PECARN Rule in diagnostic process of pediatric patients with minor head trauma in emergency department

Abstract

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%.

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

“…In 4/24 (16.7%) of our sample, headaches lasted for at least 6 months. While studies of the adult population report that 58% of patients after traumatic brain injury continue to have headaches one year later [ 9 ], the rate in children remains unclear, with few studies reporting a prevalence between 7.8% and 12% at 1 year [ 17 , 30 , 42 ]. The short observation time of our study does not allow making comparisons with these papers; it is possible that similar percentages would be present after one year.…”

“…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 ].…”

Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France

“…Teleradiology uses interoperable information and technology tools that enable rapid collection of large multicentric data sets, especially when structured requests and reports are made. 14 Since the publication of the PECARN guidelines in 2009, 4 clinical investigations have emphasized their sensitivity, safety, and validity, 15 , 16 with a reduction of HCT rate in patients younger than 2 years without increasing the number of missed clinically important TBIs. 17 The guidelines have also been acknowledged for their usefulness and ease of use for rapid decision-making by the medical staff, 15 , 18 although their specificity may be lower than the specificity from clinical suspicion.…”

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

“…This avoids exposing children with minor head traumas to unnecessary radiation. Accurate and reliable decision‐making rules are available on using imaging in patients who present to emergency departments within 24 h of a head trauma 7–11 . However, there are a lack of clear‐cut indications on neuroimaging for children who access emergency departments after 24 h with a minor head trauma 12 .…”

“…Accurate and reliable decision-making rules are available on using imaging in patients who present to emergency departments within 24 h of a head trauma. [7][8][9][10][11] However, there are a lack of clear-cut indications on neuroimaging for children who access emergency departments after 24 h with a minor head trauma. 12 This leads to heterogeneous behaviour among clinicians and the extensive, and potentially inappropriate, use of CT. 13 The aim of this study was to compare the presence of clinically important traumatic brain injuries detecting by neuroimaging in children presenting to five Italian paediatric emergency departments within and after 24 h of sustaining a minor head trauma.…”