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CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury
Martin H Osmond1, Terry P Klassen, George A Wells
1Department of Pediatrics, University of Ottawa and the Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario. osmond@cheo.on.ca
Insights
A new clinical decision rule helps identify children with minor head injuries who need a computed tomography (CT) scan. This rule aims to improve the accuracy and standardization of CT use in pediatric head trauma cases.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Clinical Decision Making
Background:
- Controversy exists regarding the necessity of computed tomography (CT) for children experiencing minor head injuries.
- Developing a precise clinical decision rule is crucial for optimizing CT utilization in this patient group.
Purpose of the Study:
- To create a highly sensitive clinical decision rule for guiding the use of CT scans in children with minor head injuries.
- To enhance the accuracy and consistency of CT imaging decisions in pediatric head trauma.
Main Methods:
- A multicenter cohort study enrolled children with blunt head trauma and Glasgow Coma Scale scores of 13-15.
- A standardized assessment form was used to collect data before CT scans.
- Recursive partitioning was employed to develop a decision rule combining reliable and strongly associated predictor variables.
Main Results:
- The study included 3866 children; 4.1% had brain injuries, and 0.6% required neurologic intervention.
- A decision rule with four high-risk factors (e.g., failure to reach Glasgow Coma Scale score of 15, suspected open skull fracture) and three medium-risk factors was derived.
- The high-risk factors demonstrated 100.0% sensitivity for predicting the need for neurologic intervention, while medium-risk factors showed 98.1% sensitivity for predicting brain injury on CT.
Conclusions:
- The developed decision rule stratifies children with minor head injuries into two risk levels.
- Prospective validation of this rule could lead to standardized and improved CT use in pediatric minor head injury cases.
Background:
There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury.
Methods:
For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13-15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity.
Results:
Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%-100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%-99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT.
Interpretation:
The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.
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