62 Multicenter validation of the C-3PO rule to identify young children at risk of skull fracture following head trauma

Abstract

Abstract Background There is no widely accepted clinical tool to safely predict skull fracture in young children who sustained a head trauma. The C-3PO rule is a clinical decision rule which reported that age up to 3 months, or parietal/occipital scalp hematoma are predictors of skull fracture in young children. Objectives The present study prospectively evaluated the C-3PO rule in multiple new settings. Design/Methods This was a prospective multi-centre observational study conducted in three tertiary Emergency Departments (ED) in Canada and Switzerland. Patients were included if they were up to the age of 24 months of age and had a head trauma without high risk factors for clinically important intracranial injury according to the PECARN head trauma rule. The primary outcome was a radiologically identified skull fracture identified by any radiographic imaging modalities. The independent variables were the three components of the C-3PO rule as assessed by the treating physician. The patients were treated as per the physician’s discretion and followed up by phone if there was no initial skull radiological imaging. Criterion validity of the rule was calculated. Results A total of 844 patients were included with a median age of 8 months. Thirty percent of these patients (n=263) received radiological imaging, and 52 (6.2%) patients had a skull fracture. The C-3PO rule identified 51/52 children with a fracture for a sensitivity of 98% (95% CI: 90-100%), and a specificity of 70% (95% CI: 67-74%). Applying the rule would have reduced radiological imaging from 263 to 211 patients (-20%; 95%CI: 15-25%). Conclusion The C-3PO rule can safely be applied by pediatric emergency physicians evaluating children younger than 24 months with a head trauma. It helps ED clinicians to identify young children at low risk for skull fracture, improving decision making regarding the use of CT scan for children at intermediate risk of clinically important traumatic brain injury.