BACKGROUND: There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury. METHODS: For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13-15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity. RESULTS: Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%-100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%-99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT. INTERPRETATION: The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.
BACKGROUND: There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury. METHODS: For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13-15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity. RESULTS: Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%-100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%-99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT. INTERPRETATION: The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.
Authors: I G Stiell; G A Wells; K Vandemheen; C Clement; H Lesiuk; A Laupacis; R D McKnight; R Verbeek; R Brison; D Cass; M E Eisenhauer; G Greenberg; J Worthington Journal: Lancet Date: 2001-05-05 Impact factor: 79.321
Authors: I G Stiell; G A Wells; K L Vandemheen; C M Clement; H Lesiuk; V J De Maio; A Laupacis; M Schull; R D McKnight; R Verbeek; R Brison; D Cass; J Dreyer; M A Eisenhauer; G H Greenberg; I MacPhail; L Morrison; M Reardon; J Worthington Journal: JAMA Date: 2001-10-17 Impact factor: 56.272
Authors: T P Klassen; M H Reed; I G Stiell; C Nijssen-Jordan; M Tenenbein; G Joubert; A Jarvis; G Baldwin; D St-Vil; C Pitters; F Belanger; D McConnell; K Vandemheen; M G Hamilton; T Sutcliffe; M Colbourne Journal: Acad Emerg Med Date: 2000-07 Impact factor: 3.451
Authors: S A Schutzman; P Barnes; A C Duhaime; D Greenes; C Homer; D Jaffe; R J Lewis; T G Luerssen; J Schunk Journal: Pediatrics Date: 2001-05 Impact factor: 7.124
Authors: Shireen M Atabaki; Ian G Stiell; Jeffrey J Bazarian; Karin E Sadow; Tien T Vu; Mary A Camarca; Scott Berns; James M Chamberlain Journal: Arch Pediatr Adolesc Med Date: 2008-05
Authors: Blake Bulloch; Gina Neto; Amy Plint; Rodrick Lim; Per Lidman; Martin Reed; Cheri Nijssen-Jordan; Milton Tenenbein; Terry P Klassen; Ravi Bhargava Journal: Ann Emerg Med Date: 2003-07 Impact factor: 5.721
Authors: Linda Papa; Manoj K Mittal; Jose Ramirez; Salvatore Silvestri; Philip Giordano; Carolina F Braga; Ciara N Tan; Neema J Ameli; Marco A Lopez; Crystal A Haeussler; Diego Mendez Giordano; Mark R Zonfrillo Journal: J Neurotrauma Date: 2017-04-18 Impact factor: 5.269
Authors: Jacob K Greenberg; Donna B Jeffe; Christopher R Carpenter; Yan Yan; Jose A Pineda; Angela Lumba-Brown; Martin S Keller; Daniel Berger; Robert J Bollo; Vijay M Ravindra; Robert P Naftel; Michael C Dewan; Manish N Shah; Erin C Burns; Brent R O'Neill; Todd C Hankinson; William E Whitehead; P David Adelson; Mandeep S Tamber; Patrick J McDonald; Edward S Ahn; William Titsworth; Alina N West; Ross C Brownson; David D Limbrick Journal: J Neurosurg Pediatr Date: 2018-10-26 Impact factor: 2.375
Authors: Silvia Bressan; Marco Daverio; Francesco Martinolli; Daniele Dona'; Federica Mario; Ivan P Steiner; Liviana Da Dalt Journal: Childs Nerv Syst Date: 2014-03 Impact factor: 1.475