Clinical decision rule to obtain
CT scan for infants with
minor head injury
Comparison with PECARN and
application of quantification methods type II
Miyagawa T1, Yabuki M2, Watanabe Y2,
Tamaki K2, Karasudani H2, Yamaura A2
1 Department of Pediatric Neurosurgery,
2 Neurosurgery, Matsudo City Hospital
Annual Meeting of
the International Society for Pediatric Neurosurgery
Disclosure of Conflict of Interest
Name of first author： Tadashi Miyagawa
I have no COI
with regard to our presentation.
3 m/o baby girl
Fell down from table (1m of height)
when mother left for a while. Visited ER.
In ER
awake alert, no neurological deficit.
LOC(-), N/V (-)
subq hematoma in parietal, otherwise
acting normally as per mom
Should we take a CT scan?
Clinical Decision Rule
for children with
mHI to obtain CT
PECARN, USA
CATCH, Canada
CHALICE, UK
CDR comparison
Prediction Rule Process
Derivation
Validation
Implementation
Impact
Analysis
The most important for
implementation
To understand our population, our
clinical settings and our practioners
BECAUSE
even well-validated rule may not be
the best for our clinical setting
To compare with PECARN for
its applicability to clinical practice in Japan
To apply Quantification
Methods type II as a new clinical
decision method
1091 children <2y/o
2005 Nov-2014 Sep
Retrospective Cohort study
Inclusion & Exclusion criteria
according to PECARN
visit <24h after trauma
GCS 14-15
minor head injury
CT
performed
PECARN
Our study
35.3
25.7
(%)
TBI on CT
ciTBI
PECARN
Our study
8.1
0.9
2.7
2.6
(%)
6 predictors in the rule
PECARN
Altered mental status
Non-frontal scalp hematoma
Loss of consciousness for ≧5sec
Severe injury mechanism
Palpable skull Fx
Not acting normally per parent
Prediction Tree
for ciTBI
PECARN Fig2
CDRfor ciTBI
Sensitivity
Specificity
NPV
PPV
PECARN
Our study
98.6
53.7
99.9
1.8
85.7
56.9
99.3
5.0
(%)
CT algorithm
PECARN Fig3
Risk of ciTBI
ciTBI
PECARN
Our study
CT recommended
4.4
0.9
15.1
2.6
<0.02
0.4
Observation vs
CT
CT not
recommended
(%)
ciTBI clinically important traumatic brain injury
death
neurosurgical interventions
intubation for >24hr
hospital admission ≧2 nights
Discriminant Analysis
y
used to
determine which
variables
discriminate
between two or
more naturally
occurring groups.
x
Need to pick up
CT recommended + observation versus CT
Discriminant Function
z = ax1+bx2+・・・+ux21+C
a
-0.01
b
0.05
c
1.80
d
0.03
e
-11.21
f
12.72
g
12.39
h
12.18
o
i
11.40
p
j
-0.34
q
k
0.55
r
l
0.48
s
m
0.45
t
n
1.16
u
0.17
C
0.74
-0.16
-0.105
0.42
1.55
1.38
0.01
Stats for DA
DA
Sensitivity
Specificity
NPV
PPV
99.2
100
99.6
100
(%)
Stats for DA
DA
identification
rate
99.7
(%)
3 m/o baby girl
Fall down from table (1m of hight) when
mother left for a while. Visited ER.
In ER
Awake alert, no neurological deficit.
LOC(-), N/V (-)
Sunq hematoma in parietal, otherwise
acting normally as per mom
Should we take a CT scan?
0
Sex
Sex
Age
Age
Severity of injury
Severity of injury
mechanism
Hx of LOC
1
2
male
female
0
1
mild
moderate
LOC duration
Hx of LOC
no
yes
Hx of vomiting
LOC duration
no
<5sec
Hx of vomiting
no
yes
GCS
No of vomiting
0
1
Altered mental status
Acting normally
no
yes
GCS
15
14
Altered mental status
no
yes
Sign of basilar
skull Fx
no
yes
Palpable skull Fx
no
yes
Scalp hematoma
no
F
No of vomiting
Acting normally
Sign of basilar skull Fx
Palpable skull Fx
Scalp hematoma
Z score
CT
3
4
5-60sec
1-5min
>5min
2
>2
T or P
O
severe
0
Sex
Age
Severity of injury
Hx of LOC
LOC duration
Hx of vomiting
No of vomiting
Acting normally
GCS
Altered mental status
Sign of basilar skull Fx
Palpable skull Fx
Scalp hematoma
Z score
CT
2
0
2
0
0
0
0
0
0
0
0
0
2
3.76898
RECOMMENDED
Sex
Age
1
2
male
female
0
1
mild
moderate
Hx of LOC
no
yes
LOC duration
no
<5sec
Hx of vomiting
no
yes
No of vomiting
0
1
Acting normally
no
yes
GCS
15
14
Altered mental status
no
yes
Sign of basilar
skull Fx
no
yes
Palpable skull Fx
no
yes
Scalp hematoma
no
F
Severity of injury
mechanism
3
4
5-60sec
1-5min
>5min
2
>2
T or P
O
severe
The PECARN rule would
successfully be applied in Japan.
A new CDR produced with
quantification methods type II
would be better to identify
children at very low risk of ciTBI.