Department of Emergency Medicine, Okmeydani Training and Research Hospital, University of Health Sciences, Istanbul, Turkey.
Department of Emergency Medicine, Umraniye Training and Research Hospital, University of Health Sciences, Istanbul, Turkey.
Eur J Trauma Emerg Surg. 2019 Oct;45(5):849-855. doi: 10.1007/s00068-017-0865-8. Epub 2017 Oct 25.
Computerized brain tomography (CBT) imaging plays a key role in the management of patients with head trauma, and there is an indication for CBT in moderate and severe injuries. However, it is difficult to determine an indication for CBT in patients with minor head trauma. The primary aim of this study is to compare the efficiency of the most commonly used clinical decision rules: the guidelines of the Pediatric Emergency Care Applied Research Network (PECARN), and those of the Canadian Assessment of Tomography for Childhood Head Injury (CATCH).
The study, which was designed as a prospective cohort study, sought to determine the appropriate CBT indications for children younger than 18 years who were referred to the emergency department with minor blunt head trauma. The effectiveness of PECARN and CATCH clinical decision rules, which are recommended by literature to be applied in order to diagnose severely injured patients and minimize inappropriate CBT requests, was investigated. All patients included in this study were younger than 18 years of age, were admitted to the study with an isolated blunt head trauma, had a GCS of > 13, and had parental permission to participate in the study. Patients ages 18 and older, those with penetrating head trauma or trauma to other systems, those with GCS ≤ 13, those with incomplete data, and those whose parents did not agree to participate in the study, were excluded.
A total of 256 patients were included in the study. PECARN and CATCH rules were both shown to be statistically significant in detecting the presence of pathology (p < 0.001, p = 0.002, respectively). Overall, PECARN was more successful than CATCH in detecting intracranial pathology. The sensitivity of PECARN was 95 (95% CI 72-100%) and specificity was 53 (95% CI 47-60%), while the sensitivity of CATCH was 48 (95% CI 25-71%) and specificity was 83 (95% CI 79-88%). Multivariate regression analyses were performed on the parameters (low GCS, abnormal mental status, age, non-frontal hematoma) and other parameters (vomiting, headache, abnormal behavior according to parents) that were considered to be clinically significant despite having a p value of < 0.3. Age, low GCS, and non-frontal hematoma presence were found to be significant in predicting the presence of pathology. In particular, low GCS increased the probability of pathology 5.94-fold and non-frontal hematoma presence 4.37-fold.
While both PECARN and CATCH were found to be effective in determining the necessity of CBT for children with minor blunt head trauma, PECARN proved to be more useful for emergency services because of its higher sensitivity. The authors suggest that conducting a CBT scan based on clinical decision rules may be a suitable approach for early detection of the presence of intracranial acute pathologies in young children with minor blunt head trauma, especially if the GCS score is < 15 and non-frontal hematomas are present.
计算机化脑断层扫描（CBT）成像在颅脑外伤患者的治疗中起着关键作用，中度和重度损伤有 CBT 的适应证。然而，对于轻度颅脑外伤患者，确定 CBT 的适应证是困难的。本研究的主要目的是比较最常用的临床决策规则的效率：儿科急诊护理应用研究网络（PECARN）的指南和加拿大儿童颅脑外伤 CT 评估（CATCH）的指南。
本研究为前瞻性队列研究，旨在确定因轻度钝性颅脑外伤就诊于急诊科的 18 岁以下儿童的适当 CBT 适应证。研究了 PECARN 和 CATCH 临床决策规则的有效性，文献推荐应用这些规则来诊断重伤患者并尽量减少不必要的 CBT 请求。所有纳入本研究的患者年龄均小于 18 岁，因孤立性钝性颅脑外伤入院，格拉斯哥昏迷评分（GCS）＞13，并获得了父母同意参加研究的许可。18 岁及以上的患者、有穿透性颅脑外伤或其他系统外伤的患者、GCS≤13 的患者、数据不完整的患者以及不同意参加研究的患者均被排除在外。
共纳入 256 例患者。PECARN 和 CATCH 规则在检测病理存在方面均具有统计学意义（p<0.001，p=0.002）。总体而言，PECARN 在检测颅内病理方面比 CATCH 更成功。PECARN 的灵敏度为 95%（95%CI 72-100%），特异性为 53%（95%CI 47-60%），而 CATCH 的灵敏度为 48%（95%CI 25-71%），特异性为 83%（95%CI 79-88%）。对参数（低格拉斯哥昏迷评分、异常精神状态、年龄、非额部血肿）和其他参数（呕吐、头痛、父母报告的异常行为）进行了多变量回归分析，这些参数被认为具有临床意义，尽管 p 值＜0.3。年龄、低格拉斯哥昏迷评分和非额部血肿的存在被发现是预测病理存在的显著因素。特别是，低格拉斯哥昏迷评分使病理存在的概率增加了 5.94 倍，非额部血肿的存在使病理存在的概率增加了 4.37 倍。
虽然 PECARN 和 CATCH 均被证明在确定轻度钝性颅脑外伤儿童行 CBT 的必要性方面有效，但由于其较高的灵敏度，PECARN 对急救服务更为有用。作者建议，根据临床决策规则进行 CBT 扫描可能是一种合适的方法，可早期发现轻度钝性颅脑外伤的幼儿颅内急性病变，尤其是 GCS 评分＜15 且存在非额部血肿时。
