Funded Projects

Childhood Head Trauma: A Neuroimaging Decision Rule

Grantee: Regents of the University of California
Principal Investigator: Nathan Kuppermann
Project Number: R40MC02461
Project Date: 01/01/2004

Final Report

Childhood Head Trauma: A Neuroimaging Decision Rule Final Report (PDF)

Age group(s)

• Perinatal/Infancy (0-12 months)
• Toddlerhood (13-35 months)
• Early Childhood (3-5 years)
• Middle Childhood (6-11 years)
• Adolescence (12-18 years)

Abstract

The long-term objective of this study is to develop a highly accurate decision rule for the evaluation of children with blunt head trauma on which to base evidence-driven guidelines on this topic. This decision rule will identify all children with traumatic brain injury (TBI) in need of acute intervention, yet also will result in less frequent use of computerized tomography (CT) scans in children with blunt head trauma evaluated in emergency departments (EDs). The specific aims are to derive and internally validate a clinical decision rule with a high degree of confidence which accurately and reliably identifies children at high risk and those at near-zero risk of TBI after blunt head trauma. TBI is the leading cause of death and disability in children older than one year. Some children with TBIs are initially not identified, leading to preventable morbidity. Although CT scanning is the reference standard for diagnosing TBI in head-injured children, and failure to diagnose TBI increases morbidity and mortality, overuse of CT scanning has important drawbacks. The most important among these is radiation exposure which may result in death from malignancy, estimated as 1 radiation-induced fatality per 2000-5000 pediatric cranial CT scans. Fewer than 10% of CT scans currently performed on children with head injury reveal TBI, thus CT scans are used inefficiently. The methods of our study will be a prospective, multicenter observational study of children with blunt head trauma evaluated in the 25 hospitals of the Pediatric Emergency Care Applied Research Network (PECARN) of the Maternal and Child Health Bureau. These 25 hospitals evaluate more than 808,000 children of diverse geographic and racial/ethnic background in their EDs on an annual basis. Children with blunt head trauma at PECARN EDs will be enrolled into the study over two years, and will be followed prospectively to detect the outcomes of interest: 1) TBI on CT scan and, 2) TBI in need of acute intervention (defined by the need for neurosurgery, endotracheal intubation for 24 hours or more, or hospitalization for 2 or more nights). The clinical data from the time of ED presentation will be analyzed using binary recursive partitioning to generate a clinical decision rule(s) for the identification of children at high-risk, and near-zero risk of TBI. Once externally validated and disseminated widely, the decision rule will result in safer, more efficient, evidence-based evaluation of children with head trauma, a decrease in the frequency of unnecessary CT use, and improved child health.

Publications

Listed is descending order by year published.

Dayan PS, Holmes JF, Atabaki S, et al. Traumatic Brain Injury (TBI) Study Group of the Pediatric Emergency Care Applied Research Network (PECARN). Association of traumatic brain injuries with vomiting in children with blunt head trauma. Ann Emerg Med. 2014;63(6):657-665.

Dayan PS, Holmes JF, Schutzman S, et al. Traumatic Brain Injury (TBI) study group of the Pediatric Emergency Care Applied Research Network (PECARN). Risk of traumatic brain injuries in children younger than 24 months with isolated scalp hematomas. Ann Emerg Med. 2014;64(2):153-162.

Hoyle JD Jr, Callahan JM, Badawy M, et al. Traumatic Brain Injury (TBI) study group for the Pediatric Emergency Care Applied Research Network (PECARN). Pharmacological sedation for cranial computed tomography in children after minor blunt head trauma. Pediatr Emerg Care. 2014 Jan;30(1):1-7.

Lee LK, Monroe D, Bachman MC, et al. Traumatic Brain Injury (TBI) working group of Pediatric Emergency Care Applied Research Network (PECARN). Isolated loss of consciousness in children with minor blunt head trauma. JAMA Pediatr. 2014;168(9):837-843.

Leonard JR, Jaffe DM, Kuppermann N, Olsen CS. Pediatric Emergency Care Applied Research Network (PECARN) cervical spine study group. Cervical spine injury patterns in children. Pediatrics. 2014 May;133(5):e1179-e1188.

Quayle KS, Powell EC, Mahajan P, et al. Epidemiology of blunt head trauma in children in U.S. emergency departments. N Engl J Med. 2014 Nov 13;371(20):1945-1947.

Stanley RM, Hoyle JD Jr, Dayan PS, et al. Pediatric Emergency Care Applied Research Network (PECARN). Emergency department practice variation in computed tomography use for children with minor blunt head trauma. J Pediatr. 2014;165(6):1201-1206.

Nigrovic LE, Lillis K, Atabaki SM, Dayan PS, Hoyle J, Tunik MG, Jacobs ES, Monroe D, Wootton-Gorges SW, Miskin M, Holmes JF, Kuppermann N; Traumatic Brain Injury (TBI) Working Group of the Pediatric Emergency Care Applied Research Network (PECARN). The prevalence of traumatic brain injuries after minor blunt head trauma in children with ventricular shunts. Ann Emerg Med. 2013 Apr;61(4):389-93. Epub 2012 Nov 2.

Rogers AJ, Maher CO, Schunk JE, Quayle K, Jacobs E, Lichenstein R, Powell E, Miskin M, Dayan P, Holmes JF, Kuppermann N; Pediatric Emergency Care Applied Research Network. Incidental findings in children with blunt head trauma evaluated with cranial CT scans. Pediatrics. 2013 Aug;132(2):e356-63. doi: 10.1542/peds.2013-0299. Epub 2013 Jul 22. PubMed PMID: 23878053.

Sheehan B, Nigrovic LE, Dayan PS, et al. Pediatric Emergency Care Applied Research Network (PECARN). Informing the design of clinical decision support services for evaluation of children with minor blunt head trauma in the emergency department: a sociotechnical analysis. J Biomed Inform. 2013 Oct;46(5):905-913.

Horeczko T, Kuppermann N. To scan or not to scan: pediatric minor head trauma in your office, clinic or emergency department. Contemporary Pediatrics. 2012;29(8):40-47.

Lichenstein R, Glass TF, Quayle KS, et al. Presentations and outcomes of children with intraventricular hemorrhage after blunt head trauma. Archives of Pediatric and Adolescent Medicine. 2012;166(8):725-731.

Natale JE, Joseph JG, Rogers AJ, et al. Cranial computed tomography use among children with minor blunt head trauma: association with race/ethnicity. Archive of Pediatric Adolescent Medicine. 2012;166(8):732-737.

Nigrovic LE, Lee LK, Hoyle J, et al. Prevalence of clinically important traumatic brain injuries in children with minor blunt head trauma and isolated severe injury mechanisms. Archives of Pediatric and Adolescent Medicine. 2012;166(4):356-361.

Holmes JF, Holubkov R, Kuppermann N; Pediatric Emergency Care Applied Research Network. Guardian availability in children evaluated in the emergency department for blunt head trauma. Acad Emerg Med. 2009 Jan;16(1):15-20.

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD, Atabaki SM, Holubkov R, et al;Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. Epub 2009 Sep 14.

Gorelick MH, Atabaki SM, Hoyle JD, Dayan PS, Holmes JF, Holubkov R, et al; Pediatric Emergency Care Applied Research Network. Interobserver agreement in assessment of clinical variables in children with blunt head trauma. Acad Emerg Med. 2008 Sep;15(9):812-818.