A decision rule for identifying children at low risk for brain injuries after blunt head trauma

Palchak, Michael J.; Holmes, James F.; Vance, Cheryl; Gelber, Rebecca E.; Schauer, Bobbie A.; Harrison, Mathew; Willis-Shore, Jason; Wootton‐Gorges, Sandra L.; Derlet, Robert W.; Kuppermann, Nathan

doi:10.1067/s0196-0644(03)00425-6

Cited by 235 publications

(231 citation statements)

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“…Osmond et al 20 found ''moderate'' agreement (kappa between 0.4 and 0.6) for 3 of 12 findings evaluated and substantial agreement (j > 0.6) for 8 of the 12 findings. Palchak et al,22 studying 109 children with head injury at a single general emergency department, found acceptable agreement (j > 0.5) for all 10 findings they evaluated. Our study confirms these previous results, but also extends them to a larger number of patients and to a greater variety of settings and observers.…”

Section: Discussionmentioning

confidence: 99%

Interobserver Agreement in Assessment of Clinical Variables in Children with Blunt Head Trauma

Gorelick

Atabaki

Hoyle

et al. 2008

Academic Emergency Medicine

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Objectives: To be useful in development of clinical decision rules, clinical variables must demonstrate acceptable agreement when assessed by different observers. The objective was to determine the interobserver agreement in the assessment of historical and physical examination findings of children undergoing emergency department (ED) evaluation for blunt head trauma.Methods: This was a prospective cohort study of children younger than 18 years evaluated for blunt head trauma at one of 25 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). Patients were excluded if injury occurred more than 24 hours prior to evaluation, if neuroimaging was obtained at another hospital prior to evaluation, or if the patient had a clinically trivial mechanism of injury. Two clinicians independently completed a standardized clinical assessment on a templated data form. Assessments were performed within 60 minutes of each other and prior to clinician review of any neuroimaging (if obtained). Agreement between the two observers beyond that expected by chance was calculated for each clinical variable, using the kappa (j) statistic for categorical variables and weighted kappa for ordinal variables. Variables with a lower 95% confidence limit (LCL) of j > 0.4 were considered to have acceptable agreement.Results: Fifteen-hundred pairs of observations were obtained. Acceptable agreement was achieved in 27 of the 32 variables studied (84%). Mechanism of injury (low, medium, or high risk) had j = 0.83. For subjective symptoms, kappa ranged from 0.47 (dizziness) to 0.93 (frequency of vomiting); all had 95% LCL > 0.4. Of the physical examination findings, kappa ranged from 0.22 (agitated) to 0.89 (Glasgow Coma Scale [GCS] score). The 95% LCL for kappa was <0.4 for four individual signs of altered mental status and for quality (i.e., boggy or firm) of scalp hematoma if present.Conclusions: Both subjective and objective clinical variables in children with blunt head trauma can be assessed by different observers with acceptable agreement, making these variables suitable candidates for clinical decision rules.

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Section: Discussionmentioning

confidence: 99%

Interobserver Agreement in Assessment of Clinical Variables in Children with Blunt Head Trauma

Gorelick

Atabaki

Hoyle

et al. 2008

Academic Emergency Medicine

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“…The estimated lifetime risk of cancer from a head CT is substantially higher for children than for adults because of a longer latency period and the greater sensitivity of developing organs to radiation. [4][5][6][7] However, intracranial injury may occur without skull fracture, and clinicians must use clinical judgment or decision rules [25][26][27][28] for obtaining CT scan regardless of the presence or absence of skull fracture. In addition, ultrasound can also be performed in young children without the need for sedation.…”

Section: Discussionmentioning

confidence: 99%

Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children

et al. 2013

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WHAT'S KNOWN ON THIS SUBJECT: Head injuries and concern for skull fracture are common in pediatrics. Point-of-care ultrasound is an imaging tool that can be used to diagnose fractures. However, there are scant data regarding the accuracy of point-ofcare ultrasound in skull fracture diagnosis. WHAT THIS STUDY ADDS:Clinicians with focused point-of-care ultrasound training are able to diagnose skull fractures in children with high specificity. Ultrasound may be valuable to diagnose skull fractures in children at the point of care. abstract OBJECTIVE: To determine the test performance characteristics for point-of-care ultrasound performed by clinicians compared with computed tomography (CT) diagnosis of skull fractures. METHODS:We conducted a prospective study in a convenience sample of patients #21 years of age who presented to the emergency department with head injuries or suspected skull fractures that required CT scan evaluation. After a 1-hour, focused ultrasound training session, clinicians performed ultrasound examinations to evaluate patients for skull fractures. CT scan interpretations by attending radiologists were the reference standard for this study. Pointof-care ultrasound scans were reviewed by an experienced sonologist to evaluate interobserver agreement.RESULTS: Point-of-care ultrasound was performed by 17 clinicians in 69 subjects with suspected skull fractures. The patients' mean age was 6.4 years (SD: 6.2 years), and 65% of patients were male. The prevalence of fracture was 12% (n = 8). Point-of-care ultrasound for skull fracture had a sensitivity of 88% (95% confidence interval [CI]: 53%-98%), a specificity of 97% (95% CI: 89%-99%), a positive likelihood ratio of 27 (95% CI: 7-107), and a negative likelihood ratio of 0.13 (95% CI: 0.02-0.81). The only false-negative ultrasound scan was due to a skull fracture not directly under a scalp hematoma, but rather adjacent to it. The k for interobserver agreement was 0.86 (95% CI: 0.67-1.0). CONCLUSIONS:Clinicians with focused ultrasound training were able to diagnose skull fractures in children with high specificity. Pediatrics

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“…Although these reports provide some preliminary evidence, limitations in study design, including retrospective chart review, small sample size, and restricted age or selection criteria, limit the strength of any of these instruments. [7][8][9][10][11][13][14][15][18][19][20][21][22][23][24][25] The National Emergency X-Radiography Utilization Study II (NEXUS II) is an ongoing, prospective, multicenter study of blunt head trauma victims that was designed to derive and subsequently validate a decision aid to identify a group of patients, from among those with head trauma, who are at very low risk for significant ICI, thus enabling a reduction in unwarranted cranial CT imaging. 26,27 The derivation set of NEXUS II identified a decision aid, based on both adult and pediatric patients, that was highly sensitive (98.3%; 95% confidence interval [CI]: 97.2-99.0) for ICI in this cohort, excluded a significant lesion with high negative predictive value (NPV: 99.1%; 95% CI: 98.5-99.5), and, if prospectively validated, should be able to identify safely a small subset of patients who can be discharged without imaging (13.7%; 95% CI: 13.1-14.3).…”

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confidence: 99%

Performance of a Decision Rule to Predict Need for Computed Tomography Among Children With Blunt Head Trauma

Oman

Cooper

Holmes³

et al. 2006

Pediatrics

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OBJECTIVE. To assess the ability of the NEXUS II head trauma decision instrument to identify patients with clinically important intracranial injury (ICI) from among children with blunt head trauma.METHODS. An analysis was conducted of the pediatric cohort involved in the derivation set of National Emergency X-Radiography Utilization Study II (NEXUS II), a prospective, observational, multicenter study of all patients who had blunt head trauma and underwent cranial computed tomography (CT) imaging at 1 of 21 emergency departments. We determined the test performance characteristics of the 8-variable NEXUS II decision instrument, derived from the entire NEXUS II cohort, in the pediatric cohort (0 -18 years of age), as well as in the very young children (Ͻ3 years). Clinically important ICI was defined as ICI that required neurosurgical intervention (craniotomy, intracranial pressure monitoring, or mechanical ventilation) or was likely to be associated with significant long-term neurologic impairment.RESULTS. NEXUS II enrolled 1666 children, 138 (8.3%) of whom had clinically important ICI. The decision instrument correctly identified 136 of the 138 cases and classified 230 as low risk. A total of 309 children were younger than 3 years, among whom 25 had ICI. The decision instrument identified all 25 cases of clinically important ICI in this subgroup.CONCLUSIONS. The decision instrument derived in the large NEXUS II cohort performed with similarly high sensitivity among the subgroup of children who were included in this study. Clinically important ICI were rare in children who did not exhibit at least 1 of the NEXUS II risk criteria. a common cause of emergency-department (ED) presentation, accounting for ϳ1 million visits annually. 1 Although the majority of patients with head trauma have a minor injury that requires no specific therapy, a small number prove to have clinically significant intracranial injury (ICI). Because of the risk of unrecognized ICI, clinicians liberally order cranial computed tomography (CT) in blunt trauma, generating annual charges of nearly $750 million while revealing significant ICI in Ͻ60 000 patients. [2][3][4] The overuse of CT may be even more pronounced in children, who comprise almost 40% of these patients, 5 because of the greater difficulty in assessing neurologic function in at least some of them.A number of investigators have attempted to identify clinical criteria that accurately predict which patients are at risk for ICI and thus limit CT imaging to such patients. Although these reports provide some preliminary evidence, limitations in study design, including retrospective chart review, small sample size, and restricted age or selection criteria, limit the strength of any of these instruments. [7][8][9][10][11][13][14][15][18][19][20][21][22][23][24][25] The National Emergency X-Radiography Utilization Study II (NEXUS II) is an ongoing, prospective, multicenter study of blunt head trauma victims that was designed to derive and subsequently validate a decision aid to ide...

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A decision rule for identifying children at low risk for brain injuries after blunt head trauma

Cited by 235 publications

References 44 publications

Interobserver Agreement in Assessment of Clinical Variables in Children with Blunt Head Trauma

Interobserver Agreement in Assessment of Clinical Variables in Children with Blunt Head Trauma

Accuracy of Point-of-Care Ultrasound for Diagnosis of Skull Fractures in Children

Performance of a Decision Rule to Predict Need for Computed Tomography Among Children With Blunt Head Trauma

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