Change in guardians' preference for computed tomography after explanation by emergency physicians in pediatric head injury

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report

Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.

Risk Stratification of Intermediate-Risk Children With Minor Head Injury

The Pediatric Emergency Care Applied Research Network rule helps emergency physicians identify very low-risk children with minor head injury who can forgo head computed tomography. This rule contributes to reduction in lifetime risk of radiation-induced cancers while minimizing missing clinically important traumatic brain injury. However, in intermediate-risk children, decisions on whether to perform computed tomography remain at the emergency physicians' discretion. To reduce this gray zone, this review summarizes evidence for risk stratification of intermediate-risk children with minor head injury.

Clinical Decision Rule to Identify Orbital Wall Fracture Among Children: Retrospective Derivation and Validation Study

OBJECTIVES

Head and face injuries are leading causes of emergency department visits in children. There is yet no clinical decision rule on face CT such as pediatric head CT rules. The goal was to develop and validate a clinical decision rule for identifying orbital wall fractures in children with periorbital trauma in the emergency department.

METHODS

This was a retrospective derivation and validation study. Children younger than 18 years who underwent orbit CT after periorbital trauma were included between January 2011 and December 2013 in 3 emergency centers. Among 16 candidate clinical variables, 13 clinical signs and symptoms were selected as clinical predictors. For the fracture model, these clinical predictors were analyzed by 3-fold cross-validation. Diagnostic performance was assessed using the area under the receiver operating characteristic (AUROC) curve in both cohorts.

RESULTS

Four variables (orbital rim tenderness, periorbital ecchymosis, painful extraocular movement, and nausea/vomiting) had the best predictive model with the highest AUROC value. The AUROC values for fracture prediction were 0.793 (95% confidence interval, 0.741-0.844) and 0.809 (95% confidence interval, 0.742-0.877) in the derivation cohort and validation cohort, respectively. The sensitivity and negative predictive values were 96.4% and 93.4%, respectively, in the derivation cohort, and 97.8% and 98.1%, respectively, in the validation cohort. The sum of these scores ranged from 0 to 4. Patients with a sum of scores of 1 or higher showed significantly increased risk for fracture.

CONCLUSIONS

The 4-variable predictive model can be useful for finding clinically important orbital wall fractures in children.