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Clinical decision rules for children with minor head injury: a systematic review
  1. Alastair Pickering1,
  2. Susan Harnan2,
  3. Patrick Fitzgerald2,
  4. Abdullah Pandor2,
  5. Steve Goodacre1
  1. 1Health Services Research, ScHARR, University of Sheffield, Sheffield, UK
  2. 2Health Economics and Decision Science, ScHARR, University of Sheffield, Sheffield, UK
  1. Correspondence to Dr Alastair Pickering, Health Services Research, ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK; a.pickering{at}


Introduction Clinical decision rules aid clinicians with the management of head injured patients. This study aimed to identify clinical decision rules for children with minor head injury and compare their diagnostic accuracy for detection of intracranial injury (ICI) and injury requiring neurosurgical intervention (NSI).

Methods Relevant studies were identified by an electronic search of key databases. Papers in English were included with a cohort of at least 20 children suffering minor head injury (GCS 13–15). Studies of a decision rule derived to identify patients at risk of ICI or NSI had to include a proportion of the cohort undergoing imaging. Study quality was assessed using the QUADAS checklist.

Results 16 publications, representing 14 cohorts, with 79 740 patients were included. Only four rules were tested in more than one cohort. Of the validated rules the paediatric emergency care applied research network (PECARN) rule was most consistent (sensitivity 98%; specificity 58%). For neurosurgical injury all had high sensitivity (98–100%) but the children's head injury algorithm for the prediction of important clinical events (CHALICE) rule had the highest specificity (86%) in its derivation cohort.

Conclusion Of the current decision rules for minor head injury the PECARN rule appears the best for children and infants, with the largest cohort, highest sensitivity and acceptable specificity for clinically significant ICI. Application of this rule in the UK would probably result in an unacceptably high rate of CT scans per injury, and continued use of the CHALICE-based NICE guidelines represents an appropriate alternative.

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  • Funding This project was funded by the NETSCC Health Technology Assessment programme (ref 07/37/08) as part of a larger review of management strategies for minor head injuries.

  • Competing interests None.

  • Provenance and peer review Not commissioned; externally peer reviewed.