Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study.
BACKGROUND
CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary.


METHODS
We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights).


RESULTS
We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations.


CONCLUSIONS
These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated.


BACKGROUND
The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.
Kuppermann
Nathan
N
Department of Emergency Medicine, University of California, Davis School of Medicine, Davis, CA, USA. nkuppermann@ucdavis.edu
Holmes
James F
JF
Dayan
Peter S
PS
Hoyle
John D
JD
Atabaki
Shireen M
SM
Holubkov
Richard
R
Nadel
Frances M
FM
Monroe
David
D
Stanley
Rachel M
RM
Borgialli
Dominic A
DA
Badawy
Mohamed K
MK
Schunk
Jeff E
JE
Quayle
Kimberly S
KS
Mahajan
Prashant
P
Lichenstein
Richard
R
Lillis
Kathleen A
KA
Tunik
Michael G
MG
Jacobs
Elizabeth S
ES
Callahan
James M
JM
Gorelick
Marc H
MH
Glass
Todd F
TF
Lee
Lois K
LK
Bachman
Michael C
MC
Cooper
Arthur
A
Powell
Elizabeth C
EC
Gerardi
Michael J
MJ
Melville
Kraig A
KA
Muizelaar
J Paul
JP
Wisner
David H
DH
Zuspan
Sally Jo
SJ
Dean
J Michael
JM
Wootton-Gorges
Sandra L
SL
D000465:Algorithms; D001696:Biomechanical Phenomena; D001930:Brain Injuries / Q000000981:diagnostic imaging / Q000209:etiology* / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D006259:Craniocerebral Trauma / Q000150:complications / Q000175:diagnosis; D003661:Decision Support Techniques; D003663:Decision Trees; D004635:Emergency Medicine / Q000379:methods; D006801:Humans; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data; D010343:Patient Admission / Q000706:statistics & numerical data; D018579:Patient Selection; D010372:Pediatrics / Q000379:methods; D011237:Predictive Value of Tests; D011446:Prospective Studies; D018570:Risk Assessment / Q000379:methods* / Q000592:standards; D012307:Risk Factors; D012720:Severity of Illness Index; D014057:Tomography, X-Ray Computed / Q000009:adverse effects / Q000706:statistics & numerical data