Kuppermann et al for the Pediatric Emergency Care Applied Research Network published in the Lancet last year a study encompassing 25 hospital EDs in North America. They looked at > 40,000 children with head injuries and GCS of 14-15. They excluded trivial injuries (trip and fall, walking into stationary objects) and children with known neurologic disorders or penetrating injuries. Severe mechanism of injury was defined as: motor vehicle crash with ejection of the child, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 1.5 meters (5 feet) for children 2 years and older and more than 0.9 meter (3 feet) for those younger than 2 years; or head struck by a high-impact object. In the validation set, the presence of any of these factors was 97% sensitive (89% - 99.6%), but only 60% specific (58.6% - 61%). Thus a child having none of these factors is very unlikely to have a serious injury and does not need CT. Palchak et al (including Kuppermann) looked at 1865 children with TBI and rated physician judgement as to the presence of clinically significant brain injury to the prediction of a clinical decision rule derived from the same database. The decision rule trended toward greater sensitivity than clinician judgment for identifying children with TBI on CT after blunt head trauma but was less specific. Because decisions to order cranial CT did not strictly follow clinician judgment, however, use of the decision rule would have resulted in less frequent use of CT. Maguire et al did a literature search. 3357 titles and abstracts were assessed. 8 clinical prediction rules were identified. Unfortunately there was significant variation regarding population, methodologic quality and performance. They concluded that future effors should attempt to validate a rule with high quality and high performance. Hopefully Kuppermann et al have accomplished that.
Lancet. 2009 Oct 3;374(9696):1160-70. Epub 2009 Sep 14.
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P, Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN).
Collaborators (109)
Gerardi M, Tunik M, Tsung J, Melville K, Lee L, Lillis K, Mahajan P, Dayan P, Nadel F, Powell E, Atabaki S, Brown K, Glass T, Hoyle J, Cooper A, Jacobs E, Monroe D, Borgialli D, Gorelick M, Bandyopadhyay S, Bachman M, Schamban N, Callahan J, Kuppermann N, Holmes J, Lichenstein R, Stanley R, Badawy M, Babcock-Cimpello L, Schunk J, Quayle K, Jaffe D, Kuppermann N, Alpern E, Chamberlain J, Dean JM, Gerardi M, Goepp J, Gorelick M, Hoyle J, Jaffe D, Johns C, Levick N, Mahajan P, Maio R, Melville K, Miller S, Monroe D, Ruddy R, Stanley R, Treloar D, Tunik M, Walker A, Kavanaugh D, Park H, Dean M, Holubkov R, Knight S, Donaldson A, Chamberlain J, Brown M, Corneli H, Goepp J, Holubkov R, Mahajan P, Melville K, Stremski E, Tunik M, Gorelick M, Alpern E, Dean JM, Foltin G, Joseph J, Miller S, Moler F, Stanley R, Teach S, Jaffe D, Brown K, Cooper A, Dean JM, Johns C, Maio R, Mann NC, Monroe D, Shaw K, Teitelbaum D, Treloar D, Stanley R, Alexander D, Brown J, Gerardi M, Gregor M, Holubkov R, Lillis K, Nordberg B, Ruddy R, Shults M, Walker A, Levick N, Brennan J, Brown J, Dean JM, Hoyle J, Maio R, Ruddy R, Schalick W, Singh T, Wright J.
Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA, USA.
Comment in:
Lancet. 2010 Jan 16;375(9710):198-9; author reply 199.
Lancet. 2009 Oct 3;374(9696):1127-9.
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 >or=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 1176/1176 (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 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) 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.
PMID: 19758692 [PubMed - indexed for MEDLINE
Pediatr Emerg Care. 2009 Feb;25(2):61-5.
Clinician judgment versus a decision rule for identifying children at risk of traumatic brain injury on computed tomography after blunt head trauma.
Palchak MJ, Holmes JF, Kuppermann N.
Department of Emergency Medicine, UC Davis School of Medicine, Davis, CA 95817-2282, USA.
OBJECTIVE: To compare a decision rule with clinician judgment for identifying children at risk of traumatic brain injury (TBI) after blunt head trauma. METHODS: We performed an observational study of children with blunt head trauma. Emergency department physicians documented suspicion for TBI before cranial computed tomography (CT), rating suspicion as very low, low, intermediate, or high. Our outcome variable was TBI on CT. We compared clinician judgment (very low vs. higher suspicion) for TBI on CT with a decision rule derived from the same database. RESULTS: Of 1865 children enrolled for whom physician suspicion was recorded, 1168 (62.6%) underwent CT and comprised the study population. Eighty-nine (7.6%; 95% confidence interval [CI], 6.2% to 9.3%) of the 1168 had TBIs on CT. The decision rule had a sensitivity of 88 (98.9%) of 89 versus 84 (94.4%) of 89 for clinician judgment (difference, 4.5%; 95% CI, -0.9% to 9.9%). The specificity of the decision rule was 288 (26.7%) of 1079 versus 329 (30.5%) 1079 for clinician judgment (difference, 3.8%; 95% CI, 0.5% to 7.1%). Application of the decision rule to the study population would have resulted in 289 (24.7%) fewer CT scans, although missing 1 child with a TBI (who was discharged home from the emergency department). CONCLUSIONS: A decision rule trended toward greater sensitivity than clinician judgment for identifying children with TBI on CT after blunt head trauma but was less specific. Because decisions to order cranial CT did not strictly follow clinician judgment, however, use of the decision rule would have resulted in less frequent use of CT.
PMID: 19194349 [PubMed - indexed for MEDLINE]
Pediatrics. 2009 Jul;124(1):e145-54.
Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules.
Maguire JL, Boutis K, Uleryk EM, Laupacis A, Parkin PC.
Division of Pediatric Medicine and the Pediatric Outcomes Research Team (PORT, Hospital for Sick Children, Toronto, Ontario, Canada.
CONTEXT: Given radiation- and sedation-associated risks, there is uncertainty about which children with head trauma should receive cranial computed tomography (CT) scanning. A high-quality and high-performing clinical prediction rule may reduce this uncertainty. OBJECTIVE: To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury. METHODS: Medline and Embase were searched in December 2008. Studies were selected if they included clinical prediction rules involving children aged 0 to 18 years with a history of head injury. Prediction-rule quality was assessed by using 14 previously published items. Prediction-rule performance was evaluated by rule sensitivity and the predicted frequency of CT scanning if the rule was used. RESULTS: A total of 3357 titles and abstracts were assessed, and 8 clinical prediction rules were identified. For all studies, the rule derivations were reported; no study validated a rule in a separate population or assessed its impact in actual practice. The rules differed considerably in population, predictors, outcomes, methodologic quality, and performance. Five of the rules were applicable to children of all ages and severities of trauma. Two of these were high quality (>or=11 of 14 quality items) and had high performance (lower confidence limits for sensitivity >0.95 and required <or=56% to undergo CT). Four of the 8 rules were applicable to children with minor head injury (Glasgow coma score >or=13). One of these had high quality (11 of 14 quality items) and high performance (lower confidence limit for sensitivity = 0.94 and required 13% to undergo CT). Four of the 8 rules were applicable to young children, but none exhibited adequate quality or performance. CONCLUSIONS: Eight clinical prediction-rule derivation studies were identified. They varied considerably in population, methodologic quality, and performance. Future efforts should be directed toward validating rules with high quality and performance in other populations and deriving a high-quality, high-performance rule for young children.
PMID: 19564261 [PubMed - indexed for MEDLINE]
Pediatr Radiol. 2008 Nov;38 Suppl 4:S670-4. Epub 2008 Sep 23.
Pediatric head trauma: the evidence regarding indications for emergent neuroimaging.
Kuppermann N.
Department of Emergency Medicine, UC Davis Medical Center, Sacramento, CA 95817, USA.
Traumatic brain injury (TBI) is a leading cause of childhood death and disability worldwide. In the United States, childhood head trauma results in approximately 3,000 deaths, 50,000 hospitalizations, and 650,000 emergency department (ED) visits annually. Children presenting to the ED with seemingly minor head trauma account for approximately one-half of children with documented TBIs. Despite the frequency and importance of childhood minor head trauma, there exists no highly accurate, reliable and validated clinical scoring system or prediction rule for assessing risk of TBI among those with minor head trauma. At the same time, use of CT scanning in these children in recent years has increased substantially. The major benefit of CT scanning is early identification (and treatment) of TBIs that might otherwise be missed and result in increased risk of morbidity and mortality. Unnecessary CT imaging, however, exposes the child needlessly to the risk of radiation-induced malignancies. What constitutes appropriate criteria for obtaining CT scans in children after minor blunt head trauma remains controversial. Current evidence to guide clinicians in this regard is limited; however, large studies performed in multi-center research networks have recently been conducted. These studies should provide the foundation of evidence to guide CT decisions by clinicians, help identify TBIs in a timely fashion, and reduce unnecessary radiation exposure.
PMID: 18810402 [PubMed - indexed for MEDLINE]