PECARN、CATCH 和 CHALICE 头部损伤决策规则在儿童中的准确性：一项前瞻性队列研究。

Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study.

机构信息

Royal Children's Hospital, Melbourne, VIC, Australia; Murdoch Children's Research Institute, Melbourne, VIC, Australia; Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, VIC, Australia.

Princess Margaret Hospital for Children, Perth, WA, Australia; Schools of Paediatrics and Child Health and Primary, Aboriginal and Rural Healthcare, University of Western Australia, Crawley, WA, Australia.

出版信息

Lancet. 2017 Jun 17;389(10087):2393-2402. doi: 10.1016/S0140-6736(17)30555-X. Epub 2017 Apr 11.

DOI:10.1016/S0140-6736(17)30555-X

PMID:28410792

Abstract

BACKGROUND

Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and CHALICE) in a large sample of children.

METHODS

In this prospective observational study, we included children and adolescents (aged <18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged <2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury [TBI], need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13-15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673.

FINDINGS

Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (<1%) underwent neurosurgery, and 15 (<1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7-100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4-100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2-99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2-93·4; 125/141) and CHALICE (92·3%, 89·2-94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules.

INTERPRETATION

The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules.

FUNDING

National Health and Medical Research Council, Emergency Medicine Foundation, Perpetual Philanthropic Services, WA Health Targeted Research Funds, Townsville Hospital Private Practice Fund, Auckland Medical Research Foundation, A + Trust.

摘要

背景

临床决策规则可帮助确定儿童头部受伤后是否需要进行 CT 成像。我们旨在通过大样本量的儿童患者来验证三个临床决策规则（PECARN、CATCH 和 CHALICE）。

方法

这是一项前瞻性观察性研究，我们纳入了来自澳大利亚和新西兰 10 家医院急诊科的所有严重程度的儿童和青少年（年龄<18 岁）患者。我们评估了 PECARN（分为年龄<2 岁和≥2 岁的患儿）、CATCH 和 CHALICE 在预测每个规则特定的结局指标（分别为有临床意义的颅脑损伤[TBI]、需要神经干预和有临床意义的颅内损伤）方面的诊断准确性。对于每个计算，我们在满足每个规则纳入和排除标准的人群中使用规则特定的预测变量（验证队列）。在二次分析中，我们汇总了轻度头部损伤（格拉斯哥昏迷量表评分 13-15 分）患者的比较队列，并使用规则特定的预测变量计算了有临床意义的 TBI 这一标准结局的准确性。本研究在澳大利亚和新西兰临床试验注册中心注册，编号为 ACTRN12614000463673。

发现

2011 年 4 月 11 日至 2014 年 11 月 30 日，我们分析了 20 137 例因头部受伤就诊的儿童和青少年患者。2106 例（10%）患者进行了 CT 检查，4544 例（23%）患者入院，83 例（<1%）接受了神经外科手术，15 例（<1%）死亡。PECARN 适用于<2 岁的 4011 例（75%）患者和≥2 岁的 11 152 例（76%）患者。CATCH 适用于 4957 例患者，CHALICE 适用于 20 029 例（99%）患者。PECARN 在<2 岁的患儿中显示出最高的阳性预测值（100.0%，95%CI 90.7-100.0；38 例患者中 38 例有结局[38/38]）和 PECARN 在 2 岁及以上的患儿中（99.0%，94.4-100.0；97/98），其次是 CATCH（仅高风险预测因素；95.2%，76.2-99.9；20/21；中风险和高风险预测因素 88.7%，82.2-93.4；125/141）和 CHALICE（92.3%，89.2-94.7；370/401）。在 18 913 例轻度损伤患者的比较队列中，有临床意义的 TBI 的敏感性相似。两种分析的阴性预测值均>99%。