Minor Head Trauma: PECARN PitfallsHow to use prediction rules to supplement clinical judgment

Kathy Shaw, MD, MSCEProfessor and Associate Chair, Department of PediatricsUniversity of Pennsylvania Perelman School of Medicine

The Nicholas Crognale Endowed Chair in Pediatric Emergency Medicine, The Children’s Hospital of Philadelphia

Essentials of Pediatric Emergency Medicine: Anaheim CA, March 2018

DO NEED

?

Case Minor Head Trauma

Evaluation and Management

• 22 month old– fell down several steps – May have had brief loss

of consciousness? – Active and playful– Forehead hematoma– No palpable skull

fractureCT or not?

• 90% with seemingly mild injuries

• 325,000 will have a CT scan

• 90% of these CT scans are negative

• Cancer Risk 0.07% Lifetime

Estimated 650,000 children/ adolescents each year with MTBI

CT Use for Pediatric MTBI in USA is High

US Hospitals 2005-2009 (PHIS data, Mannix, J Peds 2012)

Discharged from ED with MTBI DX

Median Rate 36% No correlation between institution-specific rates of CT imaging and

intracranial hemorrhage, admission, or return-visit rates.

19%

58%

CT Use for MTBI Varies by Hospital Type25 PECARN Hospitals

CT Rate 19-69%(Stanely, J Peds 2014)

LOWER HIGHERURBAN 33.8% SUBURBAN 41.5%TEACHING 34.9% NON-TEACHING 36.8FREE STANDING CHILDREN’S HOSPITAL 31.0%

NOT FREE STANDING CHILDREN’S HOSPITAL 40.6%

• Inform clinical decision making, not replace it

• Are tools based on evidence that clinicians may use to supplement their decision making

• May decrease practice variation

• May aid in teaching…CLINICAL

JUDGEMENT

• Rule developed prospectively on > 33,000 children <18 yrs with GCS 14-15

• Validated on >9,000 children (25%<2 years)• Outcomes – Clinically Important Brain Injury (ciBI)

• Death (none)• Neurosurgical procedure (0.1%)• Intracranial Injury (ICI) and 2 days in hospital

(0.9%)

Kuppermann Lancet 2009

Rule developed to identify which Children with MTBI

do not need CT

Predictors of ciTBI

One-way Rules:• Rule out a condition by identifying low-risk patients requiring

no further investigation (identifies MTBI children who don’t have ciTBI or need a CT)

• Do not identify patients at high risk for the condition (doesn’t identify MTBI children who have ciTBI)

• Altered mental status• Palpable skull fracture• LOC ≥ 5 sec• Severe mechanism of injury• Parietal or occipital scalp hematoma• Not acting normally

Kuppermann N. Lancet 2009

PECARN Predictors of ciTBI

<2 years >2years

Neg Predictive Value 99.9% (99.88-99.99)

• Altered mental status• Suspicion of basilar skull fracture• LOC• Severe mechanism of injury• Vomiting within prior 4 hours• Severe headache

Neg Predictive Value 99.95%

IE: If none of these predictors are present –doesn’t need a CT

ValidationDoes the PECARN Rule

perform well in Australia & New Zealand?

YES

Babl FE: Lancet 2017; 389: 2393–402

For age <2 yrs (N>2,000) – no ciTBI missed100∙0%, 95% CI:90∙7–100∙0; (38/38)

For age > 2yrs (N>11,000) – 1 ciTBI missed (didn’t need neurosurgery)99∙0%, 95%CI:94∙4–100∙0; (97/98)

Prospective

If clinicians got CT’s for any predictor present …

CT rate of 41-47%!

In PECARN Validation Study CT rate was 23% for clinical suspicion <1%

How do we put PECARN rules into clinical practice?

What if the child with MTI has a predictor of ciTBI?

X

Evaluation of Children < 2y with Minor Head Injury: Stepwise Approach

Kuppermann, Lancet 2009

Predicts having none of the 6 variables would decrease CT use by 25%

Kuppermann, Lancet 2009

CLINICAL JUDGEMENT

Needed!

Evaluation of Children > 2y with Minor Head Injury: Stepwise Approach

Kuppermann, Lancet 2009

Predicts none of the 6 variables would decrease CT use by 21%

CLINICAL JUDGEMENT

needed

Case Minor Head Trauma

Evaluation and Management using PECARN Rules

• 22 month old– Fell down several steps (Not major

mechanism – series of small falls)– If Loss of Consciousness? <5 seconds– Active and playful – normal mental status– Forehead hematoma ≠ SCALP hematoma– No palpable skull fracture

No Predictors =No CT

• Altered mental status• Palpable skull fracture• LOC ≥ 5 sec (0.6%; 3.5%)• Severe mechanism of injury

(0.3%;0.8%)• Parietal or occipital scalp hematoma

(0.5%;1.2%)• Not acting normally

(0.2%;1.3%)

Homme: Emerg Med Clin N Am 36 (2018)

What if the child has an isolated risk factor?Intermediate Risk

<2 years >2years• Altered mental status• Suspicion of basilar skull fracture• LOC (0.5%;0.8%)• Severe mechanism of injury

(0.6%; 1.0%)• Vomiting within prior 4 hours

(0.7%;1.2%)• Severe headache (1.4;4.1%)

Overall Risk is 0 – 1.4% Isolated Risk Factor (Upper 95%CI: 0.6-4.1%)

CT Recommended

Case Minor Head Trauma

Evaluation and Management considering PECARN Rules

• 22 month old– Fell 4 feet off porch (major mechanism)– ?Loss of Consciousness? ?5-10 seconds– Active and playful – normal mental status– Forehead hematoma ≠ SCALP hematoma– No palpable skull fracture1-2 Risk Factors? - Observe or CT?

Homme: Emerg Med Clin N Am 36 (2018) 287–304 https://doi.org/10.1016/j.emc.2017.12.015

What is your risk tolerance?

More than one Risk Factor?

A High Risk Factor?

Confusing Combination of Signs?

Think About Observation

What about Parental Preference?

Using PECARN RULES TO ENHANCE CLINICAL PRACTICEImage Guidelines

Parental Opinion of CT Scans for MTBI…

If told about radiation exposure,Less willing to get scan (90% to 70%)(Boutis: Pediatrics. 2013 Aug)

Given educational materials on risks vs benefits of Observation vs CT(Pediatr Emerg Care. 2013 Jan)

More preferred observation (57%) to immediate CT (40%)

During PECARN study, Black and Non-Hispanic children less likely to get CT scans… (Natalie: Arch Pediatr Adolesc Med 2012)

Parental influence on Clinician?

http://shareddecisions.mayoclinic.org/decision-aid-information/head-ct-choice-decision-aid

Shared Decision Making

with Family

Intermediate risk for ciTBI(60% were observed)

Significant decrease in imaging rate (5% vs 34%)

Impact analysis Does the PECARN Rule

increase or decrease CT use for MTBI?

Does it depend on the baseline CT rate for MTBI in

children…?

CT Use for MTBI Varies by MD Training and Risk of ciTBI

25 PECARN Hospitals in Original Study(Stanely, J Peds 2014)

MTBI Patients atMiddle Risk

> 1 PECARN non-high risk factors

CT Ordering49-60%

Low RiskNo PECARN non-high risk

factors

CT Ordering10-20%

EM>PEM>PEDS

High RiskGC =14, altered mental status,

palpable skull fractures (<2 yrs), or signs of basilar skull

fx (>2 yrs)

CT Ordering80-84%

EM>PEDS>PEM

Negative PV 100%, 95% CI 99.6% to 100 Schonfeld D: Arch Dis Child 2014

Impact analysis PECARN Rule decreased CT use for

MTBI in Boston and Padova

10-20%; 49-60%

Dayan, Pediatrics Volume 1 39, number 4 , April 2017

USA:5 PEDS and 8 General EDs (2011-2014)

Intervention sites Baseline 5.3%

Decreased CT rates (1.7%–6.2%).

IMPACT ANALYSIS:Does the PECARN Rule with decision support increase CT use in low risk patients?

NO

When clinicians have a higher suspicion of ciTBI, they are more often right (less false positives)

When they don’t have a high suspicion, they are often wrong (many false negatives)….

CLINICAL JUDGEMENT

PECARN StudyBaseline CT rate 35%

GCS 14-15

Atabaki SM et al: Academic Emerg Med 2016

PECARN RULE

Sensitivity100% (25/25)96.8 (60/62)*

Specificity53.6%58.3%

CLINICALJUDGEMENT

Sensitivity60.0% (15/25)+ 64.5% (40/62)+

Specificity92.4%90.6%

Clinicians were more accurate than the PECARN rules…Similar sensitivity, higher specificity…

But…

CLINICAL JUDGEMENT

Better in Australia & New Zealand?

Baseline CT rate 8.3%GCS13-15

Babl FE: AEM June 2018

+?CLINICAL

JUDGEMENT

Sensitivity98.8% (158/160)

Specificity= 92.4%

PECARN RULE

Sensitivity100% (42/42)99.0% (117/118)

Specificity53.8%45.8%

Clinicians admitted more & may have used rules to supplement judgement, & PECARN is a one way rule!

“In these nationalized health care settings, clinical

decision rules for pediatric head injury did not

improve on clinical judgment and would likely

increase CT use..”

CLINICAL JUDGEMENT

Better in Australia & New Zealand?

Baseline CT rate 8.3%GCS 13-15

Babl FE: AEM June 2018

MOREciTBI

CATCH and

CHALICE

98.8% Sensitivity

91.9%

92.5%

So you got the CT - Now What?Discharge vs Home?

Use this PECARN information to aid your clinical judgment

IT’s NORMALNo discharged children with a normal initial CT scan required neurosurgical intervention.GCS 15: NPV 100% (95% CI, 99.97%-100.00%) N=12,584 (82% discharged)GCS 14: NPV 100% (95% CI, 99.6%-100.00%) N=959 (61% discharged)

There is an Isolated non-depressed skull fxNone of the 350 required neurosurgical intervention (95%CI:0-1%)

Powell Pediatrics 201542% discharged; 13% reimaged with no new findings58% admitted; 21% reimaged, 5 with new traumatic findings

There is an Isolated cerebral contusionVarano J Trauma Acute Care Surg 2015

None of the 54 with GCS or 14 or 15 had neurologic deterioration (0%: 95% CI: 0-6.6%)

Clinical Judgement

• Inform clinical decision making, notreplace it

• Are tools based on evidence that clinicians may use to supplement their decision making

• May decrease practice variation

• May aid in shared decision making with patients and families

CLINICAL JUDGEMENT

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