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Children With Minor Blunt Head Trauma Presenting to the Lise E. Nigrovic, MD, MPH,a Nathan Kuppermann, MD, MPHb,c,d

In our state-of-the-art review, we summarize the best-available evidence for abstract the optimal emergency department management of children with minor blunt head trauma. Minor blunt head is a common reason for emergency department evaluation, although clinically important traumatic (TBIs) as a result are uncommon. Cranial computed tomography (CT) scanning is the reference standard for the diagnosis of TBIs, although they should be used judiciously because of the risk of lethal malignancy from ionizing radiation exposure, with the greatest risk to the youngest children. Available TBI prediction rules can assist with CT decision- making by identifying patients at either low risk for TBI, for whom CT scans may safely be obviated, or at high risk, for whom CT scans may be indicated. aDivision of , Boston Children’s Hospital, For clinical prediction rules to change practice, however, they require active Boston, Massachusetts; and bDepartments of Emergency implementation. Observation before CT decision-making in selected patients Medicine and cPediatrics, School of Medicine, University of California, Davis, Davis, California; and dUC Davis Health, may further reduce CT rates without missing children with clinically Sacramento, California important TBIs. Future work is also needed to incorporate patient and family Dr Nigrovic wrote the first draft of this manuscript; preferences into these decision-making algorithms when the course of action and both authors conducted the literature review, is not clear. interpreted the data, critically revised the manuscript, approved the final manuscript as submitted, and agree to be accountable for all aspects of the work. Minor blunt head trauma is a common (CT) scans5 and therefore will not be DOI: https://doi.org/10.1542/peds.2019-1495 reason for emergency department (ED) further discussed. One of the challenges Accepted for publication Jun 10, 2019 1,2 evaluation across the globe. Health for clinicians evaluating children after Address correspondence to Lise E. Nigrovic, MD, care use for children with head trauma minor blunt head trauma, however, is MPH, Division of Emergency Medicine, Boston in the primary care setting and the ED appropriately identifying children with Children’s Hospital, 300 Longwood Ave, Boston, MA has increased substantially over the TBIs without overtesting those children 02115. E-mail: [email protected] past decade.3,4 Among severely injured at very low risk. In this review, we will PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, children, traumatic brain (TBI) summarize the current evidence 1098-4275). remains a major cause of morbidity and around the initial management of Copyright © 2019 by the American Academy of mortality. children with minor blunt head trauma. Pediatrics FINANCIAL DISCLOSURE: The authors have indicated However, relatively few children with they have no financial relationships relevant to this minor blunt head trauma, defined in article to disclose. this article by Glasgow Scale NEUROIMAGING FUNDING: No external funding. (GCS) scores of 14 to 15, have clinically The reference standard for the POTENTIAL CONFLICT OF INTEREST: The authors have important TBIs (defined by TBIs diagnosis of TBI is cranial CT, which is indicated they have no potential conflicts of interest requiring acute interventions, including used to rapidly diagnose TBIs, allowing to disclose. or hospitalization, for appropriate management of these ongoing symptoms or signs of TBI). injured children. Although access to To cite: Nigrovic LE and Kuppermann N. Children Children with GCS scores of 13 and less and use of CT scans for children after With Minor Blunt Head Trauma Presenting to the after blunt head trauma have a 35% minor blunt head trauma varies Emergency Department. Pediatrics. 2019;144(6): e20191495 rate of TBIs on computed tomography globally, the CT rate in children in EDs

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 144, number 6, December 2019:e20191495 STATE-OF-THE-ART REVIEW ARTICLE in the United States with minor blunt a public health threat, given the high because scanner technology and head trauma ranges from 10% to rates of CT use in childhood. imaging protocols vary by institution, 40%,6–12 with lower rates seen in EDs the radiation dose at pediatric and using computerized decision Trade-offs Between Clinical trauma centers is often lower than at support10,13,14 or active quality Evaluations With and Without CT general EDs,30 where most injured Scans improvement efforts.11,12,15 In children receive care.17 Additionally, a recent cross-sectional study of US Arguments can be made both for with the widespread availability of pediatric ED visits for children with more aggressive and for more high-speed helical CT scanners, only head trauma from the National conservative use of CT scans in a minority of children undergoing CT Hospital Ambulatory Medical Care children after minor blunt head scanning receive pharmacological Survey database, 32% had CT scans trauma. A normal CT scan in a sedation.31 performed (2007–2015),16 who is neurologically normal can “ ” emphasizing the importance of active facilitate appropriate ED discharge, Quick-brain MRI offers a potential implementation to change practice.16 sparing the costs and risks of radiation-sparing approach to the Although cranial CT scan rates for hospitalization.24 In a prospective diagnostic imaging of children with 32–34 children with head trauma have cohort of children with minor blunt head trauma. Given the short ∼ declined at US children’s hospitals head trauma and initial GCS scores time to acquire images ( 90 (adjusted odds ratio by year $14, 13 453 children had CT scans seconds), most children will likely not 2005–2009: 0.94; 95% confidence without evidence of intracranial require pharmacological sedation. In interval [CI]: 0.92–0.97),8 only the injuries (ie, no intracranial a pilot study of 54 children with head minority of injured children are hemorrhage, cerebral , injury who had both a cranial CT and treated at pediatric centers.17 , or fracture).24 a quick-brain MRI performed, MRI However, ,1% of children with Of these, 2485 (18% of those with had a 100% sensitivity (95% CI: – fi minor blunt head trauma require any normal CT scans) were nevertheless 61% 100%) for clinically signi cant fi acute intervention,7 suggesting that hospitalized, although none required TBI but only an 85% speci city (95% – 33 CT scans are still overused. neurosurgery (negative predictive CI: 73% 93%). In a prospective value: 100%; 95% CI: study of 223 children with head CT Scans and Ionizing Radiation 99.75%–100%). Another strategy to injuries who had both a quick brain CT scans expose children to ionizing reduce CT use that is frequently used MRI and CT scan performed, MRI had radiation, which increases the lifetime in Australia and New Zealand is to a sensitivity of 92.8% for risk of lethal malignancies.18–22 hospitalize rather than perform an ED radiographically apparent TBI (95% – Children are at greater risk for CT scan, allowing more time for CI 86.3 96.8%), but only missed one radiation-induced malignancies than a child’s symptoms to clinically important TBI (a child with because of their rapid growth either progress or resolve before CT a small subdural who required a two 34 rates (ie, more-rapid cellular decision-making.25 However, that night hospitalization). Although turnover) and longer life strategy incurs the costs and risks of MRI appears to have excellent 26,27 fi expectancies, with the youngest hospitalization. sensitivity for clinically signi cant children being at the highest risk.20,23 TBI, this newer imaging modality Although initial risk estimates were Imaging Modalities of the Future needs more rigorous evaluation in derived by applying mortality rates Advances in CT scan technology as children with head injury. In addition, from studies of atomic bomb well as customized pediatric imaging even if new quick-brain imaging survivors,18 more-recent estimates protocols have improved the CT scan protocols for trauma were are based on long-term follow-up of safety profile by minimizing both implemented, many EDs do not have children who underwent CT scans. In ionizing radiation exposure as well as 24-hour MRI access for a retrospective cohort study of the requirement for pharmacological emergency use. 178 604 children in Great Britain who sedation while obtaining the needed had undergone at least 1 CT scan (of images. The As Low as Reasonably any type) before 22 years of age, Achievable campaign has taken TBI CLINICAL PREDICTION RULES investigators identified a dose- a multifaceted approach to reduce Clinical prediction rules combine dependent increase in the risk of patient radiation exposure.19,28 available clinical factors to estimate leukemia and brain tumors over the Current-generation CT scanners have the probability of an outcome to 10-year follow-up period.20 Although the potential for rapid acquisition of assist clinical decision-making35–38 the absolute risk from a single CT images with higher image quality at but must be derived and validated by scan is small, the radiation exposure lower radiation doses compared with using rigorous methodologic from diagnostic imaging presents older CT scanners.29 However, standards.39 The need to reduce

Downloaded from www.aappublications.org/news by guest on September 25, 2021 2 NIGROVIC and KUPPERMANN unnecessary CT scans while , and 3 To assess rule accuracy, the PECARN minimizing the risk of missing mechanism predictors. In the TBI clinical prediction rules were clinically important TBIs has driven derivation population, 4 children with dichotomized (very low risk versus the development of clinical prediction clinically significant TBIs were not very low risk). In the concurrent rules designed to guide clinicians misclassified as very low risk for TBI validation cohort of 8647 children, through CT decision-making. In this (sensitivity: 98.6% [95% CI: only 2 children (both older than review, we focus on the 3 CT decision 96.4%–99.6%]; specificity: 86.9% 2 years) with clinically important rules in children with minor blunt [95% CI: 86.5%–87.4%]). TBIs were misclassified as very low head trauma with the largest risk for having a TBI (sensitivity of The National Institute for Health and derivation populations (Table 1): the 100% [95% CI: 86.3%–100%] in Clinical Excellence guideline for the Children’s Head Injury Algorithm for children ,2 years and sensitivity of management of infants and children the Prediction of Important Clinical 96.8% [95% CI: 89.0%–99.6%] in in the United Kingdom is based on the Events (CHALICE) rule,40 the children $2 years).7 Neither of the 2 CHALICE rule.48 Subsequently, the Pediatric Emergency Care Applied misclassified patients required CHALICE rule was used to identify all Research Network (PECARN) rules neurosurgery. In 4 independent significant head injuries in 2 distinct (for those younger or older than validation studies of .15 000 retrospective cohorts of children with 2 years),7 and the Canadian children with minor blunt head head injury (1091 from Australia49 Assessment of Tomography for trauma,25,47,51,52 only 1 child with and 394 from the United Kingdom50). Childhood Head Injury (CATCH).41 a clinically important TBI (who did However, real-time implementation of Each of the rules had somewhat not require neurosurgery) was the CHALICE rule could have different aims and study populations, classified as very low risk by the increased cranial CT rates from 19% making the rules difficult to PECARN TBI rules. to 46% in the Australian cohort25 and compare.25,42 The inclusion criteria from 7% to 20% in the UK cohort.50 for each of these rules were different; How should the PECARN TBI rules be the CHALICE rule including all applied in clinical practice? Although children with head trauma, PECARN PECARN TBI Rules children in the lowest risk group (ie, being used to evaluate children with The PECARN TBI prediction rules those with none of the 6 PECARN risk GCS scores of 14 to 15, and CATCH were derived in a prospective cohort factors) can safely be managed rule including patients with GCS of 33 785 children presenting to 1 of without CT use, those in the high-risk scores of 13 to 15. Because most 25 EDs in the United States between group (those with altered mental children with head injury present for 2004 and 2006 with minor blunt status or signs of ) care within the first day,43 the head trauma defined by GCS scores of should have careful consideration of PECARN and CATCH rules were 14 to 15.7 The primary outcome a cranial CT scan. However, many (and limited to children presenting within measure was a clinically important likely most) of the children in the the first 24 hours after injury. TBI, defined as head injury resulting intermediate-risk group do not require Importantly, none of these 3 rules in 1 or more of the following: , CT scanning, if they can be observed were designed to identify children neurosurgery, intubation for 24 hours for a period of time in the ED. For with abusive head trauma,44 which or more due to the head injury, or 2 children in the intermediate-risk requires a comprehensive approach or more nights in the hospital in group with an isolated intermediate- to evaluation.45 association with TBI on CT. Only risk PECARN TBI predictor, the risk of candidate clinical predictors with a clinically important TBI was low CHALICE TBI Rule acceptable interrater reliability were (Table 2) but increased with multiple – The CHALICE TBI clinical prediction considered for inclusion in the PECARN TBI risk factors.53 58 Because rule was derived in a prospective models.46 The 2 age-based PECARN clinical factors such as a history of cohort of 22 722 children presenting TBI rules (1 for children younger than a posttraumatic substantially to 10 EDs in the United Kingdom 2 years old and 1 for children 2 years increase the risk of TBI on CT scan between 2000 and 2002 for and older) each include 3 patient (seizure was not identified as evaluation of head trauma of all history and 3 physical examination a PECARN risk factor in the rule severities.40 The primary outcome predictors. The PECARN TBI clinical derivation, likely because it was measure was a clinically significant prediction rules, in broad terms, sufficiently infrequent in the PECARN TBI defined by death, neurosurgery, classify children in 3 groups on the cohort and subsumed by the loss of or marked abnormalities on CT scan basis of the risk of a clinically consciousness variable),59 clinicians (281 children had 1 of these important TBI (Fig 1): high (14% of should have a low threshold to outcomes; 1.2% of enrolled). This study population), intermediate perform CT after a posttraumatic rule includes 6 patient history, 5 (31%), and very low risk (55%).7 seizure.

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 144, number 6, December 2019 3 4 TABLE 1 Comparison of TBI Clinical Prediction Rules CHALICE46 PECARN6 CATCH47 Study design Prospective cohort Prospective cohort Prospective cohort Setting 10 EDs in England 25 EDs in the United States 10 EDs in Canada Enrollment period February 2000 through August 2002 June 2004 through March 2006 July 2001 through November 2005 Inclusion and Age ,16 y Age ,18 y Age #16 y exclusion criteria Any head injury regardless of time Nontrivial blunt head trauma within 24 h Blunt head trauma within 24 h All GCS scores GCS score of 14–15 GCS score of 13–15 No penetration injuries, coagulopathies, or preexisting Any of the following: LOC, , disorientation, $2

Downloaded from neurologic disorders episodes of , irritability (,2y) Sample size 22 772 derivation 33 785 derivation, 8627 concurrent validation 3866 derivation Enrollment rate Not reported 77% 64% Predictors Patient history: witnessed LOC .5 min, amnesia .5 min, ,2 y of age: severe injury mechanisma; loss of consciousness High risk: GCS score ,15 2 hours from injury, abnormal drowsiness, $3 episodes of vomiting, suspicion for .5 s; acting abnormally, per parent; GCS score ,15 or suspicion for open or depressed skull fracture, nonaccidental trauma, and seizure (if no history of epilepsy) altered mental status; palpable skull fracture; and nonfrontal worsening , and irritability

www.aappublications.org/news Physical examination: GCS score ,14 or GCS score ,15 if ,1yof $2 y of age: severe injury mechanisma, any loss of Medium risk (used with high risk for positive CT age, penetrating or depressed injury or tense fontanel, signs of consciousness, severe headache, any vomiting, GCS score secondary outcome): large, boggy scalp hematoma; , focal neurologic examination, and , ,15 or altered mental status, and signs of basilar skull signs of basal skull fracture; and dangerous injury swelling, or laceration .5cmif#1 y old fracture mechanism Mechanism: high-speed motor vehicle collision as a pedestrian, cyclist, or occupant; fall .3 m; and high-speed projectile injury Outcome Death, neurosurgery, marked abnormalities on CT Death, intubation $24 h, neurosurgery, or $2 nights in the Death, intubation, neurosurgery hospital for management of head injury in association with TBI on CT – fi – , – fi – – fi

byguest on September25, 2021 Derivation: Sensitivity: 98.6 (96.4 99.6); speci city: 86.9 (86.5 87.4) 2 y: sensitivity of 98.6 (92.6 100), speci city of 53.7 (52.6 54.8) High risk: sensitivity of 100 (86.2 100), speci city of performance, % 70.2 (68.8–71.6) (95% CI) $2 y: sensitivity of 96.7 (93.4–98.7), specificity of 57.6 (57.0–58.2) Medium risk: sensitivity of 98.1 (94.6–99.4), specificity of 50.1 (48.5–51.7) Concurrent validation: ,2 y: sensitivity of 100 (86.3–100), specificity of 53.6 (51.5–55.7) Concurrent validation: $2 y: sensitivity of 96.8 (89.0–99.6), specificity of 58.2 (57.0–59.4) LOC, loss of consiousness. a Motor vehicle collision with patient ejection, death of another passenger, or rollover; a pedestrian or bicyclist without a helmet struck by a motorized vehicle; falls (at a height of $3 ft for children ,2 y and $5 ft for children $2 y); or head struck with a high-impact object. IRVCadKUPPERMANN and NIGROVIC International Collaborative network of EDs in New Zealand and Australia performed a simultaneous prospective validation of the CHALICE, PECARN, and CATCH TBI prediction rules.25 This study enrolled 20 317 children ,18 years of age with minor blunt head trauma and GCS scores of 13 to 15, of whom, 2106 (10%) had CT scans performed and 83 (,1%) underwent neurosurgery. The TBI rules were applied only to those children who met the inclusion criteria for each of the respective prediction rules (CHALICE applicable to 99% of enrolled children, PECARN applicable to 75%, and CATCH applicable to 25%) (Table 3). Each of the 3 TBI rules worked well in the patient populations for which they were designed. Clinician Judgment The question remains whether head trauma clinical prediction rules improve the care of children with head injury compared with usual care FIGURE 1 (aka clinician judgment). In a recent Suggested CT algorithm for children ,2 years (A) and for those aged 2 years or older (B)6 large prospective study, clinician a (reprinted with permission). ciTBI, clinically important . Signs of altered judgment had similar sensitivity to mental status include agitation, , repetitive questioning, or slow response to verbal communication. b Severe mechanism of injury is defined as motor vehicle crash with patient the CHALICE, PECARN, and CATCH ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by clinical prediction rules for the a motorized vehicle; falls of more than 3 feet (A) or more than 5 feet (B); or head struck by a high- identification of children with c d impact object. Risk of ciTBI increases with the number of risk factors present. As risk of ciTBI is clinically important TBIs.61 exceedingly low and may be lower than risk of CT-induced malignancy, CT scans are not recom- mended for most patients in this group. Importantly, because this study was conducted at high-volume pediatric centers in Australia and New Zealand, these results may not be applicable to CATCH TBI Rule validation study of 4060 children, 3 low-volume centers in different The CATCH TBI prediction rule was children requiring neurosurgery were regions of the world or those without fi derived in a prospective cohort of misclassi ed as low risk (sensitivity: pediatric emergency practitioners – 60 3866 children presenting to 10 EDs in 91%[95%CI:72% 99%]). These because clinician judgment is Canada between 2001 and 2005 with investigators subsequently suggested developed over time caring for mild to moderate head trauma, adding 1 clinical predictor, 4 or more children with head injury. Because the defined by GCS scores of 13 to 15 as episodes of vomiting, to the CATCH prediction rules were already well as loss of consciousness, amnesia, rule to improve sensitivity (100% published at the time of the study and – 60 disorientation, persistent vomiting, or [95% CI: 85% 100%]), but these clinicians in the study had to fi irritability, and was conducted by the modi cations require additional document the presence or absence of Pediatric Emergency Research Canada validation. the predictors that were in the rules, network.41 The it is likely that “clinician judgment” for the primary outcome, need for Comparison Between 3 TBI Clinical was informed by the rules.26,27 neurosurgical intervention, included 1 Prediction Rules Furthermore, increasing clinician patient history predictor and 3 The Pediatric Research in the awareness of ionizing radiation risks physical examination predictors. In the Emergency Departments may also have reduced CT use.

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 144, number 6, December 2019 5 TABLE 2 The Risk of Clinically Important TBI for Children With “Isolated” PECARN TBI Predictors by after Patient Age (,2vs$2 y of Age) 6 hours (upper limit 95% CI of Children ,2 y Children $2y 0.02%), suggesting that the vast N = 10 718 N = 31 694 majority of clinically important TBIs n Out of N (%) (95% CI) n Out of N (%) (95% CI) will become apparent in this time period. Severe injury mechanism60 4 out of 1327 (0.3) (0.1–0.8) 12 out of 1975 (0.6) (0.3–1.1) History of loss of consciousness61,a 1 out of 157 (0.6) (0–3.5) 12 out of 2623 (0.5) (0.2–0.8) Nonfrontal scalp hematoma62 4 out of 820 (0.5) (0.1–1.2) n/a Clinicalobservationisanimportant Vomiting63 n/a 10 out of 1501 (0.7) (0.3–1.2) management strategy for children Severe headache64 n/a 3 out of 209 (1.4) (0.3–4.1) with minor blunt head trauma in the 65 – Not acting normally, as per parent 1 out of 411 (0.2) (0 1.3) n/a ED who have more-than-negligible n/a, not applicable. risk for TBI but who are not at high a Loss of consciousness .5 s for children ,2 y and any for children $2y. risk (for whom CT scans are typically indicated). This approach allows Additionally, clinician judgment had actually have clinically important time for the child’ssymptomsand a higher specificity than the 3 TBI TBIs will initially be asymptomatic signs to improve or evolve and hence clinical prediction rules, raising the (or minimally symptomatic) but will inform CT decision-making. concern that implementation of these later clinically deteriorate. Such Observation before the decision of prediction rules might increase CT clinical deterioration is typically due whether to obtain a CT allows rates. Clinical prediction rule to increased intracranial clinicians to selectively image those implementation can occur in a variety from either an expanding intracranial children whose symptoms fail to of ways, including provider education, hematoma or progressive cerebral improve (or whose symptoms clinical pathways, and computerized edema. Although rare, epidural worsen) over the observation period. decision support. Although only are classically associated By delaying the decision of whether PECARN TBI implementation studies with delayed development of to obtain a CT scan for a few hours, have been published to date, symptoms after an initial lucid clinicians can safely reduce researchers in these studies have interval.62,64 unnecessary CT scans without demonstrated a safe, evidence-based missing clinically important TBIs.66 decrease in CT scan use for children In clinical practice, children with The Choosing Wisely campaign has with head injury.10,14 In an Italian significantTBIsonlyrarelyhave been adopted by .70 medical pediatric ED, cranial CT rates a delayed presentation after specialties,67 including the American decreased after implementation of presenting with apparently minor the PECARN rules despite relatively head trauma. Researchers in an 8- Academy of Pediatrics and the low baseline CT rates (8.4% year population-based study in the American College of Emergency preimplementation versus 7.3% Calgary Health Region investigated Physicians. Both societies have postimplementation).63 Quality the incidence of delayed diagnosis of recommended the use of the improvement initiatives based on the intracranial injury (defined as a child PECARN TBI prediction rules in PECARN TBI rules at a tertiary care with initial normal GCS score and children with minor blunt head children’s ED,11 a community normal physical examination who trauma to limit inappropriate CT pediatric ED,12 and a general ED15 had any type of intracranial injury scan use, with observation in have also been associated with safe diagnosed by neuroimaging .6 a monitored setting as an important reductions in cranial CT rates. hours after injury).65 In this management strategy to further limit retrospective cohort study of 17 692 CT use.68 All children discharged Observation children with minor blunt head after observation without a CT scan Rarely, children with apparently trauma presenting to EDs in Calgary, should have a reliable caregiver with minor blunt head trauma but who no child had a delayed diagnosis of the ability to return to medical

TABLE 3 Performance of the 3 TBI Rules in the Prospective Cohort of Children With Head Injury Presenting to 10 EDs in Australia and New Zealand24 CHALICE PECARN ,2 y PECARN $2 y CATCH No. included 20 029 4011 11 152 4957 No. with outcome 401 clinically important TBI 38 clinically important TBI 98 clinically important TBI 21 neurosurgery, 141 brain injury on CT Sensitivity, % (95% CI) 92.3 (89.2–94.7) 100 (90.7–100) 99.0 (94.4–100) High risk: 95.2 (76.2–99.9) Medium risk: 88.7 (82.2–93.4) Specificity, % (95% CI) 78.1 (77.5–78.7) 53.8 (52.3–55.4) 45.8 (44.9–46.8) High risk: 84.2 (83.2–85.2) Medium risk: 56.4 (55.0–57.8)

Downloaded from www.aappublications.org/news by guest on September 25, 2021 6 NIGROVIC and KUPPERMANN attention if the child’ssymptoms qualitative study to describe the cost, waiting time, parental and worsen. existing ED environment and clinician comfort level). Decision and workflow for the care of children cost-effective analysis allow rigorous Clinical observation has been with minor blunt head trauma75 to mathematical modeling to be applied associated with a lower CT rate. In inform the design of an optimal to clinical decision-making to a planned secondary analysis of the computerized decision support compare various management PECARN TBI study, clinical system. The resulting multisite strategies. One model compared 2 observation before CT decision- implementation study successfully management strategies (CT all making was associated with a lower integrated the PECARN TBI rules versus no immediate CT) for children rate of overall CT use, with no into electronic medical records and ,2 years with minor blunt head change in rate of clinically important delivered both TBI risk estimates trauma presenting to the ED for TBI after adjustment for head injury and CT-versus-observation evaluation.76 The “no immediate CT” severity (adjusted odds ratio of CT recommendations to clinicians at the strategy was optimal if the expected use: 0.53 [95% CI: 0.43–0.66]).66 In point of care. This implementation probability of a clinically important a subsequent prospective single- study included 4 pediatric and 7 TBI was ,5%. In a separate cost- center study of children with minor general EDs as well as 1 pediatric effectiveness analysis comparing the blunt head trauma, each hour of ED and 1 general ED control sites to PECARN TBI rules to usual care, observation was associated with monitor secular trends.10 Although application of the PECARN rules (ie, a decrease in cranial CT rate for the impact of the CDS on CT rates for comparing PECARN risk group children in each of the 3 PECARN TBI children at the lowest risk for assignment to unstructured CT risk groups (very low, intermediate, clinically important TBI varied decision-making) was both more and high risk) after adjusting for across centers, the overall CT rate effective and less costly for children time from injury to ED evaluation.69 decreased at CDS intervention sites with minor blunt head trauma.77 The None of the observed children in compared with control sites PECARN strategy dominated despite either of these studies had a missed (intervention sites CT rate: 5.3% vs a slight increase in the rate of missed clinically important TBI. Rigorous 4.2%, P = .04 versus control sites CT clinically important TBIs, reflecting evidence combined with common rate: 4.1% vs 2.7%, P = .13). Three the lower costs and reduced rate of sense suggests that ∼4to6hoursof children with clinically important radiation-induced malignancies. A monitored observation from the time TBIs were missed by the tool but recent analysis of a cohort of nearly of head injury will substantially identified by treating clinicians, 19 000 children with head injuries in decrease the CT rate without missing although 2 had missing or Australia and New Zealand important TBIs or needlessly inaccurately recorded risk factors, demonstrated that usual care was prolonging ED stays. and the other had a clinical concern the most cost-effective approach in for nonaccidental trauma; none that country ($36 Australian cost COMPUTERIZED DECISION SUPPORT underwent neurosurgery. savings per child with head injury; Importantly, computerized decision 95% CI: $7–$77 savings) when Historically, translating knowledge support did not increase the rate of compared with the PECARN, CATCH, including clinical prediction rules into CT for children at non-neglible risk and CHALICE TBI prediction rules.78 routine clinical practice has taken for clinically important TBI by the However, given that the latter study decades.70 Passive diffusion of PECARN rules, despite these was conducted on a different evidence through publication and theoretical concerns.10,14 However, continent than the other 2 cost- presentation is typically not sufficient CDS implementation can be time- effectiveness studies and cost to change behavior on a broad scale consuming and expensive, making assumptions were different by and in a sustained fashion.71,72 In the widespread implementation necessity, direct comparison is complex and chaotic ED environment, challenging. challenging. effective implementation strategies are especially challenging.73 Clinical decision support (CDS) tools COST-EFFECTIVENESS ANALYSES SHARED DECISION-MAKING are important aids to enable For an individual child with blunt Patient, parental, and physician evidence uptake74 but have only head trauma, the risk of missing preferences should each play a role in recently been studied in the ED a clinically important TBI must be clinical decision-making for all setting and require local clinical balanced against the potential of children with minor , informatics support for development future lethal malignancy from particularly when a course of action is and deployment. A collaborative exposure to ionizing radiation from not clear. In 2 prospective cohorts group conducted a multisite CT scans, among other concerns (eg, from the United States79 and Japan,80

Downloaded from www.aappublications.org/news by guest on September 25, 2021 PEDIATRICS Volume 144, number 6, December 2019 7 parental preference was associated providers using the decision aid lethal malignancies. High-quality with obtaining a cranial CT scan. compared with usual care providers validated TBI clinical prediction rules However, parents are often willing to were more knowledgeable and had can assist clinical decision-making by consider observation rather than an greater physician trust after the estimating the risk of clinically immediate CT scan when they intervention, although the ED CT rate important TBIs on the basis of understand the trade-offs involved. was similar. No clinically important presenting . TBIs were missed in either group. These prediction rules are best used In a recent clinical trial, researchers Interestingly, there was less health in conjunction with clinical judgment, investigated the optimal method of care use, laboratory testing, and other based on many factors, including risk communication as well as imaging tests in the 7-day follow-up setting and clinician experience. parenteral preferences for the ED period in the decision-aid group. Use Observation before CT decision- management of children with minor of shared decision-making with making is an important management head trauma at intermediate risk of similar tools has the potential to strategy for children at low to clinically important TBI by the inform patient and family-centered intermediate risk that allows selective PECARN rules (ie, having 1 or 2 decision-making for children with CT use for those children whose intermediate PECARN TBI risk minor blunt head trauma, although symptoms worsen or fail to improve factors).81 A pictorial shared decision- further study is needed.82,83 during the observation period. making aid was developed, which Importantly, shared decision-making included a representation of the between provider and patient-parent child’s individual risk of having CONCLUSIONS dyad is an important strategy when a clinically important TBI and the Across the globe, children with minor the decision to obtain a CT scan is not risks and benefits of observation blunt head trauma frequently present clear. Investigators in future research without CT scan versus immediate CT to EDs for evaluation. Clinicians should focus on the optimal strategies scan (Fig 2). Providers at each of the caring for these children must decide for clinical prediction rule 7 participating pediatric EDs were whether to obtain a cranial CT scan, implementation in different clinical randomly assigned to either the the diagnostic gold standard, as part settings as well as better integration pictorial shared decision-making aid of their evaluation. CT scans, however, of shared decision-making into ED or usual care. Of the 971 patients expose children to ionizing radiation encounters for children with head enrolled, parents cared for by that increases long-term risks of injuries.

FIGURE 2 A sample head CT choice decision aid shared with permission (E. Hess, MD, MSc; personal communication).

Downloaded from www.aappublications.org/news by guest on September 25, 2021 8 NIGROVIC and KUPPERMANN 7. Kuppermann N, Holmes JF, Dayan PS, at nonnegligible risk for traumatic ABBREVIATIONS et al; Pediatric Emergency Care Applied brain injuries. Ann Emerg Med. 2019; CATCH: Canadian Assessment of Research Network (PECARN). 73(5):440–451 fi Tomography for Identi cation of children at very low 15. Puffenbarger MS, Ahmad FA, Argent M, Childhood Head Injury risk of clinically-important brain et al. Reduction of computed injuries after head trauma: CDS: clinical decision support tomography use for pediatric closed a prospective cohort study. Lancet. CHALICE: Children’s Head Injury head injury evaluation at 2009;374(9696):1160–1170 Algorithm for the a nonpediatric community emergency Prediction of Important 8. Mannix R, Meehan WP, Monuteaux MC, department. Acad Emerg Med. 2019; – Clinical Events Bachur RG. 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