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How Many PECARN-Negative Kids Have ICH or Fracture on CT?

June 16, 2023

Written by Seth Walsh-Blackmore and Clay Smith

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This database review of pediatric head trauma patients who had a head CT identified GCS 3-8 as an exam finding associated with intracranial hemorrhage (ICH); age, gender, and GCS were also associated with facial or skull fracture. It also found significant imaging results may exist in PECARN-negative patients.

Why does this matter?
Pediatric traumatic brain injury (TBI) is medically and legally risky. This is why decision tools help providers avoid unnecessary CT imaging, with PECARN being the best recognized. What are the risk factors for ICH and fracture in children, and how well are EPs doing at following PECARN when they order CT?

Double down on the donut?
This was a teleradiology database review of a radiology group partnered with 91 hospitals in France. Providers completed a checklist of PECARN-derived variables to order head CTs at these sites. The authors built a multivariate regression model to determine the association of both clinical as well as radiographic findings with ICH and fracture (skull and facial).

5,146 pediatric head trauma cases were included, with 600 randomly selected to apply the French ED decision algorithm (based on PECARN) from the order template data. Clinical features associated with fracture were age, gender, and GCS. Boys had greater odds of fracture than girls (OR 1.48, 95%CI 1.17-1.88); odds of facial fracture increased with older age, and odds of skull fracture increased with decreasing age. GCS 13-14 (1.80, 1.32-1.41) was associated with fracture. GCS <13 showed no statistically significant association with fracture. Extracranial hematoma on CT was strongly associated with fracture (26.60,19.06-37.68).

The only clinical feature associated with ICH was GCS ≤8 (5.83, 1.97-14.60). Imaging findings associated with ICH were extracranial hematoma on CT (2.54,1.59-4.02), skull base fracture (9.32, 5.03-16.97), upper c-spine fracture (19.2, 1.79-143.59), and skull vault fracture (35.6, 24.04-53.83). GCS data were missing for 1,503 patients. In the absence of extracranial hematoma and fracture on CT, the odds of ICH dropped drastically (0.034, 0.026-0.045).

When retrospectively applying the PECARN-based decision algorithm (shown below) to the sub-cohort of 600, only 193 (32.8%) met the criteria for immediate CT, and 226 (38.4%) theoretically should have been discharged without observation or CT. If these 226 had been discharged without CT, 11 (4.9%) would have left with an ICH and 29 (11.2%) with a fracture. Remember, PECARN was developed for clinical important TBI outcomes, not CT findings. Regardless, this reminds us decision tools are a guide but not a replacement for a provider’s judgment.

Decision algorithms used in French emergency departments for performing head computed tomography (HCT) in children: (from article supplement)

From cited article; 1: Fall > 0.9 m if age < 2 years or > 1.5 m if age ≥ 2 years; motor vehicle accident with ejection, fatality, rollover; bike or pedestrian versus vehicle without helmet; struck by high impact object. 2: headache, vomiting ; agitation, somnolence, slow response, repetitive questioning.

Another Spoonful
Read about some challengers to PECARN here and here .

Risk Factors Associated with Traumatic Brain Injury and Implementation of Guidelines for Requesting Computed Tomography After Head Trauma Among Children in France. JAMA Netw Open. 2023 May 1;6(5):e2311092. doi: 10.1001/jamanetworkopen.2023.11092.

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