Mark D Lyttle

Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries.

Many children present to emergency departments following head injury (HI), with a small number at risk of avoidable poor outcome. Difficulty identifying such children, coupled with increased availability of cranial CT, has led to variation in practice and increased CT rates. Clinical decision rules (CDRs) have been derived for paediatric HI but there is no published comparison to assist in deciding which to implement. The content of the three of highest quality and accuracy are described and compared. Systematic reviews of paediatric HI CDRs were published in 2009 and 2011. To identify CDRs published since the most recent review, key databases were searched, selecting studies which included CDRs involving children aged 0–18 years with a history of HI. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies Tool, and performance evaluated by reported accuracy. Three high quality CDRs were identified: CATCH (Canadian Assessment of Tomography for Childhood Head Injury) CHALICE (Childrens Head Injury Algorithm for the Prediction of Important Clinical Events) and PECARN (Paediatric Emergency Care Applied Research Network). All were derived with high methodological standards but differed in key areas, including study population, outcomes and severity of HI. Each stated different predictor variables and only PECARN provided a separate algorithm for young children. CATCH and CHALICE identify children requiring CT and PECARN those who do not. All perform with high sensitivity and low specificity. PECARN is the only validated CDR, and none has undergone impact analysis. These three CDRs should undergo validation and comparison in a single population, with analysis of their impact on practice and financial implications, to aid relevant bodies in deciding which to implement.

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.

Applicability of the CATCH, CHALICE and PECARN paediatric head injury clinical decision rules: pilot data from a single Australian centre

Background Clinical decision rules (CDRs) for paediatric head injury (HI) exist to identify children at risk of traumatic brain injury. Those of the highest quality are the Canadian assessment of tomography for childhood head injury (CATCH), Childrens head injury algorithm for the prediction of important clinical events (CHALICE) and Pediatric Emergency Care Applied Research Network (PECARN) CDRs. They target different cohorts of children with HI and have not been compared in the same setting. We set out to quantify the proportion of children with HI to which each CDR was applicable. Methods Consecutive children presenting to an Australian paediatric Emergency Department with HIs were enrolled. Published inclusion/exclusion criteria and predictor variables from the CDRs were collected prospectively. Using these we determined the frequency with which each CDR was applicable. Results 1012 patients (69.9%) were enrolled with 949 available for analysis. Mean age was 6.8 years (21% <2 years). 95% had initial Glasgow Coma Scale 15. CT rate was 12.8% and neurosurgery rate was 0.7%. No CDR was applicable to all patients. CHALICE was applicable to the most (97%, 95% CI 96% to 98%) and CATCH to the fewest (26%, 95% CI 24% to 29%). PECARN was applicable to 76% (95% CI 70% to 82%) aged <2 years, and 74% (95% CI 71% to 77%) aged 2–<18 years. Conclusions Each CDR is applicable to a different proportion of children with HI. This makes a direct comparison of the CDRs difficult. Prior to selection of any for implementation they should undergo validation outside the derivation setting coupled with an analysis of their performance accuracy, usability and cost effectiveness.

Which intravenous bronchodilators are being administered to children presenting with acute severe wheeze in the UK and Ireland

During a prospective 10-week assessment period, 3238 children aged 1–16 years presented with acute wheeze to Paediatric Emergency Research in the UK and Ireland centres. 110 (3.3%) received intravenous bronchodilators. Intravenous magnesium sulfate (MgSO4) was used in 67 (60.9%), salbutamol in 61 (55.5%) and aminophylline in 52 (47.3%) of cases. In 35 cases (31.8%), two drugs were used together, and in 18 cases (16.4%), all three drugs were administered. When used sequentially the most common order was salbutamol, then MgSO4, then aminophylline. Overall, 30 different intravenous treatment regimens were used varying in drugs, dose, rate and duration.

The accuracy of existing prehospital triage tools for injured children in England--an analysis using trauma registry data.

Objectives To investigate the performance characteristics of prehospital paediatric triage tools for identifying seriously injured children in England. Design Eight prehospital paediatric triage tools were identified by literature review and by survey of the Lead Trauma Clinicians across English Strategic Health Authorities. Retrospective clinical registry data from the Trauma Audit and Research Network were used to determine the performance characteristics of each tool, using ‘gold standards’ for under- and over-triage of <5% and <25–50%, respectively, as benchmarks for performance. Participants 701 patient records were included. Inclusion criteria were all injured patients aged <16 years admitted to a receiving unit direct from the scene of accident in the period 2007–2010, for whom all key discriminator fields were recorded in the Trauma Audit and Research Network database. Outcome measures The main outcome measure was how each tool functioned with regard to their under- and over-triaging features. Other performance characteristics, for example, predictive values and likelihood ratios were also calculated. Results Two (of eight) triage tools demonstrated acceptable under-triage rates (3% and 4%) but had unacceptably high over-triage rates (83% and 72%). Two tools demonstrated acceptable over-triage rates (7% and 16%), but with unacceptably high under-triage rates (61% and 63%). Four tools had unacceptably high under- and over-triage rates. Conclusions None of the prehospital triage tools currently used or being developed in England meet recommended criteria for over- and under-triage rates. There is an urgent need for the development of triage tools to accurately risk-stratify injured children in the prehospital setting.

British guideline on the management of asthma: SIGN Clinical Guideline 141, 2014

### Clinical bottom line This latest revision of national guidance on asthma management was produced jointly by the British Thoracic Society (BTS) and the Scottish Intercollegiate Guidelines Network (SIGN) in October 2014 and marks the largest revision to date including changes to the guideline structure.1 Established standards for guideline development were followed to produce recommendations for the emergency and long-term management of asthma in children, adolescents and adults. There was wide stakeholder input from national and international individuals and institutions, with opportunity for feedback via conferences and websites; the guideline was also reviewed by independent expert referees and underwent editorial review to ensure comments were addressed and bias was minimised. It provides a basis for high-quality care for acute and chronic asthma, and a stimulus for research in the areas in which evidence is still lacking. The first joint BTS/SIGN asthma guideline was published in 2003 as a ‘living guideline’, with annual updates between 2004 and 2012, and every two years since; this is the first such update. In this revision, BTS/SIGN have helpfully presented a new section of key recommendations for implementation and linked these to the National Institute for Health and Care Excellence (NICE) Quality Standard (QS) for asthma, which was published in February 2013.2 ### Diagnosis

Are you a SCEPTIC? SoCial mEdia Precision & uTility In Conferences

We analysed Twitter feeds at an emergency medicine scientific conference to determine the (1) accuracy of disseminated educational messages and the (2) use in providing rapid feedback to speakers. Most speakers were happy for key messages to be tweeted, and the majority of tweets (34/37) represented these accurately. It is important that speakers and conference organisers consider Twitter use and its potential benefits and disadvantages.

Variation in treatment of acute childhood wheeze in emergency departments of the United Kingdom and Ireland: an international survey of clinician practice

Objective National clinical guidelines for childhood wheeze exist, yet despite being one of the most common reasons for childhood emergency department (ED) attendance, significant variation in practice occurs in other settings. We, therefore, evaluated practice variations of ED clinicians in the UK and Ireland. Design Two-stage survey undertaken in March 2013. Stage one examined department practice and stage two assessed ED consultant practice in acute childhood wheeze. Questions interrogated pharmacological and other management strategies, including inhaled and intravenous therapies. Setting and participants Member departments of Paediatric Emergency Research in the United Kingdom and Ireland and ED consultants treating children with acute wheeze. Results 30 EDs and 183 (81%) clinicians responded. 29 (97%) EDs had wheeze guidelines and 12 (40%) had care pathways. Variation existed between clinicians in dose, timing and frequency of inhaled bronchodilators across severities. When escalating to intravenous bronchodilators, 99 (54%) preferred salbutamol first line, 52 (28%) magnesium sulfate (MgSO4) and 27 (15%) aminophylline. 87 (48%) administered intravenous bronchodilators sequentially and 30 (16%) concurrently, with others basing approach on case severity. 146 (80%) continued inhaled therapy after commencing intravenous bronchodilators. Of 170 who used intravenous salbutamol, 146 (86%) gave rapid boluses, 21 (12%) a longer loading dose and 164 (97%) an ongoing infusion, each with a range of doses and durations. Of 173 who used intravenous MgSO4, all used a bolus only. 41 (24%) used non-invasive ventilation. Conclusions Significant variation in ED consultant management of childhood wheeze exists despite the presence of national guidance. This reflects the lack of evidence in key areas of childhood wheeze and emphasises the need for further robust multicentre research studies.

When do children get burnt

Burns are a cause of more than 5000 paediatric hospital admissions per year in England and Wales. Injury prevention and service provision may be better planned with knowledge of burn timing. Prospectively collected records from 1st January 2010 to 31st December 2011 were analysed. All episodes involving patients less than 16 years of age reviewed by the South West Childrens Burns Centre were included. Data was collected from 1480 records to investigate seasonal, weekly, and daily variation. Day to day analysis showed significantly more burns occurred on Saturday and Sunday than Monday-Friday (p<0.001). Of all burns, 46% occurred within the time-period 08:00-15:59; however the mean hourly rate of burns was highest between 16:00 and 18:59. Of the larger burns (>10% body surface area), 38% occurred after 19:00. There was no statistically significant variation in the monthly (p=0.105) or seasonal (p=0.270) distribution of burns. Bank holidays did not cause a statistically significant increase in numbers. Injury prevention strategies are likely to have most volume impact by increasing awareness of the peak time for burns in children, enabling parents at home with young children to modify any risky behaviour and by targeting older children and their behaviour.

Pediatric Emergency Research in the UK and Ireland (PERUKI): developing a collaborative for multicentre research

Paediatric Emergency Medicine (PEM) has evolved significantly in the UK and Ireland. Recognition as a subspecialty by the Royal College of Paediatrics & Child Health (RCPCH) and the College of Emergency Medicine, and the existence of the Association of Pediatric Emergency Medicine (PEM), have resulted in structured training programmes and enhanced paediatric emergency care. However, the limited evidence base for a number of childhood conditions treated in Emergency Departments (EDs) leads to variability in practice.1 To further improve emergency care of children in our population, further evidence must be generated. This can only be achieved through cohesive multicentre PEM research. With presentations encompassing the full spectrum of childhood illness and injury, EDs theoretically provide an ideal research environment, yet there are a number of perceived challenges. These are resource, clinical, attitudinal, or system based, and impact on development, delivery and translation of findings. They include: