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Proctor A, Lyttle M, Billing J, Shaw P, Simpson J, Voss S, Benger JR. Which elements of hospital-based clinical decision support tools for the assessment and management of children with head injury can be adapted for use by paramedics in prehospital care? A systematic mapping review and narrative synthesis. BMJ Open 2024; 14:e078363. [PMID: 38355171 PMCID: PMC10868315 DOI: 10.1136/bmjopen-2023-078363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 01/31/2024] [Indexed: 02/16/2024] Open
Abstract
OBJECTIVE Hospital-based clinical decision tools support clinician decision-making when a child presents to the emergency department with a head injury, particularly regarding CT scanning. However, there is no decision tool to support prehospital clinicians in deciding which head-injured children can safely remain at scene. This study aims to identify clinical decision tools, or constituent elements, which may be adapted for use in prehospital care. DESIGN Systematic mapping review and narrative synthesis. DATA SOURCES Searches were conducted using MEDLINE, EMBASE, PsycINFO, CINAHL and AMED. ELIGIBILITY CRITERIA Quantitative, qualitative, mixed-methods or systematic review research that included a clinical decision support tool for assessing and managing children with head injury. DATA EXTRACTION AND SYNTHESIS We systematically identified all in-hospital clinical decision support tools and extracted from these the clinical criteria used in decision-making. We complemented this with a narrative synthesis. RESULTS Following de-duplication, 887 articles were identified. After screening titles and abstracts, 710 articles were excluded, leaving 177 full-text articles. Of these, 95 were excluded, yielding 82 studies. A further 14 studies were identified in the literature after cross-checking, totalling 96 analysed studies. 25 relevant in-hospital clinical decision tools were identified, encompassing 67 different clinical criteria, which were grouped into 18 categories. CONCLUSION Factors that should be considered for use in a clinical decision tool designed to support paramedics in the assessment and management of children with head injury are: signs of skull fracture; a large, boggy or non-frontal scalp haematoma neurological deficit; Glasgow Coma Score less than 15; prolonged or worsening headache; prolonged loss of consciousness; post-traumatic seizure; amnesia in older children; non-accidental injury; drug or alcohol use; and less than 1 year old. Clinical criteria that require further investigation include mechanism of injury, clotting impairment/anticoagulation, vertigo, length of time of unconsciousness and number of vomits.
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Affiliation(s)
| | - Mark Lyttle
- Faculty of Health and Applied Sciences, University of the West of England Bristol, Bristol, UK
| | | | | | | | - Sarah Voss
- Health and Life Sciences, University of the West of England, Bristol, UK
| | - Jonathan Richard Benger
- Academic Department of Emergency Care, The University Hospitals NHS Foundation Trust, Bristol, UK
- Faculty of Health & Life Sciences, University of the West of England, Bristol, UK
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Gambacorta A, Moro M, Curatola A, Brancato F, Covino M, Chiaretti A, Gatto A. PECARN Rule in diagnostic process of pediatric patients with minor head trauma in emergency department. Eur J Pediatr 2022; 181:2147-2154. [PMID: 35194653 PMCID: PMC9056473 DOI: 10.1007/s00431-022-04424-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 02/04/2022] [Accepted: 02/14/2022] [Indexed: 11/13/2022]
Abstract
UNLABELLED This study aims to evaluate the efficacy of the PECARN Rule (PR) in reducing radiological investigations in children with mild traumatic head injury in comparison with current clinical practice. A retrospective study was performed in our hospital between July 2015 and June 2020. Data of all children < 18 years of age admitted to the emergency department (ED), within 24 h after a head trauma with GCS ≥ 14, were analyzed. PECARN Rule was retrospectively applied to all patients. In total, 3832 patients were enrolled, 2613 patients ≥ 2 years and 1219 < 2 years. In the group of children ≥ 2 years, 10 presented clinically important traumatic brain injury (ciTBI) and were hospitalized, 7/10 underwent neurosurgery, and 3/10 clinical observation in the pediatric ward for more than 48 h. In children < 2 years, only 3 patients presented ciTBI, 2 underwent neurosurgery and 1 hospitalized. Applying the PR, no patient with ciTBI would have been discharged without an accurate diagnosis and we would have avoided 139 CT scans in patients ≥ 2 years, and 23 in those < 2 years of age (29% less). CONCLUSION We demonstrated the safety and validity of the PR in our setting with 100% sensitivity in both age groups in identifying patients with ciTBI and theoretically in reducing performed CT scans by 29%. Therefore, in patients classified in the low-risk category, it is a duty not to expose the child to ionizing radiation. WHAT IS KNOWN • CT is the gold standard to identify intracranial pathology in children with head injury but CT imaging of head-injured children expose them to higher carcinogenic risk. • PECARN Rules support doctors in identifying children with ciTBI in order to reduce exposure to ionizing radiation. WHAT IS NEW • We demonstrate the safety and validity of the PR with 100% sensitivity in both age groups in identifying patients with ciTBI. • In our setting, the application of PECARN Rule would theoretically have allowed us to reduce the CT scan by 29%.
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Affiliation(s)
- Alessandro Gambacorta
- Dipartimento Di Pediatria, Fondazione Policlinico Universitario “Agostino Gemelli”, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marianna Moro
- grid.8142.f0000 0001 0941 3192Dipartimento Di Pediatria, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonietta Curatola
- Dipartimento Di Pediatria, Fondazione Policlinico Universitario “Agostino Gemelli”, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Federica Brancato
- Dipartimento Di Pediatria, Fondazione Policlinico Universitario “Agostino Gemelli”, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marcello Covino
- grid.8142.f0000 0001 0941 3192Dipartimento Di Medicina d’Emergenza, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Chiaretti
- Dipartimento Di Pediatria, Fondazione Policlinico Universitario “Agostino Gemelli”, IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Antonio Gatto
- Dipartimento Di Pediatria, Fondazione Policlinico Universitario "Agostino Gemelli", IRCCS, Rome, Italy.
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Babl FE, Tavender E, Ballard DW, Borland ML, Oakley E, Cotterell E, Halkidis L, Goergen S, Davis GA, Perry D, Anderson V, Barlow KM, Barnett P, Bennetts S, Bhamjee R, Cole J, Craven J, Haskell L, Lawton B, Lithgow A, Mullen G, O'Brien S, Paproth M, Wilson CL, Ring J, Wilson A, Leo GS, Dalziel SR. Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children. Emerg Med Australas 2021; 33:214-231. [PMID: 33528896 DOI: 10.1111/1742-6723.13722] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 12/22/2020] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Children frequently present with head injuries to acute care settings. Although international paediatric clinical practice guidelines for head injuries exist, they do not address all considerations related to triage, imaging, observation versus admission, transfer, discharge and follow-up of mild to moderate head injuries relevant to the Australian and New Zealand context. The Paediatric Research in Emergency Departments International Collaborative (PREDICT) set out to develop an evidence-based, locally applicable, practical clinical guideline for the care of children with mild to moderate head injuries presenting to acute care settings. METHODS A multidisciplinary Guideline Working Group (GWG) developed 33 questions in three key areas - triage, imaging and discharge of children with mild to moderate head injuries presenting to acute care settings. We identified existing high-quality guidelines and from these guidelines recommendations were mapped to clinical questions. Updated literature searches were undertaken, and key new evidence identified. Recommendations were created through either adoption, adaptation or development of de novo recommendations. The guideline was revised after a period of public consultation. RESULTS The GWG developed 71 recommendations (evidence-informed = 35, consensus-based = 17, practice points = 19), relevant to the Australian and New Zealand setting. The guideline is presented as three documents: (i) a detailed Full Guideline summarising the evidence underlying each recommendation; (ii) a Guideline Summary; and (iii) a clinical Algorithm: Imaging and Observation Decision-making for Children with Head Injuries. CONCLUSIONS The PREDICT Australian and New Zealand Guideline for Mild to Moderate Head Injuries in Children provides high-level evidence and practical guidance for front line clinicians.
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Affiliation(s)
- Franz E Babl
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Emma Tavender
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Dustin W Ballard
- Clinical Research on Emergency Services and Treatment (CREST) Network and Division of Research, Kaiser Permanente, Oakland, California, USA
| | - Meredith L Borland
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,Divisions of Emergency Medicine and Paediatrics, School of Medicine, The University of Western Australia, Perth, Western Australia, Australia.,School of Nursing, Curtin University, Perth, Western Australia, Australia
| | - Ed Oakley
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Elizabeth Cotterell
- School of Rural Medicine, University of New England, Armidale, New South Wales, Australia
| | - Lambros Halkidis
- Emergency Department, Cairns Hospital, Cairns, Queensland, Australia
| | - Stacy Goergen
- Monash Health Imaging, Monash Health, Melbourne, Victoria, Australia.,Departments of Surgery and Medical Imaging, School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia
| | - Gavin A Davis
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Neurosurgery, Cabrini Hospital, Melbourne, Victoria, Australia
| | - David Perry
- Radiology Department, Starship Children's Hospital, Auckland, New Zealand
| | - Vicki Anderson
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Psychology Service, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Karen M Barlow
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,Neurosciences Unit, Queensland Paediatric Rehabilitation Service, Children's Health Queensland, Brisbane, Queensland, Australia
| | - Peter Barnett
- Emergency Department, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Scott Bennetts
- Clinical Effectiveness, Ambulance Victoria, Melbourne, Victoria, Australia
| | - Roisin Bhamjee
- Department of General Practice, The University of Melbourne, Melbourne, Victoria, Australia
| | - Joanne Cole
- Emergency Department, Tauranga Hospital, Tauranga, New Zealand
| | - John Craven
- Emergency Department, Women and Children's Hospital, Adelaide, South Australia, Australia.,MedSTAR, SA Ambulance, Adelaide, South Australia, Australia.,Emergency Department, Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Libby Haskell
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand
| | - Ben Lawton
- Child Health Research Centre, The University of Queensland, Brisbane, Queensland, Australia.,Emergency Department, Queensland Children's Hospital, Brisbane, Queensland, Australia.,Don't Forget the Bubbles, Sydney, New South Wales, Australia.,Emergency Department, Logan Hospital, Logan, Queensland, Australia
| | - Anna Lithgow
- Emergency Department, The Royal Darwin Hospital, Darwin, Northern Territory, Australia
| | - Glenda Mullen
- Emergency Department, Sydney Children's Hospital, Sydney, New South Wales, Australia
| | - Sharon O'Brien
- Emergency Department, Perth Children's Hospital, Perth, Western Australia, Australia.,School of Nursing, Curtin University, Perth, Western Australia, Australia
| | | | - Catherine L Wilson
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia
| | - Jenny Ring
- Health Research Consulting, Sydney, New South Wales, Australia
| | - Agnes Wilson
- Health Research Consulting, Sydney, New South Wales, Australia
| | - Grace Sy Leo
- Don't Forget the Bubbles, Sydney, New South Wales, Australia.,Emergency Department, Sydney Children's Hospital, Sydney, New South Wales, Australia.,School of Women and Children's Health, The University of New South Wales, Sydney, New South Wales, Australia
| | - Stuart R Dalziel
- Children's Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Departments of Surgery and Paediatrics: Child and Youth Health, The University of Auckland, Auckland, New Zealand
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