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To CT, or not to CT? Clinical Decision Rules for Concussion

May 08, 2015

May 11, 2015 - This week's post is also available from the Cochrane Child Health blog.

Head trauma. Headache. Nausea. Loss of balance. Dizziness. Difficulty concentrating. Confusion. Behavioural changes. Sleep changes.

It might be a concussion. What next?

With growing attention in research and the media, it is becoming clear that concussions are very serious injuries with sometimes lasting effects. As an emergency physician, the chances are good that you have treated many children with these symptoms – pediatric concussion is considered a silent epidemic [1]. In the US, estimates suggest up to 3.8 million concussions occur every year, resulting in over 700,000 Emergency Department visits [2]. Because of this, head trauma is one of the most common reasons for consultation in the Emergency Department [3]. 

Concussion symptoms typically alleviate within 72 hours, and completely resolve in 7 to 10 days [4]. However, in many cases, children and youth experience ongoing or recurrent headache, behavioural changes, and other physical symptoms, requiring subsequent Emergency Department and primary care physician visits [4]. It was estimated in one Canadian study that 58% of children with concussion remained symptomatic in the first month, 11% at 3 months, and 2% beyond one year [5]. These findings reinforce that concussions are serious injuries that can last over time. 

Considering the significant morbidity of concussion, and its impact on quality of life and school participation, identifying kids at risk for long-term consequences and those in need of neurosurgical intervention is crucial. There is an increasing tendency by physicians to perform early diagnostic imaging through CT scan for suspected concussion because it is linked to better outcomes, lower admission rates, and serves as the diagnostic standard for identifying intracranial injury [6]. However, it isn’t feasible or necessary to conduct this scan with all children presenting with concussion symptoms. This makes a clinical decision rule for CT scans important. With summer around the corner, and team sports ramping up for the season, understanding and using effective and validated clinical decision rules is essential to identify children at risk for intracranial injury. 

When to CT: The evidence

In a recent systematic review, Pickering et al. reviewed evidence from 16 RCTs (representing 14 cohorts and 79,740 patients) to determine which clinical decision tool is most accurate at predicting which pediatric patients will have an intracranial injury on CT or require neurosurgical intervention [6]. Sensitivity and specificity were determined for 11 decision rules: 

  • - UCD Rule
  • - NEXUS II
  • - Chalice Rule
  • - PECARN (≥2yrs <18yrs, and <2 yrs)
  • - Buchanich 2007 Rule
  • - Dietrich 1993 Rule
  • - Greenes 1999 Rule
  • - Greenes 2001 Scoring System
  • - Atabaki 2008 Rule
  • - CATCH Rule
  • - New Orleans Criteria

Which rule? 

Of the 11 clinical decision rules published at the time of the review (2011), methodologically, PECARN was identified as the strongest rule with the greatest validity, largest study cohort, highest sensitivity and acceptable specificity for clinically significant intracranial injury.

PECARN is the recommended clinical decision rule for identifying children at risk for intracranial injury who require imaging in Canada [1]. However, in the UK, because the CHALICE-derived National Institute for Health and Clinical Excellence (NICE) criteria for CT scan forms the basis for 85% of management decisions in the Emergency Department [6], the authors acknowledged its continued use as an acceptable and cost-effective alternative more in keeping with National Health Service-based practice. 

The PECARN Management Algorithm for Children after Head Trauma was initially published in the Lancet in 2009, and was based on a derivation and validation study involving 42,412 children [7]. The algorithm has separate considerations for children younger than 2 years and 2 years or older. It is available through trekk.ca or directly on the Ontario Neurotrauma Foundation website on page 53 of their Guidelines for Diagnosing and Managing Pediatric Concussion [8].

The authors concluded that the PECARN algorithm provides "highly accurate prediction rules for children at very low risk of clinically-important traumatic brain injuries for whom CT scans should be avoided. Application of these rules could limit CT use, protecting children from unnecessary radiation risks” [7].

Limitations

The heterogeneity of the rules included in the review prevented any meta-analysis of the data. The authors noted that a shift in practice from identification of any lesion on a CT scan to focusing on clinically significant lesions has made results of studies difficult to compare. The authors suggested: “future research efforts in this field should concentrate on the universal application of definitions for patient populations, inclusion criteria, reference standards, and outcome criteria” [7].

Resources:

Translating Emergency Knowledge for Kids (TREKK):

Concussion Evidence Repository

Emergency Medicine Cases Podcast: Pediatric head injury

References:

1. TREKK Bottom Line Recommendations: Concussion (English Version)

2. McCrory, P., Meeuwisse, W., Aubry, M., Cantu, B., Dvorak, J., Echemendia, R., . . . Turner, M. (2013). Consensus statement on Concussion in Sport - The 4th International Conference on Concussion in Sport held in Zurich, November 2012. Phys Ther Sport, 14(2), e1-e13. doi: 10.1016/j.ptsp.2013.03.002

3. Farrell, C. A. (2013). Management of the paediatric patient with acute head trauma. Paediatrics and Child Health (Canada), 18(5), 253-258.

4. Scorza, K. A., Raleigh, M. F., & O'Connor, F. G. (2012). Current concepts in concussion: Evaluation and management. American Family Physician, 85(2), 124-132.

5. Barlow, K. M., Crawford, S., Stevenson, A., Sandhu, S. S., Belanger, F., & Dewey, D. (2010). Epidemiology of postconcussion syndrome in pediatric mild traumatic brain injury. Pediatrics, 126(2), e374-381. doi: 10.1542/peds.2009-0925

6. Pickering, A., Harnan, S., Fitzgerald, P., Pandor, A., & Goodacre, S. (2011). Clinical decision rules for children with minor head injury: A systematic review. Archives of Disease in Childhood, 96(5), 414-421. doi: 10.1136/adc.2010.202820

7. Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Jr., Atabaki, S. M., Holubkov, R., . . . Wootton-Gorges, S. L. (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet, 374(9696), 1160-1170. doi: 10.1016/s0140-6736(09)61558-0

8. Zemek, R., Duval, S., Dematteo, C. et al. (2014). Guidelines for Diagnosing and Managing Pediatric Concussion. Toronto, ON: Ontario Neurotrauma Foundation

From team: News and Events

tags: Concussion Head Injury    

Author

Erin Hill


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Bicycle helmets – now that’s using your head!

April 02, 2015

April 6, 2015 - This week's post is also available from the Cochrane Child Health blog. 

Head injuries due to bicycle crashes are a common reason that children present to the emergency department. Bicycle helmets were designed to decrease head injuries. Different approaches to encourage bicycle helmet use have been evaluated. These range from legislation where individuals are required by law to wear a helmet when cycling to media campaigns and other health promotion activities, such as promoting the use of bicycle helmets in schools or offering free helmets through community-based programs.

An overview of Cochrane systematic reviews [1] was conducted in order to bring together evidence from reviews that focused on different aspects of the topic of bicycle helmet use. The reviewers identified three systematic reviews [2-4] that included 35 studies involving children. The reviews looked at:

  • the use of helmets for preventing head and facial injuries in bicyclists
  • bicycle helmet legislation to increase the uptake of helmet use and prevent head injuries
  • nonlegislative interventions to promote use of bicycle helmets in children (these included health education programs, subsidized or free helmets, and media campaigns)

Some of the key findings:

  • helmet use in children decreased medically reported head injuries by 63%
  • helmet use decreased brain injuries by 86%
  • mandatory helmet laws for children decreased the odds of head injury hospitalizations by 45%
  • after helmet legislation, the odds of traumatic brain injuries decreased by 18%
  • legislation resulted in an increase in the number of children wearing a helmet
  • nonlegislative helmet promotion activities also resulted in an increase in the number of children wearing a helmet
  • there were no risks involved with using bicycle helmets

The authors concluded that bicycle helmets are effective in reducing head injuries in children. They also concluded that both legislative and non-legislative interventions are helpful in reducing injuries and promoting helmet use. However, the authors noted that there are some who oppose helmet legislation. The main reasons are that they feel that this may encourage people to cycle more recklessly or less frequently.

Dr. Tony Woodward, Chief of Emergency Medicine at Seattle Children's Hospital states that "there's no question that the best way to protect your child when they're on a bike, scooter, or skates is to wear an appropriately sized helmet. In the emergency department, the children we see who are the most seriously injured are the ones that don't have helmets or have helmets that are inappropriately sized or inappropriately worn."

Finally, check out the TREKK resources on severe head injury. Helmets prevent injury, but accidents still happen! 

References:

[1] Russell, K., Foisy, M., Parkin, P., & Macpherson, A. (2011). The promotion of bicycle helmet use in children and youth: an overview of reviews. Evidence-Based Child Health: A Cochrane Review Journal, 6(6), 1780-1789. doi: 10.1002/ebch.901

[2] Owen, R., Kendrick, D., Mulvaney, C., Coleman, T., & Royal, S. (2011). Non-legislative interventions for the promotion of cycle helmet wearing by children. Cochrane Database of Systematic Reviews, (11). doi:10.1002/14651858.CD003985.pub3

[3] Macpherson, A., & Spinks, A. (2008). Bicycle helmet legislation for the uptake of helmet use and prevention of head injuries. Cochrane Database of Systematic Reviews, (3). doi:10.1002/14651858.CD005401.pub3

[4] Thompson D., Rivara, F., & Thompson, R. (1999). Helmets for preventing head and facial injuries in bicyclists. Cochrane Database of Systematic Reviews, (4). doi:10.1002/14651858.CD001855

More Information:

TREKK (Translating Emergency Knowledge for Kids) Resources:

ChildSafetyLink. (2014). Keep Kids Safe: A Parent's Guide to Helmet and Recreation Safety.

Government of Manitoba. (2013). Bike Helmet Safety Video.

From team: News and Events

tags: Head Injury Severe Head Injury    


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