Validation and refinement of a clinical decision rule for the use of computed tomography in children with minor head injury in the emergency department.

BACKGROUND: There is uncertainty about which children with minor head injury need to undergo computed tomography (CT). We sought to prospectively validate the accuracy and potential for refinement of a previously derived decision rule, Canadian Assessment of Tomography for Childhood Head injury (CATCH), to guide CT use in children with minor head injury. METHODS: This multicentre cohort study in 9 Canadian pediatric emergency departments prospectively enrolled children with blunt head trauma presenting with a Glasgow Coma Scale score of 13-15 and loss of consciousness, amnesia, disorientation, persistent vomiting or irritability. Phys icians completed standardized assessment forms before CT, including clinical predictors of the rule. The primary outcome was neurosurgical intervention and the secondary outcome was brain injury on CT. We calculated test characteristics of the rule and used recursive partitioning to further refine the rule. RESULTS: Of 4060 enrolled patients, 23 (0.6%) underwent neurosurgical intervention, and 197 (4.9%) had brain injury on CT. The original 7-item rule (CATCH) had sensitivities of 91.3% (95% confidence interval [CI] 72.0%-98.9%) for neurosurgical intervention and 97.5% (95% CI 94.2%-99.2%) for predicting brain injury. Adding "≥ 4 episodes of vomiting" resulted in a refined 8-item rule (CATCH2) with 100% (95% CI 85.2%-100%) sensitivity for neurosurgical intervention and 99.5% (95% CI 97.2%-100%) sensitivity for brain injury. INTERPRETATION: Among children presenting to the emergency department with minor head injury, the CATCH2 rule was highly sensitive for identifying those children requiring neurosurgical intervention and those with any brain injury on CT. The CATCH2 rule should be further validated in an implementation study designed to assess its clinical impact.

Treatment of children with migraine in emergency departments: national practice variation study.

OBJECTIVE: Children with migraine may present to an emergency department (ED) when outpatient management has failed; however, only limited research has examined migraine-abortive medications among children. METHODS: A retrospective chart review of ED presentations for migraine or headache between July 1, 2004, and June 30, 2005, in 10 Canadian pediatric EDs was conducted. A priori, evidence-based treatments were defined as any treatment that was based on high-quality evidence and an absence of opioids as first-line agents. RESULTS: A total of 2515 records were screened, and 1694 (67.4%) met inclusion criteria. The average age of patients was 12.1 years, 14.5% (95% confidence interval [CI]: 12.1%-17.2%) of patients experienced headache >15 days per month, and 62.6% (95% CI: 55.7%-68.9%) had already used migraine-abortive therapy. Significant variations in practice for all classes of migraine-abortive medications were observed. Dopamine receptor antagonists (prochlorperazine, metoclopramide, or chlorpromazine) (39% [95% CI: 28.4%-50.8%]) and orally administered analgesics (acetaminophen and ibuprofen) (24.5% [95% CI: 23.9%-46.8%]) were prescribed most commonly. Predictors for the use of evidence-based treatment included older age (odds ratio: 1.15 [95% CI: 1.07-1.24]) and a discharge diagnosis of migraine (odds ratio: 1.84 [95% CI: 1.11-3.05]). CONCLUSIONS: Children presenting to EDs for treatment often have frequent attacks and have experienced failure of outpatient, migraine-abortive efforts. Practice variations were impressive for the care of children with migraine in these Canadian EDs.

Management of cellulitis in a pediatric emergency department.

OBJECTIVES: (1) To determine antibiotic choices, route of administration, and outcomes of children treated as outpatients with noncomplicated, nonfacial cellulitis at a tertiary care center. (2) To determine the number of visits and time spent in the emergency department (ED) for treatment. DESIGN: A descriptive case-control study. SETTING: A tertiary care pediatric ED at an academic medical center. METHODS: Medical records of all otherwise healthy children (aged 1-16 yrs) presenting with noncomplicated, nonfacial cellulitis over a 3-year period (January 1, 2001-December 31, 2003) were reviewed. Data extracted included the following: demographics; clinical presentation; laboratory and microbiology results; management, including choice, dose, and route of antibiotic(s); treatment failures; and time spent in the ED. INTERVENTIONS: None. MAIN RESULTS: Two hundred sixty-nine patients met the inclusion criteria, and their charts were selected for review. The oral antibiotic most often prescribed was cephalexin (N = 105). Treatment failure occurred in 10 (8.9%) of the cases. The intravenous antibiotic most often prescribed was cefazolin (N = 124; 39 received cefazolin alone, and 85 received cefazolin and probenecid). The cefazolin-only group had 12 (31%) treatment failures, whereas the cefazolin and probenecid group had 7 (8.1%) treatment failures. More time in the ED (521 +/- 287 minutes) and more visits (3.4 +/- 2.8) were seen in the intravenous group as compared with the oral group (time in ED, 164 +/- 139 minutes; visits, 1.4 +/- 1). CONCLUSIONS: Noncomplicated, nonfacial cellulitis is most commonly treated using first-generation cephalosporins. Treatment with oral antibiotics was effective and required fewer visits and less time in the ED compared with intravenous treatment. Twice-daily cefazolin and probenecid was associated with less treatment failures and admissions than cefazolin alone and may represent a reasonable alternative for children with nonfacial cellulitis requiring intravenous antibiotics.