Amit Kochar

Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study

BACKGROUND Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and CHALICE) in a large sample of children. METHODS In this prospective observational study, we included children and adolescents (aged <18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged <2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury [TBI], need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13-15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673. FINDINGS Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (<1%) underwent neurosurgery, and 15 (<1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7-100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4-100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2-99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2-93·4; 125/141) and CHALICE (92·3%, 89·2-94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules. INTERPRETATION The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules. FUNDING National Health and Medical Research Council, Emergency Medicine Foundation, Perpetual Philanthropic Services, WA Health Targeted Research Funds, Townsville Hospital Private Practice Fund, Auckland Medical Research Foundation, A + Trust.

Accuracy of Clinician Practice Compared With Three Head Injury Decision Rules in Children: A Prospective Cohort Study

Study objective: Three clinical decision rules for head injuries in children (Pediatric Emergency Care Applied Research Network [PECARN], Canadian Assessment of Tomography for Childhood Head Injury [CATCH], and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE]) have been shown to have high performance accuracy. The utility of any of these in a particular setting depends on preexisting clinician accuracy. We therefore assess the accuracy of clinician practice in detecting clinically important traumatic brain injury. Methods: This was a planned secondary analysis of a prospective observational study of children younger than 18 years with head injuries at 10 Australian and New Zealand centers. In a cohort of children with mild head injuries (Glasgow Coma Scale score 13 to 15, presenting in <24 hours) we assessed physician accuracy (computed tomography [CT] obtained in emergency departments [EDs]) for the standardized outcome of clinically important traumatic brain injury and compared this with the accuracy of PECARN, CATCH, and CHALICE. Results: Of 20,137 children, 18,913 had a mild head injury. Of these patients, 1,579 (8.3%) received a CT scan during the ED visit, 160 (0.8%) had clinically important traumatic brain injury, and 24 (0.1%) underwent neurosurgery. Clinician identification of clinically important traumatic brain injury based on CT performed had a sensitivity of 158 of 160, or 98.8% (95% confidence interval [CI] 95.6% to 99.8%) and a specificity of 17,332 of 18,753, or 92.4% (95% CI 92.0% to 92.8%). Sensitivity of PECARN for children younger than 2 years was 42 of 42 (100.0%; 95% CI 91.6% to 100.0%), and for those 2 years and older, it was 117 of 118 (99.2%; 95% CI 95.4% to 100.0%); for CATCH (high/medium risk), it was 147 of 160 (91.9%; 95% CI 86.5% to 95.6%); and for CHALICE, 148 of 160 (92.5%; 95% CI 87.3% to 96.1%). Conclusion: In a setting with high clinician accuracy and a low CT rate, PECARN, CATCH, or CHALICE clinical decision rules have limited potential to increase the accuracy of detecting clinically important traumatic brain injury and may increase the CT rate.

Computed tomography for head injuries in children: Change in Australian usage rates over time

Paediatric head injury is a common presentation to the ED. North American studies demonstrate increasing use of computed tomography (CT) brain scan (CTB) to investigate head injury. No such data exists for Australian EDs. The aim of this study was to describe CTB use in head injury over time in eight Australian EDs.

Paediatric procedural sedation within the emergency department.

Procedural sedation and analgesia in children requires the use of non‐pharmacological and pharmacological approaches to facilitate the management of painful procedures. The development of skills in such techniques has mirrored the development of paediatric emergency medicine as a subspecialty. Governance, education and credentialing must facilitate safe sedation practice, using a structured approach, as sedating children in the busy environment of an emergency department is not without risk. Emergency clinicians, patients and caregivers all have a role to play in developing a safe, effective sedation plan.

Accuracy of NEXUS II head injury decision rule in children: a prospective PREDICT cohort study

Objective The National Emergency X-Radiography Utilisation Study II (NEXUS II) clinical decision rule (CDR) can be used to optimise the use of CT in children with head trauma. We set out to externally validate this CDR in a large cohort. Methods We performed a prospective observational study of patients aged <18 years presenting with head trauma of any severity to 10 Australian/New Zealand EDs. In a planned secondary analysis, we assessed the accuracy of the NEXUS II CDR (with 95% CI) to detect clinically important intracranial injury (ICI). We also assessed clinician accuracy without the rule. Results Of 20 137 total patients, we excluded 28 with suspected penetrating injury. Median age was 4.2 years. CTs were obtained in ED for 1962 (9.8%), of whom 377 (19.2%) had ICI as defined by NEXUS II. 74 (19.6% of ICI) patients underwent neurosurgery. Sensitivity for ICI based on the NEXUS II CDR was 379/383 (99.0 (95% CI 97.3% to 99.7%)) and specificity was 9320/19 726 (47.2% (95% CI 46.5% to 47.9%)) for the total cohort. Sensitivity in the CT-only cohort was similar. Of the 18 022 children without CT in ED, 49.4% had at least one NEXUS II risk criterion. Sensitivity for ICI by the clinicians without the rule was 377/377 (100.0% (95% CI 99.0% to 100.0%)) and specificity was 18 147/19 732 (92.0% (95% CI 91.6% to 92.3%)). Conclusions NEXUS II had high sensitivity, similar to the derivation study. However, approximately half of unimaged patients were positive for NEXUS II risk criteria; this may result in an increased CT rate in a setting with high clinician accuracy.

Vomiting With Head Trauma and Risk of Traumatic Brain Injury

This is a prospective study of vomiting in children with head injury presenting to pediatric EDs and delineated factors that increase the risk of traumatic brain injury. OBJECTIVES: To determine the prevalence of traumatic brain injuries in children who vomit after head injury and identify variables from published clinical decision rules (CDRs) that predict increased risk. METHODS: Secondary analysis of the Australasian Paediatric Head Injury Rule Study. Vomiting characteristics were assessed and correlated with CDR predictors and the presence of clinically important traumatic brain injury (ciTBI) or traumatic brain injury on computed tomography (TBI-CT). Isolated vomiting was defined as vomiting without other CDR predictors. RESULTS: Of the 19 920 children enrolled, 3389 (17.0%) had any vomiting, with 2446 (72.2%) >2 years of age. In 172 patients with ciTBI, 76 had vomiting (44.2%; 95% confidence interval [CI] 36.9%–51.7%), and in 285 with TBI-CT, 123 had vomiting (43.2%; 95% CI 37.5%–49.0%). With isolated vomiting, only 1 (0.3%; 95% CI 0.0%–0.9%) had ciTBI and 2 (0.6%; 95% CI 0.0%–1.4%) had TBI-CT. Predictors of increased risk of ciTBI with vomiting by using multivariate regression were as follows: signs of skull fracture (odds ratio [OR] 80.1; 95% CI 43.4–148.0), altered mental status (OR 2.4; 95% CI 1.0–5.5), headache (OR 2.3; 95% CI 1.3–4.1), and acting abnormally (OR 1.86; 95% CI 1.0–3.4). Additional features predicting TBI-CT were as follows: skull fracture (OR 112.96; 95% CI 66.76–191.14), nonaccidental injury concern (OR 6.75; 95% CI 1.54–29.69), headache (OR 2.55; 95% CI 1.52–4.27), and acting abnormally (OR 1.83; 95% CI 1.10–3.06). CONCLUSIONS: TBI-CT and ciTBI are uncommon in children presenting with head injury with isolated vomiting, and a management strategy of observation without immediate computed tomography appears appropriate.

Penetrating head injuries in children presenting to the emergency department in Australia and New Zealand. A PREDICT prospective study

Penetrating head injuries (pHIs) are associated with high morbidity and mortality. Data on pHIs in children outside North America are limited. We describe the mechanism of injuries, neuroimaging findings, neurosurgery and mortality for pHIs in Australia and New Zealand.

Bell's palsy in children: Current treatment patterns in Australia and New Zealand. A PREDICT study

The aetiology and clinical course of Bells palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bells palsy in children. The aim of the study was to assess current practice in paediatric Bells palsy in Australia and New Zealand Emergency Departments (ED) and determine the feasibility of conducting a multicentre RCT within the Paediatric Research in Emergency Departments International Collaborative (PREDICT).

G298(P) Paediatric intentional head injuriesin the emergency department. A predict multicentre prospective cohort study

Aims While the majority of head injuries (HIs) in children are non-intentional, there is limited information on intentional HIs outside abusive head trauma. The objective of this study was to describe epidemiology, demographics and severity of intentional HIs in childhood in a multicentre study in Australia and New Zealand. Methods Planned secondary analysis of a prospective multicentre cohort study of children aged <18 years across 10 centres in Australia and New Zealand between April 2011 and November 2014. Victorian state epidemiology codes (intent, activity, place, mechanism) were used to prospectively code the injuries. Clinical information including history of injury event and examination findings were collected and data were descriptively analysed. Results Intentional injuries were found in 372 of 20 137 (1.8%) head injured children. Injuries were caused by caregivers (103, 27.7%), by peers (97, 26.1%), by sibling (47, 12.6%), due to attack by stranger (35, 9.4%), by person with unknown relation to patient (21, 5.6%), intentional self-harm (7, 1.9%), legal intervention (1, 0.3%) or undetermined intent (61, 16.4%). 75.7% of victims of assault by caregiver were under 2 years old, whereas for other causes only 4.9% were under 2 years. Overall, 66.9% of victims were male. Rates for admission, CT scan and abnormal CT rates varied from 77.7%, 68.9% and 47.6% for assault by caregiver, 37.1%, 37.1% and 5.2% for attack by stranger, 23.7%, 18.6% and 5.2% for assault by peer and 8.5%, 2.1% and 2.1% for injuries caused by sibling respectively. Conclusion Intentional head injuries are infrequent in children. The most frequent cause is injury by caregiver or peer assault. HI due to assault by caregiver results in more abnormal findings on a CT scan than other mechanisms of intentional HI.

ANNUAL ACUTE HOSPITAL COST OF PAEDIATRIC HEAD INJURY IN AUSTRALIA – A PAEDIATRIC RESEARCH IN EMERGENCY DEPARTMENTS INTERNATIONAL COLLABORATIVE (PREDICT) STUDY

Objectives & Background Children with head injuries (HIs) frequently present to acute care settings. Most injuries are mild, but a small portion of patients have clinically significant intracranial injuries. An attempt to estimate the cost of paediatric HIs using prospectively collected data has never been attempted in Australia. We aimed to estimate the total cost paediatric HI in Australia and provide an understanding of the costs associated with different causative and presentation factors. Methods The study was embedded in a prospective observational study of 20,255 children <18 years designed to validate three published clinical decision rules. Each patients hospital presentation was micro-costed and then extrapolated to an annualised Australia-wide figure using Australian Independent Hospital Pricing Authority data. Results There were 109,729 cases of HI in children aged 0–18 years across Australia in the fiscal year 2012–2013 (1.67% of total emergency presentations). The average cost of each HI was