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Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
Original TextProf Nathan Kuppermann MD a b , Prof James F Holmes MD a, Peter S Dayan MD f, John D Hoyle MD g, Shireen M Atabaki MD h, Richard Holubkov PhD i j, Frances M Nadel MD k, David Monroe MD l, Rachel M Stanley MD m, Dominic A Borgialli DO n, Mohamed K Badawy MD o, Prof Jeff E Schunk MD i, Kimberly S Quayle MD p, Prashant Mahajan MD q, Richard Lichenstein MD r, Kathleen A Lillis MD s, Michael G Tunik MD t, Elizabeth S Jacobs MD u, James M Callahan MD v, Prof Marc H Gorelick MD w, Todd F Glass MD x, Lois K Lee MD y, Michael C Bachman MD z, Prof Arthur Cooper MD aa, Elizabeth C Powell MD ab, Michael J Gerardi MD ac, Kraig A Melville MD ad, Prof J Paul Muizelaar MD c, Prof David H Wisner MD d, Sally Jo Zuspan RN i j, Prof J Michael Dean MD i j, Prof Sandra L Wootton-Gorges MD e, for the Pediatric Emergency Care Applied Research Network (PECARN)‡
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.
We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14—15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ?2 nights).
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.
These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.
Study indicates many children with apparently minor head trauma may not need CT scans.
The Sacramento Bee (9/15, Atong) reports that, according to investigators from the University of California-Davis, "a significant portion of children with seemingly minor head trauma do not need a CT scan." Specifically, "researchers analyzed the cases of more than 42,000 children younger than 18 with apparently minor head trauma in 25 hospitals across the country," finding that "of these children, 20 percent over age two and almost 25 percent under age two were at very low risk of serious brain damage, rendering the CT scan needless." The study authors pointed out that in such cases, the benefit of "catching a serious brain injury" may be "outweighed by the dangers of exposing children to radiation."
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