View source for EBQ:PECARN Pediatric Head CT Rule

{{JC info
| title=Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
| abbreviation= PECARN Pediatric Head Trauma
| expansion=Pediatric Emergency Care Applied Research Network Head Trauma Traial
| published=2009
| author=Kuppermann N. et al
| journal=The Lancet
| year=2009 
| volume=374
| issue=9696
| pages=1160-1170
| pmid= 19758692
| fulltexturl=http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(09)61558-0/fulltext
| pdfurl=http://www.pecarn.org/documents/kuppermann_2009_the-lancet.pdf
| status = Complete
}}

==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 intracranial injuries

==Major Points== 
This rule was derived from the multicenter [http://www.pecarn.org/ 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.

{{Template:PECARN Head CT Rule}}
==Study Design==
Prospective cohort study in 25 emergency departments of the pediatric research network

==Population==
*N=42,412
*Derivation Arm: 33785
*Validation Arm: 8627

===Patient Demographics===
===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:
#Death from traumatic brain injury
#Neurosurgical intervention for:
## Intracranial pressure monitoring
##Elevation of depressed skull fracture
##Ventriculostomy
##Hematoma evacuation
##Lobectomy
##Tissue debridement
##Dura repair
#Intubation for more than 24 h 
#Hospital admission of 2 nights due to CT evidence of TBI

TBI on CT was defined as:
#Intracranial haemorrhage or contusion
#Cerebral edema
#Traumatic infarction
#Diffuse axonal injury
#Shearing injury
#Sigmoid sinus thrombosis
#Midline shift or herniation
#Diastasis of the skull
#Pneumocephalus
#Skull fracture 

===Prediction Rule Characteristics===
'''<2 years old with TBI on CT'''
*Negative predictive value: 100.0%, (97.8–100·0)
*Sensitivity:100.0% for TBI on CT (94.7–100.0)
'''<2 years old with ciTBI'''
*Sensitivity: 100.00% (86.3–100.00)
*Negative predictive: 100.00% (99.7–100·00)


'''≥ 2 years old TBI on CT'''
*Negative Predictive Value for TBI on CT: 439/446 (98.4%, 96.8–99.4)
*Sensitivity of 94.0% 109/116 (88.0–97.5)
'''≥ 2 years  with ciTBI'''
Sensitivity: 96.8% (89.0–99.6)
Negative Predictive Value: 99.95% (99.81–99.99)
 
===Missed ciTBI===
*2 Chidren were missed in the validation group for children aged 2 years and older, one with a subdural hematoma and the other with an occipital lobe contusion

==Further Discussion==
*TBI and ciTBI was extremely rare in children and no one clinical factor in the high risk group could reliably predict a TBI.  The high level of sensitivity of the rule must be weight agains the risk of over utilization of CT, exposure of ionizing radiation, and risk of missing a ciTBI.
*Children with a GCS <14 are not included in this rule
*At Denver Health, this rule was demonstrated to be superior to the CHALICE and CATCH rules<ref>Easter J. et al. Comparison of PECARN, CATCH, and CHALICE Rules for Children With Minor Head Injury: A Prospective Cohort Study. Ann Emerg Med. 2014 Mar 10. PMID: 24635987</ref>
*The rarity of TBI in children was reinforced when analyzing those with isolated vomitting and no other positive factors on the decision rule<ref>Dayan, P. et al. Association of traumatic brain injuries with vomiting in children with blunt head trauma. Ann Emerg Med. 2014 Jun;63(6):657-65. PMID: 24559605</ref>
===Isolated Scalp Hematoma===
*For '''isolated scalp hematoma''' a sub analysis post-hoc analysis of the 2,998 patients with isolated scalp hematomas none required a neurosurgical intervention. The risk of clinically important traumatic brain injury overall was less than 1 in 200. <ref>Dayan PS, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med. 2014 Aug;64(2):153-62. PMID: 24635991. Not all patients received a CT scan. 9% of the patients who received CT scan demonstrated traumatic brain injuries on CT. Risk factors were: younger age (especially <3 months), non-frontal scalp hematomas, increased scalp hematoma size, and more severe injury mechanism. A large hematoma was >3cm.</ref>

===Cost effectiveness===
The application of the [[PECARN Head Trauma]] CT rule has shown to lead to beneficial outcomes and more cost-effective care<ref>Nishijima DK. et al. Cost-effectiveness of the PECARN rules in children with minor head trauma. Ann Emerg Med. 2015 Jan;65(1):72-80</ref>

==Funding==
The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, and US Department of Health and Human Services

==See Also==
{{Head Trauma Links Template}}

==External Links==
*[http://www.aliem.com/vomiting-kids-head-trauma-ct/ ALiEM PECARN Vomitting]
*[http://californiaacep.org/public-health/pecarn/ Cal ACEP PECARN Pocket cards]
==Sources==
<references/>

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