背景:由儿科急诊护理应用研究网络(PECARN)得出的腹内损伤和创伤性脑损伤预测规则旨在减少腹部和头部创伤儿童的CT不当使用,分别。我们旨在验证这些预测规则,以应对腹部钝性或轻微头部外伤的急诊儿童。
方法:对于本前瞻性验证研究,我们招募了18岁以下的儿童和青少年,向萨克拉曼多(CA)的六个急诊科就诊,达拉斯(TX),休斯顿(TX),圣地亚哥(CA),洛杉矶(CA),奥克兰(CA)2016年12月27日至2021年9月1日之间的美国。我们排除了怀孕或先前存在神经系统疾病的患者,穿透性创伤,在抵达前24小时受伤,转移前的CT或MRI,或者高度怀疑非意外创伤。出现钝性腹部创伤的儿童被纳入腹部创伤队列,将有轻微头部创伤的儿童纳入两个年龄隔离的轻微头部创伤队列中的一个(小于2岁vs大于2岁).入学儿童在急诊科接受了临床检查,和CT扫描由主治临床医生决定。在看到CT结果之前,根据相关PECARN预测规则的变量对所有入组儿童进行评估。腹部创伤队列中感兴趣的主要结果是接受急性干预的腹内损伤(治疗性剖腹手术,血管造影栓塞,输血,用于胰腺或胃肠道损伤的静脉输液≥2天,或因腹内损伤而死亡)。在年龄隔离的轻微头部创伤队列中,感兴趣的主要结果是临床上重要的创伤性脑损伤(神经外科,插管>24小时用于创伤性脑损伤,或因持续症状和CT证实的创伤性脑损伤住院≥2晚;或因创伤性脑损伤死亡)。
结果:纳入7542例腹部钝性外伤儿童和19999例头部轻微外伤儿童。腹内损伤规则的敏感性为100·0%(95%CI98·0-100·0;145例接受急性干预的腹内损伤患者中的145例正确测试)和阴性预测值(NPV)为100·0%(95%CI99·9-100·0;3488例未接受急性干预的腹内损伤患者中的3488例正确测试)。2岁以下儿童的创伤性脑损伤规则对临床重要的创伤性脑损伤的敏感性为100·0%(93·1-100·0;42个中的42个),NPV为100·0%;99·9-100·0;2940个中的2940个),而2岁及以上儿童的创伤性脑损伤规则的敏感性为98·8%(95·8-99·9;170中的168),NPV为100·0%(99·9-100·0;6017中的6015)。根据创伤性脑损伤规则错误分类的两个孩子被送进医院观察,但不需要神经外科手术。
结论:以高度的准确性验证了PECARN腹内损伤和创伤性脑损伤的规律。因此,它们在儿科急诊科的实施可以被认为是一种安全策略,可以最大程度地减少需要高质量护理腹部或头部创伤的儿童的不适当CT使用。
背景:EuniceKennedyShriver国家儿童健康与人类发展研究所。
BACKGROUND: The intra-abdominal injury and traumatic brain injury prediction rules derived by the Pediatric Emergency Care Applied Research Network (PECARN) were designed to reduce inappropriate use of CT in children with abdominal and head trauma, respectively. We aimed to validate these prediction rules for children presenting to emergency departments with blunt abdominal or minor head trauma.
METHODS: For this prospective validation
study, we enrolled children and adolescents younger than 18 years presenting to six emergency departments in Sacramento (CA), Dallas (TX), Houston (TX), San Diego (CA), Los Angeles (CA), and Oakland (CA), USA between Dec 27, 2016, and Sept 1, 2021. We excluded patients who were pregnant or had pre-existing neurological disorders preventing examination, penetrating trauma, injuries more than 24 h before arrival, CT or MRI before transfer, or high suspicion of non-accidental trauma. Children presenting with blunt abdominal trauma were enrolled into an abdominal trauma cohort, and children with minor head trauma were enrolled into one of two age-segregated minor head trauma cohorts (younger than 2 years vs aged 2 years and older). Enrolled children were clinically examined in the emergency department, and CT scans were obtained at the attending clinician\'s discretion. All enrolled children were evaluated against the variables of the pertinent PECARN prediction rule before CT results were seen. The primary outcome of interest in the abdominal trauma cohort was intra-abdominal injury undergoing acute intervention (therapeutic laparotomy, angiographic embolisation, blood transfusion, intravenous fluid for ≥2 days for pancreatic or gastrointestinal injuries, or death from intra-abdominal injury). In the age-segregated minor head trauma cohorts, the primary outcome of interest was clinically important traumatic brain injury (neurosurgery, intubation for >24 h for traumatic brain injury, or hospital admission ≥2 nights for ongoing symptoms and CT-confirmed traumatic brain injury; or death from traumatic brain injury).
RESULTS: 7542 children with blunt abdominal trauma and 19 999 children with minor head trauma were enrolled. The intra-abdominal injury rule had a sensitivity of 100·0% (95% CI 98·0-100·0; correct test for 145 of 145 patients with intra-abdominal injury undergoing acute intervention) and a negative predictive value (NPV) of 100·0% (95% CI 99·9-100·0; correct test for 3488 of 3488 patients without intra-abdominal injuries undergoing acute intervention). The traumatic brain injury rule for children younger than 2 years had a sensitivity of 100·0% (93·1-100·0; 42 of 42) for clinically important traumatic brain injuries and an NPV of 100·0%; 99·9-100·0; 2940 of 2940), whereas the traumatic brain injury rule for children aged 2 years and older had a sensitivity of 98·8% (95·8-99·9; 168 of 170) and an NPV of 100·0% (99·9-100·0; 6015 of 6017). The two children who were misclassified by the traumatic brain injury rule were admitted to hospital for observation but did not need neurosurgery.
CONCLUSIONS: The PECARN intra-abdominal injury and traumatic brain injury rules were validated with a high degree of accuracy. Their implementation in paediatric emergency departments can therefore be considered a safe strategy to minimise inappropriate CT use in children needing high-quality care for abdominal or head trauma.
BACKGROUND: The Eunice Kennedy Shriver National Institute of Child Health and Human Development.