Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries

Niele, Nicky; Houten, Marlies van; Tromp, Ellen; Goudoever, Johannes B. van; Plötz, Frans B.

doi:10.1007/s00431-020-03649-w

Cited by 8 publications

(9 citation statements)

References 18 publications

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“…4,7 The development of guidelines for the utilization of head CT for the evaluation of TBI is important and has likely reduced the number of tests ordered. 8 Nonetheless, limitations of these studies should be recognized when used clinically. For instance, one of the more robust studies to produce head CT guidelines excluded patients with "trivial injury mechanisms," evidence of penetrating trauma, known brain tumor, a neurological condition that would complicate assessment, or for patients with concerns for abusive head trauma.…”

Section: Discussionmentioning

confidence: 99%

Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case

Gruber

Klingele

Monson

et al. 2023

Journal of Neurosurgery: Case Lessons

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BACKGROUND After being struck in the left side of the head by a thin metal rod, a 10-year-old, previously healthy male presented to an urgent care clinic with a subcentimeter scalp laceration in the midline parietal area and a normal neurological exam. Evaluation included skull radiographs, which did not demonstrate a definitive fracture. Following laceration repair, the patient was discharged to home. OBSERVATIONS Subsequently, progressive neurological symptoms prompted his family to bring him back for evaluation 2 days later, and computed tomography (CT) and magnetic resonance imaging (MRI) revealed an open, depressed skull fracture. Surgical intervention was performed with debridement and closure. The patient was placed on a course of intravenous antibiotics and had no subsequent evidence of infection. LESSONS In cases involving potential cranial perforation by a thin projectile, use of CT imaging or MRI, rather than plain radiographs, may prevent a delay in diagnosis and subsequent complications.

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Section: Discussionmentioning

confidence: 99%

Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case

Gruber

Klingele

Monson

et al. 2023

Journal of Neurosurgery: Case Lessons

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“…Our study performed in an Italian pediatric ED confirmed the efficacy and safety of the PR in detecting the presence of ciTBI in patients with MHI, reducing radiological investigations and exposure to ionizing radiations. In literature, different authors proposed clinical algorithms to optimize management of pediatric patients with MHI but the PR seems to have the best methodological quality [6][7][8][9][10][11][12][13][14][15][16].…”

Section: Discussionmentioning

confidence: 99%

“…It was subsequently validated in other populations and settings [7,8]. PR is currently used in many countries for the ED management of children with MHI [9][10][11].…”

Section: Introductionmentioning

confidence: 99%

PECARN Rule in diagnostic process of pediatric patients with minor head trauma in emergency department

et al. 2022

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This study aims to evaluate the efficacy of the PECARN Rule (PR) in reducing radiological investigations in children with mild traumatic head injury in comparison with current clinical practice. A retrospective study was performed in our hospital between July 2015 and June 2020. Data of all children < 18 years of age admitted to the emergency department (ED), within 24 h after a head trauma with GCS ≥ 14, were analyzed. PECARN Rule was retrospectively applied to all patients. In total, 3832 patients were enrolled, 2613 patients ≥ 2 years and 1219 < 2 years. In the group of children ≥ 2 years, 10 presented clinically important traumatic brain injury (ciTBI) and were hospitalized, 7/10 underwent neurosurgery, and 3/10 clinical observation in the pediatric ward for more than 48 h. In children < 2 years, only 3 patients presented ciTBI, 2 underwent neurosurgery and 1 hospitalized. Applying the PR, no patient with ciTBI would have been discharged without an accurate diagnosis and we would have avoided 139 CT scans in patients ≥ 2 years, and 23 in those < 2 years of age (29% less).Conclusion: We demonstrated the safety and validity of the PR in our setting with 100% sensitivity in both age groups in identifying patients with ciTBI and theoretically in reducing performed CT scans by 29%. Therefore, in patients classified in the low-risk category, it is a duty not to expose the child to ionizing radiation. What is Known:• CT is the gold standard to identify intracranial pathology in children with head injury but CT imaging of head-injured children expose them to higher carcinogenic risk.• PECARN Rules support doctors in identifying children with ciTBI in order to reduce exposure to ionizing radiation. What is New:• We demonstrate the safety and validity of the PR with 100% sensitivity in both age groups in identifying patients with ciTBI.• In our setting, the application of PECARN Rule would theoretically have allowed us to reduce the CT scan by 29%.

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“…Yet, it would be preferable to provide clinicians better tools to make a solid choice between observation and CT scan in this large group of children. Namely up to 50% of young children under 6 years of age with MTHI classify as IR [ 22 ]. Literature shows there are several subjective factors guiding the decision of clinicians, for example clinical experience of the clinician [ 7 ] and parental preference [ 8 ].…”

Section: Discussionmentioning

confidence: 99%

Young children with a minor traumatic head injury: clinical observation or CT scan?

et al. 2022

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Currently, in young children with minor traumatic head injuries (MTHI) classified as intermediate risk (IR), PECARN recommends clinical observation over computer tomography (CT) scan depending on provider comfort, although both options being possible. In this study, we describe clinicians’ choice and which factors were associated with this decision. This was a planned sub-study of a prospective multicenter observational study that enrolled 1006 children younger than 18 years with MTHI who presented to six emergency departments in The Netherlands. Of those, 280 children classified as IR group fulfilling one or more minor criteria, leaving the clinician with the choice between clinical observation and a CT scan. In our cohort, 228/280 (81%) children were admitted for clinical observation, 15/280 (5.4%) received a CT scan, 6/280 (2.1%) received a CT scan and were admitted for observation, and 31/280 (11%) children were discharged from the emergency department without any intervention. Three objective factors were associated with a CT scan, namely age above 2 years, the presence of any loss of consciousness (LOC), and presentation on weekend days.Conclusion: In children with MTHI in an IR group, clinicians prefer clinical observation above performing a CT scan. Older age, day of presentation, and any loss of consciousness are factors associated with a CT scan. What is Known:• Clinical decision rules have been developed in the management of children of different risk groups with minor traumatic head injury (MTHI).• According to the Dutch national, clinical decision rules in children under 6 years of age up to 50% of children classify as intermediate risk (IR) and clinicians may choose between clinical observation and computed tomography (CT). What is New:• In this IR group, clinical observation is chosen in 81% children with MTHI.• In the subgroup where clinicians performed a CT scan, children were older and presented more frequently on a weekend day, and more frequently consciousness was lost.

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Application of PECARN rules would significantly decrease CT rates in a Dutch cohort of children with minor traumatic head injuries

Cited by 8 publications

References 18 publications

Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case

Occult pediatric skull fracture and implications for delay in diagnosis: illustrative case

PECARN Rule in diagnostic process of pediatric patients with minor head trauma in emergency department

Young children with a minor traumatic head injury: clinical observation or CT scan?

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