New rules derived from a large prospective study of children and adolescents could identify which head trauma patients are at low risk of serious traumatic brain injuries and thus do not need a CT scan.

The prospective cohort study included 42,412 children and adolescents who presented to 25 emergency departments in North America within 24 hours of head trauma, with Glasgow Coma Scale scores of 14-15.

“We derived and validated highly accurate prediction rules for children at very low risk of [clinically important traumatic brain injuries] for whom CT scans should be avoided,” concluded Dr. Nathan Kupperman of the department of emergency medicine and pediatrics, University of California, Davis, and his associates. “Application of these rules could limit CT use, protecting children from unnecessary radiation risks.”

The study was published online Sept. 15 in the Lancet (doi:10.1016/S0140-6736[09]61558-0). The investigators are part of the Pediatric Emergency Care Applied Research Network (PECARN).

The investigators defined clinically important traumatic brain injury (ciTBI) as death from traumatic brain injury, neurosurgery, intubation for more than 24 hours for traumatic brain injury, or hospital admission of at least 2 nights associated with traumatic brain injury on CT.

Of the study’s 42,412 patients, 97% had a Glasgow Coma Scale of 15, 0.9% had ciTBI, and 0.1% underwent neurosurgery. A total of 14,969 of the study patients underwent CT scans (35%), and 5.2% of them had traumatic brain injuries.

For children younger than 2 years (25% of the study population), the six predictors of low risk for ciTBI were as follows:

– Normal mental status.

– No scalp hematoma except frontal.

– No loss of consciousness for 5 seconds or more.

– Mild or moderate mechanism of injury.

– No palpable or unclear skull fracture.

– Acting normally based on their parents’ opinions.

When all six of those findings were present, the prediction rule correctly identified 100% of the children younger than 2 years who did not have a ciTBI and included 24% of the children who had a CT scan.

For patients aged 2-18 years, the six predictors of low ciTBI risk were as follows:

– Normal mental status.

– No loss of consciousness.

– No vomiting.

– Mild or moderate mechanism of injury.

– No clinical signs of basilar skull fracture.

– No severe headache.

Following that prediction rule correctly identified 99.95% of patients who did not have a ciTBI. (Of the 3,800 in this age group, the rule failed to identify 2 patients with a ciTBI.) This low-risk group included 20% of the patients who had a CT scan.

The investigators noted that altered mental status and signs of skull fracture “are branch points in the prediction trees with high risks for ciTBI,” and they recommended CT scans for children with either of those findings. Children with any of the other four predictors had a 0.9% risk of ciTBI, they added, “and decisions about CT use for this group should be based on other factors.”

In developing the clinical prediction rule, the PECARN investigators have “impressively derived and validated a high-quality and well-performing clinical prediction rule” that meets the need to predict whether a child with a head injury needs to have a CT scan, Dr. Patricia C. Parkin and Dr. Jonathon L. Maguire, both of the Hospital for Sick Children, Toronto, wrote in an accompanying editorial.

“The rules might not be perfect, but they represent the best current scientific evidence,” they added (Lancet 2009;[doi:10.1016/S0140-6736(09)61634-2]).

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

由一项针对儿童和青少年进行的大型前瞻性研究获得的新知，可帮助确定哪些头部创伤患者发生严重创伤性脑损伤的风险较低，因而不需要行CT检查。

 

此项前瞻性队列研究包括42,412名在发生头部创伤24 h内到25家急诊科求诊的儿童和青少年，其格拉斯哥昏迷量表(Glasgow Coma Scale)评分为14～15分。

 

 “我们从中归纳和确定了高精度的、可预测哪些儿童发生‘临床上重要的创伤性脑损伤’的风险较低的方法，因为这部分儿童可避免行CT检查，”来自加州大学急诊医学和儿科学系的Nathan Kupperman博士和其同事总结道。“这些规则的应用可减少CT的应用，保护儿童免于不必要的辐射风险。”

 

此项研究于9月15日在线发表在《柳叶刀》杂志上[doi:10.1016/S0140-6736(09)61558-0]。此研究涉及的研究人员均参与了儿童急诊医疗应用研究网络(Pediatric Emergency Care Applied Research Network, PECARN)。

 

研究者所谓的“临床上重要的创伤性脑损伤(ciTBI)”定义为死于创伤性脑损伤、需行神经外科手术、因创伤性脑损伤插管超过24  h或因CT发现有创伤性脑损伤而住院超过两夜。

 

在受试的42,412例患儿中，97%的哥拉斯哥昏迷量表评分为15分，0.9%有ciTBI，0.1%接受了神经外科手术。共14,969例(35%)患儿接受了CT检查，其中5.2%有创伤性脑损伤。

 

对于年龄小于2岁的患儿(占此项研究人群的25%)，可预测患儿发生ciTBI低风险的6个因素为：

—精神状态正常。

—除前额外无头皮血肿。

—未发生超过5 sec或更长时间的意识丧失。

—损伤轻微或中度损伤。

—无可触及或不确定的颅骨骨折。

—父母判断其行为正常。

 

当所有上述6个因素均出现时，这一预测规则正确地发现了所有未发生ciTBI的年龄小于2岁的儿童，这包括24%的接受CT检查的患儿。

 

对于年龄为2～18岁的患儿，其6个可预测ciTBI发生低风险的因素为：

—神状态正常。

—无意识丧失。

—未呕吐。

—损伤轻微或中度损伤。

—无基底颅骨骨折临床征象。

—无严重头痛。

 

依此预测规则可正确地确认99.95%的未发生ciTBI的患儿，此项研究中这一年龄段的患儿共3,800例，这项预测规则仅漏掉了2例发生ciTBI的患儿。这一低危人群包括了20%接受了CT检查的患儿。

 

研究者指出，精神状态改变和颅骨骨折体征“是ciTBI发生高风险的预测树的分支点”，他们建议发生其中任意一项的患儿进行CT检查。研究者补充道，发生其余4项因素中任意一项的患儿发生ciTBI的风险为0.9%，“而对于此部分患儿是否行CT检查应取决于其他因素”。

 

为发现此临床预测规则，PECARN研究者们“归纳和确认了一项高质量和具良好表现的临床预测规则”，这满足了预测发生头部创伤的儿童是否需行CT检查的需要，来自多伦多病童医院的Patricia C. Parkin博士和Jonathon L. Maguire博士在随后发表的评论中写道。

 

 “这种预测规则可能并不完美，但它们代表着现今最好的科学证据，”他们补充道(Lancet 2009;[doi:10.1016/S0140-6736(09)61634-2])。

 

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