How to Use PECARN with Pediatric Head Injury
Pediatric head injury, even those we otherwise would call ‘minor,’ can make any clinician (let alone parent) anxious. Furthermore, the medicolegal implications of such an injury are no joke. Appropriate neurosurgical treatment can be life-saving, while the delayed or missed diagnosis can be devastating, sometimes even deadly.
That's why the PECARN clinical decision support tool was created.
Prior to its development, in a misguided attempt at diagnostic accuracy, some clinicians would irradiate every head bump with a CT scan.
However, there are evidence-based tools to help fine-tune your ability to treat these patients with confidence by supporting your clinical decision making.
We will explore one such tool that is best used in the emergency department.
And no, it's not that new(ish) blood test. You may know it as the PECARN rule or PECARN criteria. A major reference for this article is the free resource MDCalc, where you can now earn CME just by using the platform.
The Pediatric Emergency Care Applied Research Network (PECARN) criteria is a set of risk factors that can be used to predict clinically-important pediatric head injury.
This tool is most useful when you apply it to patients aged three months to eighteen years who present with minor* head injuries.
But just how well does it work as a predictive model? Can it be applied similarly with patients injured in sports, violence, or day to day activities?
How do we ensure appropriate patient selection when applying the PECARN rule?
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What is PECARN?
The PECARN clinical decision support tool attempts to decrease unnecessary CT scans of pediatric patients with minor head injuries. It identifies those at the highest risk for clinically important traumatic brain injuries (ciTBI).
In the original paper, a clinically important TBI (ciTBI) was defined as one of the following occurring as a result of a traumatic brain injury:
Clearly, the definition of ‘clinically important’ may vary depending on whether or not you are the one who is intubated for 23 hours. Research being research, we need cutoff points.
Nevertheless, the study was performed in 2009 and enrolled 42,412 children who presented to the emergency department within twenty-four hours of a head injury.
The authors ordered 14,969 CT scans and identified 376 clinically important TBI’s, which accounted for 0.9 percent of the population. Sixty patients, or 0.1 percent, underwent neurosurgical intervention.
When To Use PECARN (and when not to)
According to the study, you can use PECARN rules to guide decision-making in patients aged three months to eighteen years with pediatric head injuries and a Glasgow Coma Score of fourteen or fifteen. As with any clinical tool, listen to your clinical spidey-sense before applying it to patients.
Go Beyond PECARN and Be an Even Better Clinician
There is so much more to the presentation, diagnosis, and treatment spectrum of traumatic brain injury than we could cover in a single post. That's why we out together a special page of the most relevant concussion resources to help you advance your knowledge. It's by no means comprehensive, but it's always growing.
There, all the resources we have independently created are available to you for free. Did you know we also have more infographics and helpful tools for differential diagnoses and such, too?
We'd love to hear if you think this new laboratory assay will be a helpful addition to your clinical practice for head injuries or not.
Kao A. Identification of Children at Very Low Risk of Clinically-Important Brain Injuries After Head Trauma: A Prospective Cohort Study. The Journal of Emergency Medicine. 2010;38(2):273-274. doi:10.1016/j.jemermed.2009.11.011
Lorton F, Poullaouec C, Legallais E, et al. Validation of the PECARN clinical decision rule for children with minor head trauma: a French multicenter prospective study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine. 2016;24(1). doi:10.1186/s13049-016-0287-3
PECARN Pediatric Head Injury/Trauma Algorithm. MDCalc. https://mdcalc.com/pecarn-pediatric-head-injury-trauma-algorithm
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