Paediatric minor head injury applied to Paediatric Emergency Care Applied Research Network CT recommendations: An audit

SA Journal of Radiology ISSN: (Online) 2078-6778, (Print) 1027-202X Page 1 of 7 Original Research Paediatric minor head injury applied to Paediatric Emergency Care Applied Research Network CT recommendations: An audit Authors: Jacques du Plessis1 Sharadini K. Gounden1 Carolyn Lewis2 Affiliations: 1 Department of Diagnostic Radiology, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa Department of Emergency Medicine, School of Clinical Medicine, University of the Witwatersrand, Johannesburg, South Africa 2 Background: Traumatic brain injury (TBI) is a common cause of paediatric morbidity and mortality, with higher TBI rates in low- and middle-income countries. Non-contrast brain CT is the gold standard for diagnosing intracranial injuries; however, it exposes patients to ionising radiation. The Paediatric Emergency Care Applied Research Network (PECARN) clinical decision rule (CDR) aids clinicians in their decision-making processes whilst deciding whether a patient at very low risk of a clinically important TBI (ciTBI) requires a CT scan. Objectives: To establish whether the introduction of the PECARN CDR would affect CT utilisation rates for paediatric patients presenting with minor blunt head injuries to an academic hospital in Gauteng, South Africa. Method: This was an audit of paediatric patients who presented with minor blunt head injuries and were referred for CT imaging at an academic hospital in Gauteng, compared with PECARN CDR recommendations, over a 1-year period. Corresponding author: Jacques du Plessis, Results: A total of 100 patients were referred for CT imaging. Twenty patients were classified as very low risk, none of whom had any CT findings of a TBI or ciTBI (p < 0.01). A total of 61 patients were classified as intermediate risk and 19 as high risk. In all, 23% of the intermediate and 47% of the high-risk patients had CT features of a TBI, whilst 8% and 37% had a ciTBI, respectively. Dates: Received: 31 Aug. 2021 Accepted: 13 Dec. 2021 Published: 14 Apr. 2022 Conclusion: Computed tomography brain imaging may be omitted in patients classified as very low risk without missing a clinically important TBI. Implementing the PECARN CDR in appropriate patients would reduce CT utilisation rates. How to cite this article: Du Plessis J, Gounden SK, Lewis C. Paediatric minor head injury applied to Paediatric Emergency Care Applied Research Network CT recommendations: An audit. S Afr J Rad. 2022;26(1), a2289. https://doi. org/10.4102/sajr.v26i1.2289 Copyright: © 2022. The Authors. Licensee: AOSIS. This work is licensed under the Creative Commons Attribution License. Read online: Scan this QR code with your smart phone or mobile device to read online. Keywords: paediatric trauma; computed tomography (CT); minor head injuries; PECARN; traumatic brain injury; diagnostic reference levels; low- and middle-income countries; ionising radiation. Introduction Traumatic brain injury (TBI) is a common cause of paediatric morbidity and mortality with an annual global reported incidence ranging between 47 and 280 per 100 000 children.1 Ninety percent of all paediatric TBIs are classified as minor,2 which is defined as a Glasgow Coma Scale (GCS) of 14–15.3 Non-contrasted head CT is the investigation of choice to diagnose an intracranial injury. In the United States, approximately half of all paediatric patients presenting with a head injury to an emergency department (ED) will be subjected to a CT examination.4 Computed tomography scans are the largest contributor to diagnostic radiation, with usage doubling between 1995 and 2005 in paediatric patients in the United States.5 The detection of lifethreatening diagnoses, however, has not changed despite the increased utilisation of CT examinations. The incidence of positive CT findings is less than 10% of examinations performed on patients with minor TBI.6,7 Population-based studies have illustrated higher TBI rates in low- and middle-income countries compared with high-income countries.8 Despite an estimated 8 million TBI cases per year in Africa, most of which occur in patients who are less than 40 years of age (incidence 801 per 100 000 persons), there is a paucity of African paediatric-specific TBI statistics.9 Paediatric patients with TBI create a diagnostic dilemma for clinicians since they present with different signs and symptoms in comparison with adults due to age-related physiological and http://www.sajr.org.za Open Access Page 2 of 7 Original Research anatomical differences. It can thus be challenging for clinicians to confidently assess the paediatric patient’s neurological status and evaluate for signs of a TBI.4,6,10 intervention; or hospital admission for observation for a period greater than or equal to two days associated with a TBI on CT.4 Treating clinicians need to balance the relative risks and benefits when deciding whether a patient requires a CT examination after sustaining minor blunt head trauma.11 The rapid diagnosis of an intracranial injury is vital to patient management;6 however, CT examinations expose patients to ionising radiation, which may result in deoxyribonucleic acid (DNA) damage.12 Paediatric patients are more susceptible to the effects of ionising radiation because of their rapid cellular turnover rates and longer life expectancy, which results in an increased risk of radiation-induced cancers when compared with adults undergoing a similar examination.11 The PECARN CDR was derived from a large, prospective cohort, which made it possible to develop two separate CDRs, one for preverbal patients (less than 2 years of age) and one for verbal patients (aged two years or more).4,15 Its use has been internally and externally validated, including in low- and middle-income countries.16 NakhjavanShahraki et al. evaluated the PECARN CDR in Iran and concluded that it had a sensitivity of 92.3% and 100.0% in predicting ciTBI in the preverbal and verbal groups, respectively.16 The PECARN CDR risk stratifies patients into one of the three groups: high, intermediate and very low risk and advises on whether CT imaging is required (see Figure 1).4,17 Diagnostic reference levels (DRLs) were introduced by the International Commission on Radiological Protection (ICRP) in 1996 to monitor procedure-specific radiation doses and thereby set the standard for acceptable clinical practice.13 Dose length product (DLP) and volume-based CT dose index (CTDIvol) are two indicators used to evaluate DRLs and quantify patient exposure to ionising radiation.11,12 The CTDIvol defines the mean dose per image slice, whilst the DLP is the product of the total scan length and CTDIvol, representing the total energy absorbed along the length of the scan.13 Many high-income countries have fixed regulations regarding the establishment and maintenance of DRLs; however, in low- and middle-income countries, a similar practice has not been widely adopted, with equipment and ma (...truncated)