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Clinical decision rules for children with minor head injury: a systematic review
Alastair Pickering1, Susan Harnan, Patrick Fitzgerald
1Health Services Research, ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, UK. a.pickering@sheffield.ac.uk
Insights
The Paediatric Emergency Care Applied Research Network (PECARN) rule is most effective for identifying intracranial injury (ICI) in children with minor head injuries. However, the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) rule offers higher specificity for neurosurgical injury.
Area of Science:
- Pediatric Emergency Medicine
- Clinical Decision Making
- Neurotrauma
Background:
- Clinical decision rules are crucial for managing head-injured patients.
- Identifying effective rules for minor head injuries in children is essential.
- This study evaluates rules for detecting intracranial injury (ICI) and neurosurgical intervention (NSI).
Purpose of the Study:
- To identify and compare the diagnostic accuracy of clinical decision rules for children with minor head injuries.
- To assess the effectiveness of these rules in detecting intracranial injury (ICI) and injuries requiring neurosurgical intervention (NSI).
Main Methods:
- Systematic electronic search of key databases for relevant studies.
- Inclusion of English-language papers with cohorts of at least 20 children (GCS 13-15) with minor head injuries.
- Quality assessment of included studies using the QUADAS checklist.
Main Results:
- 16 publications representing 14 cohorts and 79,740 patients were analyzed.
- The Paediatric Emergency Care Applied Research Network (PECARN) rule demonstrated high sensitivity (98%) and acceptable specificity (58%) for ICI.
- For neurosurgical injury, all rules showed high sensitivity (98-100%), with the Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) rule having the highest specificity (86%) in its derivation cohort.
Conclusions:
- The PECARN rule is recommended for identifying clinically significant ICI in pediatric minor head injury cases due to its high sensitivity and large cohort data.
- While PECARN is effective, its application in the UK may lead to a high rate of CT scans.
- The CHALICE rule-based NICE guidelines remain a practical alternative for managing pediatric head injuries.
Introduction:
Clinical decision rules aid clinicians with the management of head injured patients. This study aimed to identify clinical decision rules for children with minor head injury and compare their diagnostic accuracy for detection of intracranial injury (ICI) and injury requiring neurosurgical intervention (NSI).
Methods:
Relevant studies were identified by an electronic search of key databases. Papers in English were included with a cohort of at least 20 children suffering minor head injury (GCS 13-15). Studies of a decision rule derived to identify patients at risk of ICI or NSI had to include a proportion of the cohort undergoing imaging. Study quality was assessed using the QUADAS checklist.
Results:
16 publications, representing 14 cohorts, with 79 740 patients were included. Only four rules were tested in more than one cohort. Of the validated rules the paediatric emergency care applied research network (PECARN) rule was most consistent (sensitivity 98%; specificity 58%). For neurosurgical injury all had high sensitivity (98-100%) but the children's head injury algorithm for the prediction of important clinical events (CHALICE) rule had the highest specificity (86%) in its derivation cohort.
Conclusion:
Of the current decision rules for minor head injury the PECARN rule appears the best for children and infants, with the largest cohort, highest sensitivity and acceptable specificity for clinically significant ICI. Application of this rule in the UK would probably result in an unacceptably high rate of CT scans per injury, and continued use of the CHALICE-based NICE guidelines represents an appropriate alternative.
