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PECARN Pediatric Head Injury/Trauma Algorithm

Calculators  Neurology
The PECARN Pediatric Head Injury/Trauma algorithm predicts the need for brain imaging after pediatric head injury.
Age
<2 Years 0
>=2 Years 1
GCS ≤14, palpable skull fracture or signs of AMS
AMS: Agitation, somnolence, repetitive questioning, or slow response to verbal communication
No 0
Yes 10
GCS ≤14 or signs of basilar skull fracture or signs of AMS
AMS: Agitation, somnolence, repetitive questioning, or slow response to verbal communication
No 0
Yes 40
Occipital, parietal or temporal scalp hematoma; history of LOC ≥5 sec; not acting normally per parent or severe mechanism of injury?
Severe mechanism: MVC with patient ejection, death of another passenger, rollover; pedestrian or bicyclist w/o helmet struck by motorized vehicle; fall from >0.9m or 3ft; head struck by high-impact object
No 0
Yes 20
History of LOC or history of vomiting or severe headache or severe mechanism of injury
Motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; falls of more than 1.5m/5ft; head struck by a high-impact object
No 0
Yes 30
Result:

Background

Measured Factor
The need for head computed tomography (CT) imaging because clinically important traumatic brain injury cannot be ruled out.
Measured Factor Disease
  • Clinically important traumatic brain injury
Measured Factor Detail
The PECARN Pediatric Head Injury/Trauma algorithm is a clinical decision tool that helps physicians to safely rule out the presence of clinically important traumatic brain injuries without the need for CT imaging. The score only applies to children with Glasgow Coma Scales (GCS) of 14 or greater. The score takes into consideration age, GCS ≤ 14, palpable skull fracture or signs of AMS (agitation, somnolence, repetitive questioning, or slow response to verbal communication), and occipital, parietal or temporal scalp hematoma, history of Loss of Consciousness (LOC) ≥5 sec, not acting normally per parent, vomiting, severe headache, or severe mechanism of injury.
Speciality
Emergency Medicine Physician
Body System
Neurology
Measured Factor High Impact
  • Head CT imaging is recommended

Result Interpretation

Ranges Ranges
  • Critical High: 4.4% risk of clinically important traumatic brain injury
  • Normal: < 0.02% risk of clinically important traumatic brain injury
  • Normal Pediatric: < 0.02% risk of clinically important traumatic brain injury
Result High Conditions
  • Clinically important traumatic brain injury

Studies

Study Validation 1
Cross-sectional study aimed at validating the Pediatric Emergency Care Applied Research Network (PECARN) Pediatric Head Injury Algorithm. The study took place over two pediatric emergency departments (ED) located in the United States and Italy. Study population consisted of children presenting to the ED within 24 hours of a head injury who had a Glasgow Coma Score ≥ 14. Clinically important traumatic brain injury (TBI) was defined as head injury resulting in death, intubation for more than 24 hours, neurosurgery, or two or more nights of hospitalization for management of the head injury. Results included a total of 2439 children, of which 39% were younger than 2 years of age. A total of 373 of the children (15%) had a computed tomography (CT) performed, 69 children (3%) had traumatic findings on the CT and 19 children (0.8%) had clinically important TBI. The PECARN showed 100% sensitivity, 55% specificity, and 100% negative predictive value, with none of the children with a clinically important TBI being classified as very low risk. In conclusion, authors concluded the PECARN accurately identified children at very low risk for significant TBI and should be used in practice to help assist CT decision.
References: 2
Study Validation 2
Multicenter, prospective, non-interventional cohort study aimed at evaluating the diagnostic performance of the Pediatric Emergency Care Applied Research Network (PECARN) in a French pediatric population. The study took place over three different emergency departments (ED) and included patients younger than 16 years of age presenting within 24 hours of head trauma with Glasgow Coma Scores of 14-15. The study included a total of 1499 children of which 421 (28%) were younger than 2 years of age. A total of 76 patients had cranial computed tomography (CT) performed and 9 children (0.6%) had clinically-important traumatic brain injuries and none were classified as very low risk per the PECARN. In this study, the PECARN demonstrated 100% sensitivity, 69.9% specificity, and 100% negative predictive value. Overall, the PECARN was shown to have good predictive performance.
References: 3
Study Validation 3
Prospective study aimed at evaluating the accuracy of three clinical decision rules for identifying clinically important traumatic brain injuries in children with minor head injuries. The study included children younger than 18 years of age presenting with Glasgow Coma Scale scores of 13 – 15 within 24 hours of head injury. The study looked at three clinical decision rules including; the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), Pediatric Emergency Care Applied Research Network (PECARN), and 2 measures of physician judgment (estimated of <1% risk of traumatic brain injury and actual computed tomography ordering practice). Important traumatic brain injury was defined as death from the injury, need for neurosurgery, intubation greater than 24 hours, or hospital admission for more than two nights. A total of 1,009 children were enrolled in the study, of which 21 had clinically important traumatic brain injuries. The PECARN and physician practice were the only ones able to identify all clinically important brain injuries (PECARN:100% sensitivity and 62% specificity;  physician practice: 100% sensitivity and 50% specificity). The sensitivities of physician estimates, CATCH, and CHALICE were 95%, 91%, and 84%, respectively. The specificities of physician estimates, CATCH, and CHALICE were  68%, 44%, 85%, respectively.  In conclusion, only physician practice and PECARN were able to identify patients with clinically important traumatic brain injuries, with PECARN being slightly more specific.
References: 4
Study Additional 1
Prospective, observational study aimed at evaluating three clinical decision rules for their accuracy in determining the need for computed tomography (CT) imaging in children with head injuries. The study compared the Canadian Assessment of Tomography for Childhood Head Injury (CATCH), Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE), and Pediatric Emergency Care Applied Research Network (PECARN). The study was conducted over ten Australian and New Zealand emergency departments (ED) and included children younger than 18 years of age presenting with head injuries. A total of 20,137 children were included, of which 2106 had CT imaging performed. The PECARN had the highest point validation sensitivities with 100% in children younger than 2 years of age and 99% in children older than 2 years of age, both scores were better than those seen with CATCH and CHALICE.  In a secondary analysis including 18,913 patients with mild head injuries (Glasgow Coma Scale score 13-15), sensitivities for clinically important traumatic brain injury were similar. Negative predictive values in both analyses were higher than 99% for all clinical decision rules. In conclusion, investigators said the sensitivities of three clinical decision rules for head injuries in children were high when used as designed.
References: 5
Study Additional 2
This study used decision analytic modeling to conduct a cost-effectiveness analysis comparing the Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury prediction rule to usual care for selective computed tomography (CT) use. Study looked at outcomes, cost and cost-effectiveness of applying the PECARN rule in a hypothetical cohort of 1,000 children with minor head trauma. Investigators hypothesized that compared with usual case, using the PECARN would result in overall higher quality of life for children and would be a cost-effective strategy. The results showed that compared with the usual care strategies, implementing the PECARN strategy was projected to miss slightly more children with clinically important traumatic brain injuries (0.26 versus 0.02 per 1,000 children), but used less CT scans (274 versus 353). Additionally, using the PECARN resulted in fewer radiation-induced cancers (0.34 versus  0.45), cost less ($904,940 versus $954,420), and had lower net quality-adjusted life-year loss (-4.64 versus -5.79). In conclusion, investigators said that applying the PECARN prediction rule for children with minor head trauma leads to beneficial outcomes and more cost-effective care.
References: 6

Authors

Nathan Kuppermann, M.D., M.P.H. is a professor of emergency medicine and pediatrics at UC Davis Health. Dr. Kuppermann attended medical school at the University of California San Francisco and completed his pediatric residency at Harbor-UCLA Medical Center. His research interests include infectious diseases emergencies in children, management of pediatric trauma, diabetic ketoacidosis in children and multi-variate statistical modeling.
https://www.ucdmc.ucdavis.edu/emergency/ourteam/faculty/kuppermann.html

References

  1. Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, et al. 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.
  2. Schonfeld D, Bressan S, Da Dalt L, Henien MN, Winnett JA, et al. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014 May;99(5):427-31.
  3. Lorton F, Poullaouec C, Legallais E, Simon-Pimmel J, Chêne MA, Leroy H, et al. Validation of the PECARN clinical decision rule for children with minor head trauma: a French multicenter prospective study. Scand J Trauma Resusc Emerg Med. 2016 Aug 4;24:98.
  4. Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014 Aug;64(2):145-52, 152.e1-5
  5. Babl FE, Borland ML, Phillips N, Kochar A, Dalton S, McCaskill M, et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. Lancet. 2017 Jun 17;389(10087):2393-2402.
  6. Nishijima DK, Yang Z, Urbich M, Holmes JF, Zwienenberg-Lee M, Melnikow J, et al. Cost-effectiveness of the PECARN rules in children with minor head trauma. Ann Emerg Med. 2015 Jan;65(1):72-80.e6.