Discussion
Traumatic brain injury (TBI) is one of the commonly encountered conditions in the pediatric emergency department, with the leading cause of mortality and disability among trauma patients20. Nearly one-third of these cases occurred among children aged 0 to 14 years21. Many clinical decision support tools have been developed, over the past years, to support the diagnosis of blunt head trauma injuries among children with low risk22,23 and to decrease the use of computed tomography (CT) in the PED24-26 with minimizing the exposure of potentially harmful ionizing radiation among children27. The pediatric population is significantly more sensitive to radiation exposure because of the increased number of dividing cells into growing children and the longer lead time children develop cancer6. According to Khalifa etal.28, various clinical decision support (CDS) systems have proved to enhance evidence-based clinical practice, and the PECARN rule is considered the highest quality tool compared to the other tools. The present Meta-analysis is an effort to rule out the PECARN decision tool’s efficacy in children with minor blunt head trauma.
In patients below two years of age, sensitivity analysis showed a pooled sensitivity of 0.08 (95% CI of 0.074 - 0.087), which was insignificant. Pooled specificity of 0.20 (95% CI of 0.19 - 0.21), which was not significant. The positive predictive value (PPV) was 0.17 (95% CI of 0.030 - 0.989), and the negative predictive value (NPV) was 45.59 showing an insignificant result. The overall diagnostic odd ratio for patients below two years of age was 0.004 (95% CI of 0.00-0.17), which was statistically significant in depicting a good diagnostic accuracy of PECARN decision rule in patients less than two years of age with minor blunt head trauma. The patients equal or above two years of age showed a pooled sensitivity of 0.07, the specificity of 0.66, PPV of 1.46 (95% CI of 0.067 - 31.62), and NPV of 1.21 (95% CI 0.95 -1.54). The diagnostic odd ratio for patients equal or above two years of age was 0.54 (95% CI of 0.10 -2.78), which was statistically insignificant, showing no significant role of PECARN rule in patients between 2-18 years of age with minor blunt head trauma. The overall age group of 0-18years showed pooled sensitivity of 0.13 (95% CI 0.12-0.14), specificity of 0.81 (95% CI 0.80-0.82), PPV of 1.05 (95% CI of 0.25 – 4.34) and NPV of 1.36 (95% CI 1.05 -1.76). The diagnostic odd ratio of patients between 0-18 years of age was 0.79 (95% CI of 0.08 -7.71), which was statistically insignificant, indicating no specific role of PECARN rule among 0-18 age groups in patients with minor blunt head trauma.
The present Meta-analysis showed reasonable diagnosing accuracy of PECARN rule among children less than two years of age, decreasing CT’s overuse in this age group, whereas there was no significant effect of PECARN rule in children over two years of age. However, Gariepy et al.29 showed an overuse of CT for the younger group (<2 years) to be below 3% after the PECARN decision rule in mTBIs. Lyttle et al.30 in 2012 conducted a systematic review and described the PECARN rule to have a high methodological standard and an acceptable predictive value for mTBIs similar to our study. Ahmadi et al.31 also recommended the decision rule to be used in routine practice for children referring to mild traumatic brain injuries similar to the present analysis.