Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study

Nathan Kuppermann, James F Holmes Jr, Peter S. Dayan, John D. Hoyle, Shireen M. Atabaki, Richard Holubkov, Frances M. Nadel, David Monroe, Rachel M. Stanley, Dominic A. Borgialli, Mohamed K. Badawy, Jeff E. Schunk, Kimberly S. Quayle, Prashant Mahajan, Richard Lichenstein, Kathleen A. Lillis, Michael G. Tunik, Elizabeth S. Jacobs, James M. Callahan, Marc H. GorelickTodd F. Glass, Lois K. Lee, Michael C. Bachman, Arthur Cooper, Elizabeth C. Powell, Michael J. Gerardi, Kraig A. Melville, Jan Paul Muizelaar, David H Wisner, Sally Jo Zuspan, J. Michael Dean, Sandra L. Wootton-Gorges

Research output: Contribution to journalArticle

783 Citations (Scopus)

Abstract

Background: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. Methods: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights). Findings: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and 60 (0·1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100·0%, 95% CI 99·7-100 0) and sensitivity of 25/25 (100%, 86·3-100·0). 167 (24·1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99·95%, 99·81-99·99) and sensitivity of 61/63 (96·8%, 89·0-99·6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. Interpretation: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. Funding: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

Original languageEnglish (US)
Pages (from-to)1160-1170
Number of pages11
JournalThe Lancet
Volume374
Issue number9696
DOIs
StatePublished - Oct 9 2009

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Craniocerebral Trauma
Brain Injuries
Cohort Studies
Prospective Studies
Unconsciousness
Neurosurgery
Basilar Skull Fracture
United States Health Resources and Services Administration
United States Dept. of Health and Human Services
Population
Skull Fractures
Glasgow Coma Scale
Brain Death
Wounds and Injuries
Emergency Medical Services
Scalp
Intubation
Hematoma
Vomiting
Headache

ASJC Scopus subject areas

  • Medicine(all)

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Identification of children at very low risk of clinically-important brain injuries after head trauma : a prospective cohort study. / Kuppermann, Nathan; Holmes Jr, James F; Dayan, Peter S.; Hoyle, John D.; Atabaki, Shireen M.; Holubkov, Richard; Nadel, Frances M.; Monroe, David; Stanley, Rachel M.; Borgialli, Dominic A.; Badawy, Mohamed K.; Schunk, Jeff E.; Quayle, Kimberly S.; Mahajan, Prashant; Lichenstein, Richard; Lillis, Kathleen A.; Tunik, Michael G.; Jacobs, Elizabeth S.; Callahan, James M.; Gorelick, Marc H.; Glass, Todd F.; Lee, Lois K.; Bachman, Michael C.; Cooper, Arthur; Powell, Elizabeth C.; Gerardi, Michael J.; Melville, Kraig A.; Muizelaar, Jan Paul; Wisner, David H; Zuspan, Sally Jo; Dean, J. Michael; Wootton-Gorges, Sandra L.

In: The Lancet, Vol. 374, No. 9696, 09.10.2009, p. 1160-1170.

Research output: Contribution to journalArticle

Kuppermann, N, Holmes Jr, JF, Dayan, PS, Hoyle, JD, Atabaki, SM, Holubkov, R, Nadel, FM, Monroe, D, Stanley, RM, Borgialli, DA, Badawy, MK, Schunk, JE, Quayle, KS, Mahajan, P, Lichenstein, R, Lillis, KA, Tunik, MG, Jacobs, ES, Callahan, JM, Gorelick, MH, Glass, TF, Lee, LK, Bachman, MC, Cooper, A, Powell, EC, Gerardi, MJ, Melville, KA, Muizelaar, JP, Wisner, DH, Zuspan, SJ, Dean, JM & Wootton-Gorges, SL 2009, 'Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study', The Lancet, vol. 374, no. 9696, pp. 1160-1170. https://doi.org/10.1016/S0140-6736(09)61558-0
Kuppermann, Nathan ; Holmes Jr, James F ; Dayan, Peter S. ; Hoyle, John D. ; Atabaki, Shireen M. ; Holubkov, Richard ; Nadel, Frances M. ; Monroe, David ; Stanley, Rachel M. ; Borgialli, Dominic A. ; Badawy, Mohamed K. ; Schunk, Jeff E. ; Quayle, Kimberly S. ; Mahajan, Prashant ; Lichenstein, Richard ; Lillis, Kathleen A. ; Tunik, Michael G. ; Jacobs, Elizabeth S. ; Callahan, James M. ; Gorelick, Marc H. ; Glass, Todd F. ; Lee, Lois K. ; Bachman, Michael C. ; Cooper, Arthur ; Powell, Elizabeth C. ; Gerardi, Michael J. ; Melville, Kraig A. ; Muizelaar, Jan Paul ; Wisner, David H ; Zuspan, Sally Jo ; Dean, J. Michael ; Wootton-Gorges, Sandra L. / Identification of children at very low risk of clinically-important brain injuries after head trauma : a prospective cohort study. In: The Lancet. 2009 ; Vol. 374, No. 9696. pp. 1160-1170.
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abstract = "Background: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. Methods: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights). Findings: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3{\%}); ciTBIs occurred in 376 (0·9{\%}), and 60 (0·1{\%}) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100·0{\%}, 95{\%} CI 99·7-100 0) and sensitivity of 25/25 (100{\%}, 86·3-100·0). 167 (24·1{\%}) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99·95{\%}, 99·81-99·99) and sensitivity of 61/63 (96·8{\%}, 89·0-99·6). 446 (20.1{\%}) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. Interpretation: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. Funding: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.",
author = "Nathan Kuppermann and {Holmes Jr}, {James F} and Dayan, {Peter S.} and Hoyle, {John D.} and Atabaki, {Shireen M.} and Richard Holubkov and Nadel, {Frances M.} and David Monroe and Stanley, {Rachel M.} and Borgialli, {Dominic A.} and Badawy, {Mohamed K.} and Schunk, {Jeff E.} and Quayle, {Kimberly S.} and Prashant Mahajan and Richard Lichenstein and Lillis, {Kathleen A.} and Tunik, {Michael G.} and Jacobs, {Elizabeth S.} and Callahan, {James M.} and Gorelick, {Marc H.} and Glass, {Todd F.} and Lee, {Lois K.} and Bachman, {Michael C.} and Arthur Cooper and Powell, {Elizabeth C.} and Gerardi, {Michael J.} and Melville, {Kraig A.} and Muizelaar, {Jan Paul} and Wisner, {David H} and Zuspan, {Sally Jo} and Dean, {J. Michael} and Wootton-Gorges, {Sandra L.}",
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TY - JOUR

T1 - Identification of children at very low risk of clinically-important brain injuries after head trauma

T2 - a prospective cohort study

AU - Kuppermann, Nathan

AU - Holmes Jr, James F

AU - Dayan, Peter S.

AU - Hoyle, John D.

AU - Atabaki, Shireen M.

AU - Holubkov, Richard

AU - Nadel, Frances M.

AU - Monroe, David

AU - Stanley, Rachel M.

AU - Borgialli, Dominic A.

AU - Badawy, Mohamed K.

AU - Schunk, Jeff E.

AU - Quayle, Kimberly S.

AU - Mahajan, Prashant

AU - Lichenstein, Richard

AU - Lillis, Kathleen A.

AU - Tunik, Michael G.

AU - Jacobs, Elizabeth S.

AU - Callahan, James M.

AU - Gorelick, Marc H.

AU - Glass, Todd F.

AU - Lee, Lois K.

AU - Bachman, Michael C.

AU - Cooper, Arthur

AU - Powell, Elizabeth C.

AU - Gerardi, Michael J.

AU - Melville, Kraig A.

AU - Muizelaar, Jan Paul

AU - Wisner, David H

AU - Zuspan, Sally Jo

AU - Dean, J. Michael

AU - Wootton-Gorges, Sandra L.

PY - 2009/10/9

Y1 - 2009/10/9

N2 - Background: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. Methods: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights). Findings: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and 60 (0·1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100·0%, 95% CI 99·7-100 0) and sensitivity of 25/25 (100%, 86·3-100·0). 167 (24·1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99·95%, 99·81-99·99) and sensitivity of 61/63 (96·8%, 89·0-99·6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. Interpretation: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. Funding: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

AB - Background: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. Methods: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission ≥2 nights). Findings: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35·3%); ciTBIs occurred in 376 (0·9%), and 60 (0·1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100·0%, 95% CI 99·7-100 0) and sensitivity of 25/25 (100%, 86·3-100·0). 167 (24·1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99·95%, 99·81-99·99) and sensitivity of 61/63 (96·8%, 89·0-99·6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. Interpretation: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. Funding: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services.

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