Pediatric Emergency Care Applied Research Network head injuryprediction rules: on the basis of cost and effectiveness

Turkish Journal of Medical Sciences http://journals.tubitak.gov.tr/medical/ Research Article Turk J Med Sci (2017) 47: 1770-1777 © TÜBİTAK doi:10.3906/sag-1703-206 Pediatric Emergency Care Applied Research Network head injury prediction rules: on the basis of cost and effectiveness Fatma Dilek GÖKHARMAN, Sonay AYDIN*, Erdem FATİHOĞLU, Pınar Nercis KOŞAR Department of Radiology, Ankara Training and Research Hospital, Ankara, Turkey Received: 31.03.2017 Accepted/Published Online: 13.08.2017 Final Version: 19.12.2017 Background/aim: Head injuries are commonly seen in the pediatric population. Noncontrast enhanced cranial CT is the method of choice to detect possible traumatic brain injury (TBI). Concerns about ionizing radiation exposure make the evaluation more challenging. The aim of this study was to evaluate the effectiveness of the Pediatric Emergency Care Applied Research Network (PECARN) rules in predicting clinically important TBI and to determine the amount of medical resource waste and unnecessary radiation exposure. Materials and methods: This retrospective study included 1041 pediatric patients presented to the emergency department. The patients were divided into subgroups of “appropriate for cranial CT”, “not appropriate for cranial CT” and “cranial CT/observation of patient; both are appropriate”. To determine the effectiveness of the PECARN rules, data were analyzed according to the presence of pathological findings Results: “Appropriate for cranial CT” results can predict pathology presence 118,056-fold compared to the “not appropriate for cranial CT” results. With “cranial CT/observation of patient; both are appropriate” results, pathology presence was predicted 11,457-fold compared to “not appropriate for cranial CT” results. Conclusion: PECARN rules can predict pathology presence successfully in pediatric TBI. Using PECARN can decrease resource waste and exposure to ionizing radiation. Key words: Pediatric Emergency Care Applied Research Network, cost, effectiveness, computed tomography 1. Introduction Head injuries are one of the most common reasons for children to present to the emergency department (ED) (1). In the United States, blunt head trauma is the cause of more than 450,000 pediatric ED visits per year (2). Traumatic brain injury (TBI) is also an apparent reason for death and disability in children, with reports of more than 7000 deaths and 60,000 hospitalizations annually in the United States (3). Over the last decade there has been an increase in annual pediatric ED visits because of head injuries (1). More than 90% of pediatric TBIs are minor head injuries and clinically important traumatic brain injuries (ciTBIs) constitute the minority (4). Noncontrast enhanced cranial computed tomography (CT) is the method of choice to detect a possible TBI, and many children presenting at EDs with blunt head trauma are evaluated with CT scans (5%–70%) (5). Concerns about ionizing radiation exposure and body movements make the evaluation of children with minor head trauma via CT more challenging. Emergency physicians have to be sensitive about the balance between * Correspondence: 1770 missing a clinically significant traumatic brain injury and the potential risk of malignancy associated with ionizing radiation exposure (6). In 2009, using a large prospective cohort study about children with minor blunt head trauma, the Pediatric Emergency Care Applied Research Network (PECARN) stated age-based TBI clinical prediction rules to differentiate children who need a cranial CT scan from those for whom it may not be necessary (1). This rule was created according to the results of a study that included 42,412 patients examined in 25 different emergency centers in the United States. In the above-mentioned study, pediatric patients younger than 18 years having a Glasgow Coma Scale (GCS) score of 14 or 15 within 24 h after injury were divided into two main groups: those >2 years of age and those aged ≤2 years. The following criteria were stated as prediction rules for excluding ciTBI: normal mental status, no scalp hematoma except frontal, no loss of consciousness or a loss of consciousness for less than 5 s, nonsevere injury mechanisms, no palpable skull fracture, and normal activity as reported by parents (7). GÖKHARMAN et al. / Turk J Med Sci The aim of this retrospective study was to evaluate the effectiveness of the PECARN rules in the prediction of ciTBI. It was also aimed to determine the amount of medical waste and unnecessary radiation exposure and to provide some insight into unnecessary cranial CT imaging. 2. Materials and methods 2.1. Study design and setting The study protocol was approved by the Institutional Review Board of our hospital. Informed consent of the patients or their parents for participation was not required because of the design of the study. A retrospective study was made of children with minor blunt head trauma who presented at the ED between September 2015 and July 2016. The physical examination notes of children who underwent cranial CT examination after head injury were evaluated to define the necessity for head CT according to the PECARN rules. Currently, in our pediatric ED, PECARN scoring is not being used effectively to determine head CT necessity. The CT scanner available in our hospital is a 16-slice GE Optima CT540, and cranial CT examinations were obtained without contrast administration. 2.2. Study population The study included all children (<18 years of age) with blunt head trauma and an initial GCS of ≥14 who presented at the pediatric ED within 24 h of injury. Children with a trivial injury mechanism (ground-level falls, running into stationary objects, with no signs of TBI other than scalp abrasions and lacerations), neurological comorbidities, bleeding disorders, or suspected child abuse were excluded from the study. Cases were also excluded when there was insufficient information for PECARN scoring (Table 1) in the electronic archive. Table 1. PECARN TBI age-based clinical prediction forchildren children withminor blunt head trauma Table 1-PECARN TBI age-based clinical predictionrules rules for withminor blunt head trauma and initial GCSand ≥14.initial GCS ≥14. Inclusion criteria Age <18 years of age Blunt head trauma within 24 h Initial Glasgow Coma Score ≥14 Exclusion criteria Neurological comorbidities Bleeding disorders Suspected child abuse Lack of enough information for PECARN scoring PECARN TBI risk groups Any 1 of following? Yes GCS 14 Altered Mental Status† Palpable scull § NO 1 or more of following? Yes Non-frontal haematoma LOC≥ 5 seconds Severe injury mechanism¶ Not acting normal per parent Age < 2 years CT Observation vs CT Use clinical Picture to guide: MD experience ,Multi vs isolated findings, Worsening symptoms, Age < 3 months, Parental preference NO CT Any 1 of following? GCS 14 Altered Mental Status† Signs of basilar skull § NO 1 or more of following? LOC Hx vomiting Severe injury (...truncated)