A clinical decision rule to identify skull fracture among young children with isolated head trauma
CPS ePoster Library. Gravel J. 06/25/15; 99089; 26
Dr. Jocelyn Gravel
Dr. Jocelyn Gravel
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Abstract
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Background: There is no clear consensus regarding the use of skull radiological evaluation for young children who sustained a head trauma without traumatic brain injury.
Objective: The primary objective of this study was to derive and validate a clinical decision rule to identify skull fracture among children younger than 2 years old with head trauma and no need for head tomography.
Method: This was a prospective cohort study performed in three tertiary care pediatric emergency departments. Participants were all children younger than 24 months who sustained a head trauma and for whom head tomography was not highly recommended according to the PECARN head CT scan rule. The primary outcome was the presence of a skull fracture according to radiological report. A-priori, 28 independent variables were identified through a literature review and experts consensus. All participants were initially evaluated by a physician using a standardized datasheet before radiological evaluation. Radiological evaluation was left to the treating physician discretion. A clinical decision rule was derived using recursive partitioning. It was estimated that a sample of 45 cases of fracture would be necessary to derive the rule. Then, a second sample including at least 40 patients with a skull fracture were prospectively recruited for the validation.
Results: A total of 811 patients were recruited during the derivation period. Among them, 49 had a skull fracture. Recursive partitioning was used to derive a simple clinical decision rule to identify skull fracture. Parietal or occipital swelling/hematoma and age younger than 2 months old were the items of the rule. It showed a sensitivity of 94% (95%CI 83-99%) and specificity of 86% (95%CI 84-89%) in the derivation phase. Subsequently, 856 participants were recruited during the validation phase including 44 with a skull fracture. The clinical decision rule had a sensitivity of 89% (95%CI 76-95%) and a specificity of 87% (95%CI 84-89%). Using the rule would have decreased the number of radiological evaluation from 366 to 148. Four of the 5 missed fractures were in children younger than 4 months old.
Conclusion: This clinical decision rule identifies young children at higher risk of skull fractures following an acute head trauma with no definitive indication for head tomography.
Background: There is no clear consensus regarding the use of skull radiological evaluation for young children who sustained a head trauma without traumatic brain injury.
Objective: The primary objective of this study was to derive and validate a clinical decision rule to identify skull fracture among children younger than 2 years old with head trauma and no need for head tomography.
Method: This was a prospective cohort study performed in three tertiary care pediatric emergency departments. Participants were all children younger than 24 months who sustained a head trauma and for whom head tomography was not highly recommended according to the PECARN head CT scan rule. The primary outcome was the presence of a skull fracture according to radiological report. A-priori, 28 independent variables were identified through a literature review and experts consensus. All participants were initially evaluated by a physician using a standardized datasheet before radiological evaluation. Radiological evaluation was left to the treating physician discretion. A clinical decision rule was derived using recursive partitioning. It was estimated that a sample of 45 cases of fracture would be necessary to derive the rule. Then, a second sample including at least 40 patients with a skull fracture were prospectively recruited for the validation.
Results: A total of 811 patients were recruited during the derivation period. Among them, 49 had a skull fracture. Recursive partitioning was used to derive a simple clinical decision rule to identify skull fracture. Parietal or occipital swelling/hematoma and age younger than 2 months old were the items of the rule. It showed a sensitivity of 94% (95%CI 83-99%) and specificity of 86% (95%CI 84-89%) in the derivation phase. Subsequently, 856 participants were recruited during the validation phase including 44 with a skull fracture. The clinical decision rule had a sensitivity of 89% (95%CI 76-95%) and a specificity of 87% (95%CI 84-89%). Using the rule would have decreased the number of radiological evaluation from 366 to 148. Four of the 5 missed fractures were in children younger than 4 months old.
Conclusion: This clinical decision rule identifies young children at higher risk of skull fractures following an acute head trauma with no definitive indication for head tomography.
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