Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study

Nathan Kuppermann; James F. Holmes; Peter S. Dayan; John D. Hoyle; Shireen M. Atabaki; Richard Holubkov; Frances M. Nadel; David Monroe; Rachel M. Stanley; Dominic A. Borgialli; Mohamed K. Badawy; Jeff E. Schunk; Kimberly S. Quayle; Prashant Mahajan; Richard Lichenstein; Kathleen A. Lillis; Michael G. Tunik; Elizabeth S. Jacobs; James M. Callahan; Marc H. Gorelick; Todd F. Glass; Lois K. Lee; Michael C. Bachman; Arthur Cooper; Elizabeth C. Powell; Michael J. Gerardi; Kraig A. Melville; J. Paul Muizelaar; David H. Wisner; Sally Jo Zuspan; J. Michael Dean; Sandra L. Wootton-Gorges

doi:10.1016/S0140-6736(09)61558-0

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study

Nathan Kuppermann^*, James F. Holmes, Peter S. Dayan, John D. Hoyle, Shireen M. Atabaki, Richard Holubkov, Frances M. Nadel, David Monroe, Rachel M. Stanley, Dominic A. Borgialli, Mohamed K. Badawy, Jeff E. Schunk, Kimberly S. Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A. Lillis, Michael G. Tunik, Elizabeth S. Jacobs, James M. Callahan, Marc H. GorelickTodd F. Glass, Lois K. Lee, Michael C. Bachman, Arthur Cooper, Elizabeth C. Powell, Michael J. Gerardi, Kraig A. Melville, J. Paul Muizelaar, David H. Wisner, Sally Jo Zuspan, J. Michael Dean, Sandra L. Wootton-Gorges

^*Corresponding author for this work

Pediatrics

Research output: Contribution to journal › Article › peer-review

1323 Scopus citations

Abstract

Background: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. Methods: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights). Findings: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and 60 (0·1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100·0%, 95% CI 99·7-100 0) and sensitivity of 25/25 (100%, 86·3-100·0). 167 (24·1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99·95%, 99·81-99·99) and sensitivity of 61/63 (96·8%, 89·0-99·6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. Interpretation: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. Funding: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

Original language	English (US)
Pages (from-to)	1160-1170
Number of pages	11
Journal	The Lancet
Volume	374
Issue number	9696
DOIs	https://doi.org/10.1016/S0140-6736(09)61558-0
State	Published - Oct 9 2009

Funding

We thank Rene Enriquez and Li Dong at the PECARN Data Center (University of Utah) for their dedicated and diligent work; the research coordinators in PECARN, without whose dedication and hard work this study would not have been possible; all the clinicians around the PECARN network who enrolled children in this study; Mark Faul from the Centers for Disease Control and Prevention for analysing the NHAMCS databases for trends in CT usage over time. PECARN is supported by cooperative agreements U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008 from the Emergency Medical Services for Children (EMSC) programme of the Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services. This study was also supported by grant 1 R40MC02461-01-00 from the Maternal and Child Health Bureau Research Programme .

ASJC Scopus subject areas

General Medicine

UN SDGs

This output contributes to the following UN Sustainable Development Goals (SDGs)

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10.1016/S0140-6736(09)61558-0

Cite this

Kuppermann, N., Holmes, J. F., Dayan, P. S., Hoyle, J. D., Atabaki, S. M., Holubkov, R., Nadel, F. M., Monroe, D., Stanley, R. M., Borgialli, D. A., Badawy, M. K., Schunk, J. E., Quayle, K. S., Mahajan, P., Lichenstein, R., Lillis, K. A., Tunik, M. G., Jacobs, E. S., Callahan, J. M., ... Wootton-Gorges, S. L. (2009). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. The Lancet, 374(9696), 1160-1170. https://doi.org/10.1016/S0140-6736(09)61558-0

@article{cff8b421bd0743a1b2deee70cc5057fe,

title = "Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study",

abstract = "Background: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. Methods: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights). Findings: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and 60 (0·1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100·0%, 95% CI 99·7-100 0) and sensitivity of 25/25 (100%, 86·3-100·0). 167 (24·1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99·95%, 99·81-99·99) and sensitivity of 61/63 (96·8%, 89·0-99·6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. Interpretation: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. Funding: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.",

author = "Nathan Kuppermann and Holmes, {James F.} and Dayan, {Peter S.} and Hoyle, {John D.} and Atabaki, {Shireen M.} and Richard Holubkov and Nadel, {Frances M.} and David Monroe and Stanley, {Rachel M.} and Borgialli, {Dominic A.} and Badawy, {Mohamed K.} and Schunk, {Jeff E.} and Quayle, {Kimberly S.} and Prashant Mahajan and Richard Lichenstein and Lillis, {Kathleen A.} and Tunik, {Michael G.} and Jacobs, {Elizabeth S.} and Callahan, {James M.} and Gorelick, {Marc H.} and Glass, {Todd F.} and Lee, {Lois K.} and Bachman, {Michael C.} and Arthur Cooper and Powell, {Elizabeth C.} and Gerardi, {Michael J.} and Melville, {Kraig A.} and Muizelaar, {J. Paul} and Wisner, {David H.} and Zuspan, {Sally Jo} and Dean, {J. Michael} and Wootton-Gorges, {Sandra L.}",

note = "Funding Information: We thank Rene Enriquez and Li Dong at the PECARN Data Center (University of Utah) for their dedicated and diligent work; the research coordinators in PECARN, without whose dedication and hard work this study would not have been possible; all the clinicians around the PECARN network who enrolled children in this study; Mark Faul from the Centers for Disease Control and Prevention for analysing the NHAMCS databases for trends in CT usage over time. PECARN is supported by cooperative agreements U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008 from the Emergency Medical Services for Children (EMSC) programme of the Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services. This study was also supported by grant 1 R40MC02461-01-00 from the Maternal and Child Health Bureau Research Programme .",

year = "2009",

month = oct,

day = "9",

doi = "10.1016/S0140-6736(09)61558-0",

language = "English (US)",

volume = "374",

pages = "1160--1170",

journal = "The Lancet",

issn = "0140-6736",

publisher = "Elsevier B.V.",

number = "9696",

}

Kuppermann, N, Holmes, JF, Dayan, PS, Hoyle, JD, Atabaki, SM, Holubkov, R, Nadel, FM, Monroe, D, Stanley, RM, Borgialli, DA, Badawy, MK, Schunk, JE, Quayle, KS, Mahajan, P, Lichenstein, R, Lillis, KA, Tunik, MG, Jacobs, ES, Callahan, JM, Gorelick, MH, Glass, TF, Lee, LK, Bachman, MC, Cooper, A, Powell, EC, Gerardi, MJ, Melville, KA, Muizelaar, JP, Wisner, DH, Zuspan, SJ, Dean, JM & Wootton-Gorges, SL 2009, 'Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study', The Lancet, vol. 374, no. 9696, pp. 1160-1170. https://doi.org/10.1016/S0140-6736(09)61558-0

TY - JOUR

T1 - Identification of children at very low risk of clinically-important brain injuries after head trauma

T2 - a prospective cohort study

AU - Kuppermann, Nathan

AU - Holmes, James F.

AU - Dayan, Peter S.

AU - Hoyle, John D.

AU - Atabaki, Shireen M.

AU - Holubkov, Richard

AU - Nadel, Frances M.

AU - Monroe, David

AU - Stanley, Rachel M.

AU - Borgialli, Dominic A.

AU - Badawy, Mohamed K.

AU - Schunk, Jeff E.

AU - Quayle, Kimberly S.

AU - Mahajan, Prashant

AU - Lichenstein, Richard

AU - Lillis, Kathleen A.

AU - Tunik, Michael G.

AU - Jacobs, Elizabeth S.

AU - Callahan, James M.

AU - Gorelick, Marc H.

AU - Glass, Todd F.

AU - Lee, Lois K.

AU - Bachman, Michael C.

AU - Cooper, Arthur

AU - Powell, Elizabeth C.

AU - Gerardi, Michael J.

AU - Melville, Kraig A.

AU - Muizelaar, J. Paul

AU - Wisner, David H.

AU - Zuspan, Sally Jo

AU - Dean, J. Michael

AU - Wootton-Gorges, Sandra L.

N1 - Funding Information: We thank Rene Enriquez and Li Dong at the PECARN Data Center (University of Utah) for their dedicated and diligent work; the research coordinators in PECARN, without whose dedication and hard work this study would not have been possible; all the clinicians around the PECARN network who enrolled children in this study; Mark Faul from the Centers for Disease Control and Prevention for analysing the NHAMCS databases for trends in CT usage over time. PECARN is supported by cooperative agreements U03MC00001, U03MC00003, U03MC00006, U03MC00007, and U03MC00008 from the Emergency Medical Services for Children (EMSC) programme of the Maternal and Child Health Bureau, Health Resources and Services Administration, US Department of Health and Human Services. This study was also supported by grant 1 R40MC02461-01-00 from the Maternal and Child Health Bureau Research Programme .

PY - 2009/10/9

Y1 - 2009/10/9

N2 - Background: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. Methods: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights). Findings: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and 60 (0·1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100·0%, 95% CI 99·7-100 0) and sensitivity of 25/25 (100%, 86·3-100·0). 167 (24·1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99·95%, 99·81-99·99) and sensitivity of 61/63 (96·8%, 89·0-99·6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. Interpretation: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. Funding: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

AB - Background: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. Methods: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights). Findings: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and 60 (0·1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100·0%, 95% CI 99·7-100 0) and sensitivity of 25/25 (100%, 86·3-100·0). 167 (24·1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99·95%, 99·81-99·99) and sensitivity of 61/63 (96·8%, 89·0-99·6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. Interpretation: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. Funding: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

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U2 - 10.1016/S0140-6736(09)61558-0

DO - 10.1016/S0140-6736(09)61558-0

M3 - Article

C2 - 19758692

AN - SCOPUS:70349506141

SN - 0140-6736

VL - 374

SP - 1160

EP - 1170

JO - The Lancet

JF - The Lancet

IS - 9696

ER -

Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study

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UN SDGs

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