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PECARN
PECARN
February 8, 2021
Jessica Chee, Clarelle Gonsalves, Ravinder Sandhu, Shawn Varghese, Malavan Ragulojan
Discussion
Discussion
Kupperman et al. (2009) aimed to identify the PECARN criteria to define children with head trauma at very low risk of ciTBI for whom CT might be unnecessary. This study was appraised below using the guidelines for evaluation of a CDR by McGinn et al. (2000).2
Were all important predictors included in the derivation process
No. Only those predictors that had kappa statistical point estimates of >0.5 with lower bounds of the CI >0.4 were included. Ensuring the one-sided 95% CI lower bounds was 0.4 or more ensured moderate inter-observer agreement, although 2 predictors with poor inter-observer agreement were still included (dizziness and scalp hematoma). Additionally, injury mechanisms (severe, mild and moderate), as well as AMS were defined a priori without a specific regression analysis.
Were all important predictors included in a significant proportion of the study population?
Yes. All predictors included in the derivation process were assessed in the entire study population.
Were all outcome events and predictors clearly defined?
Yes, outcome events and predictors were clearly defined. Definition of all predictors, criteria for ciTBI, and criteria for TBI on CT were clearly defined.
Were those assessing outcome events blinded to the presence of predictors & vice versa?
Yes, assessors of the case reports for predictors were blinded to CT imaging results.
Was sample size adequate to account for all potential outcomes?
Yes, 33785 participants were included in the derivation study, with 8502 age <2 years old and 25283 >2 years old. The authors report having sufficient statistical power, however do not calculate the power of the study. Compared to previous studies, this derivation study does fill the need for large prospective studies of head trauma in children described in a systematic review of head CT prediction rules.3
Does the rule make clinical sense?
Yes, the PECARN CDR was intended as a tool to prevent unnecessary harmful radiation in children with a low risk of clinically-important traumatic brain injuries. Prior to the decision tool, unnecessary imaging would be done despite the fact that less than 10% of CT scans in minor head trauma demonstrate a TBI and the prevalence of requiring neurosurgery is even lower.4–6
Internal Validation
The study population of the internal validation consisted of 2216 in the <2 year-old population and 6411 in the >2 year-old population. The internal validation found that the PECARN rule had a sensitivity of 100% (86.3-100.00) and 96.8% (89.0-99.6) and specificity of 53.6% (51.5-55.7) and 58.2% (57.0-59.4), for <2 year-old population and >2 year-old population respectively.
Were the patients chosen in an unbiased fashion and do they represent a wide spectrum of disease severity?
Patients were chosen in an unbiased fashion. The patients did not represent a wide spectrum of disease severity. Children with trivial mechanisms of injury (ground-level falls or walking or running into stationary objects) and with no signs or symptoms of head trauma other than scalp abrasions and lacerations were excluded.
Was there a blinded assessment of the criterion standard for all patients?
Yes
Was there an explicit and accurate interpretation of the predictor variables and the actual rule without knowledge of the outcome?
Yes
Was there 100% follow-up for those enrolled?
Yes
In conclusion, the PECARN rule consists of accurate predictors that can be used to identify children at low risk of ciTBI following a head trauma in order to prevent unnecessary CT imaging in acute settings.
Impact of PECARN
There is currently a paucity of studies that investigate the impact of PECARN in reducing CT heads among children with mild TBI. While the existing evidence is variable in predicting overall trends of the population, there have been some consistent conclusions when populations with similar inclusion criteria were recruited.
Furtado et. al. found that after applying the PECARN, patients receiving a CT scan decreased from 36.4% to 31.6% and overall mean costs were reduced from 16.71 USD to 7.88 USD.7
Adherence to the rule and performing PECARN indicated CTs varied significantly from country to country. In America, Gerber et al.8 reported 78.7% and Mihindu et al.9 reported 64% ; Velasco et al.10 reported 50% to 70%; Bressan et al.11 reported 93.5%.
Dayan et al. was a retrospective review conducted at thirteen U.S. EDs, consisting of both pediatric emergency and general EDs, that distinguished a modest yet statistically significant drop in CT scans for children under the age of two at two centers of 2.3% and 3.7%.12 Likewise, Sawaya et al., another retrospective conducted in Lebanon demonstrated that while there was no decline in CT orders in the cohort as a whole, there was a statistically significant drop of 8.7% in the under 2 population.13
An additional US study, Gerber et al., noted no change in CT acquisition was noted when compared pre guideline to post guideline (96.6% vs. 95.7%, p = 0.63).8 In parallel to the Bressan et. al11, Sawaya et. al13, and Dayan et al12, patients less than 2 years of age had a higher rate of correctly indicated head CT scans when compared to patients greater than 2 years. Considering that the potential negative impact of CT is most pronounced in this younger population, this finding provides some support for the rule.
References
References
Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet. 2009;374(9696):1160-1170. doi:10.1016/S0140-6736(09)61558-0
McGinn TG, Guyatt GH, Wyer PC, Naylor CD, Stiell IG, Richardson WS. Users’ guides to the medical literature: XXII: how to use articles about clinical decision rules. Evidence-Based Medicine Working Group. JAMA. 2000;284(1):79-84. doi:10.1001/jama.284.1.79
Maguire JL, Boutis K, Uleryk EM, Laupacis A, Parkin PC. Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics. 2009;124(1):e145-154. doi:10.1542/peds.2009-0075
Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003;42(4):492-506. doi:10.1067/s0196-0644(03)00425-6
Quayle KS, Jaffe DM, Kuppermann N, et al. Diagnostic testing for acute head injury in children: when are head computed tomography and skull radiographs indicated? Pediatrics. 1997;99(5):E11. doi:10.1542/peds.99.5.e11
Schunk JE, Rodgerson JD, Woodward GA. The utility of head computed tomographic scanning in pediatric patients with normal neurologic examination in the emergency department. Pediatr Emerg Care. 1996;12(3):160-165. doi:10.1097/00006565-199606000-00004
Furtado LMF, da Costa Val Filho JA, Dos Santos AR, et al. Pediatric minor head trauma in Brazil and external validation of PECARN rules with a cost-effectiveness analysis. Brain Inj. 2020;34(11):1467-1471. doi:10.1080/02699052.2020.1802667
Gerber N, Sookraj K, Munnangi S, et al. Impact of the Pediatric Emergency Care Applied Research Network (PECARN) guidelines on emergency department use of head computed tomography at a level I safety-net trauma center. Emerg Radiol. 2019;26(1):45-52. doi:10.1007/s10140-018-1645-4
Mihindu E, Bhullar I, Tepas J, Kerwin A. Computed tomography of the head in children with mild traumatic brain injury. Am Surg. 2014;80(9):841-843.
Velasco R, Arribas M, Valencia C, et al. [Compliance with the PECARN and AEP guidelines in diagnostic approach of mild head trauma in patients younger than 24 months old]. An Pediatr (Barc). 2015;83(3):166-172. doi:10.1016/j.anpedi.2014.10.012
Bressan S, Romanato S, Mion T, Zanconato S, Da Dalt L. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med. 2012;19(7):801-807. doi:10.1111/j.1553-2712.2012.01384.x
Dayan PS, Ballard DW, Tham E, et al. Use of Traumatic Brain Injury Prediction Rules With Clinical Decision Support. Pediatrics. 2017;139(4). doi:10.1542/peds.2016-2709
Sawaya R, Wakil C, Wazir A, et al. Does implementation of the PECARN rules for minor head trauma improve patient-centered outcomes in a lower resource emergency department: a retrospective cohort study. BMC pediatrics. 2020;20:439. doi:10.1186/s12887-020-02328-x
Authors
Authors
Jessica Chee, BHSc, MD Candidate McMaster University (c2022). She is interested in internal medicine. Outside of medicine, she enjoys listening to podcasts and eating dumplings.
Clarelle Gonsalves, HBsc, MD Candidate Michael G. DeGroote School of Medicine, McMaster University. She is interested in pediatric health, research, and social advocacy and enjoys reading and baking.
Ravinder Sandhu, MPH, MD Candidate McMaster University, Michael G Degroote School of Medicine (c2022). She is interested in public health, patient-centered care and social advocacy and enjoys reading autobiographies.
Shawn Varghese, BHSc, MD candidate, McMaster University (c2022). He is interested in psychiatry and enjoys playing table tennis and video games.
Malavan Ragulojan, BHSc, MD Candidate c2022, Michael G DeGroote School of Medicine. He is interested in pursuing Neurosurgery and his hobbies include reading biographies and cooking.
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