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Akie TE, Gupta M, Rodriguez RM, Hendey GW, Wilson JL, Quinones AK, Mower WR. Physical Examination Sensitivity for Skull Fracture in Pediatric Patients With Blunt Head Trauma: A Secondary Analysis of the National Emergency X-Radiography Utilization Study II Head Computed Tomography Validation Study. Ann Emerg Med 2023; 81:334-342. [PMID: 36328857 DOI: 10.1016/j.annemergmed.2022.08.442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 08/09/2022] [Accepted: 08/11/2022] [Indexed: 11/16/2022]
Abstract
STUDY OBJECTIVE We evaluated the emergency department (ED) providers' ability to detect skull fractures in pediatric patients presenting with blunt head trauma. METHODS This was a secondary analysis of the National Emergency X-Radiography Utilization Study (NEXUS) Head computed tomography (CT) validation study. Demographics and clinical characteristics were analyzed for pediatric patients. Radiologist interpretations of head CT imaging were abstracted and cataloged. Detection of skull fractures was evaluated through provider response to specific clinical decision instrument criteria (NEXUS or Canadian head CT rules) at the time of initial patient evaluation. The presence of skull fracture was determined by formal radiologist interpretation of CT imaging. RESULTS Between April 2006, and December 2015, 1,018 pediatric patients were enrolled. One hundred twenty-eight (12.5%) children had a notable injury reported on CT head. Skull fracture was present in most (66.4%) children with intracranial injuries. The sensitivity and specificity of provider physical examination to detect skull fractures was 18.5% (95% confidence interval 10.5% to 28.7%) and 96.6% (95.3% to 97.7%), respectively. The most common injuries associated with skull fractures were subarachnoid hemorrhage (27%) and subdural hematoma (22.3%). CONCLUSION Skull fracture is common in children with intracranial injury after blunt head trauma. Despite this, providers were found to have poor sensitivity for skull fractures in this population, and these injuries may be missed on initial emergency department assessment.
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Affiliation(s)
- Thomas E Akie
- Department of Emergency Medicine, UMass Chan Medical School, Worcester, MA; Department of Emergency Medicine, Ronald Reagan - University of California, Los Angeles Medical Center, Los Angeles, CA.
| | - Malkeet Gupta
- Department of Emergency Medicine, Ronald Reagan - University of California, Los Angeles Medical Center, Los Angeles, CA; Antelope Valley Hospital, Lancaster, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California, San Francisco School of Medicine, San Francisco, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, Ronald Reagan - University of California, Los Angeles Medical Center, Los Angeles, CA
| | - Jake L Wilson
- Department of Emergency Medicine, Ronald Reagan - University of California, Los Angeles Medical Center, Los Angeles, CA; Antelope Valley Hospital, Lancaster, CA
| | | | - William R Mower
- Department of Emergency Medicine, Ronald Reagan - University of California, Los Angeles Medical Center, Los Angeles, CA
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2
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Nigrovic LE, Kuppermann N. Children With Minor Blunt Head Trauma Presenting to the Emergency Department. Pediatrics 2019; 144:peds.2019-1495. [PMID: 31771961 DOI: 10.1542/peds.2019-1495] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/10/2019] [Indexed: 11/24/2022] Open
Abstract
In our state-of-the-art review, we summarize the best-available evidence for the optimal emergency department management of children with minor blunt head trauma. Minor blunt head trauma in children is a common reason for emergency department evaluation, although clinically important traumatic brain injuries (TBIs) as a result are uncommon. Cranial computed tomography (CT) scanning is the reference standard for the diagnosis of TBIs, although they should be used judiciously because of the risk of lethal malignancy from ionizing radiation exposure, with the greatest risk to the youngest children. Available TBI prediction rules can assist with CT decision-making by identifying patients at either low risk for TBI, for whom CT scans may safely be obviated, or at high risk, for whom CT scans may be indicated. For clinical prediction rules to change practice, however, they require active implementation. Observation before CT decision-making in selected patients may further reduce CT rates without missing children with clinically important TBIs. Future work is also needed to incorporate patient and family preferences into these decision-making algorithms when the course of action is not clear.
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Affiliation(s)
- Lise E Nigrovic
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts; and
| | - Nathan Kuppermann
- Departments of Emergency Medicine and.,Pediatrics, School of Medicine, University of California, Davis, Davis, California; and.,UC Davis Health, Sacramento, California
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3
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Lehner M, Deininger S, Wendling-Keim D. Management des Schädel-Hirn-Traumas im Kindesalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00770-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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4
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Affiliation(s)
| | - Andrew Grock
- Division of Emergency Medicine, Greater Los Angeles VA Healthcare System, Los Angeles, CA; David Geffen School of Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Enid Picart
- University of California-Davis School of Medicine, Sacramento, CA
| | - Jessica Mason
- Department of Emergency Medicine, University of California, San Francisco-Fresno, Fresno, CA
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5
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Khalifa M, Gallego B. Grading and assessment of clinical predictive tools for paediatric head injury: a new evidence-based approach. BMC Emerg Med 2019; 19:35. [PMID: 31200643 PMCID: PMC6570950 DOI: 10.1186/s12873-019-0249-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 06/03/2019] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Many clinical predictive tools have been developed to diagnose traumatic brain injury among children and guide the use of computed tomography in the emergency department. It is not always feasible to compare tools due to the diversity of their development methodologies, clinical variables, target populations, and predictive performances. The objectives of this study are to grade and assess paediatric head injury predictive tools, using a new evidence-based approach, and to provide emergency clinicians with standardised objective information on predictive tools to support their search for and selection of effective tools. METHODS Paediatric head injury predictive tools were identified through a focused review of literature. Based on the critical appraisal of published evidence about predictive performance, usability, potential effect, and post-implementation impact, tools were evaluated using a new framework for grading and assessment of predictive tools (GRASP). A comprehensive analysis was conducted to explain why certain tools were more successful. RESULTS Fourteen tools were identified and evaluated. The highest-grade tool is PECARN; the only tool evaluated in post-implementation impact studies. PECARN and CHALICE were evaluated for their potential effect on healthcare, while the remaining 12 tools were only evaluated for predictive performance. Three tools; CATCH, NEXUS II, and Palchak, were externally validated. Three tools; Haydel, Atabaki, and Buchanich, were only internally validated. The remaining six tools; Da Dalt, Greenes, Klemetti, Quayle, Dietrich, and Güzel did not show sufficient internal validity for use in clinical practice. CONCLUSIONS The GRASP framework provides clinicians with a high-level, evidence-based, comprehensive, yet simple and feasible approach to grade, compare, and select effective predictive tools. Comparing the three main tools which were assigned the highest grades; PECARN, CHALICE and CATCH, to the remaining 11, we find that the quality of tools' development studies, the experience and credibility of their authors, and the support by well-funded research programs were correlated with the tools' evidence-based assigned grades, and were more influential, than the sole high predictive performance, on the wide acceptance and successful implementation of the tools. Tools' simplicity and feasibility, in terms of resources needed, technical requirements, and training, are also crucial factors for their success.
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Affiliation(s)
- Mohamed Khalifa
- Australian Institute of Health Innovation, Faculty of Medicine and Health Sciences, Macquarie University, 75 Talavera Road, North Ryde, Sydney, NSW, 2113, Australia.
| | - Blanca Gallego
- Centre for Big Data Research in Health, Faculty of Medicine, University of New South Wales, Lowy Cancer Research Centre, Level 4, Cnr High &, Botany St, Kensington, Sydney, NSW, 2052, Australia
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6
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Khalid MT, Chan DWS, Tan EEK, Seow WT, Ng LP, Low DCY, Low SYY. Right middle cerebral artery infarct after minor head trauma in an infant: Case report and literature review. Int J Pediatr Adolesc Med 2019; 6:121-124. [PMID: 31700972 PMCID: PMC6824157 DOI: 10.1016/j.ijpam.2019.05.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/01/2019] [Accepted: 05/26/2019] [Indexed: 12/28/2022]
Abstract
Ishaemic stroke (IS) in the paediatric population is extremely rare. In this age group, the occurrence of IS often concurs with underlying congenital heart disease, haematological, metabolic or immunological conditions. In contrast, the association between IS and minor head injury in children has been sparse in current literature. The authors report a case of a healthy 9-month-old male who was found to have a right middle cerebral artery territory infarct after a minor head injury. An extensive medical workup was performed, and it was negative for any previously undiagnosed co-morbidities. Given the paucity of such cases, the condition and its management are discussed in corroboration with current literature.
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Affiliation(s)
- Md Tauseef Khalid
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore
| | - Derrick W S Chan
- Neurology Service, Department of Pediatrics, KK Women's and Children's Hospital, 100 Bukit Timah Roa, 229899, Singapore
| | - Enrica E K Tan
- Paediatric Haematology/Oncology Service, KK Women's and Children's Hospital, Singapore
| | - Wan Tew Seow
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433, Singapore
| | - Lee Ping Ng
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore
| | - David C Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, 308433, Singapore
| | - Sharon Y Y Low
- Neurosurgical Service, KK Women's and Children's Hospital, 100 Bukit Timah Road, 229899, Singapore.,Department of Neurosurgery, National Neuroscience Institute, 11 Jalan Tan Tock Seng, 308433, Singapore.,SingHealth Duke-NUS Neuroscience Academic Clinical Program, 11 Jalan Tan Tock Seng, 308433, Singapore
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7
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Dalziel K, Cheek JA, Fanning L, Borland ML, Phillips N, Kochar A, Dalton S, Furyk J, Neutze J, Dalziel SR, Lyttle MD, Bressan S, Donath S, Molesworth C, Hearps SJ, Oakley E, Babl FE. A Cost-Effectiveness Analysis Comparing Clinical Decision Rules PECARN, CATCH, and CHALICE With Usual Care for the Management of Pediatric Head Injury. Ann Emerg Med 2019; 73:429-439. [DOI: 10.1016/j.annemergmed.2018.09.030] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/24/2018] [Accepted: 09/26/2018] [Indexed: 11/16/2022]
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8
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Stopa BM, Amoroso S, Ronfani L, Neri E, Barbi E, Lee LK. Comparison of minor head trauma management in the emergency departments of a United States and Italian Children's hospital. Ital J Pediatr 2019; 45:24. [PMID: 30744682 PMCID: PMC6371605 DOI: 10.1186/s13052-019-0615-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 01/30/2019] [Indexed: 11/23/2022] Open
Abstract
Background Pediatric head trauma management varies between emergency departments globally. Here we aim to compare the pediatric minor head trauma management between a US and Italian hospital. Methods We conducted a retrospective chart review of children 0–18 years old presenting after minor head trauma (Glasgow Coma Scale 14–15) from two emergency departments, in Boston, Massachusetts, United States and Trieste, Italy, between January and December 2013. Frequencies of demographic, clinical, and management characteristic were calculated. We compared rate ratios for characteristics of patients receiving cranial computed tomography (CT) scans between the two populations. Results There were 1783 patients in Boston, Massachusetts and 183 patients in Trieste, Italy. Patients in Boston had more reported neurologic symptoms (61.2%) than in Trieste (6%) (p < 0.001). More CT scans were ordered on the patients in Boston (17.3% vs. 6.6%) (p < 0.001), while more children were hospitalized in Trieste (55.7% vs. 8.6%) (p < 0.001). Patients with neurological symptoms more commonly had a CT scan in Trieste (45.5%) than in Boston (23.5%) (RR 0.52, 95% CI 0.27, 1.00), while more patients without neurological symptoms had CTs in Boston (7.5%) than in Trieste (4.1%) (RR 1.85, 95% CI 0.86, 4.00). Assignment of triage levels and definitions of head injury severity varied considerably between the two hospitals, resulting in dissimilar populations presenting to the two hospitals, and thus, differences in the management of these children. Conclusion The population of head trauma patients and the management of pediatric minor head trauma differs between Boston and Trieste, with a preference for CT scans in Boston and a preference for hospitalization in Trieste. Clinical guidelines used at each institution likely lead to this variation in care influenced by the different patient populations and institutional resources.
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Affiliation(s)
- Brittany M Stopa
- Computational Neuroscience Outcomes Center of Harvard, Brigham and Women's Hospital, Boston, MA, USA
| | - Stefano Amoroso
- University of Trieste, Piazzale Europa, 1, 34127, Trieste, Italy
| | - Luca Ronfani
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", via dell'Istria 65/1, 34137, Trieste, Italy
| | - Elena Neri
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", via dell'Istria 65/1, 34137, Trieste, Italy
| | - Egidio Barbi
- University of Trieste, Piazzale Europa, 1, 34127, Trieste, Italy.,Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", via dell'Istria 65/1, 34137, Trieste, Italy
| | - Lois K Lee
- Division of Emergency Medicine, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.
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9
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Undén J, Dalziel SR, Borland ML, Phillips N, Kochar A, Lyttle MD, Bressan S, Cheek JA, Neutze J, Donath S, Hearps S, Oakley E, Dalton S, Gilhotra Y, Babl FE. External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC Med 2018; 16:176. [PMID: 30309392 PMCID: PMC6182797 DOI: 10.1186/s12916-018-1166-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2018] [Accepted: 09/07/2018] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Clinical decision rules (CDRs) aid in the management of children with traumatic brain injury (TBI). Recently, the Scandinavian Neurotrauma Committee (SNC) has published practical, evidence-based guidelines for children with Glasgow Coma Scale (GCS) scores of 9-15. This study aims to validate these guidelines and to compare them with other CDRs. METHODS A large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, we compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13-15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT. RESULTS The SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1-100.0; 32/32), 97.8% (94.5-99.4; 179/183) and 95% (95% CI 91.6-97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs. CONCLUSION The SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI.
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Affiliation(s)
- Johan Undén
- Department of Operation and Intensive Care, Hallands Hospital, Halmstad, Sweden.,Lund University, Lund, Sweden
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Health, 2 Park Rd, Grafton, Auckland, 1023, New Zealand.,Liggins Institute, University of Auckland, 85 Park Ave, Grafton, Auckland, 1023, New Zealand
| | - Meredith L Borland
- Emergency Department, Princess Margaret Hospital for Children, Roberts Rd, Subiaco, Perth, Western Australia, 6008, Australia.,Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, 35 Stirling Hwy, Crawley, Western Australia, 6009, Australia
| | - Natalie Phillips
- Emergency Department, Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, 501 Stanley St, South Brisbane, Queensland, 4101, Australia
| | - Amit Kochar
- Emergency Department, Women's & Children's Hospital, Adelaide, 72 King William St, North Adelaide, South Australia, 5006, Australia
| | - Mark D Lyttle
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Emergency Department, Bristol Children's Hospital, Paul O'Gorman Building, Upper Maudlin St, Bristol, BS2 8BJ, UK.,Academic Department of Emergency Care, University of the West of England, Blackberry Hill, Bristol, BS16 1XS, UK
| | - Silvia Bressan
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Women's and Children's Health, University of Padova, Via Giustiniani3, 2, 35128, Padova, Padova, Italy
| | - John A Cheek
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Emergency Department, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, 3186, Australia
| | - Jocelyn Neutze
- Emergency Department, Kidzfirst Middlemore Hospital, 100 Hospital Rd, Auckland, 2025, New Zealand
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, Victoria, 3010, Australia
| | - Stephen Hearps
- Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia
| | - Ed Oakley
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia.,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, Victoria, 3010, Australia
| | - Sarah Dalton
- Emergency Department, The Children's Hospital at Westmead, 212 Hawkesbury Rd, Westmead, New South Wales, 2145, Australia
| | - Yuri Gilhotra
- Emergency Department, Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, 501 Stanley St, South Brisbane, Queensland, 4101, Australia
| | - Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, 50 Flemington Rd, Parkville, Victoria, 3052, Australia. .,Murdoch Children's Research Institute, Melbourne, 50 Flemington Rd, Parkville, Victoria, 3052, Australia. .,Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Grattan St, Parkville, Victoria, 3010, Australia.
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10
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Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study. Ann Emerg Med 2018; 71:703-710. [DOI: 10.1016/j.annemergmed.2018.01.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 12/26/2017] [Accepted: 01/05/2018] [Indexed: 11/22/2022]
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11
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Babl FE, Borland ML, Phillips N, Kochar A, Dalton S, McCaskill M, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Lyttle MD, Bressan S, Donath S, Molesworth C, Jachno K, Ward B, Williams A, Baylis A, Crowe L, Oakley E, Dalziel SR. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet 2017; 389:2393-2402. [PMID: 28410792 DOI: 10.1016/s0140-6736(17)30555-x] [Citation(s) in RCA: 170] [Impact Index Per Article: 24.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 11/21/2016] [Accepted: 12/06/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and CHALICE) in a large sample of children. METHODS In this prospective observational study, we included children and adolescents (aged <18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged <2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury [TBI], need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13-15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673. FINDINGS Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (<1%) underwent neurosurgery, and 15 (<1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7-100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4-100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2-99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2-93·4; 125/141) and CHALICE (92·3%, 89·2-94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules. INTERPRETATION The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules. FUNDING National Health and Medical Research Council, Emergency Medicine Foundation, Perpetual Philanthropic Services, WA Health Targeted Research Funds, Townsville Hospital Private Practice Fund, Auckland Medical Research Foundation, A + Trust.
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Affiliation(s)
- Franz E Babl
- Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.
| | - Meredith L Borland
- Princess Margaret Hospital for Children, Perth, WA, Australia; Schools of Paediatrics and Child Health and Primary, Aboriginal and Rural Healthcare, University of Western Australia, Crawley, WA, Australia
| | - Natalie Phillips
- Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Amit Kochar
- Women's & Children's Hospital, Adelaide, SA, Australia
| | - Sarah Dalton
- The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - Mary McCaskill
- The Children's Hospital at Westmead, Sydney, NSW, Australia
| | - John A Cheek
- Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Monash Medical Centre, Melbourne, VIC, Australia
| | - Yuri Gilhotra
- Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Jeremy Furyk
- The Townsville Hospital, Townsville, QLD, Australia
| | | | - Mark D Lyttle
- Murdoch Children's Research Institute, Melbourne, VIC, Australia; Bristol Royal Hospital for Children, Bristol, UK; Academic Department of Emergency Care, University of the West of England, Bristol, UK
| | - Silvia Bressan
- Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Women's and Children's Health, University of Padova, Padova, Italy
| | - Susan Donath
- Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | | | - Kim Jachno
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Brenton Ward
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Amanda Williams
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Amy Baylis
- Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Louise Crowe
- Murdoch Children's Research Institute, Melbourne, VIC, Australia
| | - Ed Oakley
- Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia
| | - Stuart R Dalziel
- Starship Children's Health, Auckland, New Zealand; Liggins Institute, University of Auckland, Auckland, New Zealand
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12
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Kemp A, Nickerson E, Trefan L, Houston R, Hyde P, Pearson G, Edwards R, Parslow RC, Maconochie I. Selecting children for head CT following head injury. Arch Dis Child 2016; 101:929-34. [PMID: 27449674 PMCID: PMC5050290 DOI: 10.1136/archdischild-2015-309078] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 04/02/2016] [Indexed: 12/02/2022]
Abstract
OBJECTIVE Indicators for head CT scan defined by the 2007 National Institute for Health and Care Excellence (NICE) guidelines were analysed to identify CT uptake, influential variables and yield. DESIGN Cross-sectional study. SETTING Hospital inpatient units: England, Wales, Northern Ireland and the Channel Islands. PATIENTS Children (<15 years) admitted to hospital for more than 4 h following a head injury (September 2009 to February 2010). INTERVENTIONS CT scan. MAIN OUTCOME MEASURES Number of children who had CT, extent to which NICE guidelines were followed and diagnostic yield. RESULTS Data on 5700 children were returned by 90% of eligible hospitals, 84% of whom were admitted to a general hospital. CT scans were performed on 30.4% of children (1734), with a higher diagnostic yield in infants (56.5% (144/255)) than children aged 1 to 14 years (26.5% (391/1476)). Overall, only 40.4% (984 of 2437 children) fulfilling at least one of the four NICE criteria for CT actually underwent one. These children were much less likely to receive CT if admitted to a general hospital than to a specialist centre (OR 0.52 (95% CI 0.45 to 0.59)); there was considerable variation between healthcare regions. When indicated, children >3 years were much more likely to have CT than those <3 years (OR 2.35 (95% CI 2.08 to 2.65)). CONCLUSION Compliance with guidelines and diagnostic yield was variable across age groups, the type of hospital and region where children were admitted. With this pattern of clinical practice the risks of both missing intracranial injury and overuse of CT are considerable.
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Affiliation(s)
- A Kemp
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - E Nickerson
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - L Trefan
- College of Biomedical and Life Sciences, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - R Houston
- Research fellow CMACE (at the time of the project). Placements Manager at Kids Company, London, UK
| | - P Hyde
- Paediatric Intensive Care Unit, Southampton Children's Hospital, Southampton, UK
| | - G Pearson
- Consultant in Intensive Care, Birmingham Children's Hospital, Birmingham, UK
| | - R Edwards
- Department of Neurosurgery, Bristol Hospital for Children, Bristol, UK
| | - RC Parslow
- Senior Lecturer in Epidemiology, Leeds Institute of Cardiovascular and Metabolic Medicine, School of Medicine, University of Leeds, Leeds, UK
| | - I Maconochie
- Paediatric Emergency Medicine Consultant, Imperial College NHS Healthcare Trust, London, UK
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13
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Burns EC, Grool AM, Klassen TP, Correll R, Jarvis A, Joubert G, Bailey B, Chauvin-Kimoff L, Pusic M, McConnell D, Nijssen-Jordan C, Silver N, Taylor B, Osmond MH. Scalp Hematoma Characteristics Associated With Intracranial Injury in Pediatric Minor Head Injury. Acad Emerg Med 2016; 23:576-83. [PMID: 26947778 DOI: 10.1111/acem.12957] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Revised: 11/09/2015] [Accepted: 11/15/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Minor head trauma accounts for a significant proportion of pediatric emergency department (ED) visits. In children younger than 24 months, scalp hematomas are thought to be associated with the presence of intracranial injury (ICI). We investigated which scalp hematoma characteristics were associated with increased odds of ICI in children less than 17 years who presented to the ED following minor head injury and whether an underlying linear skull fracture may explain this relationship. METHODS This was a secondary analysis of 3,866 patients enrolled in the Canadian Assessment of Tomography of Childhood Head Injury (CATCH) study. Information about scalp hematoma presence (yes/no), location (frontal, temporal/parietal, occipital), and size (small and localized, large and boggy) was collected by emergency physicians using a structured data collection form. ICI was defined as the presence of an acute brain lesion on computed tomography. Logistic regression analyses were adjusted for age, sex, dangerous injury mechanism, irritability on examination, suspected open or depressed skull fracture, and clinical signs of basal skull fracture. RESULTS ICI was present in 159 (4.1%) patients. The presence of a scalp hematoma (n = 1,189) in any location was associated with significantly greater odds of ICI (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 3.06 to 6.02), particularly for those located in temporal/parietal (OR = 6.0, 95% CI = 3.9 to 9.3) and occipital regions (OR = 5.6, 95% CI = 3.5 to 8.9). Both small and localized and large and boggy hematomas were significantly associated with ICI, although larger hematomas conferred larger odds (OR = 9.9, 95% CI = 6.3 to 15.5). Although the presence of a scalp hematoma was associated with greater odds of ICI in all age groups, odds were greatest in children aged 0 to 6 months (OR = 13.5, 95% CI = 1.5 to 119.3). Linear skull fractures were present in 156 (4.0%) patients. Of the 111 patients with scalp hematoma and ICI, 57 (51%) patients had a linear skull fracture and 54 (49%) did not. The association between scalp hematoma and ICI attenuated but remained significant after excluding patients with linear skull fracture (OR = 3.3, 95% CI = 2.1 to 5.1). CONCLUSIONS Large and boggy and nonfrontal scalp hematomas had the strongest association with the presence of ICI in this large pediatric cohort. Although children 0 to 6 months of age were at highest odds, the presence of a scalp hematoma also independently increased the odds of ICI in older children and adolescents. The presence of a linear skull fracture only partially explained this relation, indicating that ruling out a skull fracture beneath a hematoma does not obviate the risk of intracranial pathology.
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Affiliation(s)
- Emma C.M. Burns
- Department of Emergency Medicine; Dalhousie University; Halifax Nova Scotia Canada
| | - Anne M. Grool
- Pediatric Emergency Research Group; Children's Hospital of Eastern Ontario Research Institute; Ottawa Ontario Canada
| | - Terry P. Klassen
- Department of Pediatrics; University of Alberta; Edmonton Alberta Canada
| | - Rhonda Correll
- Clinical Research Unit; Children's Hospital of Eastern Ontario Research Institute; Ottawa Ontario Canada
| | - Anna Jarvis
- Department of Pediatrics; University of Toronto; Toronto Ontario Canada
| | - Gary Joubert
- Department of Pediatrics; University of Western Ontario; London Ontario Canada
| | - Benoit Bailey
- Department of Pediatrics; CHU Sainte-Justine; Montreal Quebec Canada
| | | | - Martin Pusic
- Pediatric Emergency Medicine; Columbia University Medical Centre; New York NY
| | - Don McConnell
- Department of Pediatrics; University of Calgary; Calgary Alberta Canada
| | | | - Norm Silver
- Department of Pediatrics; University of Manitoba; Winnipeg Manitoba Canada
| | - Brett Taylor
- Department of Pediatrics; Dalhousie University; Halifax Nova Scotia Canada
| | - Martin H. Osmond
- Pediatric Emergency Research Group; Children's Hospital of Eastern Ontario Research Institute; Ottawa Ontario Canada
- Department of Pediatrics; University of Ottawa; Ottawa Ontario Canada
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14
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Di F, Gao Q, Xiang J, Zhang D, Shi X, Yan X, Zhu H. Clinical Practice Experiences in Diagnosis and Treatment of Traumatic Brain Injury in Children: A Survey among Clinicians at 9 Large Hospitals in China. PLoS One 2015; 10:e0142983. [PMID: 26565400 PMCID: PMC4643937 DOI: 10.1371/journal.pone.0142983] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Accepted: 10/29/2015] [Indexed: 11/18/2022] Open
Abstract
Proper diagnosis and treatment of traumatic brain injury (TBI) in children is becoming an increasingly problematic issue in China. This study investigated Chinese clinicians to provide information about their knowledge and experiences in diagnosis and treatment of pediatric TBI. We conducted a questionnaire survey among clinicians in the emergency departments and neurosurgery departments at 9 major hospitals in China. The questionnaire included demographic information, and knowledge and experiences regarding the diagnosis and treatment of pediatric TBI. A total of 235 clinicians completed questionnaires. 43.8% of the surveyed clinicians reported children with only scalp hematoma without any other signs and symptoms of concussion as TBI cases. Most clinicians (85.1%) reported no existing uniform diagnostic criteria for children with TBI in China. The majority of clinicians (91.9%) reported that CT scans were performed in all patients with suspected head injury as a routine procedure in their hospitals. Only 20.9% of clinicians believed that radiation from CT scanning may increase cancer risk in children. About 33.6% of the clinicians reported that they ordered CT scans to investigate suspected head injury due to the poor doctor-patient relationship in China, and to protect themselves against any medical lawsuits in the future. About 80% of the clinicians reported that there are no existing pediatric TBI treatment guidelines in China. Instead a senior doctor’s advice is the most reported guidelines regarding treating pediatric TBI (66.0%). All of the surveyed clinicians reported that the lack of diagnosis and/or treatment standard is the biggest problem in effectively diagnosing and treating pediatric TBI in China. Developing guidelines for the diagnosis and treatment of children with TBI is a high priority in China. The extremely high usage of CT for pediatric TBI in China suggests that it is important to establish evidence-based clinical decision rules to help Chinese clinicians make diagnostic and therapeutic decisions during their practice in order to identify children unlikely to have a clinically-important TBI who can be safely discharged without a CT scan.
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Affiliation(s)
- Fei Di
- Department of Neurosurgery, Beijing Tian Tan Hospital, Capital Medical University, Beijing, China
| | - Qi Gao
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
| | - Joe Xiang
- Center for Injury Research and Policy, The Research Institute at Nationwide Children's Hospital, The Ohio State University College of Medicine, 700 Children's Drive, Columbus, Ohio, United States of America
| | - Di Zhang
- Department of Neurosurgery, Beijing Children's Hospital, Capital Medical University, Beijing, China
| | - Xiuquan Shi
- Department of Epidemiology and Health Statistics, School of Public Health, Zunyi Medical University, Zunyi, Guizhou, China
| | - Xueqiang Yan
- Department of Neurosurgery, Wuhan Children's Hospital, Wuhan, Hubei, China
| | - Huiping Zhu
- Department of Epidemiology and Health Statistics, School of Public Health, Capital Medical University, Beijing, China
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15
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Chong SL, Barbier S, Liu N, Ong GYK, Ng KC, Ong MEH. Predictors for moderate to severe paediatric head injury derived from a surveillance registry in the emergency department. Injury 2015; 46:1270-4. [PMID: 25907402 DOI: 10.1016/j.injury.2015.04.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 03/17/2015] [Accepted: 04/02/2015] [Indexed: 02/02/2023]
Abstract
INTRODUCTION AND AIM Head injuries are a common complaint among children presenting to the emergency department (ED). This study is part of an ongoing prospective surveillance of head injured children presenting to a paediatric ED. We aim to derive predictors for moderate to severe head injury in our population. MATERIALS AND METHODS We performed an unmatched case-control study. Cases were defined as those who presented to the ED with moderate to severe head injury, during the period from 2006 to 2014. Controls were obtained from the prospective surveillance head injury database and were children who presented to the ED with head injury but who remained well on follow up. We compared variables from demographics, mechanism of injury, history, and physical examination. RESULTS There were 39 cases and 1173 controls. In the prospective database, our event rate was 0.5% and our computed tomography (CT) rate was 1%. Among those with moderate to severe head injury, they were more likely to be involved in road traffic accidents, have a history of difficult arousal, confusion or disorientation and a history of seizure. On physical examination, cases were more likely to have the presence of altered mental status, base of skull fracture, scalp hematoma and anisocoria. On multivariable analysis, the following 4 predictors remained statistically significant: Involvement in road traffic accident (p<0.001), difficult arousal (p<0.001), vomiting (p=0.003) and signs of base of skull fracture (p<0.001). Using these 4 variables, the Area under Curve was 0.97 {Sensitivity 92.3% (79.1-98.4%), Specificity 93.0% (91.4-94.4%), positive predictive value 30.5% (22-40%), negative predictive value 99.7% (99.2-99.9%)}. CONCLUSION Involvement in road traffic accident, difficult arousal, base of skull fracture and vomiting are independent predictors for moderate to severe head injury in our paediatric population.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Duke-NUS Graduate Medical School, Singapore.
| | - Sylvaine Barbier
- Centre for Quantitative Medicine,Duke-NUS Graduate Medical School, Singapore
| | - Nan Liu
- Centre for Quantitative Medicine,Duke-NUS Graduate Medical School, Singapore; Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Gene Yong-Kwang Ong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Duke-NUS Graduate Medical School, Singapore
| | - Kee Chong Ng
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore; SingHealth Duke-NUS Paediatrics Academic Clinical Programme, Duke-NUS Graduate Medical School, Singapore
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore; Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore
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16
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Chong SL, Liu N, Barbier S, Ong MEH. Predictive modeling in pediatric traumatic brain injury using machine learning. BMC Med Res Methodol 2015; 15:22. [PMID: 25886156 PMCID: PMC4374377 DOI: 10.1186/s12874-015-0015-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2015] [Accepted: 03/05/2015] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Pediatric traumatic brain injury (TBI) constitutes a significant burden and diagnostic challenge in the emergency department (ED). While large North American research networks have derived clinical prediction rules for the head injured child, these may not be generalizable to practices in countries with traditionally low rates of computed tomography (CT). We aim to study predictors for moderate to severe TBI in our ED population aged < 16 years. METHODS This was a retrospective case-control study based on data from a prospective surveillance head injury database. Cases were included if patients presented from 2006 to 2014, with moderate to severe TBI. Controls were age-matched head injured children from the registry, obtained in a 4 control: 1 case ratio. These children remained well on diagnosis and follow up. Demographics, history, and physical examination findings were analyzed and patients followed up for the clinical course and outcome measures of death and neurosurgical intervention. To predict moderate to severe TBI, we built a machine learning (ML) model and a multivariable logistic regression model and compared their performances by means of Receiver Operating Characteristic (ROC) analysis. RESULTS There were 39 cases and 156 age-matched controls. The following 4 predictors remained statistically significant after multivariable analysis: Involvement in road traffic accident, a history of loss of consciousness, vomiting and signs of base of skull fracture. The logistic regression model was created with these 4 variables while the ML model was built with 3 extra variables, namely the presence of seizure, confusion and clinical signs of skull fracture. At the optimal cutoff scores, the ML method improved upon the logistic regression method with respect to the area under the ROC curve (0.98 vs 0.93), sensitivity (94.9% vs 82.1%), specificity (97.4% vs 92.3%), PPV (90.2% vs 72.7%), and NPV (98.7% vs 95.4%). CONCLUSIONS In this study, we demonstrated the feasibility of using machine learning as a tool to predict moderate to severe TBI. If validated on a large scale, the ML method has the potential not only to guide discretionary use of CT, but also a more careful selection of head injured children who warrant closer monitoring in the hospital.
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Affiliation(s)
- Shu-Ling Chong
- Department of Emergency Medicine, KK Women's and Children's Hospital, Singapore, Singapore.
| | - Nan Liu
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore, Singapore.
| | - Sylvaine Barbier
- Centre for Quantitative Medicine, Duke-NUS Graduate Medical School, Singapore, Singapore.
| | - Marcus Eng Hock Ong
- Department of Emergency Medicine, Singapore General Hospital, Singapore, Singapore.
- Health Services and Systems Research, Duke-NUS Graduate Medical School, Singapore, Singapore.
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17
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Babl FE, Bressan S. Physician practice and PECARN rule outperform CATCH and CHALICE rules based on the detection of traumatic brain injury as defined by PECARN. ACTA ACUST UNITED AC 2014; 20:33-4. [DOI: 10.1136/ebmed-2014-110090] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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18
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Babl FE, Krieser D, Oakley E, Dalziel S. A platform for paediatric acute care research. Emerg Med Australas 2014; 26:419-22. [DOI: 10.1111/1742-6723.12286] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Franz E Babl
- Department of Emergency Medicine; Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- Department of Paediatrics; Faculty of Medicine, Dentistry, and Health Sciences; The University of Melbourne; Melbourne Victoria Australia
| | - David Krieser
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- Department of Paediatrics; Faculty of Medicine, Dentistry, and Health Sciences; The University of Melbourne; Melbourne Victoria Australia
- Paediatric Emergency Department; Sunshine Hospital; Melbourne Victoria Australia
| | - Ed Oakley
- Department of Emergency Medicine; Royal Children's Hospital; Melbourne Victoria Australia
- Murdoch Children's Research Institute; Melbourne Victoria Australia
- Department of Paediatrics; Faculty of Medicine, Dentistry, and Health Sciences; The University of Melbourne; Melbourne Victoria Australia
| | - Stuart Dalziel
- Children's Emergency Department; Starship Children's Hospital; Auckland New Zealand
- Liggins Institute; University of Auckland; Auckland New Zealand
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19
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Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med 2014; 64:145-52, 152.e1-5. [PMID: 24635987 PMCID: PMC4731042 DOI: 10.1016/j.annemergmed.2014.01.030] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 01/24/2014] [Accepted: 01/31/2014] [Indexed: 10/25/2022]
Abstract
STUDY OBJECTIVE We evaluate the diagnostic accuracy of clinical decision rules and physician judgment for identifying clinically important traumatic brain injuries in children with minor head injuries presenting to the emergency department. METHODS We prospectively enrolled children younger than 18 years and with minor head injury (Glasgow Coma Scale score 13 to 15), presenting within 24 hours of their injuries. We assessed the ability of 3 clinical decision rules (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]) and 2 measures of physician judgment (estimated of <1% risk of traumatic brain injury and actual computed tomography ordering practice) to predict clinically important traumatic brain injury, as defined by death from traumatic brain injury, need for neurosurgery, intubation greater than 24 hours for traumatic brain injury, or hospital admission greater than 2 nights for traumatic brain injury. RESULTS Among the 1,009 children, 21 (2%; 95% confidence interval [CI] 1% to 3%) had clinically important traumatic brain injuries. Only physician practice and PECARN identified all clinically important traumatic brain injuries, with ranked sensitivities as follows: physician practice and PECARN each 100% (95% CI 84% to 100%), physician estimates 95% (95% CI 76% to 100%), CATCH 91% (95% CI 70% to 99%), and CHALICE 84% (95% CI 60% to 97%). Ranked specificities were as follows: CHALICE 85% (95% CI 82% to 87%), physician estimates 68% (95% CI 65% to 71%), PECARN 62% (95% CI 59% to 66%), physician practice 50% (95% CI 47% to 53%), and CATCH 44% (95% CI 41% to 47%). CONCLUSION Of the 5 modalities studied, only physician practice and PECARN identified all clinically important traumatic brain injuries, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.
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Affiliation(s)
- Joshua S Easter
- Denver Emergency Center for Children, Department of Emergency Medicine, Denver Health, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Emergency Medicine, Bon Secours St. Mary's Hospital, Richmond, VA; Department of Emergency Medicine, University of Virginia, Charlottesville, VA.
| | - Katherine Bakes
- Denver Emergency Center for Children, Department of Emergency Medicine, Denver Health, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | | | | | - Emily Caruso
- Denver Emergency Center for Children, Department of Emergency Medicine, Denver Health, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Jason S Haukoos
- Denver Emergency Center for Children, Department of Emergency Medicine, Denver Health, Denver, CO; Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO; Department of Epidemiology, Colorado School of Public Health, Aurora, CO
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20
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Babl FE, Lyttle MD, Bressan S, Borland M, Phillips N, Kochar A, Dalziel SR, Dalton S, Cheek JA, Furyk J, Gilhotra Y, Neutze J, Ward B, Donath S, Jachno K, Crowe L, Williams A, Oakley E. A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC Pediatr 2014; 14:148. [PMID: 24927811 PMCID: PMC4074143 DOI: 10.1186/1471-2431-14-148] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2014] [Accepted: 05/27/2014] [Indexed: 12/05/2022] Open
Abstract
Background Head injuries in children are responsible for a large number of emergency department visits. Failure to identify a clinically significant intracranial injury in a timely fashion may result in long term neurodisability and death. Whilst cranial computed tomography (CT) provides rapid and definitive identification of intracranial injuries, it is resource intensive and associated with radiation induced cancer. Evidence based head injury clinical decision rules have been derived to aid physicians in identifying patients at risk of having a clinically significant intracranial injury. Three rules have been identified as being of high quality and accuracy: the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) from Canada, the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) from the UK, and the prediction rule for the identification of children at very low risk of clinically important traumatic brain injury developed by the Pediatric Emergency Care Applied Research Network (PECARN) from the USA. This study aims to prospectively validate and compare the performance accuracy of these three clinical decision rules when applied outside the derivation setting. Methods/design This study is a prospective observational study of children aged 0 to less than 18 years presenting to 10 emergency departments within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network in Australia and New Zealand after head injuries of any severity. Predictor variables identified in CATCH, CHALICE and PECARN clinical decision rules will be collected. Patients will be managed as per the treating clinicians at the participating hospitals. All patients not undergoing cranial CT will receive a follow up call 14 to 90 days after the injury. Outcome data collected will include results of cranial CTs (if performed) and details of admission, intubation, neurosurgery and death. The performance accuracy of each of the rules will be assessed using rule specific outcomes and inclusion and exclusion criteria. Discussion This study will allow the simultaneous comparative application and validation of three major paediatric head injury clinical decision rules outside their derivation setting. Trial registration The study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR)-
ACTRN12614000463673 (registered 2 May 2014).
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Affiliation(s)
- Franz E Babl
- Department of Emergency Medicine, Royal Children's Hospital, Flemington Rd, Parkville Vic 3052, Australia.
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