Abstract
STUDY OBJECTIVE: We evaluate the diagnostic accuracy of clinical decision rules and physician judgment for identifying clinically important traumatic brain injuries in children with minor head injuries presenting to the emergency department. METHODS: We prospectively enrolled children younger than 18 years and with minor head injury (Glasgow Coma Scale score 13 to 15), presenting within 24 hours of their injuries. We assessed the ability of 3 clinical decision rules (Canadian Assessment of Tomography for Childhood Head Injury [CATCH], Children's Head Injury Algorithm for the Prediction of Important Clinical Events [CHALICE], and Pediatric Emergency Care Applied Research Network [PECARN]) and 2 measures of physician judgment (estimated of <1% risk of traumatic brain injury and actual computed tomography ordering practice) to predict clinically important traumatic brain injury, as defined by death from traumatic brain injury, need for neurosurgery, intubation greater than 24 hours for traumatic brain injury, or hospital admission greater than 2 nights for traumatic brain injury. RESULTS: Among the 1,009 children, 21 (2%; 95% confidence interval [CI] 1% to 3%) had clinically important traumatic brain injuries. Only physician practice and PECARN identified all clinically important traumatic brain injuries, with ranked sensitivities as follows: physician practice and PECARN each 100% (95% CI 84% to 100%), physician estimates 95% (95% CI 76% to 100%), CATCH 91% (95% CI 70% to 99%), and CHALICE 84% (95% CI 60% to 97%). Ranked specificities were as follows: CHALICE 85% (95% CI 82% to 87%), physician estimates 68% (95% CI 65% to 71%), PECARN 62% (95% CI 59% to 66%), physician practice 50% (95% CI 47% to 53%), and CATCH 44% (95% CI 41% to 47%). CONCLUSION: Of the 5 modalities studied, only physician practice and PECARN identified all clinically important traumatic brain injuries, with PECARN being slightly more specific. CHALICE was incompletely sensitive but the most specific of all rules. CATCH was incompletely sensitive and had the poorest specificity of all modalities.