Cranial CT for Minor Head Injury

7 April, 2011 by: colinparker

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Most children with a minor head injury (GCS 14-15) have an excellent prognosis, but a small number will deteriorate unexpectedly, and go on to require neurosurgical intervention.  The last decade has seen valiant attempts at trying to define and predict this subgroup of kids who need a cranial CT, to pre-empt this deterioration.


Clinical Decision Rules seem to be the fashion when it comes to making the risk-benefit analysis in high-volume clinical conditions with a small risk of a bad outcome, but how useful are these in everyday Paediatric Emergency Medicine practice? Join us for a discussion and comparison of your favourite head CT decision instruments… Canadian, CHALICE, NICE, PECARN, CATCH – we’ve got ‘em all!


Outline: Cranial CT for MHI PEMcast

[CP] Welcome, disclaimer, intro

Traditional approach – observation, selected CT, limited evidence base
Pressures of cost and litigation
Increasing use of CT in North America – risks – XRayrisk.com
Cognitive impairment (Scandinavian studies – Hall BMJ 2004)
Consent for radiation (and contrast) and General Anaesthetic

Problem is identifying the child at risk for intracranial injury without clinical signs of intracranial injury at time of assessment (vs identifying low-risk children who do not need CT)

Ideal tool would use clinical features (ie non-invasive) in history & examination to risk stratify for intracranial injury – ie high NPV for low-risk, high PPV for high risk, with a good balance between sensitivity and specificity (ROC curve).
Also, easy to remember, prospectively validated in population of interest.

Population is important – any test looks good when prevalence of bad outcome is very low (or very high). Clinical prediction rules most helpful in situations where clinician is not sure… or to justify with science your intuitive risk assessment.

So, what combination of clinical features is useful in predicting risk?

Papers: Decision Rules

[CP] [Canadian CT Head 2001 = adults]

[KR] Palchak 2003 Annals Emerg Med

[KB] Dunning 2006 – CHALICE

[CP] Maguire 2009 Systematic Review

[KR] PECARN (Kupperman 2009 Lancet)

[CP] CATCH (Osmond 2010 CMAJ)

[KB] Pickering 2011 Systematic Review

Guidelines

[CP] [NICE 2003 = Canadian CT head mostly]

[KR] NICE  Guideline 2007

[KB] RCH Head Injury CPG

[CP] Starship

[KR] PMH – focus on minor head injury

[KB] PMH – return to sport advice

[CP] PREDICT (MB personal communication) survey findings
-plan to prospectively compare all rules

[ALL] Clinical bottom line, tips, personal experience

[CP] Summary, goodbye

References

Hall P, Adami HO, Trichopoulos D, Pedersen NL, Lagiou P, Ekbom A, Ingvar M, Lundell M, Granath F. Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study. BMJ. 2004 Jan 3;328(7430):19. PubMed PMID: 14703539

Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, McKnight RD, Verbeek R, Brison R, Cass D, Eisenhauer ME, Greenberg G, Worthington J. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001 May 5;357(9266):1391-6. PubMed PMID: 11356436.

Palchak MJ, Holmes JF, Vance CW, Gelber RE, Schauer BA, Harrison MJ, Willis-Shore J, Wootton-Gorges SL, Derlet RW, Kuppermann N. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003 Oct;42(4):492-506. PubMed PMID: 14520320.

Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K; Children’s head injury algorithm for the prediction of important clinical events study group. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006 Nov;91(11):885-91. PubMed PMID: 17056862.

Maguire JL, Boutis K, Uleryk EM, Laupacis A, Parkin PC. Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics. 2009 Jul;124(1):e145-54. Review. PubMed PMID: 19564261.

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P,Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. Epub 2009 Sep 14. PubMed PMID: 19758692.

Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G, Bailey B, Chauvin-Kimoff L, Pusic M, McConnell D, Nijssen-Jordan C, Silver N, Taylor B, Stiell IG; Pediatric Emergency Research Canada (PERC) Head Injury Study Group. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010 Mar 9;182(4):341-8. Epub 2010 Feb 8. PubMed PMID: 20142371

Pickering A, Harnan S, Fitzgerald P, Pandor A, Goodacre S. Clinical decision rules for children with minor head injury: a systematic review. Arch Dis Child. 2011 Feb 10. [Epub ahead of print] PubMed PMID: 21310894.

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