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Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules
Jonathon L Maguire1, Kathy Boutis, Elizabeth M Uleryk
1Division of Pediatric Medicine and the Pediatric Outcomes Research Team (PORT, Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
This study reviewed clinical prediction rules for head-injured children, finding two high-quality rules for general use and one for minor head injuries. Further validation is needed, especially for young children.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Decision Support
- Evidence-Based Practice
Background:
- Cranial computed tomography (CT) scanning in children with head trauma carries risks from radiation and sedation.
- Uncertainty exists regarding which pediatric patients necessitate cranial CT scans.
- High-quality clinical prediction rules could aid in decision-making for CT use.
Purpose of the Study:
- To systematically review the quality and performance of published clinical prediction rules for intracranial injury in children with head injury.
- Evaluate existing prediction rules for their applicability and accuracy in pediatric head trauma cases.
Main Methods:
- Systematic literature search of Medline and Embase databases (December 2008).
- Inclusion criteria: clinical prediction rules for children (0-18 years) with head injury history.
- Assessment of prediction-rule quality using 14 established items and performance evaluation based on sensitivity and predicted CT scan frequency.
Main Results:
- Eight clinical prediction rules were identified from 3357 assessed titles/abstracts.
- Two rules demonstrated high quality and performance for children of all ages/trauma severities.
- One rule showed high quality and performance for minor head injuries (Glasgow Coma Scale >or=13).
- No identified rules met adequate quality or performance standards for young children.
Conclusions:
- Significant variability exists in the quality and performance of existing clinical prediction rules for pediatric head injury.
- Future research should focus on validating high-quality, high-performance rules in diverse populations.
- Development of a robust clinical prediction rule is needed specifically for young children with head injuries.
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
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.
