Decision rules can identify children at very low risk of clinically important traumatic brain injury

Article Outline

• Question
• Design
• Setting
• Participants
• Outcomes
• Main Results
• Conclusions
• Commentary
• Copyright

Kuppermann N, Holmes J, Dayan P, Hoyle JJ, Atabaki S, Holubkov R, et al. Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374:1160-70.

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Question 

Among children with head injuries, what factors identify those at very low risk of clinically important traumatic brain injuries (ciTBI) for whom CT might be unnecessary?

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Design 

Prospective cohort study.

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Setting 

25 North American emergency departments.

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Participants 

Children (<18 years) presenting within 24 hours of head trauma, with Glasgow Coma Scale scores of 14 to 15.

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Outcomes 

Age-specific prediction rules for ciTBI (defined as death from traumatic brain injury, neurosurgery, intubation >24 hours, or hospital admission ≥2 nights).

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Main Results 

42412 children were included in the derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 ages 2 years and older. CT scans were obtained on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp hematoma except frontal, no loss of consciousness or loss of consciousness for <5 seconds, non–severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%; 95% CI, 99.7 to 100.0) and sensitivity of 25/25 (100%; 86.3 to 100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children ages 2 years and older (normal mental status, no loss of consciousness, no vomiting, non–severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%; 99.81 to 99.99) and sensitivity of 61/63 (96.8%; 89.0 to 99.6). 446 (20.1%) of 2223 CT-imaged patients ages 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.

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Conclusions 

These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be omitted.

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Commentary 

In the last decade, new insight into the risks of exposure to CT scanning instigated research to determine which children with minor head injury need a CT and which ones do not need imaging and can “just” be observed. Kupperman, from the Pediatric Emergency Care Applied Research Network (PECARN), derived and validated prediction rules for ciTBI to determine when a CT scan can be precluded in children younger or older than 2 years. The rules derived and validated are clear and easily applicable to children with a Glasgow Coma Scale of 14 or 15. Two questions are left after reading this study. First, if we can identify children who do not need a CT scan, can we determine that all of the others need a CT, or do we need a separate decision rule? The answer is likely the latter—further rules are needed for prompting CT scanning. Second, will the results of this paper increase or decrease the rate of CT scans in children? The answer to this question is likely a matter of the level of the practitioner's comfort and local guidelines.