CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury
CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury
复制标题
DOI：
10.1503/cmaj.091421
复制
发表时间：
2010-03-09
影响因子：
14.6
通讯作者：
Stiell, Ian G.
中科院分区：
文献类型：
--
作者：
Osmond, Martin H.;Klassen, Terry P.;Stiell, Ian G.
背景：对于哪些轻微头部损伤的儿童需要接受计算机断层扫描（CT）存在争议。我们的目的是开发一个高度敏感的临床决策规则，使用CT在儿童轻微的头部injure.Methods：对于这个多中心队列研究，我们连续招募儿童钝性头部外伤的评分为13-15的格拉斯哥昏迷量表和意识丧失，健忘症，定向障碍，持续呕吐或烦躁不安。对于每一个孩子，急诊科的工作人员在做CT之前都要填写一份标准化的评估表。主要结局是需要神经干预和CT确定的脑损伤。我们开发了一个决策规则，通过使用递归分割来组合联合收割机变量，这些变量既可靠又与结果指标密切相关，从而找到预测变量的最佳组合，这些预测变量对检测具有最大特异性的结果指标高度敏感。在入组的3866例患者（平均年龄9.2岁）中，95例（2.5%）的格拉斯哥昏迷量表评分为13，282例（7.3%）评分为14，3489例（90.2%）评分为15。CT显示159例（4.1%）有脑损伤，24例（0.6%）接受了神经干预。我们推导出了一个头部CT的决策规则，包括四个高危因素（两小时内格拉斯哥昏迷量表评分未达到15分，怀疑开放性颅骨骨折，头痛恶化和易怒）和三个额外的中等风险因素（头皮大，沼泽状血肿;颅底骨折的迹象;危险的损伤机制）。高危因素预测神经系统干预需求的敏感性为100.0%（95%CI 86.2%-100.0%），需要30.2%的患者接受CT检查。中等风险因素导致98.1%的敏感性（95%CI 94.6%-99.4%）的预测脑损伤的CT，并要求52.0%的患者接受CT.Interpretation：在这项研究中开发的决策规则确定儿童在两个级别的风险。一旦决策规则得到前瞻性验证，它就有可能标准化和改善CT在儿童轻微头部损伤中的应用。
Background: There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury.Methods: For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13-15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity.Results: Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%-100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%-99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT.Interpretation: The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.