When less is more

Head injuries are one of the most common reasons children present in the emergency department. To rule out a serious brain injury, some children require a CT scan. For serious head injuries the decision to perform a CT can be straightforward, however for less severe injuries determining whether a CT scan is warranted has posed a challenge.

Balancing the need to accurately diagnose an injury with the importance of keeping radiation exposure to a minimum has in the past been controversial.

Emergency clinicians have had three rules to help guide their decision in referring patients for a CT scan, each using slightly different criteria. In minor head injuries, the preferred course of treatment is to avoid a CT scan, however, determining which rule to use to best identify children at very low risk of traumatic brain injury was a challenge.

Over the past five years a collaborative group of emergency physicians has been researching practices across 10 Australian and New Zealand tertiary hospitals with a view to refining these clinical decision rules.

Two of our Emergency clinicians, Dr Mary McCaskill and Dr Sarah Dalton were part of this collaborative team that compared the three clinical decision rules:

• The Pediatric Emergency Care Applied Research Network (PECARN, USA)
• The Canadian Assessment of Tomography for Childhood Head Injury (CATCH) rule
• The Children's Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE, UK).

The research which involved 20,137 children under the age of 18 years with head injuries, was undertaken by the PREDICT (Paediatric Research in Emergency Departments International Collaborative) network. A significant number of patients attending our Emergency Department between 2013 and 2015 contributed to this large-scale, multicentre validation study.

The goal was to determine which of the three rules provided the best guidance when it came to identifying children who were at very low risk of a traumatic brain injury and therefore did not need a head CT. The researchers found that although all three rules were good, only one, the PECARN criteria from the US, identified every patient needing neurosurgery.

Emergency Specialist, Dr Sarah Dalton said the research results are extremely useful and very topical.

“This work is a useful piece of the puzzle in educating clinicians about when a CT scan is indicated and warranted to ensure children are not unnecessarily exposed to radiation.

“The next step is to translate this research into changing practice by developing and implementing national guidelines that clearly instruct when CTs will optimise the management of children with head injuries to achieve the best outcomes.

“This study will also help inform further reviews by NSW Health in relation to understanding implications when investigative procedures are performed but don’t improve patient outcomes,” Dr Dalton said.