Validation of the PECARN clinical decision rule for children with minor head trauma: a French multicenter prospective study

F Lorton, C Poullaouec, E Legallais, J Simon-Pimmel, M A Chêne, H Leroy, M Roy, E Launay, C Gras-Le Guen, F Lorton, C Poullaouec, E Legallais, J Simon-Pimmel, M A Chêne, H Leroy, M Roy, E Launay, C Gras-Le Guen

Abstract

Background: To date, the Pediatric Emergency Care Applied Research Network (PECARN) rule for identifying children who are at very low risk of clinically-important traumatic brain injuries after minor head trauma has not been validated prospectively in an independent population. Our goal was to evaluate the diagnostic performance of the PECARN clinical decision rule in a French pediatric population in multiple clinical settings.

Methods: We conducted a multicenter, prospective, non-interventional cohort study of patients with minor head trauma who presented to three emergency departments in France. We enrolled patients younger than 16 years of age seeking a consultation within 24 h of head trauma with Glasgow Coma Scale scores of 14-15.

Results: During the study period, we included 1499 children of which 421 (28 %) were under 2 years of age, and 955 (64 %) were male. A cranial computed tomography (CT) scan was performed on 76 patients (5.1 %). Of the 1499 included patients, 9 children (0.6 %) had a clinically-important traumatic brain injury, and none were classified as very low risk by the PECARN rule. In our study, the sensitivity of this clinical decision rule was 100 % (95 % CI 66.4 to 100 %), the specificity was 69.9 % (95 % CI 67.5 to 72.2 %) and the negative predictive value was 100 % (95 % CI 99.7 to 100 %).

Discussion: Our study confirmed the good predictive performances of the PECARN clinical decision rule for minor head trauma in children. The PECARN rule performed similarly to our study and to its internal validation study.

Conclusions: We conducted an external validation study of the PECARN clinical decision rule for the detection of clinically-important traumatic brain injuries in children with minor head trauma, according to the methodological standards. The PECARN rule successfully identified all patients with clinically-important traumatic brain injuries, with a limited use of CT scans. Conducting a broad validation study with a large cohort is a prerequisite to provide sufficient statistical power before authorizing its implementation and generalization.

Trial registration: This study has been registered in ClinicalTrials.gov with identifier number: NCT02752711 on April 27, 2016.

Keywords: Children; Clinical decision rule; Cranial computed tomography; External validation; Minor head trauma.

Figures

Fig. 1
Fig. 1
PECARN rules for children: (a) younger than 2 years, (b) aged 2 years and older. GCS Glasgow Coma Scale, ciTBI clinically-important traumatic brain injury, CT computed tomography, LOC loss of consciousness. † Severe mechanism of injury: motor vehicle crash with patient ejection, death of another passenger, or rollover; pedestrian or bicyclist without helmet struck by a motorized vehicle; fall of more than 0.9 m for children younger than 2 years, or more than 1.5 m for children aged 2 years and older; or head struck by a high-impact object
Fig. 2
Fig. 2
Flow chart. GCS Glasgow Coma Scale, ciTBI clinically-important traumatic brain injury, CT computed tomography
Fig. 3
Fig. 3
Fagan nomogram of the PECARN rule. The pre-test probability (prevalence) was 0.6 % (95 % CI 0.27 to 1.14 %) and the post-test probability was 0 % (95 % CI 0 to 1 %) when the rule was negative

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