Department of Pediatrics, University of Ottawa and the Clinical Research Unit, Children's Hospital of Eastern Ontario Research Institute, Ottawa, Ontario.
CMAJ. 2010 Mar 9;182(4):341-8. doi: 10.1503/cmaj.091421. Epub 2010 Feb 8.
There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury.
For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13-15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity.
Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%-100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%-99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT.
The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.
对于哪些轻度颅脑损伤的患儿需要进行 CT 检查，存在争议。我们旨在制定一种高度敏感的临床决策规则，用于指导轻度颅脑损伤患儿行 CT 检查。
本多中心队列研究纳入了就诊时格拉斯哥昏迷量表评分 13-15 分且存在意识丧失、遗忘、定向障碍、持续呕吐或易激惹的钝性颅脑创伤患儿。对于每例患儿，急诊科工作人员在进行任何 CT 检查之前都要填写一份标准化评估表。主要结局为是否需要神经介入治疗以及 CT 检查是否显示有脑损伤。我们通过递归分区法，将可靠且与结局测量值高度相关的变量结合起来，从而找到预测变量的最佳组合，以实现高灵敏度和最大特异性检测结局测量值。
共纳入 3866 例患儿（平均年龄 9.2 岁），95 例（2.5%）格拉斯哥昏迷量表评分 13 分，282 例（7.3%）评分 14 分，3489 例（90.2%）评分 15 分。CT 检查发现 159 例（4.1%）有脑损伤，24 例（0.6%）行神经介入治疗。我们得出了一个头部 CT 决策规则，包括 4 个高危因素（2 小时内格拉斯哥昏迷量表评分未达到 15 分、疑有开放性颅骨骨折、头痛加剧和易激惹）和 3 个中危因素（头皮大而肿胀的血肿、颅底骨折的体征、危险的损伤机制）。高危因素对预测神经介入治疗的需求有 100.0%的灵敏度（95%CI 86.2%-100.0%），需要进行 CT 检查的患者比例为 30.2%。中危因素对 CT 检查发现脑损伤的灵敏度为 98.1%（95%CI 94.6%-99.4%），需要进行 CT 检查的患者比例为 52.0%。
本研究制定的决策规则可识别出处于两种风险水平的患儿。该决策规则一旦前瞻性验证通过，将有可能实现对轻度颅脑损伤患儿 CT 检查的标准化和改善。
