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Impact Of An Integrated Algorithm Combining POCUS And The Pecarn Clinical Decision Rules In Children Presenting To The Pediatric Emergency Department Following Minor Head Injury.

Mazin Alhamdani, Patrick Mcgrory, Stephanie J. Doniger, Sharon Yellin, Gerardo Chiricolo, Kyle Derouen, Adetunbi Ayeni.

BACKGROUND

Often computed tomography (CT) is used in the evaluation of children with closed head injury (CHI), but they carry risk associated with radiation exposure.

The Pediatric Emergency Care Applied Research Network (PECARN) conducted a study to identify children at low risk for clinically important traumatic brain injury (ciTBI).

Patients with non-frontal scalp hematomas were more likely to have an underlying skull fracture (which is a risk factor for ciTBI).  Many studies have shown that point-of-care ultrasound (POCUS) can reliably diagnose skull fractures.

Our primary objective is to assess if integrating POCUS into the PECARN clinical decision rules impacts clinical decision-making.

Our secondary objective is assessing if POCUS has an impact on parental expectations.

METHODS

A prospective study of a convenience sample of patients aged 0-18 years who presented to the ED with CHI and a non-frontal scalp hematoma.

Physicians documented their clinical exam findings and plan based on the PECARN clinical decision rules.

A clinical ultrasound fellowship-trained physician performed POCUS over the scalp hematoma to assess for presence or absence of a skull fracture.

The results were relayed to the treating physician, who documented if the results affected his/her plan.

Parents completed a survey regarding expectations before and after POCUS.

RESULTS

Preliminary data from 43 patients suggested that POCUS does not often impact clinical decisions as only 6/43 encounters (14%) underwent a change in treatment plan.

Eleven patients had a CT scan of the head performed. The physician initially ordered CT scans for 5 patients, and the decision did not change after Point-of-care ultrasound.

In six cases, a CT scan was ordered when the original plan was observation. CT scan revealed an underlying skull fracture and a small epidural hemorrhage in 4/6 patients.

While 2/6 patients had a negative CT scan of the head. Thirty-two patients had reassuring point-of-care ultrasound results and did not have a CT scan of the head performed.

Follow up phone calls made 2 weeks later, revealed no significant adverse clinical outcomes.

Fifteen parents indicated they initially expected a CT scan despite reassurance from the physician.

After POCUS, 10 of the 15 parents (67%) changed their initial expectations. Thirty-eight out of 43 parents (88%) felt confident in the point-of-care ultrasound results.

CONCLUSIONS

Point-of-care ultrasound may not have a substantial impact on clinical decision-making when integrated with the PECARN clinical decision rule for minor pediatric head injury. However, point-of-care ultrasound can be helpful in borderline cases.

Our parental survey suggests that point-of-care ultrasound can further reassure concerned parents, as most parents changed their initial imaging expectations after the performance of the point-of-care ultrasound. Most parents had confidence in the point-of-care ultrasound results.

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