Abstract
BackgroundClinical decision rules (CDRs) aid in the management of children with traumatic brain injury (TBI). Recently, the Scandinavian Neurotrauma Committee (SNC) has published practical, evidence-based guidelines for children with Glasgow Coma Scale (GCS) scores of 9–15. This study aims to validate these guidelines and to compare them with other CDRs.MethodsA large prospective cohort of children (< 18 years) with TBI of all severities, from ten Australian and New Zealand hospitals, was used to assess the SNC guidelines. Firstly, a validation study was performed according to the inclusion and exclusion criteria of the SNC guideline. Secondly, we compared the accuracy of SNC, CATCH, CHALICE and PECARN CDRs in patients with GCS 13–15 only. Diagnostic accuracy was calculated for outcome measures of need for neurosurgery, clinically important TBI (ciTBI) and brain injury on CT.ResultsThe SNC guideline could be applied to 19,007/20,137 of patients (94.4%) in the validation process. The frequency of ciTBI decreased significantly with stratification by decreasing risk according to the SNC guideline. Sensitivities for the detection of neurosurgery, ciTBI and brain injury on CT were 100.0% (95% CI 89.1–100.0; 32/32), 97.8% (94.5–99.4; 179/183) and 95% (95% CI 91.6–97.2; 262/276), respectively, with a CT/admission rate of 42% (mandatory CT rate of 5%, 18% CT or admission and 19% only admission). Four patients with ciTBI were missed; none needed specific intervention. In the homogenous comparison cohort of 18,913 children, the SNC guideline performed similar to the PECARN CDR, when compared with the other CDRs.ConclusionThe SNC guideline showed a high accuracy in a large external validation cohort and compares well with published CDRs for the management of paediatric TBI.
Highlights
Clinical decision rules (CDRs) aid in the management of children with traumatic brain injury (TBI)
The Scandinavian Neurotrauma Committee (SNC) guideline is intended for all children (< 18 years) with head injury and a Glasgow Coma Scale (GCS) of 9–15, presenting within 24 h of injury [20]
In this study, we were able to apply a multinational clinical head injury guideline from Scandinavia to a large, previously collected data set of head injured children and externally assess the accuracy of the guideline
Summary
Clinical decision rules (CDRs) aid in the management of children with traumatic brain injury (TBI). Several CDRs for children have been developed including the Pediatric Emergency Care Applied Research Network (PECARN) rule, the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) rule and the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) rule [14,15,16]. These were derived using high-quality methods and have recently been externally validated in a large prospective cohort [17]. Not borne out by recent data [18, 19], there is an ongoing concern that these rules may increase CT use in some settings [20]
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