Pediatric Blunt Head Trauma Management Study Findings
Do children WITH BLUNT head
Do children WITH BLUNT head
trauma and normal CT scan
trauma and normal CT scan
require hospitalization for
require hospitalization for
neurological observation?
neurological observation?
2. study design?
•
Prospective, multicenter observational analytic cohort
Prospective, multicenter observational analytic cohort
planned sub-study.
planned sub-study.
•
Redesign
Redesign
•
-primary prospective randomised study- patients
-primary prospective randomised study- patients
randomised to either hospital stay or discharge home.
randomised to either hospital stay or discharge home.
•
-All patients receive receive a either a repeat CT or
-All patients receive receive a either a repeat CT or
MRI, not both at end of 1 week, or if their GCS drops.
MRI, not both at end of 1 week, or if their GCS drops.
•
Do a power calculation before setting up the study
Do a power calculation before setting up the study
2. What is sensitivity
analysis?
•
Sensitivity analysis is a way to predict the outcome of
Sensitivity analysis is a way to predict the outcome of
a decision if the situation turns out to be different.
a decision if the situation turns out to be different.
Assumptions are made when key values are missing
Assumptions are made when key values are missing
and values are put in. The results are then compared
and values are put in. The results are then compared
with initial analysis, which excludes the missing data.
with initial analysis, which excludes the missing data.
•
Normally used to deal with missing data or drop outs
Normally used to deal with missing data or drop outs
•
Worst case scenario was used in this paper.
Worst case scenario was used in this paper.
•
Sensitivity analysis for subsequent traumatic findings
Sensitivity analysis for subsequent traumatic findings
was 0.5% for pts with GCS 15 and 1% for pts with
was 0.5% for pts with GCS 15 and 1% for pts with
GCS 14.
GCS 14.
3.What is negative predictive
value?
•
The proportion of subjects with a negative test result
The proportion of subjects with a negative test result
who do not have the illness
who do not have the illness
•
D/C+D
D/C+D
•
We can safely predict that your child will not require
We can safely predict that your child will not require
any neurosurgical intervention with 95% confidence.
any neurosurgical intervention with 95% confidence.
However there is 1% chance of having a traumatic
However there is 1% chance of having a traumatic
finding on subsequent scans.
finding on subsequent scans.
•
NPV will change with prevalence of the disorder. If
NPV will change with prevalence of the disorder. If
prevalence increases NPV will decrease. However it
prevalence increases NPV will decrease. However it
may not change simply by doubling the population.
may not change simply by doubling the population.
4. List two limitations of this
study-Authors limitations
•
Not all patients enrolled to the primary study
Not all patients enrolled to the primary study
underwent CT head- Selection Bias
underwent CT head- Selection Bias
•
Most patients with negative CT did not undergo a
Most patients with negative CT did not undergo a
repeat CT head.
repeat CT head.
•
Lack of standardization in the level of CT reporting.
Lack of standardization in the level of CT reporting.
•
Long term assessment of neuro-cognitive function was
Long term assessment of neuro-cognitive function was
not done.
not done.
•
Some patients had social admissions.
Some patients had social admissions.
other limitations
•
Secondary study
Secondary study
•
Large number of patients were excluded from the
Large number of patients were excluded from the
study- 30361
study- 30361
•
Performance bias- patients hospitalized v.s persons
Performance bias- patients hospitalized v.s persons
discharged
discharged
•
Although large number of patients enrolled actual
Although large number of patients enrolled actual
power calculation was not performed.
power calculation was not performed.
strengths of this study
•
Large sample size- patient no (135443)
Large sample size- patient no (135443)
•
Multicenter
Multicenter
•
Prospective study and easily generalizable.
Prospective study and easily generalizable.
•
Good follow up method and rate 79%
Good follow up method and rate 79%
•
Suggested Practice change- for blunt head injury with
Suggested Practice change- for blunt head injury with
GCS>14. Observe at home if initial CT is normal may
GCS>14. Observe at home if initial CT is normal may
be followed by in clinic in 1 week time for a repeat CT.
be followed by in clinic in 1 week time for a repeat CT.
1. Summarize the paper in 200words?
•
IMRAD
IMRAD
•
Introduction- The aim of this study was to identify the
Introduction- The aim of this study was to identify the
frequency with which children with minor blunt head injury
frequency with which children with minor blunt head injury
and normal initial CT scan results have either traumatic
and normal initial CT scan results have either traumatic
findings identified on a subsequent neuroimaging study or
findings identified on a subsequent neuroimaging study or
the need for neurosurgery in their follow up.
the need for neurosurgery in their follow up.
•
Methods-Design-prospective observational study-Setting- 25
Methods-Design-prospective observational study-Setting- 25
ED across the US.
ED across the US.
•
Population-<18 with blunt head trauma. GCS=14 or 15.
Population-<18 with blunt head trauma. GCS=14 or 15.
Normal CT head.
Normal CT head.
•
Index test-initial CT
Index test-initial CT
•
Reference test- follow up CT
Reference test- follow up CT
•
Outcome measure- traumatic findings on subsequent CT or
Outcome measure- traumatic findings on subsequent CT or
MRI and neurosurgical intervention.
MRI and neurosurgical intervention.
•
Follow up- hospitalized patients-neurological outcome.
Follow up- hospitalized patients-neurological outcome.
Discharged patients-telephone/mail follow up.
Discharged patients-telephone/mail follow up.
•
RESULTS
RESULTS
•
13453 pts ----93%(12584) GCS 15- & 7% (957) GCS 14
13453 pts ----93%(12584) GCS 15- & 7% (957) GCS 14
•
18% (2485)Hospitalized- 17% of GCS 15 & 39% of GCS 14
18% (2485)Hospitalized- 17% of GCS 15 & 39% of GCS 14
•
2%(197) received subsequent CT or MRI scan
2%(197) received subsequent CT or MRI scan
•
21 patients had traumatic finding on their subsequent
21 patients had traumatic finding on their subsequent
CT/MRI scans- 15 with GCS 15 and 6 with GCS14.
CT/MRI scans- 15 with GCS 15 and 6 with GCS14.
•
NPV for neurosurgical intervention in either groups
NPV for neurosurgical intervention in either groups
were 100% CI 95%.
were 100% CI 95%.
•
DISCUSSION- Children with blunt injury head with
DISCUSSION- Children with blunt injury head with
initial GCS 14 or 15 and a normal CT are at a low risk
initial GCS 14 or 15 and a normal CT are at a low risk
for subsequent traumatic findings on neuroimaging
for subsequent traumatic findings on neuroimaging
and unlikely to require neurosurgical intervention.
and unlikely to require neurosurgical intervention.
A study on children with blunt head trauma and normal CT scans investigated the need for hospitalization for neurological observation. The study design involved a prospective multicenter observational cohort with a primary randomization to hospital stay or discharge home. Sensitivity analysis and negative predictive value calculations were conducted, highlighting limitations such as selection bias and lack of standardization in CT reporting. The study's strengths include a large sample size and practical recommendations for managing blunt head injuries in children.
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Presentation Transcript
Do children WITH BLUNT head trauma and normal CT scan require hospitalization for neurological observation?
2. study design? Prospective, multicenter observational analytic cohort planned sub-study. Redesign -primary prospective randomised study- patients randomised to either hospital stay or discharge home. -All patients receive receive a either a repeat CT or MRI, not both at end of 1 week, or if their GCS drops. Do a power calculation before setting up the study
2. What is sensitivity analysis? Sensitivity analysis is a way to predict the outcome of a decision if the situation turns out to be different. Assumptions are made when key values are missing and values are put in. The results are then compared with initial analysis, which excludes the missing data. Normally used to deal with missing data or drop outs Worst case scenario was used in this paper. Sensitivity analysis for subsequent traumatic findings was 0.5% for pts with GCS 15 and 1% for pts with GCS 14.
3.What is negative predictive value? The proportion of subjects with a negative test result who do not have the illness D/C+D We can safely predict that your child will not require any neurosurgical intervention with 95% confidence. However there is 1% chance of having a traumatic finding on subsequent scans. NPV will change with prevalence of the disorder. If prevalence increases NPV will decrease. However it may not change simply by doubling the population.
4. List two limitations of this study-Authors limitations Not all patients enrolled to the primary study underwent CT head- Selection Bias Most patients with negative CT did not undergo a repeat CT head. Lack of standardization in the level of CT reporting. Long term assessment of neuro-cognitive function was not done. Some patients had social admissions.
other limitations Secondary study Large number of patients were excluded from the study- 30361 Performance bias- patients hospitalized v.s persons discharged Although large number of patients enrolled actual power calculation was not performed.
strengths of this study Large sample size- patient no (135443) Multicenter Prospective study and easily generalizable. Good follow up method and rate 79% Suggested Practice change- for blunt head injury with GCS>14. Observe at home if initial CT is normal may be followed by in clinic in 1 week time for a repeat CT.
1. Summarize the paper in 200words? IMRAD Introduction- The aim of this study was to identify the frequency with which children with minor blunt head injury and normal initial CT scan results have either traumatic findings identified on a subsequent neuroimaging study or the need for neurosurgery in their follow up. Methods-Design-prospective observational study-Setting- 25 ED across the US. Population-<18 with blunt head trauma. GCS=14 or 15. Normal CT head.
Index test-initial CT Reference test- follow up CT Outcome measure- traumatic findings on subsequent CT or MRI and neurosurgical intervention. Follow up- hospitalized patients-neurological outcome. Discharged patients-telephone/mail follow up. RESULTS 13453 pts ----93%(12584) GCS 15- & 7% (957) GCS 14 18% (2485)Hospitalized- 17% of GCS 15 & 39% of GCS 14
2%(197) received subsequent CT or MRI scan 21 patients had traumatic finding on their subsequent CT/MRI scans- 15 with GCS 15 and 6 with GCS14. NPV for neurosurgical intervention in either groups were 100% CI 95%. DISCUSSION- Children with blunt injury head with initial GCS 14 or 15 and a normal CT are at a low risk for subsequent traumatic findings on neuroimaging and unlikely to require neurosurgical intervention.
