Monday, March 31, 2014

Head Injury Showdown: PECARN Wins!

Most are familiar with the Pediatric Emergency Care Applied Research Network (PECARN) decision instrument for children with mild traumatic brain injury.  While they enrolled the largest number of patients in their derivation, they’re not alone:  the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) and Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) address similar clinical questions.

And, now that you know about them, you might as well forget about them.

This is a prospective validation of each of the three decision instruments at Denver Health, enrolling 1,009 children with blunt head injury and GCS 13 or greater.  52 patients had head injuries on CT, 21 of which were judged clinically significant, and 4 required neurosurgical intervention.  Based on the 90% of their cohort for whom they had complete outcome data, the PECARN rule was 100% sensitive and 62% specific, CATCH was 91% sensitive and 44% specific, and CHALICE was 84% sensitive and 85% specific.  Therefore it is most defensible to use the PECARN decision instrument in a setting concerned with maximal sensitivity.

However, what’s most interesting in this study – only 188 children underwent CT, and physician practice had 100% sensitivity.  All told, the PECARN instrument classified 47 as "high risk" and 335 as “intermediate risk”.  The original derivation publication states this intermediate cohort may be eligible for observation vs. CT, depending on provider comfort level.  Ultimately, the management of "intermediate risk" is the key to this instrument's role in reducing resource utilization.  In many settings, such as this one, if the “intermediate risk” group predominantly undergoes CT rather than observation, resource utilization will increase, rather than decrease.

However, the Denver Health expertise is not generalizable to most institutions – but provides an interesting perspective on the performance of PECARN to expert clinical judgment.

“Comparison of PECARN, CATCH, and CHALICE Rules for Children With Minor Head Injury: A Prospective Cohort Study”
http://www.ncbi.nlm.nih.gov/pubmed/24635987

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