The Australasian Paediatric Head Injury Rules: a prospective validation of 3 international clinical decision rules for acute head injury in children presenting to emergency departments.

Developing a pathway to assist doctors in diagnosing children with head injuries

Grant ID: EMPJ-11-162-ACWORTH-APHIRST

Project Summary

Many children sustain head injuries and present to emergency departments for evaluation. Even a seemingly minor incident may lead to serious injury requiring neurosurgery. While head computer tomography (CT) identifies all important injuries, there is an increasing recognition that radiation from CTs can increase the risk of fatal brain cancers, especially in younger children.

Failure to identify a significant intracranial injury quickly may result in catastrophic consequences including long-term neurological disability and or death. A number of evidence-based head injury (HI) clinical decision rules (CDRs) have been developed to help physicians identify patients at risk of having a significant head injury. These CDRs provide recommendations (including CTs) based on the presence of certain features of the history or physical examination. No HI CDRs have been validated outside of their original settings.

The identification of an optimal CDR for implementation would help to minimise risks, both of missing a clinically significant intracranial injury, and of exposure to radiation from cranial CT scans. The results will likely have a major impact on head injury management in children in Australia, New Zealand and worldwide.

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Outcomes

The prospective observational study involved 20,137 children with head injuries and was run by the PREDICT network (Paediatric Research in Emergency Departments International Collaborative) with seven grants worth $1.391 million.

In the study, the research team compared three clinical decision rules, which have been developed to identify children at higher risk of intracranial injuries:

• The Pediatric Emergency Care Applied Research Network (PECARN, USA)
• The Canadian Assessment of Tomography for Childhood Head Injury (CATCH) rule
• The Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE, UK)

The goal was to determine which of these three decision rules provided the best option when it came to identifying children at very low risk of a traumatic brain injury and the research team found that while all three rules were good options only one, the PECARN rule, achieved a 100 per cent success rate. Their findings published in the prestigious medical journal, The Lancet. Based on the research findings, the next step is for the group of emergency physicians to develop a national approach to optimise the management of children with head injuries.

In Queensland, the $298,000 grant from the Emergency Medicine Foundation (funded by Queensland Health) enabled the study to run at the Queensland Children's Hospital (formerly Lady Cilento Children’s Hospital, the Mater Children's Hospital and the Royal Brisbane Children's Hospital) and The Townsville Hospital. Other hospitals participating in the study included: Royal Children’s Hospital, Melbourne; Princess Margaret Hospital, Perth; Monash Children’s Hospital, Melbourne; Kidzfirst Middlemore Hospital, New Zealand; Starship Hospital, Auckland; Women’s and Children’s Hospital, Adelaide; and The Children’s Hospital at Westmead, Sydney.

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Leveraged Funds

- NHMRC ($814,825)
- Murdoch Childrens Research Institute
- Auckland Medical Research Foundation
- A+ Trust, Auckland District Health Board
- Townsville Hospital and Health Service Private Practice Research and Education Trust fund
- WA Health Targeted Research Fund

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Dissemination

Publications:

- Borland, M.L., Dalziel, S.R., Phillips, N., Dalton, S., Lyttle, M.D., Bressan, S., Oakley, E., Kochar, A., Furyk, J., Cheek, J.A. and Neutze, J., 2022. Incidence of traumatic brain injuries in head‐injured children with seizures. Emergency Medicine Australasia.

- Bressan, S., Monagle, P., Dalziel, S.R., Borland, M.L., Phillips, N., Kochar, A., Lyttle, M.D., Cheek, J.A., Neutze, J., Oakley, E. and Dalton, S., 2020. Risk of traumatic intracranial haemorrhage in children with bleeding disorders. Journal of Paediatrics and Child Health, 56(12), pp.1891-1897.

- Babl, F.E., Lyttle, M.D., Phillips, N., Kochar, A., Dalton, S., Cheek, J.A., Furyk, J., Neutze, J., Bressan, S., Williams, A. and Hearps, S.J., 2020. Mild traumatic brain injury in children with ventricular shunts: a PREDICT study. Journal of Neurosurgery: Pediatrics, 27(2), pp.196-202.

- Pfeiffer, H., Cowley, L.E., Kemp, A.M., Dalziel, S.R., Smith, A., Cheek, J.A., Borland, M.L., O'Brien, S., Bonisch, M., Neutze, J. and Oakley, E., 2020. Validation of the PredAHT-2 prediction tool for abusive head trauma. Emergency medicine journal, 37(3), pp.119-126.

- Phillips, N., Dalziel, S.R., Borland, M.L., Dalton, S., Lyttle, M.D., Bressan, S., Oakley, E., Hearps, S.J., Kochar, A., Furyk, J. and Cheek, J.A., 2020. Imaging and admission practices in paediatric head injury across emergency departments in Australia and New Zealand: a predict study. Emergency medicine Australasia, 32(2), pp.240-249.

- Eapen, N., Davis, G.A., Borland, M.L., Phillips, N., Oakley, E., Hearps, S., Kochar, A., Dalton, S., Cheek, J., Furyk, J. and Lyttle, M.D., 2019. Clinically important sport‐related traumatic brain injuries in children. Medical Journal of Australia, 211(8), pp.365-366.

- Babl, F.E., Pfeiffer, H., Dalziel, S.R., Oakley, E., Anderson, V., Borland, M.L., Phillips, N., Kochar, A., Dalton, S., Cheek, J.A. and Gilhotra, Y., 2019. Paediatric intentional head injuries in the emergency department: a multicentre prospective cohort study. Emergency Medicine Australasia, 31(4), pp.546-554.

- Bressan, S., Kochar, A., Oakley, E., Borland, M., Phillips, N., Dalton, S., Lyttle, M.D., Hearps, S., Cheek, J.A., Furyk, J. and Neutze, J., 2019. Traumatic brain injury in young children with isolated scalp haematoma. Archives of disease in childhood, 104(7), pp.664-669.

- Dalziel, K., Cheek, J.A., Fanning, L., Borland, M.L., Phillips, N., Kochar, A., Dalton, S., Furyk, J., Neutze, J., Dalziel, S.R. and Lyttle, M.D., 2019. A cost-effectiveness analysis comparing clinical decision rules PECARN, CATCH, and CHALICE with usual care for the management of pediatric head injury. Annals of emergency medicine, 73(5), pp.429-439.

- Borland, M.L., Dalziel, S.R., Phillips, N., Lyttle, M.D., Bressan, S., Oakley, E., Hearps, S.J., Kochar, A., Furyk, J., Cheek, J.A. and Neutze, J., 2019. Delayed presentations to emergency departments of children with head injury: a predict study. Annals of emergency medicine, 74(1), pp.1-10.

- Babl, F.E., Oakley, E., Dalziel, S.R., Borland, M.L., Phillips, N., Kochar, A., Dalton, S., Cheek, J.A., Gilhotra, Y., Furyk, J. and Neutze, J., 2018. Accuracy of clinician practice compared with three head injury decision rules in children: a prospective cohort study. Annals of emergency medicine, 71(6), pp.703-710.

- Crowe, L.M., Hearps, S., Anderson, V., Borland, M.L., Phillips, N., Kochar, A., Dalton, S., Cheek, J.A., Gilhotra, Y., Furyk, J. and Neutze, J., 2018. Investigating the variability in mild traumatic brain injury definitions: a prospective cohort study. Archives of physical medicine and rehabilitation, 99(7), pp.1360-1369.

- Undén, J., Dalziel, S.R., Borland, M.L., Phillips, N., Kochar, A., Lyttle, M.D., Bressan, S., Cheek, J.A., Neutze, J., Donath, S. and Hearps, S., 2018. External validation of the Scandinavian guidelines for management of minimal, mild and moderate head injuries in children. BMC medicine, 16(1), pp.1-10.

- Babl, F.E., Borland, M.L., Phillips, N., Kochar, A., Dalton, S., McCaskill, M., Cheek, J.A., Gilhotra, Y., Furyk, J., Neutze, J. and Lyttle, M.D., 2017. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. The lancet, 389(10087), pp.2393-2402.

- Cheek, J.A., Lyttle, M., Oakley, E., Babl, F., Borland, M., Dalziel, K., Kanal, G.N., Phillips, N., Gilhotra, Y., Kochar, A. and Dalton, S., 2016. ANNUAL ACUTE HOSPITAL COST OF PAEDIATRIC HEAD INJURY IN AUSTRALIA–A PAEDIATRIC RESEARCH IN EMERGENCY DEPARTMENTS INTERNATIONAL COLLABORATIVE (PREDICT) STUDY. Emergency Medicine Journal, 33(12), pp.903-903.

- Babl, F.E., Lyttle, M.D., Bressan, S., Borland, M., Phillips, N., Kochar, A., Dalziel, S.R., Dalton, S., Cheek, J.A., Furyk, J. and Gilhotra, Y., 2014. A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC pediatrics, 14(1), pp.1-10.

- Babl, F.E., Rausa, V.C., Borland, M.L., Kochar, A., Lyttle, M.D., Phillips, N., Gilhotra, Y., Dalton, S., Cheek, J.A., Furyk, J. and Neutze, J., 2021. Characteristics of concussion based on patient age and sex: a multicenter prospective observational study. Journal of Neurosurgery: Pediatrics, 28(6), pp.647-656.

Conference presentations/abstracts:

- Babl F.E, Borland M. et al., “Accuracy of NEXUS II head injury decision rule in children. A PREDICT prospective cohort study”, PAS Annual Meeting, 2017, San Francisco, USA: Poster

- Babl F.E., Borland M., Phillips N. et al., “Accuracy of Physician Practice as compared to PECARN, CATCH and CHALICE head injury decision rules in children. A PREDICT prospective cohort study.”, PAS Annual Meeting, 2017, San Francisco, USA: Oral

- Crowe L., Hearps S., Neutze J. et al., “Defining mild traumatic brain injury: how classification differs across studies when applied to a large prospective data set. A PREDICT prospective cohort study”, PAS Annual Meeting, 2017, San Francisco, USA: Poster

- Cheek J., Borland M., et al., “Comparison of cost effectiveness of usual care versus PECARN, CATCH and CHALCE in pediatric head injury in a prospective multicentre cohort. A PREDICT study.”, PAS Annual Meeting, 2017, San Francisco, USA: Poster

- Pfeiffer H., Smith A., Kemp A. et al…, “External Validation of the PediBIRN Clinical Prediction Rule for Paediatric Abusive Head Trauma. A PREDICT study.”, PAS Annual Meeting, 2017, San Francisco, USA: Poster

- Crowe L., Hearps S., Neutze J., et al., “Defining mild traumatic brain injury: how classification differs across studies when applied to a large prospective data set. A PREDICT prospective cohort study.”, PAS Annual Meeting, 2017, San Francisco, USA: Poster

- Babl F.E., Borland M. et al., “Accuracy of NEXUS II head injury decision rule in children. A PREDICT prospective cohort study.”, Royal College of Paediatrics and Child Health Annual Meeting, 2017, UK: Poster; Arch Dis Child 2017;102(suppl 1): A1-218

- Babl F.E., Borland M., Phillips N. et al., “Accuracy of Physician Practice as compared to PECARN, CATCH and CHALICE head injury decision rules in children. A PREDICT prospective cohort study.”, Royal College of Paediatrics and Child Health Annual Meeting, 2017, UK: Poster; Arch Dis Child 2017;102(suppl 1): A1-218

- Crowe L., Hearps S., Neutze J., et al., “Defining mild traumatic brain injury: how classification differs across studies when applied to a large prospective data set. A PREDICT prospective cohort study.”, Royal College of Paediatrics and Child Health Annual Meeting, 2017, UK: Poster; Arch Dis Child 2017;102(suppl 1): A1-218

- Cheek J., Borland M., et al., “Comparison of cost effectiveness of usual care versus PECARN, CATCH and CHALCE in pediatric head injury in a prospective multicentre cohort. A PREDICT study.”, Royal College of Paediatrics and Child Health Annual Meeting, 2017, UK: Poster; Arch Dis Child 2017;102(suppl 1): A1-218

- Pfeiffer H., Borland M. et al., “Paediatric intentional head injuries in the emergency department. A PREDICT multicenter prospective cohort study.”, Royal College of Paediatrics and Child Health Annual Meeting, 2017, UK: Poster; Arch Dis Child 2017;102(suppl 1): A1-218

- Pfeiffer H., Hearps S., Babl F.E., et al., “Paediatric Abusive Head Trauma in the Emergency Department: A Multicentre Prospective Cohort Study.”, IBIA 12th World Congress of Brain Injury, 2017, New Orleans, USA: Oral

- Pfeiffer H., Hearps S., Babl F.E., et al., “Paediatric Intentional Head Injuries in the Emergency Department: A Multicentre Prospective Cohort Study.”, IBIA 12th World Congress of Brain Injury, 2017, New Orleans, USA: Poster

- Pfeiffer H., Smith A., Kemp A., et al., “External Validation of the PediBIRN Clinical Prediction Rule for Paediatric Abusive Head Trauma. A PREDICT study.”, Sixth Annual Penn State International Conference on Pediatric Abusive Head Trauma, 2017, USA: Oral

- Babl F., Borland M., Phillips .N, Kochar A. et al “Accuracy of PECARN, CATCH and CHALICE Head Injury Decision Rules in Children”, 16th International Conference on Emergency Medicine (ICEM) conference, 2016, Cape Town, South Africa

- Babl F., Borland M., Phillips N. et al., “Accuracy of PECARN, CATCH and CHALICE Head Injury Decision Rules in Children”, Paediatric Academic Societies (PAS) Annual Meeting, 2016, Baltimore, Maryland, USA

- Cheek J.A., Lyttle M., Oakley E., et al., “Annual acute hospital cost of paediatric head injury in Australia – A PREDICT study”, ACEM ASM 2016, Queenstown, New Zealand: Oral

- Babl F., Cheek J., Dalziel S., ret. al., “Emergency Department clinical decision rules for head injured children: Results from the APHIRST study of 20,000 children in Australia and New Zealand”, ACEM ASM, 2016, Queenstown, New Zealand: Oral

- Babl F., Borland M., Phillips N., et .al., “Choosing When to Use Computed Tomography in Paediatric Head Injury”, Townsville Hospital and Health Service Research Week Symposium, 2016, Townsville

- Cheek J.A., Lyttle M., Oakley E., et al., “Annual acute hospital cost of paediatric head injury in Australia: A PREDICT study”, Royal College of Emergency Medicine Scientific Meeting, 2016: Oral; Emerg Med J 2016; 33:897-940

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