Performance of a Decision Rule to Predict Need for Computed Tomography Among Children With Blunt Head Trauma

Abstract

OBJECTIVE. To assess the ability of the NEXUS II head trauma decision instrument to identify patients with clinically important intracranial injury (ICI) from among children with blunt head trauma.METHODS. An analysis was conducted of the pediatric cohort involved in the derivation set of National Emergency X-Radiography Utilization Study II (NEXUS II), a prospective, observational, multicenter study of all patients who had blunt head trauma and underwent cranial computed tomography (CT) imaging at 1 of 21 emergency departments. We determined the test performance characteristics of the 8-variable NEXUS II decision instrument, derived from the entire NEXUS II cohort, in the pediatric cohort (0 -18 years of age), as well as in the very young children (Ͻ3 years). Clinically important ICI was defined as ICI that required neurosurgical intervention (craniotomy, intracranial pressure monitoring, or mechanical ventilation) or was likely to be associated with significant long-term neurologic impairment.RESULTS. NEXUS II enrolled 1666 children, 138 (8.3%) of whom had clinically important ICI. The decision instrument correctly identified 136 of the 138 cases and classified 230 as low risk. A total of 309 children were younger than 3 years, among whom 25 had ICI. The decision instrument identified all 25 cases of clinically important ICI in this subgroup.CONCLUSIONS. The decision instrument derived in the large NEXUS II cohort performed with similarly high sensitivity among the subgroup of children who were included in this study. Clinically important ICI were rare in children who did not exhibit at least 1 of the NEXUS II risk criteria. a common cause of emergency-department (ED) presentation, accounting for ϳ1 million visits annually. 1 Although the majority of patients with head trauma have a minor injury that requires no specific therapy, a small number prove to have clinically significant intracranial injury (ICI). Because of the risk of unrecognized ICI, clinicians liberally order cranial computed tomography (CT) in blunt trauma, generating annual charges of nearly $750 million while revealing significant ICI in Ͻ60 000 patients. [2][3][4] The overuse of CT may be even more pronounced in children, who comprise almost 40% of these patients, 5 because of the greater difficulty in assessing neurologic function in at least some of them.A number of investigators have attempted to identify clinical criteria that accurately predict which patients are at risk for ICI and thus limit CT imaging to such patients. Although these reports provide some preliminary evidence, limitations in study design, including retrospective chart review, small sample size, and restricted age or selection criteria, limit the strength of any of these instruments. [7][8][9][10][11][13][14][15][18][19][20][21][22][23][24][25] The National Emergency X-Radiography Utilization Study II (NEXUS II) is an ongoing, prospective, multicenter study of blunt head trauma victims that was designed to derive and subsequently validate a decision aid to ide...

Neuroimaging findings in pediatric sports-related concussion

“…15,23 Head injury occurring during a sporting activity has consistently failed to be identified as a risk factor for an abnormal CT finding across pediatric studies, which includes other risk factors such as low Glasgow Coma Scale score; suspected open, depressed, or basal skull fractures; persistent headache or irritability; large or boggy scalp hematoma; and dangerous mechanism of injury (i.e., motor vehicle accident, fall from bicycle with no helmet). 3,16,24,27,[35][36][37] These studies have informed the development of several clinical decision rules that help guide the judicious use of CT imaging in pediatric patients with mTBI who are evaluated in the emergency department. 3,16,24,27,[35][36][37] In the present study, 21% of CT imaging studies performed by emergency department physicians in patients with suspected SRC demonstrated abnormal findings, including calvarial skull fracture (1 patient), orbital floor fracture (1 patient), suspected ICH (2 patients), and posterior fossa arachnoid cyst (1 patient).…”

“…3,16,24,27,[35][36][37] These studies have informed the development of several clinical decision rules that help guide the judicious use of CT imaging in pediatric patients with mTBI who are evaluated in the emergency department. 3,16,24,27,[35][36][37] In the present study, 21% of CT imaging studies performed by emergency department physicians in patients with suspected SRC demonstrated abnormal findings, including calvarial skull fracture (1 patient), orbital floor fracture (1 patient), suspected ICH (2 patients), and posterior fossa arachnoid cyst (1 patient). One patient was found to have a normal anatomical variant of the septum pellucidum, including a cavum septum pellucidum and a cavum vergae, which was classified as a normal finding and is present in up to 20% of the general pediatric population on neuroimaging.…”

CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury

“…A number of studies have been conducted in the past 10 years to identify a set of high-risk findings that would clearly indicate which children with minor head injury should undergo CT. [29][30][31][32][33][34] Unfortunately, those studies have been highly variable in design, and few could be considered robust according to methodologic standards for the development of clinical decision rules. 11 Interestingly, all of the clinical variables that Note: CI = confidence interval, NA = not applicable, OR = odds ratio, SD = standard deviation.…”

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“…19 Porém, a especificidade desse sintoma na predição de lesão intracraniana é baixa, especialmente em crianças abaixo de 3 anos de idade. 26 Alguns autores relacionam a presença de VPTCE como fator de risco de lesão intracraniana em pacientes com nível de consciência preservado. 27,28 Nosso trabalho está de acordo com outros autores para os quais episódio de vômito isolado pós-TCE não é fator de risco independente.…”