Date: July 16th, 2018

Reference: Gupta M et al. Validation of the Pediatric NEXUS II Head Computed Tomography Decision Instrument for Selective Imaging of Pediatric Patients with Blunt Head Trauma. AEM July 2018

Guest Skeptics: Dr. Corey Heitz is an emergency physician in Roanoke, Virginia. He is also the CME editor for Academic Emergency Medicine

Case: You’re working in a small rural emergency department when a seven-year-old girl comes in by EMS with a head injury. Her father was teaching her how to bike and he got a little ambitious and sent her down a small hill. She hit a rock, and went over the bars, striking her head on a small tree as she fell. She was helmeted, she did not lose consciousness, has not been vomiting, but the helmet was scratched up where it struck the tree. It’s been one hour since the accident and the child’s exam is otherwise normal; she’s behaving normally and only has a minor headache and some scrapes on her knees. Dad, on the other hand, may need something for anxiety.

Background: Blunt head trauma is a common presenting complaint in emergency departments, accounting for approximately two million visits per year in the US. CT imaging is often performed but comes with radiation risks and increased medical costs.

Several decision instruments have been developed to assess the risk of significant intracranial injury in children with head trauma (CATCH, CHALICE and PECARN). The PECARN tool has been found to have a high sensitivity, but in one study was shown to increase CT use compared to  physician judgement.

We covered concussions on SGEM#112. This episode included the pediatric head trauma CT decisions guide for children less than two years of age and those two years of age and older.

The NEXUS Head CT decision instrument was developed as a “one way” instrument, which would hopefully serve to rule out those children who might otherwise receive imaging (as opposed to classifying many as “high risk”.) In the original cohort, use of NEXUS Head CT decision instrument decreased the need for CT by 25%.

Clinical Question: In pediatric patients with blunt head trauma, can the NEXUS Head CT decision instrument be used to rule out the need for imaging in patients who otherwise would have received CT imaging?

Reference: Gupta M et al. Validation of the Pediatric NEXUS II Head Computed Tomography Decision Instrument for Selective Imaging of Pediatric Patients with Blunt Head Trauma. AEM July 2018

Population: Patients less than 18-years-old with blunt head trauma who underwent CT imaging at one of four participating hospitals

Intervention: Clinical judgement followed by the application of the pediatric NEXUS II Head CT decision instrument

Comparison: There is no comparison

Outcome:

Primary Outcome: Sensitivity, specificity, and negative predictive value (NPV) for the need for neurologic intervention defined as:

Death due to head injury

Need for craniotomy

Elevation of skull fracture

Intubation related to head injury

Intracranial pressure monitoring, within seven days of head injury

Secondary Outcome: Clinically significant head injury on CT imaging

Study Design: Pre-planned secondary analysis of the decision instrument

This is a summer SGEM HOP and we are pleased to have one of the authors on the episode, Dr. William Mower. Bill is a professor in-residence at the UCLA School of Medicine in Los Angeles and among many other things, the director of UCLA Emergency Medicine Research Assistance program.

Pediatric NEXUS II Head CT Decision Instrument?

Pediatric patients with blunt head trauma are classified as low-risk,