Effectiveness of Guidelines for Head Injury Decisions in Children

Children


A recent study found the three common guidelines to be similarly effective at identifying patients likely and patients unlikely to benefit from a CT scan, providing physicians with a solid basis for making informed head injury decisions.

Though a computer tomography (CT) scan can be used to conclusively identify head trauma as requiring or not requiring neurosurgical intervention, the X-ray exposure necessary for the procedure brings with it a risk of developing cancer, especially in younger patients. Guidelines for determining whether a CT scan should be used on younger patients have been developed, though their differing criteria and measures make them difficult to compare. An accurate appraisal of such guidelines would enable physicians to make better-informed head injury decisions for their young patients, especially concerning the diagnosis and treatment of traumatic brain injuries.

In a recent study published in the Lancet, researchers evaluated three sets of guidelines for their ability to accurately determine the need for CT scanning in children with head injuries: Pediatric Emergency Care Applied Research Network (PECARN), Canadian Assessment of Tomography for Childhood Head Injury (CATCH), and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE).

Researchers recruited children under the age of 18 who presented to the emergency departments with head injuries of any severity. They excluded those only having minor facial damage, who had a history of brain trauma or known to have a brain tumour, or who had already received a brain scan of some kind were excluded.

They obtained a Glasgow Coma Score (GCS) for each patient. THE GCS is a measure of patient consciousness assessing eye responsiveness from 1-4, verbal ability from 1-5, and motor function from 1-6). They also obtained method of head injury, incidences of lost consciousness, and behavioural changes.

In total, 20,137 patients were included in the analysis. CT scans were administered to 10.5% of patients while 22% were admitted to the hospital. Brain surgery was performed on 83 patients and there were 15 deaths. CT scans revealed 321 cases of bleeding or bruising within the brain and 100 cases of depressed skull fractures. Blood pressure within the brain was monitored for 51 patients and procedures involving removal of part of the skull were performed for 48. Clinically significant traumatic brain injury was diagnosed in 1% of the patients according to the criteria of PECARN, 1% according to CATCH, and 2%according to CHALICE.

The PECARN rules identified all eligible patients but one needing a CT scan: the one patient missed was over 2 years of age and had TBI, but did not require surgery. The CATCH rules missed one eligible patient, who ended up requiring surgery due to a bleeding disorder. The CHALICE rules failed to identify 31 patients needing a CT scan, and two requiring brain surgery. Necessary CT scans were administered for all of those under 2 years old and 99% for those over 2 years old under PECARN rules. CATCH and CHALICE did not identify 13 and 12 patients with TBI, respectively, who may have benefitted from a CT scan. One of the CATCH patients and two of the CHALICE patients required brain surgery. Of the patients determined not to have TBI by rules-assisted assessment alone, all PECARN patients, all of medium-risk and 99.4% of high-risk CATCH patients, and 99.8% of CHALICE patients were TBI-free.

This study is the first large, multicentre study to externally validate the PECARN, CATCH, and CHALICE clinical decision rules. The study findings suggest the PECARN, CATCH, and CHALICE rules for assessing head injuries in children have similarly high accuracy for identifying patients likely to benefit from a CT scan as part of the diagnostic process, and that PECARN did not miss a single patient requiring neurosurgery. Furthermore, the proportion of patients correctly identified as TBI-free was above 99% for all guidelines. These guidelines may, therefore, serve as effective tools for clinicians making head injury decisions.  As the study population consisted of children referred to the study centres for specialized care, a future study may benefit from assessing the roles of physician experience and the willingness to employ CT scans at different sites on the effectiveness of these rules.

Written by Raishard Haynes, MBS

Reference:

Babl, F.E. et al. (2017). Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. The Lancet http://dx.doi.org/10.1016/ S0140-6736(17)30555-X.

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