Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study
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DOI：
10.1016/s0140-6736(09)61558-0
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发表时间：
2009-10-03
期刊：
影响因子：
168.9
通讯作者：
Wootton-Gorges, Sandra L.
中科院分区：
文献类型：
--
作者：
Kuppermann, Nathan;Holmes, James F.;Wootton-Gorges, Sandra L.
研究背景：颅脑损伤儿童的CT成像存在放射性恶性肿瘤的风险。我们的目的是确定儿童在非常低的风险，临床上重要的创伤性脑损伤（ciTBI）的人CT可能是necessary.Methods我们招募了年龄小于18岁的患者，提出在24小时内的头部外伤与格拉斯哥昏迷量表评分为14-15在25个北美急诊科。我们推导并验证了特定年龄的预测规则ciTBI（死亡创伤性脑损伤，神经外科，插管>24小时，或入院>= 2 nights）。结果我们招募和分析了42412名儿童（推导和验证人群：8502和2216小于2岁，25 283和6411岁2岁及以上）。我们对14969例（35.3%）患者进行了CT扫描; 376例（0.9%）患者发生了ciTBI，60例（0.1%）患者接受了神经外科手术。在验证人群中，2岁以下儿童的预测规则（精神状态正常，除额部外无头皮血肿，无意识丧失或意识丧失少于5秒，非严重损伤机制，无可触及的颅骨骨折，且根据父母表现正常）对ciTBI的阴性预测值为1176/1176（100.0%，95% CI 99.7-100.0），敏感性为25/25（100%，86.3-100.0）。在694例年龄小于2岁的CT成像患者中，有167例（24.1%）属于低风险组。2岁及以上儿童的预测规则（精神状态正常、无意识丧失、无呕吐、无严重损伤机制、无颅底骨折体征、无严重头痛）阴性预测值为3798/3800（99.95%，99.81-99.99），敏感性为61/63（96.8%，89.0-99.6）。2223例年龄≥ 2岁的CT成像患者中有446例（20.1%）属于低风险组。解释这些有效的预测规则确定了儿童在非常低的风险ciTBI的CT可以定期避免。资助妇幼保健局的儿童紧急医疗服务计划，以及妇幼保健局研究计划，卫生资源和服务管理局，美国卫生和人类服务部。
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 42412 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 14969 (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.