CAVEATS: Clinical decision making is still key
The PECARN rules should guide, rather than dictate, clinical decision making. They use a narrow definition of “clinically important” TBI outcomes—basically death, neurosurgery to prevent death, or prolonged observation to prevent neurosurgery. There are other important, albeit less dire, clinical decisions associated with TBI for which a brain CT may be useful—determining if a high school athlete can safely complete the football season or whether a child should receive anticonvulsant medication to decrease the likelihood of posttraumatic seizures.
We worry, too, that some providers may be tempted to use the rules for after-hours telephone triage. However, clinical assessment of the presence of signs of skull fracture, basilar or otherwise, requires in-person assessment by an experienced clinician.
CHALLENGES TO IMPLEMENTATION: Over- (or under-) reliance on the rules
The PECARN decision rules should simplify head trauma assessment in children. Physicians should first check for altered mental status and signs of skull fracture and immediately send the patient for imaging if either is present. Otherwise, physicians should continue the assessment—looking for the other clinical predictors and ordering a brain CT if 1 or more are found. However, risk of ciTBI is only 1% when only 1 prediction criterion is present. These cases require careful consideration of the potential benefit and risk.
Some emergency physicians may resist using a checklist approach, even one as useful as the PECARN decision guide, and continue to rely solely on their clinical judgment. And some parents are likely to insist on a CT scan for reassurance that there is no TBI, despite the absence of any clinical predictors.
Acknowledgements
The PURLs Surveillance System is supported in part by Grant Number UL1RR024999 from the National Center for Research Resources; the grant is a Clinical Translational Science Award to the University of Chicago. The content is solely the responsibility of the authors and does not necessarily represent the official views of either the National Center for Research Resources or the National Institutes of Health.
The authors wish to thank Sarah-Anne Schumann, MD, Department of Medicine, University of Chicago, for her guidance in the preparation of this manuscript.
PURLs methodology
This study was selected and evaluated using FPIN’s Priority Updates from the Research Literature (PURL) Surveillance System methodology. The criteria and findings leading to the selection of this study as a PURL can be accessed at www.jfponline.com/purls