I. Abd El-shafy1,2, N. L. Denning1, M. L. Reppucci,1, J. T. Avarello1, M. Mittler1, N. A. Christopherson1, J. M. Prince1 1North Shore University And Long Island Jewish Medical Center,Pediatric Surgery,Manhasset, NY, USA 2Maimonides Medical Center,Surgery,Brooklyn, NY, USA
Early identification of clinically-important traumatic brain injury (ciTBI) is essential for providing acute intervention for pediatric patients with head trauma. Approximately 50% of children in North American emergency departments receive a CT following head trauma, highlighting the need to limit radiation exposure. The use of the PECARN head injury clinical prediction rules have been shown to reduce the number of head CTs completed without an increase in missed injuries. We sought to define the potential impact of strict adherence to PECARN guidelines at a newly designated level I ACS-verified pediatric trauma center.
Methods
A retrospective chart review was conducted of all pediatric head trauma patients with GCS of 14 or greater who underwent a head CT, at a level 1 ACS-verified pediatric trauma center in 2015. Patients with coagulative disorders, neurological comorbidities, or whose mechanism of injury is related to suspected child abuse were excluded. Children transferred from an outside hospital specifically for head CT were also excluded. Data collected included basic demographics, the severity of the injury, loss of consciousness, components of clinical presentation used in the PECARN algorithm, CT scan findings, and the presence of clinically important traumatic brain injury (ciTBI). We used clinical events used by PECARN to define ciTBI. Descriptive statistics were used to describe the sample and determine the percent of subjects classified by the PECARN algorithm; namely, CT recommended vs. CT not recommended. All analysis was conducted in SAS version 9.4 (SAS Institute, Inc., Cary, NC).
Results
A total of 381 pediatric subjects presented to the ED with head trauma that received a head CT. 16 subjects were removed because their head CT was canceled and never performed. Patients had an average age of 8.33 ± 6.01 years with a male predominance of 63.76%. The PECARN algorithm classified 331 (86.88%) as no CT recommended, 38 (9.97%) as CT recommended and 12 (3.15%) could not be classified due to missing data points. Among all subjects with a definitive PECARN classification, either recommending head CT or not, there were no injuries or positive CT finding.
Discussion
In patients with minor head trauma discharged from the emergency room, who underwent a head CT there may have been an over utilization of head CT with 90% receiving a non-indicated head CT based on PECARN head injury clinical prediction rules at a single institution. This has led our institution to embark on the further incorporation of PECARN head injury clinical prediction rules in evaluating pediatric head trauma.