As a PEM physician, I recognize the importance of advocating for evidence-based testing and practice (when available), and in the setting of head injury scenario, it seems that PECARN's algorithm would be applicable. However, this patient, as we've been told, presented with chief complaint of HA x2 days with associated photophobia. There was head collision some weeks prior, but I'm not certain application of PECARN ci-TBI is germane to this scenario at present, given the history provided. What other history that the patient failed to provide, we simply don't know.
MRI may well have been worthwhile to consider, but availability and accessibility vary from one institution to the next. I realize we try to limit ionizing radiation in children--who are of course not small adults--but on the whole, a teenager's risk is also not likely the same as that of a toddler undergoing single CT. It is worth considering what this patient's risk of NOT undergoing CT may have been.
What continues to confuse me is the amount of handwringing from our specialty on whether or not to CT the patient whose baseline cancer risk is uncertain, yet surveillance/recurrence screening for many pediatric cancers routinely utilizes CT imaging. Even with ALARA techniques applied, it seems that perhaps this cancer-susceptible population may be the one for whom we consider different imaging modalities. But pediatric hem-onc is certainly not my domain, and I'm not savvy enough to modify time-/evidence-tested protocols in another specialty.
Neither am I saying we should CT everyone who walks in with a chief complaint of "I'm here for my cat scan." Simply adding to assertion that the gray zone can be quite broad and the black & white stripes narrow, so we really are left with the patient before us, attempting to mesh the evidence with our own experiences and gestalt/gut senses.
Great job caring for this patient. It remains to be seen how this will impact future cases I encounter.
Benjamin F. Jackson, MD
MUSC Pediatric Emergency Medicine
On Nov 5, 2012, at 3:49 PM, "Chris Pruitt, M.D" <[log in to unmask]> wrote:
> For the >2 year old group in the PECARN study, you're correct about the sensitivity of the rule, but sensitivity is not the best approximation of bedside utility (or harm) for a test (because of the low prevalence of ciTBI, and how prevalence goes hand-in-hand with predictive values, etc.). Number needed to harm is probably the most helpful way to think about it -- how many patients with no risk factors according to the rule would be harmed if the rule were strictly applied? For their population, this was approximately 2,000.
> Chris Pruitt
> From: Pediatric Emergency Medicine Discussion List [[log in to unmask]] on behalf of Jay Fisher [[log in to unmask]]
> Sent: Monday, November 05, 2012 9:13
> To: [log in to unmask]
> Subject: Re: Teenager with two days of headache
> I am surprised by everyone's surprise.
> We see patients with a normal neuro exam and positive head CTs with a low
> but steady frequency.
> We had a school age girl with just headache with a spontaneous ICH a few
> years ago and a walking, talking teenager with an operable EDH just last
> year. He had fallen off a bike with a brief LOC two days prior.
> All the head injury/ CT research demonstrates that our standard decision
> rules will miss ICH at a steady clip.
> Even the PECARN data had a sensitivity of 96.8% for clinically important
> ICH. That means one in thirty important injury gets missed. The confidence
> interval (which is what you should really be looking at) went as low as 89%!
> That means the best research ever on this topic says our decision rule,
> within statistical confidence, could miss as many as 1 in 10 clinically
> important ICH.
> My experience is consistent with this.
> Jay Fisher MD
> Peds EM
> Children's Hospital of NV
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