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.