PediatricsA decision rule for identifying children at low risk for brain injuries after blunt head trauma
Introduction
Trauma is the leading cause of childhood death.1 Traumatic brain injury is the leading cause of death and disability caused by trauma in children,2, 3, 4 resulting in approximately 3,000 deaths, 50,000 hospitalizations, and 650,000 emergency department (ED) visits per year in the United States.5, 6 Cranial computed tomography (CT) is routinely used in the assessment of children evaluated in the ED with head trauma; however, less than 10% of these CT scans are diagnostic of traumatic brain injuries.7, 8, 9, 10
Some studies have proposed that clinical signs and symptoms may be used to identify children at low risk for traumatic brain injuries after blunt head trauma.7, 11 Others have concluded that clinical signs and symptoms are inadequate for identifying these children.9, 10, 12, 13, 14 Many studies, however, were limited by small size of the study populations, retrospective design, uncontrolled or univariable data analyses, and nonstandardized age inclusion criteria and outcome variable definition.
Although CT is the diagnostic test of choice for evaluating children with head trauma, this procedure has disadvantages, including exposure to ionizing radiation,15, 16, 17, 18 transport of the child away from the direct supervision of emergency physicians, the frequent requirement for pharmacologic sedation,19, 20, 21 additional health care costs, and increased time for completing ED evaluation. Therefore, CT scans should ideally be selectively used.
Because the results of previous studies are inconclusive, variation exists in physicians' practice patterns regarding the use of CT scans in the ED evaluation of children with blunt head trauma.22, 23 Published guidelines acknowledge the limitations of available data and highlight the need for larger, prospective studies on this topic.8, 24, 25, 26 In this study, we sought to derive a clinical decision rule with high sensitivity for traumatic brain injury and high negative predictive value for identifying children without traumatic brain injuries after blunt head trauma, with the goal of maximizing the clinical efficiency of CT use. We hypothesized that a set of clinical signs and symptoms can accurately identify individuals at very low risk of traumatic brain injuries.
Section snippets
Materials and methods
We conducted a prospective observational cohort study in the pediatric ED of a Level I trauma center. The study was approved by the study site's Human Subjects Research Committee.
From July 1998 to September 2001, we enrolled children younger than 18 years and presenting to the pediatric ED after a history of nontrivial blunt head trauma with historical or physical examination findings consistent with head trauma. These findings included a history of loss of consciousness, amnesia, seizures,
Results
We enrolled 2,043 (77.4%) of 2,640 eligible children. The mean age was 8.3 years (SD 5.3 years; range 10 days to 17.9 years), 327 (16%) were 2 years or younger, 65% were male patients, and 36% had histories of loss of consciousness. The mechanisms of injury were fall (35%), motor vehicle crash (19%), automobile versus pedestrian (11%), assault (8%), fall off bicycle (7%), automobile versus bicyclist (5%), child abuse (0.2%), and other (15%). Fifty-three percent of enrolled patients had isolated
Discussion
In this study, we derived a decision rule with high sensitivity for traumatic brain injury and high negative predictive value for identifying children without traumatic brain injury after blunt head trauma. This rule uses abnormal mental status, clinical evidence of skull fracture, a history of vomiting, scalp hematoma (in children ≤2 years), and headache. These variables are routinely assessed by emergency physicians and have a high degree of interobserver agreement. These predictors
Acknowledgments
We thank Rahman Azari, PhD, for helpful discussions about the analysis of the data and comments on the manuscript, and Nicole Glaser, MD, for her thoughtful reviews of the manuscript.
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This article is dedicated to the memory of our beloved friend and colleague, James Seidel, MD, PhD, who was a tireless and vocal advocate for the health and welfare of children.
Author contributions: MJP and NK conceived the study and obtained funding for the study. MJP, NK, REG, JFH, JWS, and RWD designed the study. MJP, NK, JFH, CWV, REG, BAS, and MJH participated in data collection, SLWG participated in radiographic interpretation, NK and MJP analyzed and interpreted the data, and MJP and NK drafted the manuscript. All authors participated in manuscript review and revision. MJP takes responsibility for the paper as a whole.
Presented in part at the 3rd National Congress for Emergency Medical Services for Children, Dallas, TX, April 2002, the Pediatric Academic Society national meeting, Baltimore, MD, May 2002, and the Society of Academic Emergency Medicine national meeting, St. Louis, MO, May 2002.
Supported by a Hibbard E. Williams Grant, University of California–Davis School of Medicine; Faculty Research Grant, University of California–Davis School of Medicine; and a Children's Miracle Network Grant.