diagnostic yield of Head injury decision rules
Last week I went to trauma for a baby who was in an MVC, and was reminded of just how hard it is to calculate a GCS on 7-week old. These authors agree, and they performed a Diagnostic Yield analysis of the 3 clinical decision rules (CDRs) related to pediatric head trauma- PECARN, CHALICE, and CATCH.
What did they do? A diagnostic yield study is one that looks at how effective a test is at identifying a specific condition (basically the positive-predictive value). Here, they wanted to see how the 3 CDRs related to pediatric head trauma performed in identifying TBI in babies aged 0-3 months. They took 151 of these infants aged 0-3 months who got a head CT after a traumatic injury, retrospectively applied the 3 CDRs based on documentation, found out who was CDR-positive, and then looked at CT results to see which ones had TBI. Notably if the patient wasn't LOW RISK, they were considered CDR-positive.
What did they find? In their cohort, 20 babies had a TBI. Out of the 151 who, again, were already scanned, 135 were PECARN positive, 95 were CATCH positive, and 78 were CHALICE positive. Very importantly, CATCH would've missed 2 if you had gone simply based on that CDR. PECARN and CHALICE missed none. Overall, CHALICE led the way with a 25% diagnostic yield, followed by CATCH at about 19%, and PECARN at 15%.
**Caveats: Remember, this study only looked at kids who already got scanned, so there is no data here about FALSE NEGATIVES (didn't scan, but should've). Also, while it looks like PECARN scanned a bunch "unnecessarily," remember they said the child was PECARN positive even if it said "recommends obs over imaging." Most of us don't scan that child when they are older, however, when you read the PECARN fine print, it says "Consider the following when making imaging decisions: physician experience, worsening signs/symptoms, age < 3 months..." as these are more high risk.
Bottom Line: Familiarize yourself with the other clinical decision rules that are out there, but remember: PECARN is the most widely validated, and more importantly, YOU are the expert. You know to never trust a baby, and things like "agitation" or "somnolence" in a baby less than 3 months old are hard to identify. When in doubt, listen to your gut, and do what's right for the baby.
What did they do? A diagnostic yield study is one that looks at how effective a test is at identifying a specific condition (basically the positive-predictive value). Here, they wanted to see how the 3 CDRs related to pediatric head trauma performed in identifying TBI in babies aged 0-3 months. They took 151 of these infants aged 0-3 months who got a head CT after a traumatic injury, retrospectively applied the 3 CDRs based on documentation, found out who was CDR-positive, and then looked at CT results to see which ones had TBI. Notably if the patient wasn't LOW RISK, they were considered CDR-positive.
What did they find? In their cohort, 20 babies had a TBI. Out of the 151 who, again, were already scanned, 135 were PECARN positive, 95 were CATCH positive, and 78 were CHALICE positive. Very importantly, CATCH would've missed 2 if you had gone simply based on that CDR. PECARN and CHALICE missed none. Overall, CHALICE led the way with a 25% diagnostic yield, followed by CATCH at about 19%, and PECARN at 15%.
**Caveats: Remember, this study only looked at kids who already got scanned, so there is no data here about FALSE NEGATIVES (didn't scan, but should've). Also, while it looks like PECARN scanned a bunch "unnecessarily," remember they said the child was PECARN positive even if it said "recommends obs over imaging." Most of us don't scan that child when they are older, however, when you read the PECARN fine print, it says "Consider the following when making imaging decisions: physician experience, worsening signs/symptoms, age < 3 months..." as these are more high risk.
Bottom Line: Familiarize yourself with the other clinical decision rules that are out there, but remember: PECARN is the most widely validated, and more importantly, YOU are the expert. You know to never trust a baby, and things like "agitation" or "somnolence" in a baby less than 3 months old are hard to identify. When in doubt, listen to your gut, and do what's right for the baby.
