• Users Online: 546
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2022  |  Volume : 11  |  Issue : 2  |  Page : 86-89

Accuracy of Pediatric Emergency Care Applied Research Network Rules in Predicting Brain Injuries


1 Emergency and Trauma Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran
2 Road Traffic Injury Research Center, Tabriz University of Medical Sciences, Tabriz, IR Iran

Date of Submission08-Jan-2022
Date of Decision13-Jun-2022
Date of Acceptance14-Jun-2022
Date of Web Publication30-Sep-2022

Correspondence Address:
Prof. Farzad Rahmani
Department of Emergency Medicine, Faculty of Medicine, Tabriz University of Medical Sciences, Golgasht Avenue, Tabriz
IR Iran
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/atr.atr_5_22

Rights and Permissions
  Abstract 


Background and Objectives: Head trauma is one of the most important causes of emergency department (ED) visits and the leading cause of disability and mortality in children. The aim of this study was to evaluate the Pediatric Emergency Care Applied Research Network (PECARN) rules to predict brain injuries in pediatrics with head trauma. Materials and Methods: This descriptive–analytic study was performed on 250 pediatric patients with head trauma referred to Imam Reza Hospital in Tabriz City from August to September 2020. All patients were evaluated in the ED for the existing of any rules of the PECARN, then the results of the PECARN rules and brain computed tomography (CT) scan findings were compared in these patients. According to the PECARN rules, patients were classified into three categories, namely low, moderate, and high risk. For all three groups, if there is an indication of brain CT scan, it was performed and reported by an emergency medicine specialist. Results: The mean age of the patients was 88 months. In this study, 162 (64.8%), 42 (16.8%), and 46 (18.4%) patients were in the low-risk, moderate-risk, and high-risk groups, respectively. Death was occurred in 18 (12.8%) patients. Results showed a statistically significant association between positive CT findings and some variables, such as behavioral change, vomiting, severe headache, LOC over 5 s, confusion, palpable skull fracture, skull base fracture, and the severe mechanism of injury (P < 0.05). Furthermore, a statistically significant association was found between PECARN rules and CT findings (P < 0.001). Conclusions: According to the results of the present study, PECARN rules have a significant association with brain CT scan findings. Therefore, using these rules is recommended to reduce the number of brain CT scan requests for pediatric patients.

Keywords: Brain trauma, child, decision support techniques, emergency service, hospital, tomography, X-ray computed tomography


How to cite this article:
Jamali F, Gholizadeh S, Kangari M, Ghaffarzad A, Bakhtavar HE, Rahmani F. Accuracy of Pediatric Emergency Care Applied Research Network Rules in Predicting Brain Injuries. Arch Trauma Res 2022;11:86-9

How to cite this URL:
Jamali F, Gholizadeh S, Kangari M, Ghaffarzad A, Bakhtavar HE, Rahmani F. Accuracy of Pediatric Emergency Care Applied Research Network Rules in Predicting Brain Injuries. Arch Trauma Res [serial online] 2022 [cited 2022 Nov 30];11:86-9. Available from: https://www.archtrauma.com/text.asp?2022/11/2/86/357567




  Introduction Top


Head trauma is one of the most important causes of emergency department (ED) visits and is the leading cause of disability and mortality in children.[1],[2],[3],[4] Falling from height, car accidents, and child abuse are the main causes of head trauma in children.[1],[5] Head trauma is among one of the prevalent acute events in children in Iran with an increasing rate.[6]

Head computed tomography (CT) is needed to evaluate head trauma severity based on the patients' symptoms.[1],[2],[4] X-ray exposure in CT is associated with an increased incidence of malignancies. In children with multiple CT scans in the first 15 years, an increased risk of leukemia and brain tumors is reported.[7] It was reported that for every 10,000 CT in children less than 10 years, one leukemia and one case of a brain tumor would occur in the next 10 years after CT.[1],[2] Delay in diagnosis and treatment of brain injuries in children will cause an increased mortality rate and have a poor prognosis.[1],[8]

However, improper use of head CT in the setting of head trauma is seen because of some reasons, including lack of physician confidence in his/her clinical ability to diagnose, psychological and verbal pressure of the child's parents to do the imaging, limitation of verbal communication with the child, difficulties in neurologic examinations and lack of a uniform strategy for imaging in hospitals, and the most important of all lack of an appropriate alternative method.[2] Pediatric Emergency Care Applied Research Network (PECARN) in 2009 introduced scoring tools and methods to identify children with low-risk trauma to prevent improper imaging. The children were classified into three categories based on the PECARN rules: low, intermediate, and high risk [Table 1]. Positive PECARN is determined by the presence of at least one item in the high- or intermediate-risk category.[8] Since the studies showed controversial results about the application of the PECARN rules in the setting of head trauma in children, this cross-sectional descriptive study was performed to investigate the diagnostic value of this method.
Table 1: Classification of patients based on PECARN rules

Click here to view



  Materials and Methods Top


This descriptive cross-sectional study was conducted on 250 pediatric brain trauma patients referred to Imam Reza Hospital in Tabriz City from August to September 2020. The inclusion criteria included children <18 years and head trauma in recent 24 h. Our exclusion criteria included nonsignificant trauma such as falling or hitting a sedentary body with no sign or with maximum damage to the scalp, penetrating trauma, confirmed brain tumor, history of previous neurologic deficits, which can lead to disruption in data analysis, brain imaging before referring to the hospital, the presence of ventricular shunt, hemorrhagic disorders, and parental dissatisfaction.

Demographic data as well as medical history were recorded using a checklist by the medical staff present in the ED without knowledge of the imaging results. These data included age (in the month), gender, Glasgow Coma Scale (GCS), change in consciousness, palpable skull fracture, signs of skull base fracture, severe mechanism of injury, loss of consciousness more than 5 s, nonfrontal hematoma, vomiting, and severe headache. Underlying diseases, history of drug use, mechanism of event, and treatment at the scene were considered confounding factors. Thus, stratification was used to control these factors. Brain CT scan (Siemens SOMATOM Emotion 6, Germany) was performed based on the indication in child head trauma, and reported by an emergency specialist.

Head trauma with clinical significance is the main point in this study. Head trauma with clinical significance defines as head trauma that leads to death, neurosurgery, intubation for more than 24 h, and hospitalization for more than one night.[8] Results of PECARN rules and CT findings were compared in these traumas. Furthermore, the relationship between the severity of trauma based on GAP score[9],[10] and PECARN rules was compared.

Finally, SPSS version 21 (IBM, Chicago, USA) was used for statistical analysis. To describe data, we used mean ± standard deviation (for quantitative variables) and frequency and percentage (for qualitative variables). Kolmogorov–Smirnov test was used to determine normal data distribution. For qualitative data analysis, the Chi-square test was used. Sensitivity, specificity, and positive and negative predictive values were also reported to determine the predictive value of PECARN rules in pediatric head trauma. P < 0.05 was considered statistically significant.

Ethical consideration

This study was approved by the Ethics Committee of Tabriz University of Medical Sciences, Tabriz, Iran. The approved ethical code was IR.TBZMED.REC.1399.645. Patients' information was preserved, and informed consent was obtained from the parents.


  Results Top


The mean age of the patients was 88.12 months. From a total of 250 patients, 117 (46.8%) patients were female and 133 (53.2%) were male. In terms of vital signs, heart rate was 72.8 ± 14.18, systolic blood pressure was 93.3 ± 16.86, diastolic blood pressure was 56.96 ± 8.88, and O2 saturation was 93.52 ± 6.49. GCS was 12.35 ± 3.19, and AP score was 19.64 ± 3.45. In this study, 75 (30%) children were under 24 months of age and 175 (70%) were above 24 months of age.

In terms of GAP severity, 178 (71.2%) patients were classified as mild, 70 (28%) as moderate, and 2 (0.8%) as severe. There is a significant statistical relationship between the GAP severity score and the PECARN rules (P < 0.001). Some of the important findings in patients are summarized in [Table 2]. During the evaluation of patients, 182 brain CT scans were performed, in which 80 (44%) cases had positive findings. Based on the PECARN rules, 162 (64.8%) patients were in the low-risk group, 42 (16.8%) patients were in the moderate-risk group, and 46 (18.4%) of them were in the high-risk group. Death was occurred in 18 (12.8%) patients. There was a statistically significant association between positive CT findings and variables including behavioral change, vomiting, severe headache, LOC over 5 s, confusion, palpable skull fracture, skull base fracture, and the severe mechanism of injury (P < 0.05). As [Table 3] shown, there was a statistically significant association between the PECARN rules and CT findings.
Table 2: Important positive findings of patients

Click here to view
Table 3: Association between PECARN rules and brain CT findings

Click here to view


[Table 4] and [Table 5] are used to determine the predictive value of the PECARN rules in two groups of patients (under 24 months and over 24 months of age). In patients < 24 months old, the sensitivity, specificity, positive predictive value, and negative predictive value of the PECARN rules were 0.91, 0.95, 0.89, and 0.96, respectively. In patients >24 months old, the sensitivity, specificity, positive predictive value, and negative predictive value of the PECARN rules were 1, 0.86, 0.78, and 1, respectively.
Table 4: Measuring the predictive value of the Pediatric Emergency Care Applied Research Network rules in under 2-year-old patients

Click here to view
Table 5: Measuring the predictive value of the Pediatric Emergency Care Applied Research Network rules in above 2-year-old patients

Click here to view



  Discussion Top


Since the results are contradictory in terms of the application of the PECARN rules, this study was performed on 250 pediatric patients with a mean age of 88 months. In the present study, a total of 182 CT scans were performed among which 80 had positive results. Among all patients, 162 (64.8%) patients were in the low-risk group, 42 (16.8%) patients were in the moderate-risk group, and 46 (18.4%) of them were in the high-risk group. Death was occurred in 18 (12.8%) patients.

Previous studies have been shown that the application of the PECARN rules decreases the need for CT scans in the head trauma of children.[8] In a study performed by PECARN in 2009, a scoring method is presented to diagnose and identify the children with low-risk head trauma to prevent improper CT. This algorithm is approved in North America and Europe and is used to help decision-making in the head trauma setting.[8] However, this algorithm is not used in Asian countries yet. High sensitivity and specificity of this method are shown in a study conducted in Japan but this study was retrospective and it is recommended to do more studies.[1]

The results of a study conducted by Osmond et al. with the purpose of CT application in children with minor head trauma showed that the PECARN rule could identify children in two danger levels. Hence, this rule is approved prospectively. It has the potential to standardize and improve the use of CT for children with minor head injuries.[11] In a study conducted by Easter et al., on children with GCS of 13–15, the sensitivity of 100% and specificity of 62% were found in children with head trauma. These results were similar to our findings.[12] In another study by Pickering et al., on children with mild head trauma, PECARN rules had the highest sensitivity and specificity compared with other rules.[13]

In a study performed by Lorton et al., the sensitivity of 100% and specificity of 69% were found for the application of the PECARN rules in head trauma in children.[14] According to another study, the application of the PECARN rules can strengthen the physician's suspiciousness and prevent inappropriate use of CT scans in children with a low risk of head trauma.[15]

CT scans to detect brain injury in children with minor trauma can lead to radiation exposure and the effects of which usually manifest years later.[8] Sedation in children may be needed to perform certain procedures such as CT, which can lead to a long stay in the emergency room or unwanted complications.[16] The purpose of the PECARN rules is to reduce the number of unnecessary CT scans in pediatric brain trauma. The authors of the PECARN rules have developed an algorithm for performing CT scans in children with head trauma and GCS 14-15.[17] Research has shown that due to the importance of minor injuries in forensic medicine, the use of these rules in brain injury following abuse is not recommended and it is better to have a low CT scan threshold in these cases.[3] The results obtained in this study showed that the use of the PECARN rules in the ED is effective in reducing the number of CT scan requests in minor head trauma in children and there is a significant statistical difference between the results of performed CT scans and the results of the PECARN rules.

One of the limitations of the present study is the limitations of performing CT scans of children to enter the project. Lack of long-term follow-up of patients was another limitation of this study.


  Conclusions Top


According to the results of the present study, PECARN rules have a significant association with brain CT scan findings. Therefore, using these rules in recommended to reduce the number of brain CT scan requests for pediatric patients, especially in patients above 24 months old with no false-positive results. Further studies are recommended with a larger sample size for the applicability of this rule in the management of pediatric head trauma. It is also recommended to compare the PECARN rules with other rules in this regard. Furthermore, after approving these rules, training them is recommended for medical students.

Acknowledgments

The authors are grateful to all participants in the study and administrative staff of the Emergency Medicine Department in Imam Reza (AS) Hospital of Tabriz City. This article was written based on a dataset of the MD. Thesis entitled “Evaluation of the Accuracy of PECARN Rules in Predicting the Brain Injuries in Pediatric with Head Trauma,” registered in this university (No: 62478).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Ide K, Uematsu S, Tetsuhara K, Yoshimura S, Kato T, Kobayashi T. External validation of the PECARN head trauma prediction rules in Japan. Acad Emerg Med 2017;24:308-14.  Back to cited text no. 1
    
2.
Lee S, Grant GA, Fisher PG, Imler D, Padrez R, Avery C, et al. R-SCAN: Imaging for pediatric minor head trauma. J Am Coll Radiol 2017;14:294-7.  Back to cited text no. 2
    
3.
Magana JN, Kuppermann N. The PECARN TBI rules do not apply to abusive head trauma. Acad Emerg Med 2017;24:382-4.  Back to cited text no. 3
    
4.
Marin JR, Weaver MD, Barnato AE, Yabes JG, Yealy DM, Roberts MS. Variation in emergency department head computed tomography use for pediatric head trauma. Acad Emerg Med 2014;21:987-95.  Back to cited text no. 4
    
5.
Rahmani F, Parsian Z, Ebrahimi Bakhtavar H, Salmasi S, Hashemi T. Epidemiologic feature and diagnostic outcome of traumatic pediatric patients referred to emergency department of Imam-Reza Hospital, Tabriz, Iran in 2016-2017. J Res Clin Med 2020;8:10.  Back to cited text no. 5
    
6.
Masoumi B, Heydari F, Hatamabadi H, Azizkhani R, Yoosefian Z, Zamani M. The relationship between risk factors of head trauma with CT scan findings in children with minor head trauma admitted to hospital. Open Access Maced J Med Sci 2017;5:319-23.  Back to cited text no. 6
    
7.
Pearce MS, Salotti JA, Little MP, McHugh K, Lee C, Kim KP, et al. Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours: A retrospective cohort study. Lancet 2012;380:499-505.  Back to cited text no. 7
    
8.
Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr., Atabaki SM, Holubkov R, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: A prospective cohort study. Lancet (London, England) 2009;374:1160-70.  Back to cited text no. 8
    
9.
Khajoei R, Abadi M, Dehesh T, Heydarpour N, Shokohian S, Rahmani F. Predictive value of the Glasgow coma scale, age, and arterial blood pressure and the new trauma score indicators to determine the hospital mortality of multiple trauma patients. Arch Trauma Res 2021;10:86-91.  Back to cited text no. 9
  [Full text]  
10.
Rahmani F, Ebrahimi Bakhtavar H, Shams Vahdati S, Hosseini M, Mehdizadeh Esfanjani R. Evaluation of MGAP and GAP Trauma Scores to Predict Prognosis of Multiple-trauma Patients. Trauma Monthly 2017;22:e33249.  Back to cited text no. 10
    
11.
Osmond MH, Klassen TP, Wells GA, Davidson J, Correll R, Boutis K, et al. Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department. CMAJ 2018;190:E816-22.  Back to cited text no. 11
    
12.
Easter JS, Bakes K, Dhaliwal J, Miller M, Caruso E, Haukoos JS. Comparison of PECARN, CATCH, and CHALICE rules for children with minor head injury: A prospective cohort study. Ann Emerg Med 2014;64:145-52, 52.e1-5.  Back to cited text no. 12
    
13.
Pickering A, Harnan S, Fitzgerald P, Pandor A, Goodacre S. Clinical decision rules for children with minor head injury: A systematic review. Arch Dis Child 2011;96:414-21.  Back to cited text no. 13
    
14.
Lorton F, Poullaouec C, Legallais E, Simon-Pimmel J, Chêne MA, Leroy H, et al. Validation of the PECARN clinical decision rule for children with minor head trauma: A French multicenter prospective study. Scand J Trauma Resusc Emerg Med 2016;24:98.  Back to cited text no. 14
    
15.
Bressan S, Romanato S, Mion T, Zanconato S, Da Dalt L. Implementation of adapted PECARN decision rule for children with minor head injury in the pediatric emergency department. Acad Emerg Med 2012;19:801-7.  Back to cited text no. 15
    
16.
Soleimanpour H, Mahmoodpoor A, Eftekhari Milani F, Shahsavari Nia K, Mehdizadeh Esfanjani R, Safari S. Effectiveness of oral ketamine, midazolam, and atropine cocktail versus oral diphenhydramine for pediatric sedation in the emergency department. Iran Red Crescent Med J 2014;16:e21366.  Back to cited text no. 16
    
17.
Luo P, Zhang L, Fei Z, Cheng G. Identification of children with low-risk brain injuries. Lancet 2010;375:198-9.  Back to cited text no. 17
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusions
References
Article Tables

 Article Access Statistics
    Viewed350    
    Printed14    
    Emailed0    
    PDF Downloaded25    
    Comments [Add]    

Recommend this journal