Ö Bozan1, G Aksel2,3, H A Kahraman4, Ö Giritli5, S E Eroğlu5. 1. Department of Emergency Medicine, Okmeydani Training and Research Hospital, University of Health Sciences, Istanbul, Turkey. 2. Department of Emergency Medicine, Okmeydani Training and Research Hospital, University of Health Sciences, Istanbul, Turkey. aksel@gokhanaksel.com. 3. Department of Emergency Medicine, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey. aksel@gokhanaksel.com. 4. Department of Emergency Medicine, Fatih Sultan Mehmet Training and Research Hospital, University of Health Sciences, Istanbul, Turkey. 5. Department of Emergency Medicine, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey.
Abstract
INTRODUCTION AND PURPOSE: Computerized brain tomography (CBT) imaging plays a key role in the management of patients with head trauma, and there is an indication for CBT in moderate and severe injuries. However, it is difficult to determine an indication for CBT in patients with minor head trauma. The primary aim of this study is to compare the efficiency of the most commonly used clinical decision rules: the guidelines of the Pediatric Emergency Care Applied Research Network (PECARN), and those of the Canadian Assessment of Tomography for Childhood Head Injury (CATCH). METHODS: The study, which was designed as a prospective cohort study, sought to determine the appropriate CBT indications for children younger than 18 years who were referred to the emergency department with minor blunt head trauma. The effectiveness of PECARN and CATCH clinical decision rules, which are recommended by literature to be applied in order to diagnose severely injured patients and minimize inappropriate CBT requests, was investigated. All patients included in this study were younger than 18 years of age, were admitted to the study with an isolated blunt head trauma, had a GCS of > 13, and had parental permission to participate in the study. Patients ages 18 and older, those with penetrating head trauma or trauma to other systems, those with GCS ≤ 13, those with incomplete data, and those whose parents did not agree to participate in the study, were excluded. RESULTS: A total of 256 patients were included in the study. PECARN and CATCH rules were both shown to be statistically significant in detecting the presence of pathology (p < 0.001, p = 0.002, respectively). Overall, PECARN was more successful than CATCH in detecting intracranial pathology. The sensitivity of PECARN was 95 (95% CI 72-100%) and specificity was 53 (95% CI 47-60%), while the sensitivity of CATCH was 48 (95% CI 25-71%) and specificity was 83 (95% CI 79-88%). Multivariate regression analyses were performed on the parameters (low GCS, abnormal mental status, age, non-frontal hematoma) and other parameters (vomiting, headache, abnormal behavior according to parents) that were considered to be clinically significant despite having a p value of < 0.3. Age, low GCS, and non-frontal hematoma presence were found to be significant in predicting the presence of pathology. In particular, low GCS increased the probability of pathology 5.94-fold and non-frontal hematoma presence 4.37-fold. CONCLUSION: While both PECARN and CATCH were found to be effective in determining the necessity of CBT for children with minor blunt head trauma, PECARN proved to be more useful for emergency services because of its higher sensitivity. The authors suggest that conducting a CBT scan based on clinical decision rules may be a suitable approach for early detection of the presence of intracranial acute pathologies in young children with minor blunt head trauma, especially if the GCS score is < 15 and non-frontal hematomas are present.
INTRODUCTION AND PURPOSE: Computerized brain tomography (CBT) imaging plays a key role in the management of patients with head trauma, and there is an indication for CBT in moderate and severe injuries. However, it is difficult to determine an indication for CBT in patients with minor head trauma. The primary aim of this study is to compare the efficiency of the most commonly used clinical decision rules: the guidelines of the Pediatric Emergency Care Applied Research Network (PECARN), and those of the Canadian Assessment of Tomography for Childhood Head Injury (CATCH). METHODS: The study, which was designed as a prospective cohort study, sought to determine the appropriate CBT indications for children younger than 18 years who were referred to the emergency department with minor blunt head trauma. The effectiveness of PECARN and CATCH clinical decision rules, which are recommended by literature to be applied in order to diagnose severely injured patients and minimize inappropriate CBT requests, was investigated. All patients included in this study were younger than 18 years of age, were admitted to the study with an isolated blunt head trauma, had a GCS of > 13, and had parental permission to participate in the study. Patients ages 18 and older, those with penetrating head trauma or trauma to other systems, those with GCS ≤ 13, those with incomplete data, and those whose parents did not agree to participate in the study, were excluded. RESULTS: A total of 256 patients were included in the study. PECARN and CATCH rules were both shown to be statistically significant in detecting the presence of pathology (p < 0.001, p = 0.002, respectively). Overall, PECARN was more successful than CATCH in detecting intracranial pathology. The sensitivity of PECARN was 95 (95% CI 72-100%) and specificity was 53 (95% CI 47-60%), while the sensitivity of CATCH was 48 (95% CI 25-71%) and specificity was 83 (95% CI 79-88%). Multivariate regression analyses were performed on the parameters (low GCS, abnormal mental status, age, non-frontal hematoma) and other parameters (vomiting, headache, abnormal behavior according to parents) that were considered to be clinically significant despite having a p value of < 0.3. Age, low GCS, and non-frontal hematoma presence were found to be significant in predicting the presence of pathology. In particular, low GCS increased the probability of pathology 5.94-fold and non-frontal hematoma presence 4.37-fold. CONCLUSION: While both PECARN and CATCH were found to be effective in determining the necessity of CBT for children with minor blunt head trauma, PECARN proved to be more useful for emergency services because of its higher sensitivity. The authors suggest that conducting a CBT scan based on clinical decision rules may be a suitable approach for early detection of the presence of intracranial acute pathologies in young children with minor blunt head trauma, especially if the GCS score is < 15 and non-frontal hematomas are present.
Entities:
Keywords:
Blunt head ınjury; Clinical decision making; Computerized tomography
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