Management of Multiply Injured Pediatric Trauma Patients in the Emergency Department

Table of Contents

 

When children with multiple serious injuries present to the ED, how do you ensure that you identify and address all of their injuries? This issue provides a systematic approach to the management of pediatric patients with multiple traumatic injuries, with specific attention to commonly missed injuries and injuries that may cause significant morbidity or mortality. You will learn:

Recommendations for initial field management and evaluation that will aid in early recognition and stabilization of injuries

Critical elements of the primary survey that will help identify and address life-threatening injures

Which diagnostic imaging modalities are warranted, and which is the best choice, based on presentation

Evidence-based recommendations for a systematic approach to managing pediatric patients with multiple traumatic injuries

1. Abstract
2. Case Presentations
3. Introduction
4. Critical Appraisal of the Literature
5. Etiology and Pathophysiology
   1. Common Mechanisms of Injury
   2. Difficulties in Assessing Pediatric Patients
   3. Commonly Missed Injuries
   4. Traumatic Brain Injuries
6. Differential Diagnosis
7. Prehospital Care
   1. Initial Stabilization and Communication With Field Emergency Medical Technicians
   2. Cervical Spine Immobilization
   3. Splinting Orthopedic Injuries
8. Emergent Management
   1. History
   2. Physical Examination
      1. Primary Survey
         • Airway Management
         • Breathing
         • Circulation
         • Disability
         • Exposure and Environmental Control
   3. Evaluation
      1. Focused Assessment With Sonography in Trauma (FAST) Examination
   4. Primary Stabilization/Management
      1. Pediatric Airway Management
      2. Management of Closed Head Injuries
      3. Stabilization of Musculoskeletal Injuries
         • Open Fractures
         • Tetanus Vaccination
         • Compartment Syndrome
      4. Fluid Resuscitation
9. Diagnostic Studies
   1. Radiographic Studies
   2. Computed Tomography
   3. Magnetic Resonance Imaging
   4. Laboratory Studies
10. Treatment
11. Special Populations
    1. Infants
    2. Pregnant Teenagers
12. Controversies and Cutting Edge
    1. Closed Head Injury
       1. Severe Traumatic Brain Injury
    2. Transportation of Pediatric Trauma Patients
13. Disposition
14. Summary
15. Risk Management Pitfalls in the Management of Pediatric Patients With Multiple Injuries
16. Case Conclusions
17. Time and Cost-Effective Strategies
18. Key Points
19. Clinical Pathway for the Management of a Pediatric Patient With Multiple Traumatic Injuries
20. Tables and Figures
    1. Table 1. Differential Diagnosis for Pediatric Trauma Patients
    2. Table 2. Pediatric Glasgow Coma Scale Scoring
    3. Figure 1. Primary Survey Evaluation for Trauma Patients
    4. Figure 2. Differences in the Pediatric Airway Compared to the Adult Airway
    5. Figure 3. AVPU System for Infant Neurologic Assessment
21. References

Abstract

Management of the child with multiple traumatic injuries can be challenging, and important injuries may not be readily recognized. Early recognition of serious injuries, initiation of appropriate diagnostic studies, and rapid stabilization of injuries are key to decreasing morbidity and mortality in the multiply injured pediatric trauma patient. The differential diagnosis for these patients is wide, and treatment is targeted to the specific injuries. In this issue, a systematic approach to the multiply injured pediatric patient will be reviewed, with specific attention to commonly missed injuries and those injuries that may cause significant morbidity or mortality.

Case Presentations

A 12-year-old previously healthy boy presents to the ED via EMS for a visible deformity of his right arm. His 18-year-old brother was pulling him around in an inner tube that was attached by a long rope to a truck traveling about 40 miles per hour through a lightly wooded area. His brother made a sharp turn, and the patient went flying off the inner tube and hit a tree. The brother said that the patient did not lose consciousness, but that he was “stunned” for a few seconds, then started complaining about his right arm. The patient said he was not wearing any personal protective equipment. He has multiple abrasions to his face, trunk, and extremities. He denies pain anywhere except in his arm. He requests to have his neck brace removed because it is “annoying.” He denies vomiting but reports feeling nauseous after receiving morphine from the paramedics en route to the hospital. Because this was a severe mechanism, though the patient appears to have an isolated injury, you begin to consider how much you should do. Should you “pan-scan” the patient and draw labs because of the mechanism? What other imaging studies do you need to obtain besides an x-ray of the arm? Is the patient at risk for internal bleeding due to this blunt impact? Should you consult the surgeons or just call the orthopedist to reduce the obvious fracture?

A 16-month-old previously healthy girl presents to the ED via EMS after a seemingly accidental fall out of a third-story apartment window. Onlookers said the girl fell into a bush and appeared stunned but did not lose consciousness. The mother says when she got downstairs, the child was crying but easily consoled. The girl has multiple abrasions all over her body and a bloody nose, but otherwise seems fine. She cries throughout the primary and secondary surveys. Is the crying merely developmentally appropriate stranger anxiety? Does this patient need labs drawn? What type of imaging is warranted? If no other injuries are identified, what is the appropriate disposition for this patient?

Introduction

Trauma is the leading cause of morbidity and mortality in children aged > 1 year.^1,2 When pediatric patients present with multiple traumatic injuries, life- or limb-threatening injuries in 2 or more organ systems are not uncommon;^1,3,4 traumatic brain injuries (TBIs) and orthopedic/musculoskeletal injuries are frequent.⁵ Death occurs in up to 27% of pediatric patients with multiple traumatic injuries and is mainly dependent upon the severity of the TBI.⁴

Typically, major issues with airway, breathing, and circulation are recognized and stabilized in a timely fashion. Problems occur when TBIs and orthopedic injuries are not identified early, as they can lead to long-term disabilities in pediatric patients.^2,6 In one study, 9% of injuries were initially missed in pediatric trauma patients, with 46% of those injuries being missed fractures. Earlier identification of these injuries can greatly decrease the rates of morbidity and mortality. Other organ systems in which certain missed injuries can lead to serious morbidity in multiple-trauma patients include the gastrointestinal and respiratory systems.⁶ Less common pathologies, such as abdominal compartment syndrome,³ if not recognized early, can lead to a decline in respiratory status and decreased cardiac output. Blunt chest trauma can cause morbidity primarily from lung contusions or hemothorax/pneumothorax or secondarily as a result of a systemic inflammatory response syndrome leading to acute lung injury.

This issue of Pediatric Emergency Medicine Practice will discuss evidence-based recommendations for early recognition of TBI during the primary survey, initiation of the proper imaging to diagnose injuries, expedient stabilization of injuries, and utilization of a systematic approach to manage pediatric patients with multiple trauma.

Critical Appraisal of the Literature

A literature search was performed in PubMed using the search terms: multiple trauma, pediatrics, emergency room, trauma, children, polytrauma, imaging, FAST, permissive hypotension, transfusion, airway, tranexamic acid, and ATLS. A total of 193 articles from 1997 to the present were reviewed. The Cochrane Database of Systematic Reviews and the National Guideline Clearinghouse were searched for systematic reviews using the key term multiple trauma pediatrics. Approximately 70 articles were found, most of them being from the view of surgical management. The ninth edition of the Advanced Trauma Life Support (ATLS) guidelines,⁷ released by the American College of Surgeons Committee on Trauma, were also reviewed. While ATLS is not pediatric-specific, it is a system based on both best available evidence and expert consensus. These guidelines are widely considered the standard approach to all injured patients. Very few guidelines or policy statements were found specifically on pediatric trauma. The American Academy of Pediatrics (AAP) issued a policy statement in August 2016 that demonstrated the importance of a diverse trauma team when caring for pediatric trauma patients.⁸

The search of the literature revealed few case reports on multiple trauma in pediatric patients; there were also few studies on the emergency medical management of these cases. There were more studies that focused on the surgical management of multiple trauma patients, including emergency surgical procedures and early involvement of surgical specialties in resuscitation. The studies were retrospective, with very few prospective or randomized double-blinded studies.

Tables and Figures

References

Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of patients. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. In addition, the most informative references cited in this paper, as determined by the author, are highlighted.

1. Schalamon J, Bismarck SV, Schober PH, et al. Multiple trauma in pediatric patients. Pediatr Surg Int. 2003;19(6):417-423. (Retrospective review; 70 patients)
2. Kay RM, Skaggs DL. Pediatric polytrauma management. J Pediatr Orthop. 2006;26(2):268-277. (Review article)
3. Letts M, Davidson D, Lapner P. Multiple trauma in children: predicting outcome and long-term results. Can J Surg. 2002;45(2):126-131. (Retrospective case series; 149 patients)
4. Dereeper E, Ciardelli R, Vincent JL. Fatal outcome after polytrauma: multiple organ failure or cerebral damage? Resuscitation. 1998;36(1):15-18. (Retrospective review; 98 patients)
5. van der Sluis CK, Kingma J, Eisma WH, et al. Pediatric polytrauma: short-term and long-term outcomes. J Trauma. 1997;43(3):501-506. (Retrospective study; 74 patients)
6. Miele V, Di Giampietro I, Ianniello S, et al. Diagnostic imaging in pediatric polytrauma management. Radiol Med. 2015;120(1):33-49. (Review article)
7. ATLS Subcommittee, American College of Surgeons' Committee on Trauma. Chapter 10: Pediatric Trauma. Advanced Trauma Life Support Student Course Manual. 9th ed: American College of Surgeons; 2013. (Textbook)
8. Committee on Pediatric Emergency Medicine, Council on Injury Violence, and Poison Prevention, Section on Critical Care, Section on Orthopaedics, Section on Surgery, Section on Transport Medicine, et al. Management of pediatric trauma. Pediatrics. 2016;138(2). (AAP policy statement)
9. Tracy ET, Englum BR, Barbas AS, et al. Pediatric injury patterns by year of age. J Pediatr Surg. 2013;48(6):1384-1388. (Review article)
10. Lallier M, Bouchard S, St-Vil D, et al. Falls from heights among children: a retrospective review. J Pediatr Surg. 1999;34(7):1060-1063. (Retrospective review; 64 patients)
11. Wang MY, Kim KA, Griffith PM, et al. Injuries from falls in the pediatric population: an analysis of 729 cases. J Pediatr Surg. 2001;36(10):1528-1534. (Retrospective review; 729 patients)
12. Thompson EC, Perkowski P, Villarreal D, et al. Morbidity and mortality of children following motor vehicle crashes. Arch Surg. 2003;138(2):142-145. (Retrospective review; 191 patients)
13. Wetzel RC, Burns RC. Multiple trauma in children: critical care overview. Crit Care Med. 2002;30(11 Suppl):S468-S477. (Review article)
14. Furnival RA, Woodward GA, Schunk JE. Delayed diagnosis of injury in pediatric trauma. Pediatrics. 1996;98(1):56-62.(Retrospective review; 1175 patients)
15. Gaines BA, Ford HR. Abdominal and pelvic trauma in children. Crit Care Med. 2002;30(11 Suppl):S416-S423. (Review article)
16. Werner C, Engelhard K. Pathophysiology of traumatic brain injury. Br J Anaesth. 2007;99(1):4-9. (Review article)
17. Sundstrom T, Asbjornsen H, Habiba S, et al. Prehospital use of cervical collars in trauma patients: a critical review. J Neurotrauma.2014;31(6):531-540. (Review article)
18. Hadley MN, Walters BC, Grabb PA, et al. Management of pediatric cervical spine and spinal cord injuries. Neurosurgery. 2002;50(3 Suppl):S85-S99. (Literature review)
19. Pandya NK, Upasani VV, Kulkarni VA. The pediatric polytrauma patient: current concepts. J Am Acad Orthop Surg. 2013;21(3):170-179. (Review article)
20. Nau C, Jakob H, Lehnert M, et al. Epidemiology and management of injuries to the spinal cord and column in pediatric multiple-trauma patients. Eur J Trauma Emerg Surg. 2010;36(4):339-345. (Retrospective analysis; 35 patients)
21. Meier R, Krettek C, Grimme K, et al. The multiply injured child. Clin Orthop Relat Res. 2005(432):127-131. (Retrospective case study; 925 patients)
22. Avarello JT, Cantor RM. Pediatric major trauma: an approach to evaluation and management. Emerg Med Clin North Am. 2007;25(3):803-836. (Review article)
23. Reilly PL, Simpson DA, Sprod R, et al. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst. 1988;4(1):30-33. (Retrospective review)
24. Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. J Pediatr Surg. 2007;42(9):1588-1594. (Meta-analysis; 25 studies, 3838 patients)
25. Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med. 2011;18(5):477-482. (Prospective study; 357 patients)
26. Calder BW, Vogel AM, Zhang J, et al. Focused assessment with sonography for trauma in children after blunt abdominal trauma: a multi-institutional analysis. J Trauma Acute Care Surg. 2017;83(2):218-224. (Prospective study; 2188 patients)
27. Holmes JF, Kelley KM, Wootton-Gorges SL, et al. Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial. JAMA. 2017;317(22):2290-2296. (Randomized controlled trial; 925 patients)
28. Stafford PW, Blinman TA, Nance ML. Practical points in evaluation and resuscitation of the injured child. Surg Clin North Am. 2002;82(2):273-301. (Review article)
29. Esposito TJ, Sanddal ND, Dean JM, et al. Analysis of preventable pediatric trauma deaths and inappropriate trauma care in Montana. J Trauma. 1999;47(2):243-251. (Retrospective chart review; 138 patients)
30. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-175. (Review)
31. Abdelgadir IS, Phillips RS, Singh D, et al. Videolaryngoscopy versus direct laryngoscopy for tracheal intubation in children (excluding neonates). Cochrane Database Syst Rev. 2017;5:CD011413. (Systematic review; 12 studies, 803 patients)
32. Kuppermann N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170. (Prospective cohort; 42,412 patients)
33. Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop. 2001;21(5):680-688. (Retrospective chart review; 33 patients)
34. Ziolkowski NI, Zive L, Ho ES, et al. Timing of presentation of pediatric compartment syndrome and its microsurgical implication: a retrospective review. Plast Reconstr Surg. 2017;139(3):663-670. (Retrospective review; 35 patients)
35. Greene N, Bhananker S, Ramaiah R. Vascular access, fluid resuscitation, and blood transfusion in pediatric trauma. Int J Crit Illn Inj Sci. 2012;2(3):135-142. (Review article)
36. Hughes NT, Burd RS, Teach SJ. Damage control resuscitation: permissive hypotension and massive transfusion protocols. Pediatr Emerg Care. 2014;30(9):651-656. (Review)
37. Kannan N, Wang J, Mink RB, et al. Timely hemodynamic resuscitation and outcomes in severe pediatric traumatic brain injury: preliminary findings. Pediatr Emerg Care. 2018;34(5):325-329. (Retrospective review; 234 patients)
38. Zebrack M, Dandoy C, Hansen K, et al. Early resuscitation of children with moderate-to-severe traumatic brain injury. Pediatrics. 2009;124(1):56-64. (Retrospective review; 299 patients)
39. Hendrickson JE, Shaz BH, Pereira G, et al. Implementation of a pediatric trauma massive transfusion protocol: one institution’s experience. Transfusion. 2012;52(6):1228-1236. (Prospective cohort; 102 patients)
40. Hwu RS, Spinella PC, Keller MS, et al. The effect of massive transfusion protocol implementation on pediatric trauma care. Transfusion. 2016;56(11):2712-2719. (Retrospective review; 11,995 patients)
41. Whittaker B, Christiaans SC, Altice JL, et al. Early coagulopathy is an independent predictor of mortality in children after severe trauma. Shock. 2013;39(5):421-426. (Retrospective review; 803 patients)
42. Smith SA, Livingston MH, Merritt NH. Early coagulopathy and metabolic acidosis predict transfusion of packed red blood cells in pediatric trauma patients. J Pediatr Surg. 2016;51(5):848-852. (Retrospective review; 96 patients)
43. Rossaint R, Bouillon B, Cerny V, et al. The European guideline on management of major bleeding and coagulopathy following trauma: fourth edition. Crit Care. 2016;20:100. (Guidelines)
44. Kozek-Langenecker SA, Afshari A, Albaladejo P, et al. Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology. Eur J Anaesthesiol. 2013;30(6):270-382. (Guidelines)
45. Eckert MJ, Wertin TM, Tyner SD, et al. Tranexamic acid administration to pediatric trauma patients in a combat setting: the pediatric trauma and tranexamic acid study (PED-TRAX). J Trauma Acute Care Surg. 2014;77(6):852-858. (Retrospective review; 766 patients)
46. Baker N, Woolridge D. Emerging concepts in pediatric emergency radiology. Pediatr Clin North Am. 2013;60(5):1139-1151. (Review article)
47. Jakob H, Lustenberger T, Schneidmuller D, et al. Pediatric polytrauma management. Eur J Trauma Emerg Surg. 2010;36(4):325-338. (Review article)
48. Frank JB, Lim CK, Flynn JM, et al. The efficacy of magnetic resonance imaging in pediatric cervical spine clearance. Spine (Phila Pa 1976). 2002;27(11):1176-1179. (Retrospective chart review)
49. Asimos A. The trauma panel: laboratory test utilization in the initial evaluation of trauma patients. Emergency Medicine Reports. February 1997. (Review)
50. Capraro AJ, Mooney D, Waltzman ML. The use of routine laboratory studies as screening tools in pediatric abdominal trauma. Pediatr Emerg Care. 2006;22(7):480-484. (Retrospective medical record review; 382 patients)
51. Keller MS, Coln CE, Trimble JA, et al. The utility of routine trauma laboratories in pediatric trauma resuscitations. Am J Surg. 2004;188(6):671-678. (Retrospective study; 240 children)
52. Mathieson S, Whalen D, Dubrowski A. Infant trauma management in the emergency department: an emergency medicine simulation exercise. Cureus. 2015;7(9):e316. (Simulation exercise report)
53. Morrissey K, Fairbrother, HE. Pediatric trauma: pearls and pitfalls. emDocs.net. Available at: http://www.emdocs.net/pediatric-trauma-pearls-pitfalls/. Accessed May 15, 2018. (Online resource)
54. Murphy NJ, Quinlan JD. Trauma in pregnancy: assessment, management, and prevention. Am Fam Physician. 2014;90(10):717-722. (Review article)
55. Nesiama JA, Pirallo RG, Lerner EB, et al. Does a prehospital Glasgow Coma Scale score predict pediatric outcomes? Pediatr Emerg Care. 2012;28(10):1027-1032. (Retrospective chart review; 185 patients)
56. Kochanek PM, Carney N, Adelson PD, et al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents--second edition. Pediatr Crit Care Med. 2012;13 Suppl 1:S1-S82. (Guidelines)
57. Andrews PJ, Sinclair HL, Rodriguez A, et al. Hypothermia for intracranial hypertension after traumatic brain injury. N Engl J Med. 2015;373(25):2403-2412. (Randomized controlled trial; 387 patients)
58. Widdel L, Winston KR. Prognosis for children in cardiac arrest shortly after blunt cranial trauma. J Trauma. 2010;69(4):783-788. (Retrospective chart review; 40 patients)
59. Missios S, Bekelis K. Transport mode to level I and II trauma centers and survival of pediatric patients with traumatic brain injury. J Neurotrauma. 2014;31(14):1321-1328. (Retrospective cohort; 15,704 patients)
60. Macnab AJ, Wensley DF, Sun C. Cost-benefit of trained transport teams: estimates for head-injured children. Prehosp Emerg Care. 2001;5(1):1-5. (Retrospective chart review; 43 patients)
61. Acierno SP, Jurkovich GJ, Nathens AB. Is pediatric trauma still a surgical disease? Patterns of emergent operative intervention in the injured child. J Trauma. 2004;56(5):960-964. (Retrospective study)
62. Amini R, Lavoie A, Moore L, et al. Pediatric trauma mortality by type of designated hospital in a mature inclusive trauma system. J Emerg Trauma Shock. 2011;4(1):12-19. (Retrospective chart review; 11,503 patients)

The Pediatric Glasgow Coma Scale allows clinicians to obtain, track, and communicate the mental status and level of consciousness in preverbal children aged ≤ 2 years. The PECARN Pediatric Head Injury Prediction Rule is a well-validated clinical decision aid that allows clinicians to safely rule out the presence of clinically important traumatic brain injuries.

1. Pediatric Glasgow Coma Scale
2. PECARN Pediatric Head Injury/Trauma Algorithm

Pediatric Glasgow Coma Scale

• Introduction
• Points & Pearls
• Why and When to Use, and Next Steps
• Calculator Review Author
• Critical Actions
• Evidence Appraisal
• Calculator Creator
• References

Introduction

The Pediatric Glasgow Coma Scale allows clinicians to obtain, track, and communicate the mental status and level of consciousness in preverbal children aged ≤ 2 years.

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Points & Pearls

• The Pediatric Glasgow Coma Scale (pGCS) is a variation of the standard Glasgow Coma Scale (GCS), with age-appropriate modifications to the motor and verbal components.
• Like the standard GCS, the pGCS score range is from 3 to 15, with components for eye opening, verbal response, and motor response.
• The total score should be reported with the scores of each of the individual components because of the difference in prognostic value and variations of individual components versus the summed score. For example: Total pGCS score of 12 = E3 + V4 + M5 (Healey 2003).
• The pGCS is as accurate for identifying clinically important traumatic brain injury (ciTBI) in preverbal children as is the GCS in verbal children.

Points to keep in mind:

• It is best to obtain a pGCS score before the administration of analgesics or other interventions that could alter the score.
• The pGCS is slightly less accurate in identifying patients with traumatic brain injury (TBI) visible on computed tomography (CT) compared to the GCS in older children (Borgialli 2016).
• In intubated patients for whom a verbal score
• cannot be obtained, consider using the FOUR (Full Outline of UnResponsiveness) score. This is a validated, expanded scoring system (Wijdicks 2005, Sadaka 2012).
• The distinction between normal and abnormal flexion may be challenging, especially for the nonspecialist (Reilly 1991).

Why and When to Use, and Next Steps

Calculator Review Author

Joyce Brown, DO, CHSE

Matthew Meigh, DO

Critical Actions

All patients with either a pGCS or standard GCS score < 15 need appropriate monitoring, and all patients with concern for mental status or neurologic compromise should be closely monitored and reassessed as needed. 

Evidence Appraisal

The pGCS was evaluated in a subanalysis of a large, prospective observational multicenter cohort study of children with blunt head trauma, to compare the accuracy of the pGCS in preverbal children (aged ≤ 2 years) to the standard GCS score in older children (aged > 2 years) for identifying patients with TBIs after blunt head trauma (Borgialli 2016). The study demonstrated statistically similar test performance for the pGCS and the standard GCS in identifying patients with ciTBIs. The pGCS had slightly lower accuracy than the standard GCS in identifying patients with TBIs visible on CT. With a 95% confidence interval, the area under the receiver operating characteristic curve for the association between GCS score and ciTBI was 0.77 for the pGCS cohort and 0.81 for the standard GCS cohort. The area under the receiver operating characteristic curve for the association between GCS score and TBI visible on CT was 0.61 for the pGCS cohort and 0.71 for the standard GCS cohort.

Interobserver agreement in each cohort for the total score and all individual score components met the criteria for at least moderate interobserver agreement (kappa 95% lower confidence limit > 0.4). Limitations of the study included an age threshold of ≤ 2 years to define the preverbal pediatric population and the fact that only 36% of the study population underwent cranial CT imaging, so it is possible that some of the children who did not undergo imaging might have had traumatic findings on CT.

Calculator Creator

Sir Graham Teasdale, MBBS, FRCP

References

Original/Primary Reference

• Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-84.
• James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatr Ann. 1986;15(1):16-22.

Validation

• Borgialli DA, Mahajan P, Hoyle JD Jr, et al. Performance of the Pediatric Glasgow Coma Scale Score in the evaluation of children with blunt head trauma. Acad Emerg  Med. 2016;23(8):878-884.

Other References

• Reilly PL, Simpson DA, Sprod R, et al. Assessing the conscious level in infants and young children: a paediatric version of the Glasgow Coma Scale. Childs Nerv Syst. 1988;4(1):30-33
• Holmes JF, Palchak MJ, MacFarlane T, et al. Performance of the pediatric Glasgow Coma Scale in children with blunt head trauma. Acad Emerg Med. 2005;12(9):814-819
• Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor. J Trauma. 2003;54(4):671-680.
• Wijdicks EF, Bamlet WR, Maramattom BV, et al. Validation of a new coma scale: The FOUR score. Ann Neurol. 2005;58(4):585-593.
• Sadaka F, Patel D, Lakshmanan R. The FOUR score predicts outcome in patients after traumatic brain injury. Neurocrit Care. 2011;16(1):95-101.
• Teasdale G. Forty years on: updating the Glasgow Coma Scale. Nursing Times. 2014;110(42):12-16.
• Simpson D, Cockington RA, Hanieh A, et al. Head injuries in infants and young children: the value of the Paediatric Coma Scale. Childs Nerv Syst. 1991;7(4):183-190.

PECARN Pediatric Head Injury/Trauma Algorithm

• Introduction
• Points & Pearls
• Why and When to Use, and Next Steps
• Calculator Review Author
• Critical Actions
• Evidence Appraisal
• Calculator Creator
• References

Introduction

The PECARN Pediatric Head Injury Prediction Rule is a well-validated clinical decision aid that allows clinicians to safely rule out the presence of clinically important traumatic brain injuries.

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Points & Pearls

• The Pediatric Emergency Care Applied Research Network (PECARN) consortium produced the largest study, to date, aiming to derive and validate clinical prediction rules to identify children with very low risk of clinically important traumatic brain injury (ciTBI) following blunt head trauma, who would not require imaging. ciTBI was chosen as the primary outcome because it is clinically driven and accounts for the imperfect test characteristics of computed tomography (CT).
• In the group of patients aged < 2 years, the rule was 100% sensitive.
• In the group of patients aged ≥ 2 years, the rule was 96.8% sensitive.
• In patients aged < 2 years with a Glasglow Coma Scale (GCS) score ≥14 or other signs of altered mental status, or palpable skull fracture, the risk of ciTBI was 4.4%, and CT imaging is recommended. Risk of ciTBI in this age group was 0.9% with the presence of any of the other 4 predictors (occipital or parietal or temporal scalp hematoma, history of loss of consciousness for ≥ 5 seconds, severe mechanism of injury, or patient not acting normally according to the parents), and < 0.02% with no predictors.
• In patients aged ≥ 2 years with a GCS score ≥ 14 or other signs of altered mental status, or signs of basilar skull fracture, risk of ciTBI was 4.3%, and CT imaging is recommended. Risk of ciTBI in this age group was 0.9% with the presence of any of the other 4 predictors (history of loss of consciousness, history of vomiting, severe mechanism of injury, or severe headache), and < 0.05% with no predictors.
• Although it was the largest trial of its kind, the PECARN study had low rates of traumatic brain injury (TBI) on head CT scan (5.2%) and even lower rates of ciTBI (0.9%), suggesting that overall TBI in children is rare. Head CT scans were obtained in approximately 35% of patients, which was lower than the average estimate of 50% (Kupperman 2009).
• The PECARN Rule outperformed both the CHALICE (Children's Head injury Algorithm for the prediction of Important Clinical Events) and CATCH (Canadian Assessment of Tomography for Childhood Head injury) clinical decision aids in an external validation study (Easter 2014).

Why and When to Use, and Next Steps

Calculator Review Author

Daniel Runde, MD

Joshua Beiner, MD

Critical Actions

In the original PECARN study, ciTBI was a rare event (0.9%), and neurosurgical intervention was even more rare (0.1%). Over 50% of each age cohort did not have any predictors, and CT imaging is not indicated for the vast majority of these patients, as risk of ciTBI was exceedingly low. Risk of ciTBI was > 4% with either of the 2 higher-risk predictors in each age cohort, and imaging is recommended for patients with these predictors.

For the remaining 4 lower-risk predictors in each cohort, the risk of ciTBI is approximately 0.9% per predictor; for patients with any of these risk factors, CT imaging is indicated rather than observation. Judgment may be based on clinical experience, single versus multiple findings, signs of clinical deterioration during the observation period, patient age, and/or parental preference (Kupperman 2009).

Evidence Appraisal

The original PECARN study included 42,412 children aged < 18 years presenting to any of the 25 North American PECARN-affiliated emergency departments (EDs). There were 33,785 patients in the derivation cohort (8502 of whom were aged < 2 years) and 8627 in the validation cohort (2216 of whom were aged < 2 years).

CT scans were performed at the physician’s discretion for 35.3% of the patients, while medical records, telephone surveys, and county morgue records were used to assess for cases of missed ciTBI in patients discharged without imaging. The potential for CT reduction quoted above is likely underestimated, given that CT utilization in this study (35.3%) was significantly lower than the estimated average in North American EDs (50%). Among the patients who had CT imaging, 5.2% had TBI visible on CT.

Nine percent of the patients in the study were admitted to the hospital, 0.9% had ciTBIs, 0.1% underwent neurosurgery, and 0 died. Among the 376 patients with ciTBIs, 60 patients (15.9%) underwent neurosurgery, 8 patients (2.1%) were intubated for > 24 hours, and 0 patients died.

In patients aged < 2 years who were negative for any PECARN risk factor, the decision aid was 100% sensitive (95% confidence interval, 86.3-100) with a negative predictive value of 100% (95% confidence interval, 99.7-100) for ruling out ciTBI in the validation cohort. In patients aged > 2 years who were negative for any PECARN risk factor, the aid was 96.8% sensitive (95% confidence interval, 89.0- 99.6) with a 99.95% negative predictive value (95% confidence interval, 99.8-99.99) for ruling out ciTBI in the validation cohort.

As a result of the infrequency of ciTBI, the lower bounds of the confidence intervals of sensitivity started at 86% and 89%, respectively, for the cohorts of patients aged < 2 years and ≥ 2 years. The negative predictive value confidence intervals very closely approximated 100%.

Although the goal was to rule out patients with very low risk of ciTBI, the PECARN Rule also performed well to rule out TBI on head CT. In patients aged < 2 years, sensitivity and negative predictive value were 100% for TBI on CT, with narrow confidence intervals. In patients aged ≥ 2 years, sensitivity was 94% and negative predictive value was 98.4% for TBI on CT, with narrow confidence intervals (Kupperman 2009).

The PECARN Rule has now been externally validated in 2 separate studies. A trial of 2439 children in 2 pediatric EDs (1 in the United States and 1 in Italy) found the PECARN Rule to be 100% sensitive for ruling out ciTBI in both age cohorts (patients aged < 2 years and ≥ 2 years). The rates of 0.8% of patients (19 of 2439) with ciTBI and 0.08% of patients (2 of 2439) requiring neurosurgery were similar to the rates in the PECARN trial (Schonfeld 2014).

A second trial involving 1009 patients aged < 18 years at a single United States ED prospectively compared the PECARN Rule to 2 other pediatric head CT decision aids, CHALICE and CATCH, as well as to physician estimates and physician practice. In this sample, 2% of patients (21 of 1009) had ciTBI and 0.4% of patients (4 of 1009) needed neurosurgery. Again, the PECARN Rule was found to be 100% sensitive for identifying ciTBI. The PECARN Rule outperformed both the CHALICE and CATCH decision aids, which were 91% and 84% sensitive for ciTBI, respectively (Easter 2014).

Two PECARN Rule subgroup analyses attempted to furth er risk stratify patients who had single predictors. In a subanalysis of patients aged < 2 years with scalp hematomas and no other PECARN predictors, ciTBI was too uncommon to apply age, hematoma size, or hematoma location predictors. There were several non–statistically significant trends for higher rates of TBI on head CT scans that may affect imaging tendencies (eg, age < 3 months, nonfrontal hematoma location, and increased hematoma size) (Dayan, Holmes, Schutzman, et al 2014).

Another subanalysis of patients aged > 18 years who had vomiting and no other PECARN predictors reiterated the parent study results. In the cohort of patients aged ≥ 2 years, there was a low rate of TBI on head CT (3.2%, 26 of 806 patients) and an even lower rate of ciTBI (0.7%, 10 of 1501 patients), so observation rather than emergent imaging was indicated in the majority of these patients. The number of vomiting episodes and timing of those episodes was not helpful in predicting ciTBI or TBI on head CT, as there was a non–statistically significant counterintuitive trend towards less ciTBI/TBI on CT with more episodes (Dayan, Holmes, Atabaki, et al 2014).

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Nate Kupperman, MD, MPH

References

Original/Primary Reference

• Kupperman N, Holmes JF, Dayan PS, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009;374(9696):1160-1170.

Validation References

• Schonfeld D, Bressan S, Da Dalt L, et al. Pediatric Emergency Care Applied Research Network head injury clinical prediction rules are reliable in practice. Arch Dis Child. 2014;99(5):427-431.

Other References

• Easter JS, Bakes K, Dhaliwal J, et al. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: a prospective cohort study. Ann Emerg Med. 2014;64(2):145-152, 152.e1-152.e5.
• Brenner D, Elliston C, Hall E, Berdon W. Estimated risks of radiation-induced fatal cancer from pediatric CT. AJR Am J Roentgenol. 2001;176(2):289-296.
• Dayan PS, Holmes JF, Atabaki S, et al. Association of traumatic brain injuries with vomiting children with blunt head trauma. Ann Emerg Med. 2014;63(6): 657-665.
• Dayan PS, Holmes JF, Schutzman S, et al. Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med. 2014;64(2):153- 162.
• Hess EP, Wyatt KD, Kharbanda AB, et al. Effectiveness of the head CT choice decision aid in parents of children with minor head trauma: study protocol for a multicenter randomized trial. Trials. 2014;15:253.

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