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Triggers for head computed tomography following paediatric head injury: Comparison of physicians' reported practice
Francis D Lockie1, Sarah Dalton, Ed Oakley
1Emergency Department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia. franlockie@gmail.com
Insights
Paediatric head injury guidelines for computed tomography (CT) scans differ between Australian/New Zealand physicians and published clinical decision rules (CDRs). Validation of CDRs is recommended before adoption into clinical practice.
Area of Science:
- Emergency Medicine
- Radiology
- Clinical Decision Making
Background:
- Published clinical decision rules (CDRs) for paediatric head injury exist.
- Practices of senior paediatric emergency physicians in Australia and New Zealand regarding CT head imaging triggers were surveyed.
Purpose of the Study:
- To compare physician-reported CT head injury triggers with established evidence-based CDRs.
- To assess the alignment of current clinical practice with published guidelines.
Main Methods:
- A survey was distributed to senior emergency physicians at PREDICT sites in Australia and New Zealand.
- Survey results were compared against CATCH, CHALICE, and PECARN CDRs.
- Clinical practice guidelines (CPGs) from participating sites were reviewed.
Main Results:
- Physician-reported triggers for head CT scans varied significantly and did not fully align with published CDRs.
- Abnormal findings like depressed or base of skull fractures were common CT triggers (>90%).
- Concerning injury mechanisms (e.g., falls >3 feet) triggered CT scans in only ~10% of respondents. CPGs were highly variable and not based on CDRs.
Conclusions:
- Existing CDRs for paediatric head injury CT are high-quality but differ from physician practices.
- Prospective validation of major head injury CDRs is needed in the Australasian setting.
- Current CPGs require updating to align with evidence-based CDRs.
Objective:
To compare head computed tomography (CT) triggers for paediatric head injury as reported by senior paediatric emergency physicians in Australia and New Zealand with triggers in published evidence-based clinical decision rules (CDRs).
Methods:
A survey of CT triggers after head injury was distributed to senior emergency physicians at PREDICT (Paediatric Research in Emergency Departments International Collaborative) sites in Australia and New Zealand. Results were compared with recommendations for CT scans in CATCH, CHALICE and PECARN CDRs. Clinical practice guidelines (CPGs) from each site were also reviewed.
Results:
The response rate was 93% (130/140). No published trigger for head CT was identified by 100% of survey participants and each CDR included several triggers not identified by many respondents. Abnormal examination findings, including depressed skull fracture and base of skull fracture, were most likely to prompt respondents to order a head CT (>90%). A concerning mechanism of injury, such as a fall greater than 3 feet or five stairs, triggered a CT response only in approximately 10% of respondents. Eight different head injury CPGs were used across the 13 PREDICT sites. These were highly variable between sites and CPGs were not explicitly based on published CDRs.
Conclusion:
High-quality, published CDRs exist for head CT use after paediatric head injury. Physician-reported CT triggers differ from CDR-recommended triggers. The major published head injury CDRs should be prospectively validated in the Australasian setting before incorporating them into local practice and CPGs.
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