CMAJ • March 9, 2010; 182 (4). First published February 8, 2010; doi:10.1503/cmaj.091421
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Research

CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury

Martin H. Osmond, MD CM, Terry P. Klassen, MD, George A. Wells, PhD, Rhonda Correll, RN, Anna Jarvis, MD, Gary Joubert, MD, Benoit Bailey, MD, Laurel Chauvin-Kimoff, MD CM, Martin Pusic, MD, Don McConnell, MD, Cheri Nijssen-Jordan, MD, Norm Silver, MD, Brett Taylor, MD, Ian G. Stiell, MD for the Pediatric Emergency Research Canada (PERC) Head Injury Study Group

From the Department of Pediatrics (Osmond), the Department of Epidemiology and Community Medicine (Wells) and the Department of Emergency Medicine (Stiell), University of Ottawa, Ottawa, Ont.; the Department of Pediatrics (Klassen, McConnell), University of Alberta, Edmonton, Alta.; the Clinical Research Unit (Correll), Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ont.; the Department of Pediatrics (Jarvis), University of Toronto, Toronto, Ont.; the Department of Pediatrics (Joubert), University of Western Ontario, London, Ont.; the Department of Pediatrics (Bailey), CHU Sainte-Justine, Montréal, Que.; the Department of Pediatrics (Chauvin-Kimoff), McGill University, Montréal, Que.; Pediatric Emergency Medicine (Pusic), Columbia University Medical Center, New York, NY; the Department of Pediatrics (Nijssen-Jordan), University of Calgary, Calgary, Alta.; the Department of Pediatrics (Silver), University of Manitoba, Winnipeg, Man.; and the Department of Pediatrics (Taylor), Dalhousie University, Halifax, NS. The other members of the Pediatric Emergency Research Canada (PERC) Head Injury Study Group are listed in the Acknowledgements section.

Correspondence to: Dr. Martin Osmond, Department of Pediatrics, Children’s Hospital of Eastern Ontario, 401 Smyth Rd., Ottawa ON K1H 8L1; osmond{at}cheo.on.ca

Background: There is controversy about which children with minor head injury need to undergo computed tomography (CT). We aimed to develop a highly sensitive clinical decision rule for the use of CT in children with minor head injury.

Methods: For this multicentre cohort study, we enrolled consecutive children with blunt head trauma presenting with a score of 13–15 on the Glasgow Coma Scale and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. For each child, staff in the emergency department completed a standardized assessment form before any CT. The main outcomes were need for neurologic intervention and presence of brain injury as determined by CT. We developed a decision rule by using recursive partitioning to combine variables that were both reliable and strongly associated with the outcome measures and thus to find the best combinations of predictor variables that were highly sensitive for detecting the outcome measures with maximal specificity.

Results: Among the 3866 patients enrolled (mean age 9.2 years), 95 (2.5%) had a score of 13 on the Glasgow Coma Scale, 282 (7.3%) had a score of 14, and 3489 (90.2%) had a score of 15. CT revealed that 159 (4.1%) had a brain injury, and 24 (0.6%) underwent neurologic intervention. We derived a decision rule for CT of the head consisting of four high-risk factors (failure to reach score of 15 on the Glasgow coma scale within two hours, suspicion of open skull fracture, worsening headache and irritability) and three additional medium-risk factors (large, boggy hematoma of the scalp; signs of basal skull fracture; dangerous mechanism of injury). The high-risk factors were 100.0% sensitive (95% CI 86.2%–100.0%) for predicting the need for neurologic intervention and would require that 30.2% of patients undergo CT. The medium-risk factors resulted in 98.1% sensitivity (95% CI 94.6%–99.4%) for the prediction of brain injury by CT and would require that 52.0% of patients undergo CT.

Interpretation: The decision rule developed in this study identifies children at two levels of risk. Once the decision rule has been prospectively validated, it has the potential to standardize and improve the use of CT for children with minor head injury.


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Can. Med. Assoc. J. 2010 182: 321. [Full Text] [PDF]



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The role of imaging and neurophysiological studies in children with minor traumatic brain injury
Sascha Meyer
CMAJ, 9 Mar 2010 [Full text]