2003 ADecisionRuleForIdChildAtLowRiskForBrainInj

Subject Headings: Decision Tree, Health Care Informatics.

Notes

Study objective

Computed tomography (CT) is frequently used in evaluating children with blunt head trauma. Routine use of CT, however, has disadvantages. Therefore, we sought to derive a decision rule for identifying children at low risk for traumatic brain injuries.

Methods

We enrolled children with blunt head trauma at a pediatric trauma center in an observational cohort study between July 1998 and September 2001. We evaluated clinical predictors of traumatic brain injury on CT scan and traumatic brain injury requiring acute intervention, defined by a neurosurgical procedure, antiepileptic medications for more than 1 week, persistent neurologic deficits, or hospitalization for at least 2 nights. We performed recursive partitioning to create clinical decision rules.

Results

Two thousand forty-three children were enrolled, 1,271 (62%) underwent CT, 98 (7.7%; 95% confidence interval [CI] 6.3% to 9.3%) had traumatic brain injuries on CT scan, and 105 (5.1%; 95% CI 4.2% to 6.2%) had traumatic brain injuries requiring acute intervention. Abnormal mental status, clinical signs of skull fracture, history of vomiting, scalp hematoma (in children ≤2 years of age), or headache identified 97/98 (99%; 95% CI 94% to 100%) of those with traumatic brain injuries on CT scan and 105/105 (100%; 95% CI 97% to 100%) of those with traumatic brain injuries requiring acute intervention. Of the 304 (24%) children undergoing CT who had none of these predictors, only 1 (0.3%; 95% CI 0% to 1.8%) had traumatic brain injury on CT, and that patient was discharged from the ED without complications.

Conclusion

Important factors for identifying children at low risk for traumatic brain injuries after blunt head trauma included the absence of: abnormal mental status, clinical signs of skull fracture, a history of vomiting, scalp hematoma (in children ≤2 years of age), and headache.

…
We internally validated the decision trees developed in the main analyses by using 10-fold cross-validation.
We combined the predictors selected in the decision trees for recognizing traumatic brain injury identified on CT scan and traumatic brain injury requiring acute intervention (which differed by only 1 predictor variable) to generate a conservative decision rule for both outcomes (Figure 3).
The decision tree for traumatic brain injury identified on CT scan included the same 4 predictor variables as in the main analysis, although the order of the variables in the resulting tree was different (Figure 4).
In the subanalysis of the 194 children aged 2 years and younger who were evaluated with CT scan, the decision tree for traumatic brain injury identified on CT scan included scalp hematoma and abnormal mental status (Figure 5), which identified all 15 (7.7%) children with traumatic brain injuries on CT scan (sensitivity 100%; 95% CI 81.9% to 100%).
Finally, in the analysis using the requirement for a neurosurgical procedure as the outcome, the 3 predictor variables in the decision tree included focal neurologic deficits, abnormal mental status, and a history of vomiting (Figure 6).

…
The importance of this variable in the decision trees may serve to remind physicians of the importance of a careful scalp examination, particularly in the evaluation of children aged 2 years and younger.
…
A large, multicenter study is needed to further narrow the CIs. Finally, although the decision trees were constructed and validated by using internal 10-fold crossvalidation, external validation with a large, diverse sample of pediatric head trauma patients is necessary.
…

,

	Author	volume	Date Value	title	type	journal	titleUrl	doi	note	year
2003 ADecisionRuleForIdChildAtLowRiskForBrainInj	Michael J. Palchak James F. Holmes Cheryl W. Vance Rebecca E. Gelber Bobbie A. Schauer Mathew J. Harrison Jason Willis-Shore Sandra L. Wootton-Gorges Robert W. Derlet Nathan Kuppermann			A Decision Rule for Identifying Children at Low Risk for Brain Injuries After Blunt Head Trauma			http://jasoncartermd.com/resources/pdf/Blunt Head Trauma.pdf	10.1067/S0196-0644(03)00425-6