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Perhaps I reviewed the study wrong, but the PECARN rules only apply to the
acute injury phase of a CHI and this is clearly outside the norm and is not
an acute injury (or the 1st 6 hours).  While there are lots of good reasons
to not CT this patient while sitting in front of a screen, am I really to
believe that none of you would consider scanning a patient who does not get
better with the standard of care for acute treatment of a NON emergent
headache in the ER setting and has had 6 weeks of HA with photophobia?

This HA was clearly outside the normal range and that is why the patient
required an intervention.  Yes, CT scans are a significant radiation risk
but they are still the best and most immediate test we have (usually given
constraints on MRI in the emergent setting and these are appropriate) in
the ER setting.  And the risk of radiation exposure must be weighed against
missing a clinically significant neurological issue, which is pretty high
in the case that was presented and should be ruled out.

To clarify, I do believe the PECARN rules work, but they are just not
relevant to this case.  I would scan this kid if in my ER.
Mike


On Mon, Nov 5, 2012 at 6:24 PM, Jay Fisher <[log in to unmask]> wrote:

> Chris - Thank you for your thoughts but I respectfully disagree - I
> apologize in advance for the rant but I am just not an EBMer on this
> topic. It probably goes back to the fact that in the mid-80s I used to have
> to ask the *radiologist's *permission to get Head CTs on my head injured
> patients. Oy - gives me an ICH just thinking about it.
>
> Simply put, the calculation of the number needed to harm in a study
> population is not my concern when I am sitting in front of a  patient
> deciding whether to image or not. I am concerned with having a false
> negative clinical assessment. I am concerned with harming 3-10% of patients
> with real injury by not obtaining the study.
>
> It really exemplifies how ridiculously confounded we are when trying to
> predict low frequency events. The PECARN study was awesome - but I
> personally don't think it was a rousing endorsement for the universal
> application of the instrument given the false negative rate.
>
> It doesn't minimize the importance of the research, and I do recognize that
> we should be parsimonious with radiation exposure.  But the number of false
> negative clinical assessments in patients with the real disease is just too
> high for my liking.
>
> IMHO
>
> Jay Fisher
> Children's Hospital of Nevada
>
>
>
>
>
>
>
> On Mon, Nov 5, 2012 at 12:46 PM, Chris Pruitt, M.D <[log in to unmask]
> >wrote:
>
> > Jay,
> >
> > 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
> > UAB
> >
> > ________________________________________
> > 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
> >
> >
> >
> > For more information, send mail to [log in to unmask] with the
> > message: info PED-EM-L
> > The URL for the PED-EM-L Web Page is:
> >                  http://listserv.brown.edu/ped-em-l.html
> >
>
> For more information, send mail to [log in to unmask] with the
> message: info PED-EM-L
> The URL for the PED-EM-L Web Page is:
>                  http://listserv.brown.edu/ped-em-l.html
>

For more information, send mail to [log in to unmask] with the message: info PED-EM-L
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