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Clinical Decision Rules for Paediatric Minor Head Injury: Are CT Scans a Necessary Evil?
Desmond Wei Thiam1, Si Hui Yap, Shu Ling Chong
1Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore.
Insights
Clinical decision rules for head-injured children show high accuracy for detecting traumatic brain injury (TBI) on CT scans. However, widespread use may increase unnecessary scans in low-risk populations, suggesting clinical observation is often preferable.
Area of Science:
- Pediatric Emergency Medicine
- Radiology
- Clinical Decision Making
Background:
- Clinical decision rules (CDRs) are vital for identifying head-injured children needing brain computed tomography (CT).
- Evaluating the performance of established CDRs in diverse populations is crucial for optimizing their use.
- This study assesses CDRs in the Singaporean pediatric population.
Purpose of the Study:
- To evaluate the performance of the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), and Pediatric Emergency Care Applied Research Network (PECARN) clinical decision rules (CDRs).
- To compare the diagnostic accuracy and impact on CT utilization of these CDRs against current clinical practices in Singapore.
Main Methods:
- A prospective observational cohort study included 1179 children under 16 with head injuries presenting to the emergency department.
- Data on predictor variables for CATCH, CHALICE, and PECARN CDRs were collected.
- Physician decisions for CT imaging and patient disposition were recorded; CDR performance was assessed.
Main Results:
- The study included 1179 children; only 1% (12) underwent CT scans, with 0.5% (6) showing positive findings.
- Applying CDRs would significantly increase CT scans: CATCH (20.1%), CHALICE (23.9%), PECARN high/intermediate-risk (38.7%), PECARN high-risk only (3.8%).
- CDRs showed high sensitivities (83.3%-100%) but varied specificities (61.6%-96.7%), indicating potential for increased unnecessary imaging.
Conclusions:
- CDRs demonstrate high accuracy in identifying children with positive CT findings for traumatic brain injury (TBI).
- Direct application of these CDRs in populations with low TBI rates may lead to a substantial increase in unnecessary CT scans.
- Clinical observation may be a more appropriate management strategy for many head-injured children in such settings.
Introduction:
High performing clinical decision rules (CDRs) have been derived to predict which head-injured child requires a computed tomography (CT) of the brain. We set out to evaluate the performance of these rules in the Singapore population.
Materials And Methods:
This is a prospective observational cohort study of children aged less than 16 who presented to the emergency department (ED) from April 2014 to June 2014 with a history of head injury. Predictor variables used in the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) and Pediatric Emergency Care Applied Research Network (PECARN) CDRs were collected. Decisions on CT imaging and disposition were made at the physician's discretion. The performance of the CDRs were assessed and compared to current practices.
Results:
A total of 1179 children were included in this study. Twelve (1%) CT scans were ordered; 6 (0.5%) of them had positive findings. The application of the CDRs would have resulted in a significant increase in the number of children being subjected to CT (as follows): CATCH 237 (20.1%), CHALICE 282 (23.9%), PECARN high- and intermediate-risk 456 (38.7%), PECARN high-risk only 45 (3.8%). The CDRs demonstrated sensitivities of: CATCH 100% (54.1 to 100), CHALICE 83.3% (35.9 to 99.6), PECARN 100% (54.1 to 100), and specificities of: CATCH 80.3% (77.9 to 82.5), CHALICE 76.4% (73.8 to 78.8), PECARN high- and intermediate-risk 61.6% (58.8 to 64.4) and PECARN high-risk only 96.7% (95.5 to 97.6).
Conclusion:
The CDRs demonstrated high accuracy in detecting children with positive CT findings but direct application in areas with low rates of significant traumatic brain injury (TBI) is likely to increase unnecessary CT scans ordered. Clinical observation in most cases may be a better alternative.
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