Summary
Usage In the pediatric population (age 18 years or younger), CT imaging of the head is thought to be associated with an increased risk of lethal malignancy over the life of the patient, with the risk decreasing with age. The estimated risk of lethal malignancy from a head CT in one year is 1 in 1000-1500. The risk decreases to 1 in 5000 once the patient is 10 years old. The Pediatric Emergency Care Applied Research Network (PECARN) conducted the largest study to derive and validate clinical prediction rules to identify children with very low risk of Clinically Important Traumatic Brain Injury (ciTBI) following blunt head trauma who do not need imaging. As a result, the PECARN Pediatric Head Injury Prediction Rule can assist providers in determining which pediatric patients they can safely discharge without obtaining a head CT. Of note, the PECARN study results suggest overall TBI in children is rare with low rates of TBI on head CT (5.2%) and even lower rates of ciTBI (0.9%).. Summary The PECARN Pediatric Head Injury Prediction Rule is a well-validated clinical decision aid. The criteria allow clinicians to safely rule out the presence of clinically important traumatic brain injuries among pediatric head injury patients without the need for CT imaging. RecommendationsCriteriaPECARN Study FindingsCT not recommended (< 2 years old)< 2 years"No" to the following: GCS¹ ≤ 14 or other signs of AMS² or palpable skull fracture"No" to the following: Occipital, parietal or temporal scalp hematoma; history of LOC³ ≥ 5 sec; not acting normally per parent or severe mechanism⁴ of injuryRepresents 53.2% of population.Risk of ciTBI⁷ (<0.02%) which is exceedingly low, generally lower than risk of CT-induced malignancies.CT not recommended ( ≥ 2 years old)≥ 2 years"No" to the following: GCS ≤ 14 or other signs of AMS or signs of basilar skull fracture"No" to the following: History of LOC or history of vomiting or severe headache or severe mechanism of injuryRepresents 57.2% of population.Risk of ciTBI (<0.05%) which is exceedingly low, generally lower than risk of CT-induced malignancies.CT recommended (< 2 years old)< 2 years"Yes" to the following: GCS ≤ 14 or other signs of AMS or palpable skull fractureRepresents 13.9% of population.Risk of ciTBI (4.4%) CT recommended (≥ 2 years old)≥ 2 years"Yes" to the following: GCS ≤ 14 or other signs of AMS or signs of basilar skull fractureRepresents 14% of population.Risk of ciTBI (4.3%)Observation versus CT on the basis of other clinical factors⁵ (< 2 years old)< 2 years"Yes" to the following: GCS ≤ 14 or other signs of AMS or palpable skull fracture"Yes" to the following: Occipital, parietal or temporal scalp hematoma; history of LOC ≥ 5 sec; not acting normally per parent or severe mechanism of injuryRepresents 32.9% of population.Risk of ciTBI (0.9%)Patients with certain isolated findings (i.e. with no other findings suggestive of traumatic brain injury) have a risk of ciTBI substantially lower than 1%Observation versus CT on the basis of other clinical factors (≥2 years old)≥ 2 years"Yes" to the following: GCS ≤ 14 or other signs of AMS or signs of basilar skull fracture"Yes" to the following: History of LOC or history of vomiting or severe headache or severe mechanism of injuryRepresents 28.8% of population.Risk of ciTBI (0.8%)Patients with certain isolated findings (i.e. with no other findings suggestive of traumatic brain injury) have a risk of ciTBI substantially lower than 1% ¹Glascow Coma Scale (GCS) ²Other signs of altered mental status (AMS): Agitation, somnolence, repetitive questioning, or slow response to verbal communication. ³Loss of Consciousness (LOC) ⁴Severe mechanism:Motor vehicle crash (MVC) with patient ejectionMVC with death of another passenger or rolloverPedestrian or bicyclist w/o helmet struck by motorized vehicleFall from > 3 ft (0.9 m)Head struck by high-impact object ⁵Other clinical factors include:Clinician experienceMultiple versus isolated findings⁶Worsening symptoms or signs after emergency department observationAge < 3 monthsParental preference ⁶Isolated findings:Isolated Loss of ConsciousnessIsolated headacheIsolated vomitingCertain types of isolated scalp hematomas in infants > 3 months ⁷Definition of clinically important traumatic brain injury (ciTBI) (any of the following)Death from traumatic brain injury (TBI)Neurosurgical intervention for TBIIntubation of more than 24 hours for TBIHospital Admission of 2 nights or more for the TBI in association with TBI on CT^ ^Definition of TBI on CT (any of the following):Intracranial hemorrhage or contusionCerebral edemaTraumatic infarctionDiffuse axonal injuryShearing injurySigmoid sinus thrombosisMidline shift of intracranial contents or signs of brain herniationDiastasis of the skullPneumocephalusSkull fracture depressed by at least the width of the table of the skull Management Considerations:Clinical judgement also plays a key role in work-up and disposition. For example, judgement may be based on:If the event was witnessed or historical reliabilityPatient ageParental preferenceClinical deteriorationPatient co-morbiditiesFor those with suspected or radiologically-confirmed traumatic brain injury (TBI):First assess ABC's and consider neurosurgical/ICU consultation Consult institutional protocols on, for example: Fluid managementSeizure prophylaxisHypertonic saline or mannitolAdmission or dispositionFor those not imaged, observation for 4-6 hours to monitor changes in clinical status.For those dischargedReassurance, education and strict return precautions. Follow-up with primary care or neurologist.If concussion suspected, return to play or school anticipatory guidance.Concussion awareness, diagnosis and treatment (AAFP) resources..