Comparison of Prediction Rules and Clinician Suspicion for Identifying Children With Clinically Important Brain Injuries After Blunt Head Trauma

Atabaki SM, Hoyle JD Jr, Schunk JE, Monroe DJ, Alpern ER, Quayle KS, Glass TF, Badawy MK, Miskin M, Schalick WO, Dayan PS, Holmes JF, Kuppermann N
Links   Pub Med   Academic Emergency Medicine

The Bottom Line

The PECARN TBI prediction rules are more sensitive than specific than clinical suspicion of ciTBI for children with minor blunt head trauma

What They Did

  • This was a secondary analysis of the original PECARN paper that everyone should have read by now (hint, hint)
  • As in past papers clinically important traumatic brain injury (ciTBI) was defined as ciTBI as;
    • Death from TBI
    • Neurosurgery
    • Intubation for more than 24 hours for TBI
    • Hospital admission of 2 nights or more associated with TBI on CT
  • Clinicians recorded their suspicion of ciTBI before CT as;
    • <1%
    • 1–5%
    • 6–10%
    • 11–50%
    • >50%
  • This secondary study was done on a validation subset of the original PECARN group – the total was 8,627 children, 98% of which had clinician suspicion recorded
  • More children with clinical suspicion >1% (94%) got a CT than <1% (27%)
  • The PECARN prediction rules were significantly more sensitive than clinician suspicion >1% of ciTBI for Preverbal (100%
[95% CI = 86.3% to 100%] vs. 60.0% [95% CI = 38.7% to 78.9%]) and verbal children (96.8% [95% CI = 88.8% to 99.6%] vs. 64.5% [95% CI = 51.3% to 76.3%])
  • PECARN prediction rule specificity was lower than clinician suspicion >1% for preverbal children (53.6% [95% CI = 51.5% to 55.7%] vs. 92.4% [95% CI = 91.2% to 93.5%]) and verbal children (58.2% [95% CI = 56.9% to 59.4%] vs. 90.6% [95% CI = 89.8% to 91.3%])

    • What You Can Do

    • This study showed that the PECARN clinical prediction rules can better help rule out head injury than rule it in
    • Especially in children very low risk for ciTBI the rules can supplement clinical judgment and help make the decision to NOT order a CT easier
    • Children in which you are very worried have a ciTBI should get a CT (GCS <15, AMS, obvious skull fracture etc,.)