UC Davis a longtime leader in appropriate CT scanning in children
UC Davis has a long history of research pertaining to appropriate CT scanning in children with trauma, and the risks to children of unnecessary CT scans. This work has been performed through its leadership in the Pediatric Emergency Care Applied Research Network (PECARN), the only federally funded pediatric emergency care research network in the U.S., co-founded by Nathan Kuppermann, chair of the UC Davis Department of Emergency Medicine and an internationally respected pediatric emergency medicine physician.
Established in 2001 and sponsored by the Health Resources and Services Administration Maternal and Child Health Bureau and the Emergency Medical Services for Children Program, PECARN is organized into six research ‘nodes,’ including one led by UC Davis. The 18 hospital emergency departments that constitute PECARN serve more than 1.2 million acutely ill and injured children every year. These emergency departments represent academic, community, general and children’s hospitals, providing an enormous and diverse database.
At any given time the network conducts six to eight major research studies. PECARN has borne substantial fruit — publication of multiple studies in influential journals that have confirmed or changed treatment practices for acutely ill or injured children.
One of the largest prospective studies conducted in PECARN, or in the field of emergency medicine, enrolled more than 42,000 infants and children from all PECARN hospitals. Led by Kuppermann and published in The Lancet in 2009, it derived and validated a prediction rule for determining whether child should or should not receive a cranial CT scan following head injury, by considering multiple clinical signs and symptoms, including the presence of physical signs of a skull fracture, mental status, vomiting and headache, among others.
"Developing prediction rules are especially important for ED doctors who must make decisions quickly based on what they see in front of them," Kuppermann said. "Prediction rules give confidence that either further study or treatment is really justified, or alternatively, that a patient is not likely to be in danger and can be sent home safely without it."
PECARN research led by Professor of Emergency Medicine James Holmes (in a subanalysis of the patients in the Lancet study) published in 2011 in the Annals of Emergency Medicine found that most children with normal head CT scans do not require hospitalization after blunt head trauma. While blunt head trauma is the leading cause of death in children older than 1 year, the study found that children with minor blunt head trauma who had normal CT scans are at very low risk for subsequent traumatic findings on neuroimaging or clinical sequelae.
In another PECARN subanalysis of the data, in a study published in 2012 in the Archives of Pediatric & Adolescent Medicine led by Associate Professor of Pediatric Critical Care Medicine Joanne Natale, the investigators found that white children are more likely to receive inappropriate cranial CT scans than are African-American or Latino children, potentially exposing them to unnecessary radiation. Natale is also the medical director of the UC Davis Pediatric Intensive Care Unit/Pediatric Cardiac Intensive Care Unit.
The research found that the children's race and/or ethnicity did not have an effect on the likelihood of receiving a CT scan in children who were at the greatest risk of a clinically important brain injury; all groups received appropriate diagnostic imaging. However, among lower-risk pediatric patients, white children were more likely to receive a CT scan. In 12 percent of the cases involving white children with the lowest risk of clinically important brain injury, emergency room physicians cited parental anxiety or parental requests as among the most important criteria in prompting them to order a CT.
Another PECARN study led by Holmes and published in the Annals of Emergency Medicine in February 2013 identified seven factors to lessen radiation exposure from abdominal CT scans among young traumatic injury victims. The study involved more than 12,000 children from emergency departments participating in PECARN. It identified seven factors including evidence of trauma to the abdomen, neurological changes, abdominal pain or tenderness, abnormal breath sounds and vomiting. If none of the variables are present, the child is at such low risk for injury requiring therapy that abdominal CT scanning is unnecessary.
"The large studies that we can carry out with the PECARN collaboration really impact standards of care worldwide," said Kuppermann. "Because of the weight of findings based on such large numbers, doctors can make confident decisions about how they treat young pediatric trauma patients."