PECARN Pediatric Head Injury/Trauma Algorithm

Why Use

Unlike in the adult population, CT imaging of the head in pediatric patients is believed 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 a 1 year is 1 in 1000-1500 and decreases to 1 in 5000 in a patient who is 10 years old. There are over 600,000 emergency department visits annually in the US for head trauma among patients aged 18 years or younger. Applying the PECARN Pediatric Head Injury Prediction Rule would allow providers to determine which pediatric patients they can safely discharge without obtaining a head CT.

When to Use

The PECARN Pediatric Head Injury Prediction Rule is a well-validated clinical decision aid that allows physicians to safely rule out the presence of clinically important traumatic brain injuries, including those that would require neurosurgical intervention among pediatric head injury patients who meet its criteria without the need for CT imaging.

Formula

Pearls / Pitfalls

The PECARN consortium produced the largest study to date aiming to derive and validate clinical prediction rules to identify children with very low risk of Clinically Important TBI (ciTBI) following blunt head trauma who would not require imaging. ciTBI (see “More Info” section for outcome definitions) was chosen as the primary outcome because it is clinically-driven and accounts for the imperfect test characteristics of CT. In the less than 2 year old group, the rule was 100% sensitive. In the greater than 2 year old group, the rule had 96.8% sensitivity. In those under 2 with GCS = 14, AMS, or palpable skull fracture, risk was 4.4% and CT imaging is recommended. Risk with any of the remaining predictors was 0.9%, and less than 0.02% with no predictors. In those over 2 with GCS = 14, AMS, or signs of basilar skull fracture, risk was 4.3% and CT imaging is recommended. Risk with any of the remaining 4 predictors was 0.9%, and less than 0.05% with no predictors. PECARN prediction rule outperformed both the CHALICE and the CATCH clinical decision aids in external validation studies. Points to keep in mind: Although the largest trial of its kind, the PECARN study had low rates of TBI on Head CT (5.2%) and even lower rates of ciTBI (0.9%) – this suggests overall TBI in children is rare! Head CTs were obtained in approximately 35% of patients, lower than the average estimate of 50%!

Management

PECARN Algorithm: Use A if <2 years old and B if ≥2 years old. Figure from Kuppermann 2009 .

Critical Actions

ciTBI was a rare event (0.9%) and neurosurgical intervention was even more rare (0.1%). Over 50% of each age cohort did not meet any predictors, and CT imaging is not indicated for the vast majority of these patients as risk of ciTBI was exceedingly low. Risk of ciTBI was >4% with either of the 2 higher-risk predictors in each age cohort, and imaging is recommended. For the remaining 4 lower-risk predictors in each cohort the risk of ciTBI is approximately 0.9% per predictor, and CT imaging versus observation is indicated. Judgment may be based on clinical experience, single versus multiple findings, signs clinical deterioration during observation period, patient age, and parental preference.

Advice

In patients with suspected or radiologically-confirmed TBI, first assess ABC’s and consider neurosurgical/ICU consultation or local policies in regards to fluid management, seizure prophylaxis, hypertonic saline/mannitol, disposition, etc. Observation for 4-6 hours for those who are not imaged to assess for changes in clinical status. Reassurance, Education, and Strict Return Precautions for those discharged without imaging. Follow-up with primary care provider or neurologist and Return to Play/School anticipatory guidance if concussion is suspected.

More Information

Definition of clinically-important traumatic brain injury (ciTBI) (any of the following satisfy definition): Death from traumatic brain injury (TBI) Neurosurgical intervention for traumatic brain injury Intracranial pressure monitoring Elevation of depressed skull fracture Ventriculostomy Hematoma evacuation Lobectomy Tissue debridement Dura repair Other Intubation of more than 24 hours for TBI Hospital admission of 2 nights or more for the TBI in association with TBI on CT Hospital admission for TBI defined by admission for persistent neurological symptoms or signs such as persistent alteration in mental status, recurrent emesis due to head injury, persistent severe headache or ongoing seizure management Definition of traumatic brain injury on CT (any of the following satisfy definition): Intracranial hemorrhage or contusion Cerebral edema Traumatic infarction Diffuse axonal injury Shearing injury Sigmoid sinus thrombosis Midline shift of intracranial contents or signs of brain herniation Diastasis of the skull Pneumocephalus Skull fracture depressed by at least the width of the table of the skull