspicion. Advanced imaging techniques have the potential to identify changes that are not seen by standard imaging, but data are currently insufficient to support routine clinical use. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Reduction of paediatric head CT utilisation at a rural general hospital emergency department

BACKGROUND

Blunt head injury is a common pediatric injury and often evaluated in general emergency departments. It estimated that 50% of children will undergo a head computed tomography (CT), often unnecessarily exposing the child to ionizing radiation. Pediatric academic centers have shown quality improvement (QI) measures can reduce head CT rates within their emergency departments. We aimed to reduce head CT utilization at a rural community emergency department.

METHODS

Children presenting with a complaint of blunt head injury and were evaluated with or without a head CT. Head CT rate was the primary outcome. We developed a series of interventions and presented these to the general emergency department over the duration of the study. The pre and intervention data was analysed with control charts.

RESULTS

The preintervention and intervention groups consisted of 576 children: 237 patients with a median age of 8.0 years and 339 patients with a median age of 9.00 years (p=0.54), respectively. The preintervention HCT rate was 41.8% (95% CI 35.6% to 48.1%) and the postintervention rate was 27.7% (95% CI 23.3% to 32.7%), a decrease of 14.1% (95% CI 6.2% to 21.9%, p=0.0004). During the intervention period, there was a decrease in HCT rate of one per month (OR 0.96, 95% CI 0.92 to 1.00, p=0.07). The initial series of interventions demonstrated an incremental decrease in HCT rates corresponding with a special cause variation.

CONCLUSION

The series of interventions dispersed over the intervention period was an effective methodology and successfully reduced HCT utilisation among children with blunt head injury at a rural community emergency department.

Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries

The aim of this study was to determine the potential impact of the Pediatric Emergency Care Applied Research Network (PECARN) rules on the CT rate in a large paediatric minor traumatic head injury (MTHI) cohort and compare this with current national Dutch guidelines. This was a planned sub-study of a prospective multicentre observational study that enrolled 1006 children younger than 18 years with MTHI. We calculated the number of recommended CT scans and described trauma-related CT scan abnormalities. The PECARN rules recommended a significantly lower percentage of CT scans in all age categories, namely 101/357 (28.3%) versus 164/357 (45.9%) (p < 0.001) in patients under 2 years of age and 148/623 (23.8%) versus 394/623 (63.2%) (p < 0,001) versus in patients 2 years and older.Conclusion: The projected CT rate can significantly be reduced if the PECARN rules are applied. We therefore advocate that the PECARN guidelines are also implemented in The Netherlands. What is Known: • To guide clinicians whether to perform a CT scan in children with a minor traumatic head injury (MTHI) clinical decision rules has been developed. • The overall CT scan rate in adherence with the Dutch MTHI guidelines is 44%. What is New: • The projected CT rate can significantly be reduced in a Dutch cohort of MTHI if the PECARN rules are applied. • The Dutch national guidelines for MTHI can safely be replaced by the PECARN rules.

Children With Minor Blunt Head Trauma Presenting to the Emergency Department

In our state-of-the-art review, we summarize the best-available evidence for the optimal emergency department management of children with minor blunt head trauma. Minor blunt head trauma in children is a common reason for emergency department evaluation, although clinically important traumatic brain injuries (TBIs) as a result are uncommon. Cranial computed tomography (CT) scanning is the reference standard for the diagnosis of TBIs, although they should be used judiciously because of the risk of lethal malignancy from ionizing radiation exposure, with the greatest risk to the youngest children. Available TBI prediction rules can assist with CT decision-making by identifying patients at either low risk for TBI, for whom CT scans may safely be obviated, or at high risk, for whom CT scans may be indicated. For clinical prediction rules to change practice, however, they require active implementation. Observation before CT decision-making in selected patients may further reduce CT rates without missing children with clinically important TBIs. Future work is also needed to incorporate patient and family preferences into these decision-making algorithms when the course of action is not clear.

A secondary analysis to inform a clinical decision rule for predicting skull fracture and intracranial injury in children under age 2

The purpose of this study was to identify factors associated with the risk of closed head injury (CHI) in children under age 2 years with suspected minor head injuries based on age-appropriate, or near age-appropriate, mental status on an exam. The study was a secondary data analysis of a public-use dataset from the largest prospective, multicenter pediatric head injury study found in the current literature. An existing, validated clinical decision rule was examined using a sample of 3,329 children under age 2 to determine whether it, or the individual variables within it, could be utilized alone, or in conjunction with other variables to accurately predict the risk of underlying CHI in this sample. Results indicated that the keys to an accurate triage assessment for children under age 2 with suspected minor head injuries include the ability to identify the specific skull region injured, the ability to assess for the presence and size of any scalp hematoma, the ability to identify signs of altered mental status in this age group, and having access to accurate information regarding the child's age and the details of the injury mechanism. The findings from this study add to the body of knowledge regarding what factors are associated with CHI in children under age 2 with suspected minor head injuries and could be used to inform age-specific recommendations for children under age 2 in triage, educational resources, and national trauma criteria.

Validation of the PECARN head trauma prediction rules in Japan: A multicenter prospective study

BACKGROUND

Head trauma in children is one of the most common causes for emergency department visits. Although most trauma cases are minor, identifying those patients who have clinically important traumatic brain injury (ciTBI) is challenging. The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules identifying children who do not require cranial computed tomography (CT) were validated and are used all over the world. However, these rules have not been validated with large cohort multicenter studies in Asia.

OBJECTIVES

To investigate whether the PECARN rules can be safely applied to Japanese children.

METHODS

We conducted a multicenter, prospective, observational cohort study. We included children younger than 16 with minor head trauma (Glasgow Coma Scale ≥14) who presented to the six participating centers within 24 h of their injuries between June 2016 and September 2017. The primary analysis was set to calculate the negative predictive value of the patients with very low risk by the PECARN rules, compared with a preset threshold of 99.85%.

RESULTS

We included 6585 children of which 463 (7.0%) had head CT scans performed and 23 (0.35%) had ciTBI. There were two patients with ciTBI who were classified as very low risk. The negative predictive value, calculated as 99.96% (95%CI: 99.86-100.00; P = .019), was significantly superior compared with the preset threshold of 99.85%.

CONCLUSIONS

The PECARN head trauma prediction rules seemed to be safely applicable to Japanese children. Further studies are needed to determine safety in hospitals where physicians do not have expertise in managing children.

Cervical Spine Injury Risk Factors in Children With Blunt Trauma

BACKGROUND

Adult prediction rules for cervical spine injury (CSI) exist; however, pediatric rules do not. Our objectives were to determine test accuracies of retrospectively identified CSI risk factors in a prospective pediatric cohort and compare them to a de novo risk model.

METHODS

We conducted a 4-center, prospective observational study of children 0 to 17 years old who experienced blunt trauma and underwent emergency medical services scene response, trauma evaluation, and/or cervical imaging. Emergency department providers recorded CSI risk factors. CSIs were classified by reviewing imaging, consultations, and/or telephone follow-up. We calculated bivariable relative risks, multivariable odds ratios, and test characteristics for the retrospective risk model and a de novo model.

RESULTS

Of 4091 enrolled children, 74 (1.8%) had CSIs. Fourteen factors had bivariable associations with CSIs: diving, axial load, clotheslining, loss of consciousness, neck pain, inability to move neck, altered mental status, signs of basilar skull fracture, torso injury, thoracic injury, intubation, respiratory distress, decreased oxygen saturation, and neurologic deficits. The retrospective model (high-risk motor vehicle crash, diving, predisposing condition, neck pain, decreased neck mobility (report or exam), altered mental status, neurologic deficits, or torso injury) was 90.5% (95% confidence interval: 83.9%-97.2%) sensitive and 45.6% (44.0%-47.1%) specific for CSIs. The de novo model (diving, axial load, neck pain, inability to move neck, altered mental status, intubation, or respiratory distress) was 92.0% (85.7%-98.1%) sensitive and 50.3% (48.7%-51.8%) specific.

CONCLUSIONS

Our findings support previously identified pediatric CSI risk factors and prospective pediatric CSI prediction rule development.

Grading and assessment of clinical predictive tools for paediatric head injury: a new evidence-based approach

BACKGROUND

Many clinical predictive tools have been developed to diagnose traumatic brain injury among children and guide the use of computed tomography in the emergency department. It is not always feasible to compare tools due to the diversity of their development methodologies, clinical variables, target populations, and predictive performances. The objectives of this study are to grade and assess paediatric head injury predictive tools, using a new evidence-based approach, and to provide emergency clinicians with standardised objective information on predictive tools to support their search for and selection of effective tools.

METHODS

Paediatric head injury predictive tools were identified through a focused review of literature. Based on the critical appraisal of published evidence about predictive performance, usability, potential effect, and post-implementation impact, tools were evaluated using a new framework for grading and assessment of predictive tools (GRASP). A comprehensive analysis was conducted to explain why certain tools were more successful.

RESULTS

Fourteen tools were identified and evaluated. The highest-grade tool is PECARN; the only tool evaluated in post-implementation impact studies. PECARN and CHALICE were evaluated for their potential effect on healthcare, while the remaining 12 tools were only evaluated for predictive performance. Three tools; CATCH, NEXUS II, and Palchak, were externally validated. Three tools; Haydel, Atabaki, and Buchanich, were only internally validated. The remaining six tools; Da Dalt, Greenes, Klemetti, Quayle, Dietrich, and Güzel did not show sufficient internal validity for use in clinical practice.

CONCLUSIONS

The GRASP framework provides clinicians with a high-level, evidence-based, comprehensive, yet simple and feasible approach to grade, compare, and select effective predictive tools. Comparing the three main tools which were assigned the highest grades; PECARN, CHALICE and CATCH, to the remaining 11, we find that the quality of tools' development studies, the experience and credibility of their authors, and the support by well-funded research programs were correlated with the tools' evidence-based assigned grades, and were more influential, than the sole high predictive performance, on the wide acceptance and successful implementation of the tools. Tools' simplicity and feasibility, in terms of resources needed, technical requirements, and training, are also crucial factors for their success.

Characteristics and Costs of Pediatric Emergency Department Visits for Sports- and Recreation-Related Concussions, 2006-2014

BACKGROUND

Although concussion-related emergency department (ED) visits increased after the passage of concussion laws, little is known about how the laws may disproportionately impact ED utilization and associated health care costs among children in different demographic groups.

OBJECTIVE

Our aim was to examine the patient and clinical characteristics of pediatric ED visits and associated health care costs for sports- and recreation-related concussions (SRRCs) before and after concussion law enactment.

METHODS

We retrospectively analyzed ED visits for SRRCs by children ages 5-18 years between 2006 and 2014 in the Pediatric Health Information System database (n = 123,220). ED visits were categorized as "pre-law," "immediate post-law," and "post-law" according to the respective state concussion law's effective date. Multinomial logistic regression models were used to assess the impact of the law on ED utilization.

RESULTS

The majority of visits were by males (n = 83,208; 67.6%), children aged 10-14 years (n = 49,863; 40.9%), and privately insured patients (n = 62,376; 50.6%). Female sex, older age, and insured by Medicaid/Medicare were characteristics associated with increased ED visits during the immediate post-law and post-law periods compared to their counterparts. A significant decrease in proportion of imaging use was observed from pre-law to post-law (adjusted odds ratio 0.49; 95% confidence interval 0.47-0.50; p < 0.0001). While annual adjusted costs per ED visits decreased, annual total adjusted costs per hospital for SRRCs increased from pre-law to post-law (p < 0.0001).

CONCLUSIONS

Concussion laws might have impacted pediatric concussion-related ED utilization, with increased annual total adjusted costs. These results may have important implications for policy interventions and their effects on health care systems.

Comparison of minor head trauma management in the emergency departments of a United States and Italian Children's hospital

Background

Pediatric head trauma management varies between emergency departments globally. Here we aim to compare the pediatric minor head trauma management between a US and Italian hospital.

Methods

We conducted a retrospective chart review of children 0–18 years old presenting after minor head trauma (Glasgow Coma Scale 14–15) from two emergency departments, in Boston, Massachusetts, United States and Trieste, Italy, between January and December 2013. Frequencies of demographic, clinical, and management characteristic were calculated. We compared rate ratios for characteristics of patients receiving cranial computed tomography (CT) scans between the two populations.

Results

There were 1783 patients in Boston, Massachusetts and 183 patients in Trieste, Italy. Patients in Boston had more reported neurologic symptoms (61.2%) than in Trieste (6%) (p < 0.001). More CT scans were ordered on the patients in Boston (17.3% vs. 6.6%) (p < 0.001), while more children were hospitalized in Trieste (55.7% vs. 8.6%) (p < 0.001). Patients with neurological symptoms more commonly had a CT scan in Trieste (45.5%) than in Boston (23.5%) (RR 0.52, 95% CI 0.27, 1.00), while more patients without neurological symptoms had CTs in Boston (7.5%) than in Trieste (4.1%) (RR 1.85, 95% CI 0.86, 4.00). Assignment of triage levels and definitions of head injury severity varied considerably between the two hospitals, resulting in dissimilar populations presenting to the two hospitals, and thus, differences in the management of these children.

Conclusion

The population of head trauma patients and the management of pediatric minor head trauma differs between Boston and Trieste, with a preference for CT scans in Boston and a preference for hospitalization in Trieste. Clinical guidelines used at each institution likely lead to this variation in care influenced by the different patient populations and institutional resources.

Follow-Up Computed Tomography Requirement of Pediatric Head Trauma Patients with Abnormal Imaging Findings

OBJECTIVE

We investigated pediatric patients presenting with isolated head trauma to emergency service. Where abnormal findings were detected on brain computed tomography (CT) scan, we evaluated the follow-up scan rate and whether follow-up scans affected the treatment protocol.

METHODS

Pediatric patients who presented to emergency service between 2014 and 2017 with isolated head trauma and were later found to have abnormal findings on CT scan were evaluated. The patients were evaluated in terms of age, sex, pediatric Glasgow Coma Scale score at emergency service, trauma mechanism, and abnormal findings on CT scan. We also documented whether follow-up CT scan altered the treatment decision in patients as to whether they underwent surgery or received conservative treatment.

RESULTS

The 105 head trauma patients with abnormal findings on CT scan consisted of 58 boys (55.2%) and 47 girls (44.8%). After the first brain CT examination, 5 of the patients (4.7%) underwent emergency surgery. For patients with linear fractures, the number of follow-up CT scans was 2.3. For patients with linear fractures, vomiting was found to be a symptom with statistical meaning as a sign of additional cranial pathology compared with headache, drowsiness, and irritability. A total of 280 follow-up CT scans with a mean number of 2.66 per patient were performed.

CONCLUSIONS

Follow-up CT scan for patients with abnormal findings on the initial CT scan after head trauma does not influence the decision to choose clinical observation or surgery except in patients with neurologic deterioration.

Head CT overuse in children with a mild traumatic brain injury within two Canadian emergency departments

Background

The validated Pediatric Emergency Care Applied Network (PECARN) rule helps determine the relevance of a head computerized tomography (CT) for children with mild traumatic brain injury (mTBI). We sought to estimate the potential overuse of head CT within two Canadian emergency departments (EDs).

Methods

We conducted a retrospective chart review of children seen in 2016 in a paediatric Level I (site 1) and a general Level II (site 2) trauma centre. We reviewed charts to determine the appropriateness of head CT use according to the PECARN rule in a random subset of children presenting with head trauma. Simple descriptive statistics were applied.

Results

One thousand five hundred and forty-six eligible patients younger than 17 years consulted during the study period. Of the 203 randomly selected cases per setting, 16 (7.9%) and 24 (12%), respectively from sites 1 and 2 had a head CT performed. Based on the PECARN rule, we estimated the overuse for the younger group (<2 years) to be below 3% for both hospitals without significant difference between them. For the older group (≥2 years), the overuse rate was higher at site 2 (9.3%, 95% confidence interval [CI]: 4.8 to 17% versus 1.2%, 95% CI: 0.2 to 6.5%, P=0.03).

Conclusion

Both EDs demonstrated overuse rates below 10% although it was higher for the older group at site 2. Such low rates can potentially be explained by the university affiliation of both hospitals and by two Canadian organizations working to raise awareness among physicians about the overuse of diagnostic tools and dangers inherent to radiation.

Use of CT for Head Trauma: 2007-2015

BACKGROUND AND OBJECTIVES

International efforts have been focused on identifying children at low risk of clinically important traumatic brain injury in whom computed tomography (CT) neuroimaging can be avoided. We sought to determine if CT use for pediatric head trauma has decreased among US emergency departments (EDs).

METHODS

This was a cross-sectional analysis of the National Hospital Ambulatory Care Medical Survey database of nationally representative ED visits from 2007 to 2015. We included children <18 years of age evaluated in the ED for head injury. Survey weighting procedures were used to estimate the annual proportion of children who underwent CT neuroimaging and to perform multivariable logistic regression.

RESULTS

There were an estimated 14.3 million pediatric head trauma visits during the 9-year study period. Overall, 32% (95% confidence interval [CI]: 29%-35%) of children underwent CT neuroimaging with no significant annual linear trend (P trend = .50). Multivariate analysis similarly revealed no difference by year (adjusted odds ratio [aOR]: 1.02; 95% CI: 0.97-1.07) after adjustment for patient- and ED-level covariates. CT use was associated with age ≥2 years (aOR: 1.51; 95% CI: 1.13-2.01), white race (aOR: 1.43; 95% CI: 1.10-1.86), highest triage acuity (aOR: 8.24 [95% CI: 4.00-16.95]; P < .001), and presentation to a nonteaching (aOR: 1.47; 95% CI: 1.05-2.06) or nonpediatric (aOR: 1.53; 95% CI: 1.05-2.23) hospital.

CONCLUSIONS

CT neuroimaging did not decrease from 2007 to 2015. Findings suggest an important need for quality improvement initiatives to decrease CT use among children with head injuries.

Occult head injury is common in children with concern for physical abuse

BACKGROUND

Studies evaluating small patient cohorts have found a high, but variable, rate of occult head injury in children <2 years old with concern for physical abuse. The American College of Radiology (ACR) recommends clinicians have a low threshold to obtain neuroimaging in these patients.

OBJECTIVES

Our aim was to determine the prevalence of occult head injury in a large patient cohort with suspected physical abuse using similar selection criteria from previous studies. Additionally, we evaluated proposed risk factors for associations with occult head injury.

MATERIALS AND METHODS

This was a retrospective, secondary analysis of data collected by an observational study of 20 U.S. child abuse teams that evaluated children who underwent subspecialty evaluation for concern of abuse. We evaluated children <2 years old and excluded those with abnormal mental status, bulging fontanelle, seizure, respiratory arrest, underlying neurological condition, focal neurological deficit or scalp injury.

RESULTS

One thousand one hundred forty-three subjects met inclusion criteria and 62.5% (714) underwent neuroimaging with either head computed tomography or magnetic resonance imaging. We found an occult head injury prevalence of 19.7% (141). Subjects with emesis (odds ratio [OR] 3.5, 95% confidence interval [CI] 1.8-6.8), macrocephaly (OR 8.5, 95% CI 3.7-20.2), and loss of consciousness (OR 5.1, 95% CI 1.2-22.9) had higher odds of occult head injury.

CONCLUSION

Our results show a high prevalence of occult head injury in patients <2 years old with suspected physical abuse. Our data support the ACR recommendation that clinicians should have a low threshold to perform neuroimaging in patients <2 years of age.

Evaluation of management and guideline adherence in children with mild traumatic brain injury

AIM

To evaluate the management and guideline adherence in children with mild traumatic brain injury (MTBI) in emergency departments (ED) in the Netherlands.

METHODS

A multicentre cohort study was conducted, including children younger than 18 years with MTBI who presented within 24 hours after trauma in the ED of hospitals in the southwest region of the Netherlands, in 2014. Primary outcome measures for management were percentages of performed computed tomography (CT) scans and hospital admissions. Guideline adherence was defined as percentages of correctly following the guideline. Secondary outcome measures were differences in management and guideline adherence between hospitals.

RESULTS

About 563 patients were analysed. Hospital admission was the most frequently performed management type (49.2% hospital admission vs. 30.9% CT). In only 49.7% of patients, the guideline was followed correctly. A substantial overuse of hospital admission (35%) and underuse of CT (40.1%) were found. Percentages of hospital admission and CT varied between 39.4-55.6% and 23.3-44.1%, respectively, across hospitals. Percentages of correctly following the guideline varied between 39.2-64.9% across hospitals.

CONCLUSION

These findings suggest that physicians in the participating hospitals prefer hospital admission of children with MTBI instead of CT despite the current recommendations of the national MTBI guideline in the Netherlands.

Italian guidelines on the assessment and management of pediatric head injury in the emergency department

OBJECTIVE

We aim to formulate evidence-based recommendations to assist physicians decision-making in the assessment and management of children younger than 16 years presenting to the emergency department (ED) following a blunt head trauma with no suspicion of non-accidental injury.

METHODS

These guidelines were commissioned by the Italian Society of Pediatric Emergency Medicine and include a systematic review and analysis of the literature published since 2005. Physicians with expertise and experience in the fields of pediatrics, pediatric emergency medicine, pediatric intensive care, neurosurgery and neuroradiology, as well as an experienced pediatric nurse and a parent representative were the components of the guidelines working group. Areas of direct interest included 1) initial assessment and stabilization in the ED, 2) diagnosis of clinically important traumatic brain injury in the ED, 3) management and disposition in the ED. The guidelines do not provide specific guidance on the identification and management of possible associated cervical spine injuries. Other exclusions are noted in the full text.

CONCLUSIONS

Recommendations to guide physicians practice when assessing children presenting to the ED following blunt head trauma are reported in both summary and extensive format in the guideline document.

Pediatric Emergency Care Applied Research Network head injuryprediction rules: on the basis of cost and effectiveness

Background/aim: Head injuries are commonly seen in the pediatric population. Noncontrast enhanced cranial CT is the method of choice to detect possible traumatic brain injury (TBI). Concerns about ionizing radiation exposure make the evaluation more challenging. The aim of this study was to evaluate the effectiveness of the Pediatric Emergency Care Applied Research Network (PECARN) rules in predicting clinically important TBI and to determine the amount of medical resource waste and unnecessary radiation exposure.Materials and methods: This retrospective study included 1041 pediatric patients presented to the emergency department. The patients were divided into subgroups of "appropriate for cranial CT", "not appropriate for cranial CT" and "cranial CT/observation of patient; both are appropriate". To determine the effectiveness of the PECARN rules, data were analyzed according to the presence of pathological findings Results: "Appropriate for cranial CT" results can predict pathology presence 118,056-fold compared to the "not appropriate for cranial CT" results. With "cranial CT/observation of patient; both are appropriate" results, pathology presence was predicted 11,457-fold compared to "not appropriate for cranial CT" results.Conclusion: PECARN rules can predict pathology presence successfully in pediatric TBI. Using PECARN can decrease resource waste and exposure to ionizing radiation.

Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study

BACKGROUND

Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and CHALICE) in a large sample of children.

METHODS

In this prospective observational study, we included children and adolescents (aged <18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged <2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury [TBI], need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13-15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673.

FINDINGS

Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (<1%) underwent neurosurgery, and 15 (<1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7-100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4-100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2-99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2-93·4; 125/141) and CHALICE (92·3%, 89·2-94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules.

INTERPRETATION

The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules.

FUNDING

National Health and Medical Research Council, Emergency Medicine Foundation, Perpetual Philanthropic Services, WA Health Targeted Research Funds, Townsville Hospital Private Practice Fund, Auckland Medical Research Foundation, A + Trust.

External Validation of the PECARN Head Trauma Prediction Rules in Japan

OBJECTIVES

The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules are used to assist computed tomography (CT) decision-making for children with minor head trauma. Although the PECARN rules have been validated in North America and Europe, they have not yet been validated in Asia. In Japan, there are no clinical decision rules for children with minor head trauma. The rate of head CT for children with minor head trauma in Japan is high since CT is widely accessible across the country. The objective of this study was to evaluate the diagnostic accuracy of the PECARN rules for identifying clinically important traumatic brain injuries (ciTBI) in children with minor head trauma in Japan.

METHODS

We conducted a retrospective cohort study at a tertiary care pediatric hospital in Japan (30,000 patients/year). We enrolled all children younger than 18 years with minor head trauma (Glasgow Coma Scale ≥ 14) who presented to the emergency department within 24 hours of their injury between January and December 2013. We retrospectively classified the children into three risk categories according to the PECARN rules. The PECARN rules were considered negative when children were classified into the very-low-risk category. The primary outcome was considered positive when a child had ciTBI defined as head injury resulting in death, neurosurgery, intubation for > 24 hours, or hospital admission ≥ 2 nights with evidence of TBI on CT.

RESULTS

Among 2,208 children included in the study, 24 (1.1%) had ciTBI. Sensitivities and specificities of the PECARN rules to predict ciTBI were 85.7% (12/14; 95% confidence interval [CI] = 57.2 to 98.2) and 73.5% (572/778; 95% CI = 70.3 to 76.6), respectively, for children < 2 years old, and 100% (10/10; 95% CI = 58.7 to 100) and 73.5% (1033/1406; 95% CI = 71.0 to 75.7) for children ≥ 2 years old, respectively. There were 10 cases of physically abused children < 2 years old, and six (60%) of them had ciTBI. Also, two cases of physically abused children with ciTBI were classified as very low risk. If we did not include physically abused children, the sensitivity of the PECARN rule for children < 2 years old improved from 85.7% to 100% (8/8).

CONCLUSIONS

The PECARN rules were less sensitive for physically abused children, although the rules showed excellent applicability for the cohort without physical abuse. Thoughtful consideration may be needed for cases of nonaccidental trauma. Further prospective studies are required to verify the applicability of the PECARN rules for children with minor head trauma in Japan.

Ambulatory or inpatient management of mild TBI in children: a post-concussion analysis

BACKGROUND

Diagnosis and treatment of children with mild traumatic brain injury (mTBI) remain a challenge since initial signs and symptoms do not always indicate the severity of the trauma. Therefore, guidelines regarding the decision upon imaging methods and ambulatory or hospitalized treatment are needed. The goal of our study was to investigate if the standard that was allied from the PECARN rules and is applied in this study can ensure that patients with clinically important brain injury are recognized and leads to outcomes with a low complication rate, a high patient satisfaction and minimal post-concussion syndrome incidence.

METHODS

We enrolled 478 children with mTBI and contacted their families with a questionnaire. Out of these, 267 valid questionnaires were received. Patient records and questionnaires were analyzed yielding a number of 140 ambulatory and 127 hospitalized patients.

RESULTS

Patients with mild TBI were admitted according to the above-mentioned guidelines or sent home for observation through their parents after thorough patient examination and information. Among ambulatory patients only 13 children (9%) underwent any imaging procedure; however, none of those showed any pathological findings. Next, in 41 of 127 hospitalized patients (32.2%) an imaging study was performed and of these only 3 according to 2.4% of hospitalized patients showed pathological findings, namely a skull fracture, two of them in combination with an intracranial hemorrhage. The duration of inpatient observation was 48 h in most cases (55.3%). Moreover, a majority of all patients (72.4%) did not seek any follow-up visit and did not need any further treatment. Of all patients in the study, only 10 patients according to 3.7% developed a post-concussion syndrome. Patient satisfaction was very high in both, the ambulatory and hospitalized patient group.

CONCLUSION

This study confirms that PECARN rules as administered in this study can ensure safe decision-making regarding ambulatory or inpatient treatment.

Concussion-Mild Traumatic Brain Injury: Recoverable Injury with Potential for Serious Sequelae

Concussion is increasingly recognized as a major public health issue. Most patients will return to baseline and experience full recovery, although a subset experiences persistent symptoms. Newer animal models and imaging studies are beginning to demonstrate that metabolic and neurovascular resolution may actually take longer than symptomatic recovery. Repeat traumatic brain injury within the metabolic window of dysfunction may result in worsened symptoms and prolonged recovery. The true risk for second impact syndrome appears to be small, and development of cerebral edema after a mild impact may be related to genetic risks rather than serial impacts.

Validation of the PECARN clinical decision rule for children with minor head trauma: a French multicenter prospective study

BACKGROUND

To date, the Pediatric Emergency Care Applied Research Network (PECARN) rule for identifying children who are at very low risk of clinically-important traumatic brain injuries after minor head trauma has not been validated prospectively in an independent population. Our goal was to evaluate the diagnostic performance of the PECARN clinical decision rule in a French pediatric population in multiple clinical settings.

METHODS

We conducted a multicenter, prospective, non-interventional cohort study of patients with minor head trauma who presented to three emergency departments in France. We enrolled patients younger than 16 years of age seeking a consultation within 24 h of head trauma with Glasgow Coma Scale scores of 14-15.

RESULTS

During the study period, we included 1499 children of which 421 (28 %) were under 2 years of age, and 955 (64 %) were male. A cranial computed tomography (CT) scan was performed on 76 patients (5.1 %). Of the 1499 included patients, 9 children (0.6 %) had a clinically-important traumatic brain injury, and none were classified as very low risk by the PECARN rule. In our study, the sensitivity of this clinical decision rule was 100 % (95 % CI 66.4 to 100 %), the specificity was 69.9 % (95 % CI 67.5 to 72.2 %) and the negative predictive value was 100 % (95 % CI 99.7 to 100 %).

DISCUSSION

Our study confirmed the good predictive performances of the PECARN clinical decision rule for minor head trauma in children. The PECARN rule performed similarly to our study and to its internal validation study.

CONCLUSIONS

We conducted an external validation study of the PECARN clinical decision rule for the detection of clinically-important traumatic brain injuries in children with minor head trauma, according to the methodological standards. The PECARN rule successfully identified all patients with clinically-important traumatic brain injuries, with a limited use of CT scans. Conducting a broad validation study with a large cohort is a prerequisite to provide sufficient statistical power before authorizing its implementation and generalization.

TRIAL REGISTRATION

This study has been registered in ClinicalTrials.gov with identifier number: NCT02752711 on April 27, 2016.

Presenting characteristics of children who required neurosurgical intervention for head injury

PURPOSE

The purpose of this study is to describe the presenting characteristics of a large group of children who required neurosurgical intervention (NSI) following a head injury and to retrospectively assess which of the criteria for imaging from Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), Pediatric Emergency Care Applied Research Network (PECARN), and Canadian Assessment of Tomography for Childhood Head Injury (CATCH) clinical decision rules (CDRs) were met by these patients.

STUDY DESIGN

We retrospectively reviewed all patients undergoing NSI following a head injury, between 2000 and 2008, at a large tertiary pediatric trauma center. We excluded patients having non-accidental injury, other neurosurgical interventions, penetrating injuries, and patients with incomplete data. To those who presented initially with mild head injury (GCS 14-15), we retrospectively applied the criteria for imaging of the CHALICE, PECARN, and CATCH CDRs.

RESULTS

Out of 289 patients undergoing NSI, 182 met inclusion criteria and comprised our cohort. Of the 72 (39.6 %) with mild head injury (GCS 14-15), 71 (98.6 %) met at least one criteria for imaging from each of the three CDRs, including severe mechanism of injury (68, 94.4 %), clinically evident skull fracture (35, 48.6 %), neurological deficit (19, 26.3 %), or severe headache (6, 8.3 %). Of the 182 patients in the entire cohort, only 1 (0.5 %) did not present with an obvious indication for CT on all three CDRs.

CONCLUSIONS

In a large sample of children requiring NSI after head trauma, the vast majority met CT criteria listed in each of the three CDRs. The most common indication for CT was a severe mechanism of injury. This, combined with clinically evident skull fracture, neurological deficit, and severe headache, identifies almost all patients requiring NSI.

Traumatic Brain Injury in Children: Role of CDRs-PECARN as a Clinical Predictive Resource for Evaluation of Intracranical Lesions and Neuropsychiatric Outcomes

Cranial computed tomography (CT) is considered the gold standard for the diagnosis of traumatic brain injury (TBI). The aim of this study was to evaluate if the clinical decision rules proposed by the Pediatric Emergency Care Applied Research Network (CDRs-PECARN) are really able to identify the patients who do not need cranial CT. This study investigates the neuropsychiatric outcome after TBI according to a pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds). We calculated the sensitivity, specificity, negative predictive value (NPV) and positive predictive value of the CDRs-PECARN in 2 age groups. Sensitivity was very high in both groups, and the NPV was very useful for predicting which subjects, of those who presented without CDRs- PECARN, would have a negative cranial CT. We also evaluated the correlations between the GOS-E Peds and Glasgow Coma Scale and between the GOS-E Peds and cranial CT scan. Our study confirms the validation of the PECARN TBI prediction rules as a clinical instrument which can play a significant role in CT decision-making for children with TBI. It also demonstrates that the GOS-E Peds is a valid pediatric outcome scale for children with TBI, despite some important limitations.