Applying the PECARN Prediction
Rules to Reduce Unnecessary CT Scans
in Children after Minor Head Trauma
A collaborative effort of California
ACEP and the Choosing Wisely
Campaign
Background
- Between 1995 and 2005, CT use in children more than doubled
- 20 - 60% of children assessed for head trauma in North American
emergency departments undergo CT—major variability in
practice from one ED to the next
- Less than 10% of CT scans in children with minor head trauma
(defined by GCS score of 14-15) show traumatic brain injury (TBI)
- Injuries needing neurosurgery are very uncommon in children
with GCS 14–15—only 0.1 – 0.2%
Migliorett et al. JAMA Pediatr. 2013.
Mannix et al. J Pediatr 2012.
Palchak et al. Ann Emerg Med 2003.
Background
• Ionizing radiation from CT scans can cause
lethal malignancies
• Risk estimated at 1/1000-1/5000
• Risk increases as age decreases
Brenner DJ. N Engl J Med 2007.
Pearce MS. Lancet 2012.
ACEP and Choosing Wisely
A multi-year effort of the ABIM Foundation
Mission: promote conversations among physicians and patients
about using appropriate tests and treatments and avoiding care
when harm may outweigh benefits.
Since launching in April 2012, over 80 specialty societies and
consumer groups have become “Choosing Wisely” partners. ACEP
officially joined in February 2013.
ACEP’s Oct 2013 recommendations were developed through a multistep process that included research and input from an expert panel
of emergency physicians and the ACEP Board of Directors.
PECARN Head Injury Prediction Rules
- Large, diverse, prospective study of 42,000 children with minor
head trauma (defined as GCS 14-15)
- Validated prediction rules to identify children at very low risk of
TBI after head trauma for whom CT is unnecessary
- Prediction rule accuracy for low-risk group in validation sample
(>50% of patients, accounting for ~ 25% of CTs):
<2yo: NPV 100%, Sensitivity 100%
>2yo: NPV 99.95%, Sensitivity 96.8%
Kuppermann et al; Lancet 2009.
Original published
PECARN rules
for < 2 years (A)
and >= 2 years (B)
PECARN Head Injury Prediction Rules
How to use the rules for children < 2 y.o.
High Risk of TBI (4.4%): GCS =14, palpable skull fracture, or altered
mental status (AMS) → CT indicated
Intermediate Risk (0.9%): occipital or parietal scalp hematoma,
LOC > 5 seconds, severe mechanism of injury, or acting different
per parent → Observation vs CT, shared decision-making
Low Risk of TBI (<0.02%): none of the PECARN predictors →
Observe in ED; CT not recommended
PECARN Head Injury Prediction Rules
How to use the rules for children >= 2 y.o.
High Risk of TBI (4.3%): GCS =14, signs of basilar skull
fracture, or AMS → CT indicated
Intermediate Risk (0.8%): LOC, history of vomiting,
severe HA, or severe mechanism of injury →
Observation vs CT, shared decision-making
Low Risk of TBI (<0.05%): none of the PECARN
predictors → Observe in ED; CT not recommended
Altered Mental Status (AMS)
“AMS” is a proxy for “GCS 14”
- agitation
- somnolence
- repetitive questioning
- slow response to verbal communication
Severe Mechanism of Injury
- motor vehicle crash with patient ejection
- death of another passenger
- rollover MVC
- pedestrian or bicyclist without helmet
struck by motor vehicle
- fall >5 ft(if >2 y.o.) or > 3 ft(if < 2 y.o.)
- head struck by high-impact object (golf ball,
baseball, golf club, horse hoof, etc.)
What if this were YOUR kid, Doc?
• If clearly high risk: CT
• If clearly low risk: Observation
• If intermediate risk: Shared DecisionMaking
- Providing information on benefits and risks
- Evaluating options based on goals and concerns
- Providing appropriate disposition and follow-up
Shared Decision Making is based on:
• Physician experience
• Parental preference
• Multiple vs. isolated findings
• Age < 3 months
Worsening signs or symptoms after initial
period of observation is an indication for
CT scan
Cal ACEP/
Choosing Wisely
Collaboration
Pediatric Head Trauma CT Decision Guide
Children younger than 2 years
GCS < 15
Palpable skull fracture
AMS (agitation, somnolence,
slow response, repetitive
questioning)
Pocket card
High Risk--4.4% risk
of ci-TBI*
Yes to any
CT
No
Scalp hematoma (excluding frontal)
LOC >5 seconds
Not acting normally per parent
Severe mechanism of injury
-Fall >3 ft
-MVA w/ ejection, rollover, or fatality
-Bike/ped vs. vehicle w/o helmet
-Struck by high-impact object
No
Intermediate
Risk--0.9%
Yes to any
Observation vs.
CT using shared
decision-making
Low risk-- < 0.02%
CT not indicated, Observe
*ci-TBI: risk of clinically important TBI needing acute intervention, based on PECARN validated prediction rules
Clinical factors used to
guide decision-making:
- Multiple vs. isolated
factors
- Worsening findings
during observation
(AMS, headache,
vomiting)
- Physician experience
- Parental preference
- <3 months old
Cal ACEP/
Choosing Wisely
Collaboration
Pediatric Head Trauma CT Decision Guide
Children 2 years and older
GCS < 15
Signs of basilar skull fracture
AMS (agitation, somnolence,
slow response, repetitive
questions)
Pocket card
High Risk--4.3% risk
of ci-TBI*
Yes to any
CT
No
Vomiting
LOC
Severe headache
Severe mechanism of injury
-Fall >5 ft
-MVA w/ ejection, rollover, or fatality
-Bike/ped vs. vehicle w/o helmet
-struck by high-impact object
No
Intermediate
Risk--0.8%
Yes to any
Observation vs.
CT using shared
decision-making
Low risk-- < 0.05%
CT not indicated, Observe
*ci-TBI: risk of clinically important TBI needing acute intervention, based on PECARN validated prediction rules
Clinical factors used to
guide decision-making:
- Multiple vs. isolated
factors
- Worsening findings
during observation
(AMS, headache,
vomiting)
- Physician experience
- Parental preference
Explaining the Rationale
Low risk = Concussion
- Concussion is a clinical dx based on symptoms
- Risks of CT outweigh benefits
Intermediate risk
- Intermediate risk symptoms warrant observation
before deciding whether to do head CT
- No increase in adverse outcome with this strategy
Information for parents: sample
page from parent pamphlet
“What is a head CT?”
“A CT (computed tomography) machine is a large scanner that uses
radiation to take detailed pictures of your brain, eyes, nose, ear, and
bones. The process usually takes 30-60 minutes, and may require your
child to be sedated. CT images help doctors decide if a child needs
surgery after a severe injury.
For a minor head injury, or a concussion, CT scans usually do not provide
any information that would change your child’s treatment, and could even
be harmful for your child because of the radiation.”
Weighing the risk in
“intermediate” patients
Give more consideration to CT scan if:
- Child is < 3 months of age
- Home observation is unreliable
- Child has more than one “intermediate” risk
factor, for example:
• vomiting AND headache
• headache AND LOC
• high-risk mechanism AND parietal hematoma
Weighing the risk factors
- If patient has worsening signs and symptoms
during observationget CT
- Experts recommend observation period of:
-
~2 hours post-injury in low-risk patients
~4 hours post-injury in intermediate-risk patients
- Some of observation period can happen at
home if there is a reliable observer
Dispelling the Myths
Myth: Delaying head CT leads to poorer outcomes
Fact: Observation in the ED for ~4 hours in intermediate
risk groups before making a decision about CT yields
equivalent outcomes to doing immediate CT
Fact: Risk of CT-induced malignancy in low risk group
outweighs benefits of imaging
Nigrovic et al. Pediatrics; 2011.
Brenner DJ et al. N Engl J Med 2007.
Dispelling the Myths
Myth: Head CT is faster and easier than observation
Fact: CT can take just as much or more time to obtain
and read, especially if sedation is necessary
Dispelling the Myths
Myth: Not recommending CT can result in lower patient
satisfaction scores and places provider at risk of
litigation in event of poor outcome
Fact: Explaining the research, including parents in the
decision-making process, and asking about parent
preference improves satisfaction
Geijerstam et al. BMJ 2006.
Case 1
A 20 month old girl falls down a flight of stairs and
presents with 3 large, 3x3 cm, boggy hematomas, one
on each side of the forehead, and one on the right
parietal scalp. She had no loss of consciousness, no
vomiting, and now 30 minutes after the event is
playing, talking to her mom, and acting normal. There
are no other clinical signs of skull fracture, and she
has normal vital signs and an otherwise normal
physical exam.
Case 1
-
< 2 years old
+ non-frontal scalp hematoma
+ severe mechanism of injury (fall > 3 ft)
no LOC, acting normally
Intermediate Risk (0.9%)- (criteria are: non-frontal
scalp hematoma, LOC > 5 sec , severe mechanism of
injury, not acting normally per parent) → Obs v CT
PECARN Head Injury Prediction Rules
Application
-MDCalc.com
algorithm
Case 1
- Parents okay with observation after
discussion with MD
- Child did well
- No sequelae on 24 hour phone follow-up
Case 2
A 9 year old boy falls off his bike and strikes his head
(unhelmeted) and sustains a large, boggy frontal scalp
hematoma. He had no loss of consciousness, a
moderate headache, no vomiting, and is mentating
normally with an otherwise normal physical exam.
Case 2
-
> 2 years old
Unhelmeted, but not hit by car
fall < 5 ft.
frontal scalp hematoma but no sign of fracture
No LOC, mentating normally, moderate headache, no
vomiting
Low Risk of TBI (0.05%)- no severe HA, N/V, or LOC
→ Obs
Case 2
MD Calc:
Case 2
After one hour of observation, he started to experience
a severe headache and vomited twice.
Intermediate Risk: multiple, worsening findings
CT performed → epidural hematoma → OR
Harry’s CT scan
Harry post-op, doing well
Case 2
PECARN and other studies provide good
evidence that delayed diagnosis of
clinically significant TBI results in the
same outcomes as doing CT
immediately—no increase in deaths or
disability
Geijerstam et al, BMJ 2006
Kuppermann N et al, Lancet 2009
Case 3
- 3 month old baby accidentally dropped
by mom
- Mom “can’t remember” if he had LOC,
or if he cried right away
- Vomited once in the ambulance; now
acting completely normal
- Smiling, no signs of trauma on exam
Case 3
<
-
2 years old
No scalp hematoma
+ severe mechanism of injury (fall > 3 ft)
Unclear LOC, now acting normally
Intermediate Risk (0.9%)- (criteria are: non-frontal
scalp hematoma, LOC > 5 sec , severe mechanism of
injury, not acting normally per parent) → Obs v CT
Case 3
MD Calc:
Case 3
- Mom is a teenager and is distraught;
this happened in the middle of a family
dispute where she was assaulted by a
family member
- Physician concerned that home
observation may not be reliable
- CT ordered
Case 3
-
Tiny frontal contusion
Observed overnight
No sequelae
No other intervention
Case 4
A 5 year old girl falls off a playground
swing, sustaining a 2 cm occipital
laceration with a boggy 3 x 3 cm
hematoma. She had no LOC, no
vomiting, and is acting normal per mom.
She cries with exam but is otherwise
normal-appearing, with no skull
Case 4
> 2 years old
- Fall of < 5 feet (not a high-risk mechanism)
- No other high-risk features: no vomiting, no
severe headache, no LOC, GCS 15, no sign of
basilar skull fracture
Low-risk (0.05%) Observation recommended
Case 4
MD Calc:
Case 4
Child was observed for 2 hours and did
well
Laceration repaired
No sequelae at 24 hour phone follow-up
Case 5
A 12 year old boy goes down during an
aggressive soccer play, hitting his head
on the ground and sustaining a 1 – 2
second loss of consciousness. He has no
vomiting but complains of severe
headache and nausea. He has an
occipital hematoma but no signs of
basilar skull fracture. GCS is 15.
Case 5
-
> 2 yrs of age
+ Severe headache
+ Brief loss of consciousness
GCS 15, no basilar skull fracture
No vomiting
Intermediate risk (0.9%) – (criteria are: GCS 15, no
basilar skull fracture, no LOC, no vomiting, no severe
headache, no severe mechanism) Obs vs. CT
Case 5
MD Calc:
Case 5
- Given acetaminophen and ondansetron
- Observed in the ED for 3 hours (4 hours
post-injury)
- Gradually improved; parents felt
comfortable not getting CT
- Doing well at 24 hour phone follow-up
Future Application Potentials
- QI process
- Evaluation of impact on physician
practice state-wide
- Outcome measures
- Grants
Resources
PECARN predicton rule:
http://www.pecarn.org/currentresearch/documents/Kuppermann_2009_
The-Lancet.pdf
PECARN prediction rule dataset:
http://www.pecarn.org/studyDatasets/TBIPredictionRule.html
Choosing Wisely communication modules:
http://modules.choosingwisely.org/modules/m_00/default_FrameSet.htm
Selected references
Miglioretti DL, Johnson E et al. The use of computed tomography in pediatrics and the associated radiation
exposure and estimated cancer risk. JAMA Pediatr. 2013;167:700-707.
Mannix R, Meehan WP et al. Computed tomography for minor head injury: variation and trends in major United
State pediatric emergency departments. J Pediatr. 2012;160:136-139.
Palchak MJ, Holmes JF, Vance CW, et al. A decision rule for identifying children at low risk for brain injuries
after blunt head trauma. Ann Emerg Med 2003; 42: 493–506.
Kuppermann N, Holmes JF et al. Identification of children at very low risk of clinically important
brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374:1160-70.
Pearce MS, Salotti JA et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia
and brain tumours: a retrospective cohort sutdy. Lancet 2012;380:499-505.
Nigrovic et al. The Effect of Observation on Cranial Computed Tomography Utilization for Children After Blunt
Head Trauma. Pediatrics 2011;127:1067-1073.
Brenner DJ, Hall EJ. Computed tomography—An increasing source of radiation exposure. N Engl J Med 2007;
357: 2277–84
Geijerstam et al. Medical outcome after immediate computed tomography or admission for observation in
patients with mild head injury: randomised controlled trial.
BMJ 2006;333:465
Schonfeld D, Fitz BM, Nigrovic LE. Effect of the duration of emergency department observation on computed
tomography use in children with minor blunt head trauma. Ann Emerg Med 2013;62:597.