EBQ:PECARN Pediatric Head CT Rule

Under Review Journal Club Article

Kuppermann N. et al. "Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.". The Lancet. 2009. 374(9696):1160-1170.
PubMed Full text PDF

Clinical Question

Can children be identified for low risk clinically-important traumatic brain injury and avoid Brain CT imaging.

Conclusion

This validated clinical decision rule provides a means of decreasing brain CT imaging in children with blunt head trauma with a sensitivity of 100% (<2years old) and 96.8% (>2yrs old) for intracraneal injuries

Major Points

This rule was derived from the multicenter PECARN network with both a derivation and validation arm to detect clinically important traumatic brain (ciTBI) injury in children to age 18yrs old after blunt head trauma.

The rule stratifies patients < 2 years old and ≥2 years old.

Rules below are according to the of PECARN Head CT Study

<2 years old

PECARN Under Age 2

Any 1 of the following?

• GCS ≤14
• Altered Mental Status
• Palpable Skull Fracture

Then obtain a Non-Con Brain CT (4.4% risk of cTBI)

1 or more of the following?

• Non-frontal scalp hematoma
• LOC ≥ 5 seconds
• Severe injury mechanism
  • pedestrian or bicyclist without helmet struck by motorized vehicle
  • fall >1m or 3ft
  • head struck by high-impact object
• Abnormal activity per parents

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

≥2 years old - 18 years

PECARN Age 2 and Up

Any 1 of the following?

• GCS ≤14
• Altered Mental Status
• Signs of a basilar skull fracture

Then obtain a Non-Con Brain CT (4.3% risk of cTBI)

1 or more of the following?

• History of vomiting^
• LOC
• Severe injury mechanism
  • Pedestrian or bicyclist without helmet struck by motorized vehicle
  • Fall >2m or 5ft
  • Head struck by high-impact object
• Severe headache

Then consider a Non-Con Brain CT or Observation (0.9% risk of cTBI)

^Consider observation in place of imaging in children with isolated vomiting (no other indication) as the sole risk factor (0.2% risk of cTBI)

Inclusion Criteria

Children presenting within 24 h of head trauma were eligible.

Exclusion Criteria

Children with trivial injury, ground-level falls, walking or running into stationary objects, no signs or symptoms of head trauma other than scalp abrasions and lacerations, penetrating trauma, brain tumours, pre-existing neurological disorders complicating assessment, or neuroimaging at an outside hospital before transfer.

Interventions

Patients were admitted to the hospital at physician discretion, research assistants identified records of admitted patients and emergency department CT results and ciTBIs. Telephone surveys were used to identify missed traumatic brain injuries from discharged patients between 7 and 90 days.

Outcome

Outcome was clinically-important traumatic brain injury (ciTBI) defined apriori as:

1. Death from traumatic brain injury
2. Neurosurgical intervention for:
   1. Intracranial pressure monitoring
   2. Elevation of depressed skull fracture
   3. Ventriculostomy
   4. Hematoma evacuation
   5. Lobectomy
   6. Tissue debridement
   7. Dura repair
3. Intubation for more than 24 h
4. Hospital admission of 2 nights due to CT evidence of TBI

TBI on CT was defined as:

1. Intracranial haemorrhage or contusion
2. Cerebral edema
3. Traumatic infarction
4. Diffuse axonal injury
5. Shearing injury
6. Sigmoid sinus thrombosis
7. Midline shift or herniation
8. Diastasis of the skull
9. Pneumocephalus
10. Skull fracture

Review Questions

Journal club article: Regarding pediatric head trauma patients, which of the following were predictors of “very low risk for clinically significant injury in children less than 2 years of age”?

	normal mental status
	no scalp hematoma except frontal
	no loss of consciousness or loss of consciousness < 5 seconds
	non-severe injury mechanism
	no palpable skull fracture