PECARN algorithms for minor head trauma: Risk stratification estimates from a prospective PREDICT cohort study

Abstract

Background The Pediatric Emergency Care Applied Research Network (PECARN) head trauma clinical decision rules informed the development of algorithms that risk stratify the management of children based on their risk of clinically important traumatic brain injury (ciTBI). We aimed to determine the rate of ciTBI for each PECARN algorithm risk group in an external cohort of patients and that of ciTBI associated with different combinations of high‐ or intermediate‐risk predictors. Methods This study was a secondary analysis of a large multicenter prospective data set, including patients with Glasgow Coma Scale scores of 14 or 15 conducted in Australia and New Zealand. We calculated ciTBI rates with 95% confidence intervals (CIs) for each PECARN risk category and combinations of related predictor variables. Results Of the 15,163 included children, 4,011 (25.5%) were aged <2 years. The frequency of ciTBI was 8.5% (95% CI = 6.0%–11.6%), 0.2% (95% CI = 0.0%–0.6%), and 0.0% (95% CI = 0.0%–0.2%) in the high‐, intermediate‐, and very‐low‐risk groups, respectively, for children <2 years and 5.7% (95% CI = 4.4%–7.2%), 0.7% (95% CI = 0.5%–1.0%), and 0.0% (95% CI = 0.0%–0.1%) in older children. The isolated high‐risk predictor with the highest risk of ciTBI was “signs of palpable skull fracture” for younger children (11.4%, 95% CI = 5.3%–20.5%) and “signs of basilar skull fracture” in children ≥2 years (11.1%, 95% CI = 3.7%–24.1%). For older children in the intermediate‐risk category, the presence of all four predictors had the highest risk of ciTBI (25.0%, 95% CI = 0.6%–80.6%) followed by the combination of “severe mechanism of injury” and “severe headache” (7.7%, 95% CI = 0.2%–36.0%). The very few children <2 years at intermediate risk with ciTBI precluded further analysis. Conclusions The risk estimates of ciTBI for each of the PECARN algorithms risk group were consistent with the original PECARN study. The risk estimates of ciTBI within the high‐ and intermediate‐risk predictors will help further refine clinical judgment and decision making on neuroimaging.

Multicentre study found no increased risk of clinically important brain injuries when children presented more than 24 h after a minor head trauma

“…The inverse association between age of the patients and the risk of clinically important traumatic brain injuries was in line with other studies 23 and this may reflect a higher susceptibility to brain damage in younger patients. 24…”

Post-Traumatic Headache in Children after Minor Head Trauma: Incidence, Phenotypes, and Risk Factors

“…HT was scored according to the PECARN score [ 8 ]. Mechanisms of injury were considered high-risk in cases of motor vehicle collision with patient ejection, death of another passenger, or rollover; pedestrians or bicyclists without helmets struck by motorized vehicles; falls > 1.5 m; or head struck by high-impact objects [ 3 ]. After discharge from PED, patients were followed up in the following 6 months to establish the incidence and clinical characteristics of PTH.…”

“…Minor head trauma (MHT) is a frequent reason for pediatric emergency department (PED) visits (more than 600,000 visits per year in the USA), accounting for 95% of cases of head trauma (HT) during childhood [ 1 ]. It is defined by normal mental status, meaning Glasgow Coma Scale (GCS) scores of 14 to 15 at the initial examination; no abnormal or focal findings on the neurologic examination; and no physical evidence of a skull fracture [ 2 , 3 ]. However, even after a MHT, variable mood, behavioral, and physical changes such as headache, nausea, dizziness, fatigue, hypersomnolence, attentional difficulties, and irritability may appear and persist for a long time, both in children and adults [ 4 , 5 , 6 ].…”

“…Despite the fact that the majority of these children do not require further testing, pediatric patients with MHT may require a head computed tomography (CT) scan to rule out a clinically important traumatic brain injury (ciTBI). As most children who undergo a head CT scan will have no relevant clinical findings, the Pediatric Emergency Care Applied Research Network (PECARN) scale is an effective tool to identify those patients who actually require this investigation in order to avoid unnecessary radiation exposure [ 3 , 8 , 9 , 10 ]. Conversely, children with the presence of isolated loss of consciousness were found to be at very low risk for ciTBI and do not routinely require CT evaluation [ 11 ].…”

Brain Point of Care Ultrasound in Young Children Receiving Computed Tomography in the Emergency Department: A Proof of Concept Study

“…In this pilot study, our primary aim was to examine the ability of brain POCUS to identify clinically significant brain injuries as defined by the Pediatric Emergency Care Applied Research Network (PECARN) as traumatic brain injuries that require neurosurgical intervention, intubation, hospital admission, or result in death 7 . Our secondary aim was to determine the sensitivity and specificity of brain POCUS in our population of children <15mo.…”