EBQ:PECARN Pediatric Head CT Rule

Complete Journal Club Article

Kuppermann N. et al. "Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.". The Lancet. 2009. 374(9696):1160-1170.
PubMed Full text PDF

Clinical Question

Can children be identified for low risk clinically-important traumatic brain injury and avoid Brain CT imaging.

Conclusion

This validated clinical decision rule provides a means of decreasing brain CT imaging in children with blunt head trauma with a sensitivity of 100% (<2years old) and 96.8% (>2yrs old) for intracranial injuries

Major Points

This rule was derived from the multicenter PECARN network with both a derivation and validation arm to detect clinically important traumatic brain (ciTBI) injury in children to age 18yrs old after blunt head trauma.

The rule stratifies patients < 2 years old and ≥2 years old.

PECARN Head CT Rule Algorithm

<2 years old

Any 1 of the following?

• GCS ≤14
• Altered Mental Status
• Palpable Skull Fracture

Then obtain a Non-Con Brain CT (4.4% risk of cTBI)

1 or more of the following?

• Non-frontal scalp hematoma
• LOC ≥ 5 seconds
• Severe injury mechanism
  • pedestrian or bicyclist without helmet struck by motorized vehicle
  • fall >1m or 3ft
  • head struck by high-impact object
• Abnormal activity per parents

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

≥2 years old - 18 years

Any 1 of the following?

• GCS ≤14
• Altered Mental Status
• Signs of a basilar skull fracture

Then obtain a Non-Con Brain CT (4.3% risk of cTBI)

1 or more of the following?

• History of vomiting^
• LOC
• Severe injury mechanism
  • Pedestrian or bicyclist without helmet struck by motorized vehicle
  • Fall >2m or 5ft
  • Head struck by high-impact object
• Severe headache

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

^Consider observation in place of imaging in children with isolated vomiting (no other indication) as the sole risk factor (0.2% risk of cTBI)

Study Design

Prospective cohort study in 25 emergency departments of the pediatric research network

Population

• N=42,412
• Derivation Arm: 33785
• Validation Arm: 8627

Inclusion Criteria

Children presenting within 24 h of head trauma were eligible.

Exclusion Criteria

Children with trivial injury, ground-level falls, walking or running into stationary objects, no signs or symptoms of head trauma other than scalp abrasions and lacerations, penetrating trauma, brain tumours, pre-existing neurological disorders complicating assessment, or neuroimaging at an outside hospital before transfer.

Interventions

Patients were admitted to the hospital at physician discretion, research assistants identified records of admitted patients and emergency department CT results and ciTBIs. Telephone surveys were used to identify missed traumatic brain injuries from discharged patients between 7 and 90 days.

Outcome

Outcome was clinically-important traumatic brain injury (ciTBI) defined apriori as:

1. Death from traumatic brain injury
2. Neurosurgical intervention for:
   1. Intracranial pressure monitoring
   2. Elevation of depressed skull fracture
   3. Ventriculostomy
   4. Hematoma evacuation
   5. Lobectomy
   6. Tissue debridement
   7. Dura repair
3. Intubation for more than 24 h
4. Hospital admission of 2 nights due to CT evidence of TBI

TBI on CT was defined as:

1. Intracranial haemorrhage or contusion
2. Cerebral edema
3. Traumatic infarction
4. Diffuse axonal injury
5. Shearing injury
6. Sigmoid sinus thrombosis
7. Midline shift or herniation
8. Diastasis of the skull
9. Pneumocephalus
10. Skull fracture

Prediction Rule Characteristics

<2 years old with TBI on CT

• Negative predictive value: 100.0%, (97.8–100·0)
• Sensitivity:100.0% for TBI on CT (94.7–100.0)

<2 years old with ciTBI

• Sensitivity: 100.00% (86.3–100.00)
• Negative predictive: 100.00% (99.7–100·00)

≥ 2 years old TBI on CT

• Negative Predictive Value for TBI on CT: 439/446 (98.4%, 96.8–99.4)
• Sensitivity of 94.0% 109/116 (88.0–97.5)

≥ 2 years with ciTBI Sensitivity: 96.8% (89.0–99.6) Negative Predictive Value: 99.95% (99.81–99.99)

Missed ciTBI

• 2 Chidren were missed in the validation group for children aged 2 years and older, one with a subdural hematoma and the other with an occipital lobe contusion

Further Discussion

• TBI and ciTBI was extremely rare in children and no one clinical factor in the high risk group could reliably predict a TBI. The high level of sensitivity of the rule must be weight agains the risk of over utilization of CT, exposure of ionizing radiation, and risk of missing a ciTBI.
• Children with a GCS <14 are not included in this rule
• At Denver Health, this rule was demonstrated to be superior to the CHALICE and CATCH rules
• The rarity of TBI in children was reinforced when analyzing those with isolated vomitting and no other positive factors on the decision rule

Isolated Scalp Hematoma

• For isolated scalp hematoma a sub analysis post-hoc analysis of the 2,998 patients with isolated scalp hematomas none required a neurosurgical intervention. The risk of clinically important traumatic brain injury overall was less than 1 in 200.

Cost effectiveness

The application of the PECARN Head Trauma CT rule has shown to lead to beneficial outcomes and more cost-effective care

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, and US Department of Health and Human Services

See Also

General/Adult

• Head Trauma (Main)
• Concussion
• Skull Fracture
• Maxillofacial Trauma
• C-spine (NEXUS)

Pediatric

• C-spine (peds)
• Abuse (Nonaccidental Trauma)
• GCS (Peds)
• EBQ:PECARN Pediatric Head CT Rule

External Links

• ALiEM PECARN Vomitting
• Cal ACEP PECARN Pocket cards

Sources

Authors

Daniel Ostermayer, Jeff Rogers, Ross Donaldson, Melody Ong