Pediatric Emergency Care Applied Research Network Rules Research Articles

The role of secondary imaging in children aged under 24 months with proven skull fracture on initial computed tomography scan.

To assess the clinical significance of repeated head imaging in children with minor blunt force head trauma who underwent computed tomography (CT), limited to those who exclude with very low risk of important traumatic brain injury. We conducted a retrospective cohort study of children aged under 24 months with minor head trauma who underwent repeated head imaging and initial CT scans according to the Pediatric Emergency Care Applied Research Network (PECARN) rules. We enrolled 741 children and 110 with skull fracture (SF). Of the 96 patients with SF on initial CT who received head magnetic resonance imaging (MRI) a few days later, 36 (37.5%) patients' initial CT findings revealed intracranial injury in addition to SF. The number of children who exhibited new intracranial findings on follow-up MRI among those with isolated SF without intracranial damage and those with SF and intracranial injury on initial CT was 25/60 (40.7%) and 14/36 (38.9%), respectively. Subcutaneous hematoma on arrival and intersection with the coronal suture and lines of fracture were significantly associated with new intracranial findings. Four children with SF and intracranial injury on initial CT received neurosurgical intervention. No intervention was needed for those with isolated SF. We demonstrated that a proportion of children with head trauma had new findings on follow-up MRI, particularly in those without very low risk of clinically important traumatic brain injury. Patients who exhibit new intracranial MRI findings that satisfy the PECARN rules may not require neurosurgical intervention if their initial CT finding is isolated SF.

Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France

Pediatric traumatic brain injuries (TBIs) are a leading cause of death and disability. The Pediatric Emergency Care Applied Research Network (PECARN) guidelines provide a framework for requesting head computed tomography (HCT) after pediatric head trauma (PHT); however, quantitative data are lacking regarding both TBIs found on HCT and justification of the HCT request according to the PECARN guidelines. To evaluate the types, frequencies, and risk factors for TBIs on HCT in children referred to emergency departments (EDs) who underwent HCT for PHT and to evaluate quality of HCT request. This multicenter, retrospective cohort study included patients younger than 18 years who underwent HCT for PHT who were referred to 91 EDs during on-call hours between January 1, 2020, to May 31, 2022. Data were analyzed between July and August 2022. All radiological reports with pathologic findings were reviewed by 4 senior radiologists. Six hundred HCT requests filled by emergency physicians were randomly sampled to review the examination justification according to the PECARN guidelines. Associations between TBIs, age, sex, and Glasgow Coma Scale (GCS) were investigated using univariable χ2 and Cochrane-Armitage tests. Multivariable stepwise binary logistic regressions were used to estimate the odds ratio (ORs) for intracranial hemorrhages (ICH), any type of fracture, facial bone fracture, and skull vault fracture. Overall, 5146 children with HCT for PHT were included (median [IQR] age, 11.2 [4.7-15.7] years; 3245 of 5146 [63.1%] boys). ICHs were diagnosed in 306 of 5146 patients (5.9%) and fractures in 674 of 5146 patients (13.1%). The following variables were associated with ICH in multivariable analysis: GCS score of 8 or less (OR, 5.83; 95% CI, 1.97-14.60; P < .001), extracranial hematoma (OR, 2.54; 95% CI, 1.59-4.02; P < .001), skull base fracture (OR, 9.32; 95% CI, 5.03-16.97; P < .001), upper cervical fracture (OR, 19.21; 95% CI, 1.79-143.59; P = .006), and skull vault fracture (OR, 35.64; 95% CI, 24.04-53.83; P < .001). When neither extracranial hematoma nor fracture was found on HCT, the OR for presenting ICH was 0.034 (95% CI, 0.026-0.045; P < .001). Skull vault fractures were more frequently encountered in children younger than 2 years (multivariable OR, 6.31; 95% CI, 4.16-9.66; P < .001; reference: children ≥12 years), whereas facial bone fractures were more frequently encountered in boys older than 12 years (multivariable OR, 26.60; 95% CI, 9.72-109.96; P < .001; reference: children younger than 2 years). The justification for performing HCT did not follow the PECARN guidelines for 396 of 589 evaluable children (67.2%) for requests filled by emergency physicians. In this cohort study of 5146 children who underwent HCT for PHT, knowing the odds of clinical and radiological features for ICHs and fractures could help emergency physicians and radiologists improve their image analysis and avoid missing significant injuries. The PECARN rules were not implemented in nearly two-thirds of patients.

Predicting Complicated Mild Traumatic Brain Injury in Adolescent Trauma to Enhance Clinical Decisions in Imaging.

The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury algorithm is used to identify children at low risk of clinically significant traumatic brain injuries to reduce computed tomography (CT) exposure. Adapting PECARN rules based on population-specific risk stratification has been suggested to improve diagnostic accuracy. This study sought to identify center-specific patient variables, beyond PECARN rules, that may enhance the identification of patients requiring neuroimaging. This single-center, retrospective cohort study was conducted from July 1, 2016, to July 1, 2020, in a Southwestern U.S. Level II pediatric trauma center. The inclusion criteria were adolescents (10-15 years), Glasgow Coma Scale (13-15), with a confirmed mechanical blow to the head. Patients without a head CT were excluded. Logistic regression was performed to identify additional complicated mild traumatic brain injury predictor variables beyond the PECARN. There were 136 patients studied; 21 (15%) presented with a complicated mild traumatic brain injury. Relative to motorcycle collision or all-terrain vehicle trauma (odds ratio [OR] 211.75, 95% confidence interval, CI [4.51, 9931.41], p < .001), an unspecified mechanism (OR 42.0, 95% CI [1.30, 1350.97], p = .03) and consult activation (OR 17.44, 95% CI [1.75, 173.31], p = .01) were significantly associated with complicated mild traumatic brain injury. We identified additional factors associated with complex mild traumatic brain injury, including motorcycle collision and all-terrain vehicle trauma, unspecified mechanism, and consult activation that are not in the PECARN imaging decision rule. Adding these variables may aid in determining the need for appropriate CT scanning.

Deep Neural Networks Predict the Need for CT in Pediatric Mild Traumatic Brain Injury: A Corroboration of the PECARN Rule.

Only 10% of CT scans unveil positive findings in mild traumatic brain injury, raising concerns of its overuse in this population. A number of clinical rules have been developed to address this issue, but they still suffer limitations in their specificity. Machine learning models have been applied in limited studies to mimic clinical rules; however, further improvement in terms of balanced sensitivity and specificity is still needed. In this work, the authors applied a deep artificial neural networks (DANN) model and an instance hardness threshold algorithm to reproduce the Pediatric Emergency Care Applied Research Network (PECARN) clinical rule in a pediatric population collected as a part of the PECARN study between 2004 and2006. The DANN model was applied using 14,983 patients younger than 18 years with Glasgow Coma Scale scores ≥ 14 who had head CT reports. The clinical features of the PECARN rules, PECARN-A (group A, age < 2 years) and PECARN-B (group B, age ≤ 2 years), were used to directly evaluate the model. The average accuracy, sensitivity, precision, and specificity were calculated by comparing the model's prediction outcome to that reported by the PECARN investigators. The instance hardness threshold and DANN model were applied to predict the need for CT in pediatric patients using 5-fold cross-validation. In the first phase, the DANN model resulted in 98.6% sensitivity and 99.7% specificity for predicting the need for CT using the predictors of the two PECARN clinical rules combined to train the model. In the second phase, the DANN model was superior to both the PECARN-A and PECARN-B rules using the predictors for each age group separately to train the model. Compared with the clinical rule, for group A, the model achieved an average sensitivity (93.7% versus 100%) and specificity (97.5% versus 53.6%); for group B, the average sensitivity of the model was 99.2% versus 98.6%, and the specificity was 98.8% versus 58.2%. In this study, a DANN model achieved comparable sensitivity and outstanding specificity for replicating the PECARN clinical rule and predicting the need for CT in pediatric patients after mild traumatic brain injury compared with the original statistically derived clinical rule.

Accuracy of Pediatric Emergency Care Applied Research Network Rules in Predicting Brain Injuries

Background and Objectives: Head trauma is one of the most important causes of emergency department (ED) visits and the leading cause of disability and mortality in children. The aim of this study was to evaluate the Pediatric Emergency Care Applied Research Network (PECARN) rules to predict brain injuries in pediatrics with head trauma. Materials and Methods: This descriptive–analytic study was performed on 250 pediatric patients with head trauma referred to Imam Reza Hospital in Tabriz City from August to September 2020. All patients were evaluated in the ED for the existing of any rules of the PECARN, then the results of the PECARN rules and brain computed tomography (CT) scan findings were compared in these patients. According to the PECARN rules, patients were classified into three categories, namely low, moderate, and high risk. For all three groups, if there is an indication of brain CT scan, it was performed and reported by an emergency medicine specialist. Results: The mean age of the patients was 88 months. In this study, 162 (64.8%), 42 (16.8%), and 46 (18.4%) patients were in the low-risk, moderate-risk, and high-risk groups, respectively. Death was occurred in 18 (12.8%) patients. Results showed a statistically significant association between positive CT findings and some variables, such as behavioral change, vomiting, severe headache, LOC over 5 s, confusion, palpable skull fracture, skull base fracture, and the severe mechanism of injury (P < 0.05). Furthermore, a statistically significant association was found between PECARN rules and CT findings (P < 0.001). Conclusions: According to the results of the present study, PECARN rules have a significant association with brain CT scan findings. Therefore, using these rules is recommended to reduce the number of brain CT scan requests for pediatric patients.

External validation and comparison of the Pediatric Emergency Care Applied Research Network and Canadian Assessment of Tomography for Childhood Head Injury 2 clinical decision rules in children with minor blunt head trauma.

ObjectiveAmong the pediatric population with minor head trauma, it is difficult to determine an indication for the usage of brain computerized tomography (CT). Our study aims to compare the efficiency of the most commonly used clinical decision rules: the Pediatric Emergency Care Applied Research Network (PECARN) and Canadian Assessment of Tomography for Childhood Head Injury 2 (CATCH2).MethodsThis retrospective study investigated whether the PECARN and CATCH2 rules were applicable to Korean children with minor head trauma for reducing the use of brain CT imaging, while detecting intracranial pathology.ResultsOverall, 251 patients (0–5 years old) admitted to emergency rooms within 24 hours of injury were included between August 2015 to August 2018. The performance results are as follows: the PECARN and CATCH2 rules had a sensitivity of 80.00% (51.91%–95.67%) and 100% (78.20%–100.00%) with a specificity of 28.39% (22.73%–34.60%) and 15.25% (10.92%–20.49%), respectively; the negative predictive values were 98.58% and 100%, respectively. Overall, the CATCH2 rule was more successful than the PECARN rule in detecting intracranial pathology; however, there was no significant difference between them. Furthermore, the PECARN and CATCH2 rules lowered the rate of head CT imaging in our study group.ConclusionBoth the rules significantly lowered the rate of indicated brain CT. However, since the CATCH2 rule had higher sensitivity and negative predictive value than the PECARN rule, it is more appropriate to be used in emergency rooms for detecting intracranial pathology in children with minor head trauma.

Imaging for Pediatric Blunt Abdominal Trauma With Different Prediction Rules: Is the Outcome the Same?

Computerized tomography (CT) of the abdomen and pelvis is the standard imaging modality to diagnose intra-abdominal injury (IAI). Clinicians must weigh the risk-benefit of CT compared with the degree of clinical suspicion for an IAI. Pediatric Emergency Care Applied Research Network (PECARN), Streck, and blunt abdominal trauma in children (BATiC) prediction rules have been published to help guide evaluation of these patients. Pediatric Emergency Care Applied Research Network uses history and physical examination findings, whereas Streck and BATiC use examination plus laboratory and imaging findings. At the time of the study, there was not a protocol that was more routinely sited. Our goal was to compare these different prediction rules. This was a retrospective electronic chart review of all children younger than 18 years presenting for either level 1 or 2 trauma activations at our pediatric emergency department (ED) between June 1, 2015, to June 30, 2017. Charts were manually reviewed for a mechanism concerning for abdominal trauma, and demographic data, history and physical examination findings, laboratory and imaging results per prediction rules, and revisits in 7 days were collected.The prediction rules were applied to all charts that had all data necessary. For study purposes, a score of zero for PECARN and Streck, and score of ≤5 for modified BATiC (mBATiC) were defined as "low risk." Patients with no CT, negative CT, and no new injury found on revisit were classified as "no IAI identified," and patients with positive CT or revisit with injury found as "IAI identified." The results were compared via Fisher exact test. A total of 249 patients met the inclusion criteria with a median age of 12 years. Of the low-risk patients, 119 (98.7%) of 121 in PECARN group, 21 (100%) of 21 in Streck, and 48 (85.7%) of 56 in mBATiC group had no IAI identified. None of the low-risk patients required any intra-abdominal intervention. No missed IAI was identified during revisit review. Negative predictive values of all 3 rules were significant for PECARN, Streck, and mBATiC (98.35%, 100%, and 85.71%, respectively). Overall, 27 patients had positive CT results for IAI. The PECARN and Streck rules have high negative predictive values to predict low-risk patients who do not require CT. When laboratory studies are not obtained, PECARN is an effective means of excluding IAI for low-risk patients. When laboratory tests were obtained, the Streck rule performed well. Overall, the results are similar to the past individual studies done on each individual rule. History and physical examination findings are of high importance in pediatric trauma. This study supports limited imaging when no abnormal findings are present in children with blunt torso trauma. This is the only study found in the literature that has compared 3 different prediction rules.

Impact of Pediatric Emergency Care Applied Research Network Rules on Admission, Cranial Computed Tomography and Skull X-ray Rates in a Central European Hospital.

Mild head injury is a common cause of pediatric emergency department visits. Cranial computed tomography (CCT) is the diagnostic standard, although it involves inherent radiation risks. Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules were developed to reduce the number of CCT scans. They provide a guideline for CCT use in mild head injuries, based on clinical parameters.Our study aims to evaluate the impact of PECARN rules on hospital admission and CCT rate in children with mild head injury. In this retrospective study, we investigated 729 children with mild head injury presenting in the pediatric emergency department between 2012 and 2016. We compared 2 groups, before and after implementation of PECARN criteria in clinical routine. Of 729 included patients (417 male; 5.6 ± 4.8 years;) 380 were seen prior to implementation of the PECARN rules, compared to 349 patients afterwards. Overall admissions to the ward decreased significantly from 83.9% (n = 319) to 71.3% (n = 249) (P < 0.001), a 31.3% reduction. Calculated from all pediatric admissions, the rate of patients with mild head injury fell from 6.0% to 4.3% (P < 0.001).We recorded a nonsignificant decrease in the CCT rate, from 14.7% to 13.2% (P = 0.555).No readmissions were recorded. Our results show a significant reduction in the rate of hospital admission following implementation of the PECARN rules in our hospital. Already low, the CCT rate did not change after implementation.The PECARN rules appear to be safe because no readmissions were recorded.

Does implementation of the PECARN rules for minor head trauma improve patient-centered outcomes in a lower resource emergency department: a retrospective cohort study

BackgroundManaging children with minor head trauma remains challenging for physicians who evaluate for the need for computed tomography (CT) imaging for clinically important traumatic brain injury (ciTBI) identification. The Pediatric Emergency Care Applied Research Network (PECARN) prediction rules were adopted in our pediatric emergency department (PED) in December 2013 to identify children at low risk for ciTBI. This study aimed to evaluate this implementation’s impact on CT rates and clinical outcomes.MethodsRetrospective cohort study on pediatric patients with head trauma presenting to the PED of the American University of Beirut Medical Center in Lebanon. Participants were divided into pre- (December 2012 to December 2013) and post-PECARN (January 2014 to December 2016) groups. Patients were further divided into < 2 and ≥ 2 years and stratified into groups of low, intermediate and high risk for ciTBI. Bivariate analysis was conducted to determine differences between both groups.ResultsWe included 1362 children of which 425 (31.2%) presented pre- and 937 (68.8%) presented post-PECARN rules implementation with 1090 (80.0%) of low, 214 (15.7%) of intermediate and 58 (4.3%) of high risk for ciTBI. CTs were ordered on 92 (21.6%) pre- versus 174 (18.6%) patients post-PECARN (p = 0.18). Among patients < 2 years, CT rates significantly decreased from 25.2% (34/135) to 16.5% (51/309) post-PECARN (p = 0.03), and dropped in all risk groups but only significantly for low risk patients from 20.7% (24/116) to 11.4% (30/264) (p = 0.02). There was no significant decrease in CT rates in patients ≥2 years (20% pre (58/290) vs 19.6% post (123/628), p = 0.88). There was no increase in bounce back numbers, nor in admission rates or positive CT findings among bounce backs.ConclusionsPECARN rules implementation did not significantly change the overall CT scan rate but reduced the CT scan rate in patients aged < 2 years at low risk of ciTBI. The implementation did not increase the number of missed ciTBI.

Pediatric minor head trauma in Brazil and external validation of PECARN rules with a cost-effectiveness analysis

ABSTRACT Background Pediatric minor head trauma approaches aim to ensure the absence of traumatic brain lesions, minimize ionizing radiation, and enhance cost control. We evaluated the applicability and cost-effectiveness of the Pediatric Emergency Care Applied Research Network (PECARN) rules after head trauma and rationalize the use of head computed tomography (CT) scans. Methods We retrospectively divided patients <18 years old who presented at a single institution in Brazil with minor head trauma into four groups: Group I (skull X-ray only), Group II (head CT only), Group III (X-ray and CT), and Group IV (observation only). Direct costs were calculated based on examination and length of hospitalization. The PECARN rules were applied retrospectively in each patient to determine who required a CT scan, and the costs were re-calculated. Results Of the 1328 patients, CT scans were performed in 36.4% and X-rays in 52.6%. The mean cost was USD 5.88, 34.58, 41.85, and 4.04 for Groups I–IV, respectively. After applying the PECARN rules, 77.6% of patients no longer required a CT scan, and overall costs were reduced from USD 16.71 to 7.88 (p < .001). Conclusion: The PECARN rules demonstrated a meaningful cost-effectiveness and should be applied to the Brazilian pediatric population.

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

The aim of this study was to determine the potential impact of the Pediatric Emergency Care Applied Research Network (PECARN) rules on the CT rate in a large paediatric minor traumatic head injury (MTHI) cohort and compare this with current national Dutch guidelines. This was a planned sub-study of a prospective multicentre observational study that enrolled 1006 children younger than 18 years with MTHI. We calculated the number of recommended CT scans and described trauma-related CT scan abnormalities. The PECARN rules recommended a significantly lower percentage of CT scans in all age categories, namely 101/357 (28.3%) versus 164/357 (45.9%) (p < 0.001) in patients under 2 years of age and 148/623 (23.8%) versus 394/623 (63.2%) (p < 0,001) versus in patients 2 years and older.Conclusion: The projected CT rate can significantly be reduced if the PECARN rules are applied. We therefore advocate that the PECARN guidelines are also implemented in The Netherlands.What is Known:• To guide clinicians whether to perform a CT scan in children with a minor traumatic head injury (MTHI) clinical decision rules has been developed.• The overall CT scan rate in adherence with the Dutch MTHI guidelines is 44%.What is New:• The projected CT rate can significantly be reduced in a Dutch cohort of MTHI if the PECARN rules are applied.• The Dutch national guidelines for MTHI can safely be replaced by the PECARN rules.

Validation of the PECARN head trauma prediction rules in Japan: A multicenter prospective study

BackgroundHead trauma in children is one of the most common causes for emergency department visits. Although most trauma cases are minor, identifying those patients who have clinically important traumatic brain injury (ciTBI) is challenging. The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules identifying children who do not require cranial computed tomography (CT) were validated and are used all over the world. However, these rules have not been validated with large cohort multicenter studies in Asia. ObjectivesTo investigate whether the PECARN rules can be safely applied to Japanese children. MethodsWe conducted a multicenter, prospective, observational cohort study. We included children younger than 16 with minor head trauma (Glasgow Coma Scale ≥14) who presented to the six participating centers within 24 h of their injuries between June 2016 and September 2017.The primary analysis was set to calculate the negative predictive value of the patients with very low risk by the PECARN rules, compared with a preset threshold of 99.85%. ResultsWe included 6585 children of which 463 (7.0%) had head CT scans performed and 23 (0.35%) had ciTBI. There were two patients with ciTBI who were classified as very low risk. The negative predictive value, calculated as 99.96% (95%CI: 99.86–100.00; P = .019), was significantly superior compared with the preset threshold of 99.85%. ConclusionsThe PECARN head trauma prediction rules seemed to be safely applicable to Japanese children. Further studies are needed to determine safety in hospitals where physicians do not have expertise in managing children.

Performance of Two Head Injury Decision Rules Evaluated on an External Cohort of 18,913 Children

BackgroundThe Pediatric Emergency Care Applied Research Network (PECARN) decision rule demonstrates high sensitivity for identifying children at low risk for clinically important traumatic brain injury (ciTBI). As with the PECARN rule, the Israeli Decision Algorithm for Identifying TBI in Children (IDITBIC) recommends proceeding directly to computed tomography (CT) in children with Glasgow Coma Score (GCS) <15. The aim was to assess the diagnostic accuracy of two clinical rules that assign children with GCS <15 at presentation directly to CT. Materials and methodsAccuracy analysis for detecting ciTBI was performed on a multicenter cohort of children used in the Australasian Pediatric Head Injury Rules Study. ResultsThe external cohort included 18,913 children; 1691 (8.9%) had CT scan, 160 had ciTBI, and 24 (0.13%) had neurosurgery. Applying IDITBIC and PECARN rules would have missed 11 and 1 ciTBI patients; respectively. All patients with missed injuries were classified as such based on a hospital stay of >2 d. None of these patients died, needed neurosurgery, or required ventilatory support. In children aged <2 y, sensitivity, specificity, positive predictive value and negative predictive value of IDITBIC and PECARN rule were 95.2%, 79.5%, 3.8%, and 99.9% and 100.0%, 59.1%, 2.0%, and 100.0%, respectively. In children ≥2 y, sensitivity, specificity, positive predictive value and negative predictive value of IDITBIC and PECARN rule were 92.4%, 75.3%, 3.1%, and 99.9% and 99.2%, 52.9%, 1.7%, and 100.0%, respectively. ConclusionsThe two decision rules demonstrated high accuracy in identifying ciTBI. As a screening tool, the PECARN rule outperformed IDITBIC. The findings suggest that clinicians should strongly consider directing children with GCS <15 at presentation to CT scan.

Comparison of Machine Learning Optimal Classification Trees With the Pediatric Emergency Care Applied Research Network Head Trauma Decision Rules

Computed tomographic (CT) scanning is the standard for the rapid diagnosis of intracranial injury, but it is costly and exposes patients to ionizing radiation. The Pediatric Emergency Care Applied Research Network (PECARN) rules for identifying children with minor head trauma who are at very low risk of clinically important traumatic brain injury (ciTBI) are widely used to triage CT imaging. To examine whether optimal classification trees (OCTs), which are novel machine-learning classifiers, improve on PECARN rules' predictive accuracy. A secondary analysis of prospective, publicly available data on emergency department visits for head trauma used by the PECARN group to develop their tool was conducted to derive OCT-based prediction rules for ciTBI in a development cohort and compare their predictive performance vs the PECARN rules in a validation cohort among children who were younger than 2 years and 2 years or older. Data on 42 412 children with head trauma and without severely altered mental status who were examined between June 1, 2004, and September 30, 2006, were gathered from 25 emergency departments in North America participating in PECARN. Data analysis was conducted from September 15, 2016, to December 18, 2018. The outcome was ciTBI, with predictive performance measured by estimating the sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, and negative likelihood ratio for the OCT and the PECARN rules. The OCT and PECARN rules' performance was compared by estimating ratios for each measure. Of the 42 412 children (15 996 [37.7%] girls) included in the analysis, 10 718 were younger than 2 years (25.3%; mean [SD] age, 11.6 [0.6] months) and 31 694 were 2 years or older (74.7%; age, 9.1 [4.9] years). Compared with PECARN rules, OCTs misclassified 0 vs 1 child with ciTBI in the younger and 10 vs 9 children with ciTBI in the older cohort, and correctly identified more children with very low risk of ciTBI in the younger (7605 vs 5701) and older (20 594 vs 18 134) cohorts. In the validation cohorts, compared with the PECARN rules, the OCTs had statistically significantly better specificity (in the younger cohort: 69.3%; 95% CI, 67.4%-71.2% vs 52.8%; 95% CI, 50.8%-54.9%; in the older cohort: 65.6%; 95% CI, 64.5%-66.8% vs 57.6%; 95% CI, 56.4%-58.8%), positive predictive value (odds ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively), and positive likelihood ratio (risk ratios, 1.54; 95% CI, 1.36-1.74 and 1.23; 95% CI, 1.17-1.30, in younger and older children, respectively). There were no statistically significant differences in the sensitivity, negative predictive value, and negative likelihood ratio between the 2 sets of rules. If implemented, OCTs may help reduce the number of unnecessary CT scans, without missing more patients with ciTBI than the PECARN rules.

Compliance with PECARN head injury decision rules in children under two years old

One of the most common complaints about presentation at the Emergency Department (ED) in childhood is minor head trauma. In recent years, clinical decision rules (CDRs) have been published to assist in determining the need for performing computed tomography (CT) in these patients. The present study aims to investigate the compliance with Pediatric Emergency Care Applied Research Network (PECARN) rules in the decisions for CT examination in children aged below two years old with minor head trauma in our center. This retrospective, single-center study was conducted on a patient group aged below two years old, who presented at the ED within 24 hours of a trauma incident and were diagnosed as mild head trauma Glasgow Coma Scale score 14 and 15). A total of 262 patients were included in this study. Of these patients, 214 (81.7%) received CT examination, and 48 (18.3%) patients did not receive any CT examination. None of these 48 patients showed clinically important traumatic brain injury (ci TBI). Among 214 patients who received CT examination, 89 (34%) patients met the PECARN rules criteria and 125 (47.7%) patients did not meet PECARN rules criteria. None of the patients who received CT examination and did not meet the PECARN rules criteria showed ci TBI. Among 89 patients who recieved a CT examination and also met the PECARN rules criteria, only 4 (1.5%) patients showed ci TBI. According to these results, the rate of compliance with PECARN rules in our institution ED was 52.3%. In this study, which was conducted by including all the predictor values of the PECARN guidelines, the rate of compliance with PECARN rules was determined to be very low. Using these rules directly or with modification could establish a starting point for clinicians to reduce the rates of unnecessary CT scans. However, the effects of the clinician's experience, parental expectations, medicolegal constraints and economic factors on the decision making process should not be forgotten.

259 Imaging for Pediatric Blunt Abdominal Trauma: Different Prediction Rules, Is the Outcome the Same?

Computerized tomography (CT) of abdominal/pelvis is the standard modality to diagnose intra-abdominal injury (IAI). Clinicians must weigh the risk-benefit of CT compared to degree of clinical suspicion of an IAI. PECARN (Pediatric Emergency Care Applied Research Network), BATIC (Blunt abdominal trauma in children) and Streck prediction rules have been published to help guide evaluation of these patients. PECARN uses history and physical examination findings, while BATIC and Streck use exam plus laboratory and imaging findings. Currently, there is not one gold standard protocol used in literature. Our goal is to compare these different prediction rules. This was a retrospective electronic chart review of all children age <18 years presenting for either Level 1 or 2 trauma activations at our pediatric emergency department between June 1st 2015 through June 30th 2017. Charts were manually reviewed for a mechanism concerning for abdominal trauma and demographic data, history and physical examination findings, laboratory and imaging results per prediction rules, revisits in 7 days were collected. The prediction rules were applied to all charts that had all data necessary. A score of zero for PECARN and Streck and score <5 for BATIC were defined as “low risk.” Patients with no CT, negative CT, and no new injury found on revisit were classified as “no IAI identified” and patients with positive CT or revisit with injury found as “IAI identified.” The results were compared via Fisher’s exact test. 249 patients met inclusion criteria with median age of 12 years. Overall 27 patients had positive CT results. Out of the low-risk patients, 119/121 (98.7%) in PECARN group, 48/56 (85.7%) in BATIC group and 21/21 (100%) in Streck group had no IAI identified. (Table 1) None of the low risk patients required any intra-abdominal intervention. No missed IAI was identified during revisits. Negative predictive values for the rules were significant for PECARN, BATIC and Streck (98.35%, 85.71% and 100%, respectively) (Table 2). PECARN and Streck have high NPV to predict low-risk patients who do not require CT. When laboratory studies are not done, PECARN is an effective means of excluding IAI for low-risk patients. Batic and Streck cohorts were smaller due to a large number of cases with missing data which could be due to clinician discretion of not obtaining labs due to well appearance of child. Overall, the results are similar to the past individual studies done on each rule. History and physical examination findings are of high importance and if there are no abnormal findings, patients with blunt torso trauma may not need further evaluation. This is the only study found in literature that has compared 3 different prediction rules.View Large Image Figure ViewerDownload Hi-res image Download (PPT)

UTILIZATION OF COMPUTED TOMOGRAPHY FOR PEDIATRIC HEAD TRAUMA FROM 2007–2014 IN THE UNITED STATES: BEFORE AND AFTER PECARN CLINICAL DECISION RULES

Abstract BACKGROUND The Pediatric Emergency Care Applied Research Network (PECARN) clinical prediction rules identify children at low risk of clinically important traumatic brain injury in whom computed tomography (CT) neuro-imaging can safely be avoided. Since publication in 2009, these rules have been externally validated and are widely used in the Emergency Department (ED) assessment of children with acute head trauma. OBJECTIVES This study sought to determine if the proportion of children receiving CT-imaging in US EDs following head trauma has decreased following the development of PECARN rules. DESIGN/METHODS This study was a cross-sectional study using the National Hospital Ambulatory Care Survey (NHAMCS) database from 2007–2014. NHAMCS collects data on approximately 30,000 nationally representative visits annually to 300 randomly selected U.S EDs. We included all children &lt;18 years old presenting with a chief complaint or discharge diagnosis of head injury. We collected data on patient demographics, reason for ED visit, discharge diagnosis, patient disposition, and use of head CT. Multivariable logistic regression was used to identify characteristics of CT use, with appropriate weighting to account for the survey methodology. The primary outcome was proportion of children receiving a head CT before and after 2009. RESULTS There were 55,253 paediatric visits during the 8-year study period. Among these, 2,783 (5.3% 95%CI 5.0%-5.6%) met inclusion criteria, representing 12,417,725 paediatric head trauma visits. Median patient age was 6 years (IQR 2–13 years), 62% were male, and a majority were evaluated in non-teaching and non-paediatric hospitals (88% and 90%, respectively). Overall, 32% (95%CI 29%-35%) underwent CT neuroimaging. There was no significant difference in CT use after 2009 (31% after vs. 33% before, p=0.41). Multivariate analysis similarly demonstrated no difference after adjustment for patient age, gender, race, insurance provider, paediatric or teaching hospital, admission status and triage acuity (AOR 1.02 after vs. before, 95%CI 0.79–1.32, p=0.85). Factors associated with increased CT use were age ≥2 years (AOR 1.4, 95%CI 1.1–1.9, p=0.02), admission (AOR 5.3, 95%CI 2.2–12.4, p&lt;0.001), highest triage acuity (AOR 7.3, 95%CI 3.5–15.3, p&lt;0.001) and presentation to a non-teaching (AOR 1.5, 95%CI 1.1–2.2, p=0.02) or non-paediatric (AOR 1.5, 95%CI 1.3–2.8, p&lt;0.01) hospital. CONCLUSION The use of CT neuro-imaging did not decrease in the 5-year period following derivation of PECARN rules. Findings suggest an important need for quality improvement initiatives to ensure appropriate CT utilization among head injured children.

External Validation of the PECARN Head Trauma Prediction Rules in Japan.

The Pediatric Emergency Care Applied Research Network (PECARN) head trauma prediction rules are used to assist computed tomography (CT) decision-making for children with minor head trauma. Although the PECARN rules have been validated in North America and Europe, they have not yet been validated in Asia. In Japan, there are no clinical decision rules for children with minor head trauma. The rate of head CT for children with minor head trauma in Japan is high since CT is widely accessible across the country. The objective of this study was to evaluate the diagnostic accuracy of the PECARN rules for identifying clinically important traumatic brain injuries (ciTBI) in children with minor head trauma in Japan. We conducted a retrospective cohort study at a tertiary care pediatric hospital in Japan (30,000 patients/year). We enrolled all children younger than 18 years with minor head trauma (Glasgow Coma Scale ≥ 14) who presented to the emergency department within 24 hours of their injury between January and December 2013. We retrospectively classified the children into three risk categories according to the PECARN rules. The PECARN rules were considered negative when children were classified into the very-low-risk category. The primary outcome was considered positive when a child had ciTBI defined as head injury resulting in death, neurosurgery, intubation for>24 hours, or hospital admission ≥ 2 nights with evidence of TBI on CT. Among 2,208 children included in the study, 24 (1.1%) had ciTBI. Sensitivities and specificities of the PECARN rules to predict ciTBI were 85.7% (12/14; 95% confidence interval [CI]= 57.2 to 98.2) and 73.5% (572/778; 95% CI= 70.3 to 76.6), respectively, for children<2 years old, and 100% (10/10; 95% CI= 58.7 to 100) and 73.5% (1033/1406; 95% CI= 71.0 to 75.7) for children ≥ 2 years old, respectively. There were 10 cases of physically abused children<2 years old, and six (60%) of them had ciTBI. Also, two cases of physically abused children with ciTBI were classified as very low risk. If we did not include physically abused children, the sensitivity of the PECARN rule for children<2 years old improved from 85.7% to 100% (8/8). The PECARN rules were less sensitive for physically abused children, although the rules showed excellent applicability for the cohort without physical abuse. Thoughtful consideration may be needed for cases of nonaccidental trauma. Further prospective studies are required to verify the applicability of the PECARN rules for children with minor head trauma in Japan.

Pediatric Emergency Care Applied Research Network head injuryprediction rules: on the basis of cost and effectiveness

Background/aim: Head injuries are commonly seen in the pediatric population. Noncontrast enhanced cranial CT is the method of choice to detect possible traumatic brain injury (TBI). Concerns about ionizing radiation exposure make the evaluation more challenging. The aim of this study was to evaluate the effectiveness of the Pediatric Emergency Care Applied Research Network (PECARN) rules in predicting clinically important TBI and to determine the amount of medical resource waste and unnecessary radiation exposure.Materials and methods: This retrospective study included 1041 pediatric patients presented to the emergency department. The patients were divided into subgroups of "appropriate for cranial CT", "not appropriate for cranial CT" and "cranial CT/observation of patient; both are appropriate". To determine the effectiveness of the PECARN rules, data were analyzed according to the presence of pathological findings Results: "Appropriate for cranial CT" results can predict pathology presence 118,056-fold compared to the "not appropriate for cranial CT" results. With "cranial CT/observation of patient; both are appropriate" results, pathology presence was predicted 11,457-fold compared to "not appropriate for cranial CT" results.Conclusion: PECARN rules can predict pathology presence successfully in pediatric TBI. Using PECARN can decrease resource waste and exposure to ionizing radiation.

Are Pediatric Emergency Care Applied Research Network Rules (PECARN) Sufficient for Computed Cranial Tomography Decision in Pediatric Patients with Mild Head Trauma?

Objective: In this study we aimed to investigate the ap­plicability of Pediatric Emergency Care Applied Research Network (PECARN) rules for decision to perform computed cranial tomography (CCT) in pediatric patients with minor head trauma (MHT). Methods: 317 pediatric patients who underwent CCT for mild head trauma were evaluated retrospectively. The pa­tients were classified in two groups according to PECARN rules: below 2 years old, above 2 years old and then, these patient groups were classified into two subgroups accord­ing to the compatibility with PECARN rules. The patients re­quiring CCT according to PECARN rules were classified as PECARN compatible (PECARN +), the patients who under­went CCT without the need of CCT according to PECARN were classified as PECARN incompatible (PECARN -). Results: Approximately 20% patients in PECARN (+) group had abnormalities leading to prolonged hospitalization and only 3.8% patients of PECARN (-) group had abnormali­ties. However, none of PECARN (-) group patients required follow-up longer than 48 hours in the hospital. The most common symptoms necessitate CCT in PECARN (+) group were scalp swelling, scalp hematoma and vomiting. In PE­CARN (-) group the most common signs were cuts in the scalp and dermal abrasions. The incidence of fracture in CCT was significantly higher in PECARN (+) group. Conclusion: Because CCT poses serious radiation expo­sure, neurological examination and clinical follow-up should be preferred in the evaluation of children with MHT. In con­clusion, PECARN rules were sufficient for CCT decision in pediatric patients with MHT.