INTRODUCTION

Background

Pediatric head injury is a common reason for emergency department visits, with minor head trauma accounting for more than 95% of cases. Only a small proportion of these injuries result in traumatic brain injury (TBI), and an even smaller percentage require neurosurgical intervention [1]. When TBI is suspected, cranial computed tomography (CT) is the standard diagnostic modality. However, CT exposes children to ionizing radiation, which has been associated with an increased lifetime risk of brain tumors and leukemia, particularly in children younger than 10 years [2–4].

To reduce unnecessary CT imaging, Kuppermann et al. [2] developed the PECARN (Pediatric Emergency Care Applied Research Network) clinical decision rule in 2009. This validated tool is used to identify children with a very low risk of clinically important traumatic brain injury (ciTBI) and to guide the need for CT imaging. For children under 2 years old, CT is recommended if there is a Glasgow Coma Scale (GCS) score of ≤14, altered mental status, or a palpable skull fracture. If a child has an occipital, parietal, or temporal scalp hematoma, loss of consciousness (≥5 seconds), a severe mechanism of injury, or abnormal behavior reported by parents, observation or CT may be considered. For children ≥2 years, CT is indicated for GCS ≤14, altered mental status, or signs of basilar skull fracture; observation or CT is considered for cases involving loss of consciousness, vomiting, severe mechanism of injury, or severe headache. Children without these risk factors are classified as very low risk, and CT is generally unnecessary. The rule, created separately for children aged <2 years and those aged 2–18 years, categorizes patients into low-, intermediate-, and high-risk groups. The PECARN head trauma prediction rules are widely used to guide CT decision-making in children with minor head trauma [5].

The PECARN rule demonstrated strong internal validity and is considered one of the highest-quality clinical decision rules for pediatric head injury [2,6,7]. It was validated in a large multicenter cohort of 42,412 patients in the United States [8,9]. The rule demonstrated 100% sensitivity for ciTBI in children aged <2 years and 96.8% sensitivity in children aged ≥2 years [10].

Development of a robust clinical decision rule requires three key phases [11]: derivation, external validation in diverse clinical settings, and impact analysis to evaluate its effect on clinical outcomes. Despite multiple international validation studies of PECARN, data from Indian clinical settings remain limited. To address this gap, we conducted a study to evaluate the performance of the PECARN rule in identifying children at low risk of ciTBI among pediatric patients with minor head trauma presenting to the emergency department of a tertiary care hospital in South India.

Objectives

The primary objective was to evaluate the diagnostic performance of the PECARN clinical decision rule in identifying pediatric patients aged <18 years with minor head trauma who are at risk of ciTBI in the emergency department. Secondary objective was to compare the incidence of ciTBI between children aged <2 years and those aged ≥2 years.

METHODS

Ethics statement

This study was approved by the Institutional Ethics Committee of Sree Gokulam Medical College and Research Foundation (No. 0015/3/SGMC/DNB/DP/2020). Written informed consent for publication of the research details and clinical images was obtained from the caregivers.

Study design and setting

This hospital-based observational study was conducted in the Department of Emergency Medicine at a tertiary care center in South India between September 2022 and April 2024.

Participants and sampling

All pediatric patients aged <18 years who presented to the emergency department within 24 hours of blunt head trauma were screened for eligibility. Consecutive sampling was employed; every eligible patient presenting during the study period was prospectively enrolled to minimize selection bias. Eligible participants were required to have a Glasgow Coma Scale (GCS) score of 14–15 at presentation. Exclusion criteria included trivial mechanisms of injury (e.g., ground-level falls or walking into stationary objects), prior CT imaging before emergency department arrival, penetrating trauma, preexisting neurological disorders (including brain tumors), known bleeding disorders, or lack of informed parental or guardian consent. A total of 235 participants met the eligibility criteria and were enrolled consecutively.

Sample size

The sample size was calculated based on a previously reported sensitivity (85.7%) and specificity (73.5%) from a validation study conducted in Japan, assuming a ciTBI prevalence of 20%, an absolute precision of 10%, and a 5% alpha error [12]. The calculated sample size was 235 patients.

Data collection

Data were collected using a standardized case record form designed to capture demographic, clinical, and radiological variables. Treating emergency physicians or supervised residents completed the forms in real time during patient evaluation to enhance data accuracy. Each record documented age, sex, GCS score, mechanism of injury, presenting symptoms (vomiting, loss of consciousness, severe headache), and physical signs (signs of basilar skull fracture and altered mental status). Data completeness was verified daily by an independent investigator. Missing entries were cross-checked against electronic medical records, nursing documentation, and imaging reports. Forms were excluded only if key variables, specifically, PECARN criteria, or outcome data, remained missing after verification.

Risk stratification using PECARN

The PECARN clinical decision rule was applied to stratify patients into high-, intermediate-, or low-risk categories for ciTBI, using age-specific algorithms for children aged <2 and ≥2 years.

(1) High-risk patients underwent immediate CT brain imaging.

(2) Intermediate-risk patients were observed for up to 24 hours. CT imaging was performed if multiple risk factors were present or if clinical symptoms worsened.

(3) Low-risk patients were discharged without imaging after caregiver counseling regarding warning signs.

Telephone follow-ups were conducted within 48 hours to identify instances of delayed deterioration.

Outcome measures

The primary outcome was the presence of ciTBI, defined as head injury resulting in death, intubation for >24 hours, neurosurgical intervention, or hospital admission for ≥2 nights in conjunction with radiological evidence of TBI. TBI on CT was defined as the presence of intracranial hemorrhage, contusion, cerebral edema, infarction, skull fracture, midline shift, or herniation.

Statistical analysis

The diagnostic accuracy of the PECARN clinical decision rule was evaluated using 2×2 contingency tables. PECARN classification (positive, intermediate/high risk; negative, low risk) was compared against the reference standard of ciTBI, as defined by clinical and radiological outcomes. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated with 95% confidence intervals (CIs) using the Wilson method.

The receiver operating characteristic (ROC) curve was constructed by plotting sensitivity (true-positive rate) against 1−specificity (false-positive rate) across varying PECARN decision thresholds. The area under the curve (AUC), along with its 95% CI, was calculated using the nonparametric DeLong method, which provides a robust estimate of AUC variance, even with modest sample sizes.

The optimal cutoff threshold for predicting ciTBI was determined using Youden J statistic (J=sensitivity+specificity−1), which maximizes overall diagnostic accuracy. AUC values were interpreted as follows: 0.5–0.7 (low discrimination), 0.7–0.9 (moderate discrimination), and >0.9 (high discrimination).

All statistical analyses were performed using Stata ver. 14.02 (StataCorp) and Microsoft Excel 2021 (Microsoft Corp). Categorical variables were summarized as frequencies and percentages, whereas continuous variables were expressed as mean±standard deviation, as appropriate. Associations between categorical variables (e.g., clinical predictors and ciTBI outcomes) were assessed using the chi-square test or Fisher exact test when expected cell counts were <5. A P-value of <0.05 was considered statistically significant.

RESULTS

A total of 235 children with minor head trauma were included in the analysis. Most participants were aged ≥2 years (n=179, 76.2%), and 154 (65.5%) were male. According to PECARN risk stratification, 128 (54.5%) were classified as intermediate risk, 37 (15.7%) as high risk, and 70 (29.7%) as low risk.

The majority of children presented with a GCS score of 15 (n=224, 95.3%), whereas 11 (4.7%) had a GCS score of 14. Nonsevere mechanisms accounted for 223 injuries (94.9%), and being struck by an object was the most common mechanism (n=119, 50.6%). The frequencies of key clinical features, including vomiting, loss of consciousness, severe headache, signs of basilar skull fracture, and altered mental status, are summarized in Table 1.

CT brain imaging was performed in 62 patients (26.4%); 19 of these scans (30.6%) demonstrated TBI. Overall, 144 children (61.3%) were managed with observation, 72 (30.6%) were discharged from the emergency department, and 19 (8.1%) required admission to the neurosurgical intensive care unit following identification of TBI on CT. Clinical deterioration occurred in 14 patients (6.0%), predominantly among those in the intermediate-risk group. Repeat CT imaging was obtained in 14 cases (6.0%), with TBI identified in 6 of the scans (42.9%). In total, 25 children (10.6%) had evidence of TBI, with 23 identified on initial CT and 2 detected on repeat imaging.

Several clinical variables were significantly associated with ciTBI. Signs of basilar skull fracture, severe headache, and loss of consciousness were strong predictors of ciTBI (all P<0.001). A severe mechanism of injury, particularly road traffic accidents, was also significantly associated with ciTBI. Children presenting with a GCS score of 14 had a markedly higher likelihood of ciTBI compared with those with a GCS score of 15 (P<0.001). No statistically significant association was observed between ciTBI and altered mental status or sex with respect to PECARN risk classification (Table 1).

PECARN risk classification was strongly correlated with clinical outcomes, with the highest proportion of ciTBI observed in the high-risk group. TBI detected on CT was significantly more frequent among children in the high- and intermediate-risk categories than among those classified as low risk (Table 1).

Children aged ≥2 years had a higher proportion of ciTBI than those aged <2 years (13.4% vs. 1.8%). Only one ciTBI event occurred in children aged <2 years; therefore, findings for this subgroup are presented descriptively without inferential statistical analysis. These results should be interpreted cautiously, as the low event rate limits statistical power and precludes definitive conclusions.

ROC analysis demonstrated good diagnostic performance of the PECARN rule for predicting ciTBI, with a sensitivity of 82.4% and specificity of 74.1%. The area under the ROC curve was 0.90 (P=0.01), indicating excellent discrimination. The negative predictive value was high (97.9%), whereas the positive predictive value was relatively low (19.6%) (Fig. 1).

DISCUSSION

Head injuries represent one of the most common reasons for pediatric emergency department visits, with more than 95% classified as minor head trauma (GCS score ≥14). However, fewer than 10% of these children require neurosurgical intervention, and <1% develop ciTBI [1,2]. Despite the low prevalence of severe outcomes, CT utilization in pediatric emergency departments increased from 10.9% to 34% between 1996 and 2008, resulting in greater radiation exposure, increased healthcare costs, and a potential iatrogenic cancer risk estimated at 1:1,500 to 1:3,000 [3,4]. These concerns underscore the importance of validated clinical decision support tools to optimize imaging practices while maintaining diagnostic safety.

Pediatric head trauma differs from adult injury patterns due to greater cranial flexibility, open sutures, and a relatively larger head to body ratio, which may increase susceptibility to injury [13,14]. Nevertheless, the clinical relevance of these anatomical differences lies primarily in their influence on presentation and risk stratification rather than in defining distinct injury subtypes. Accordingly, this discussion focuses on the applicability of the PECARN rule in identifying children at low risk for ciTBI and guiding imaging decisions in our setting.

In this cohort of 235 pediatric patients with minor head trauma, the PECARN rule demonstrated a sensitivity of 82.4%, specificity of 74.1%, positive predictive value of 19.6%, and negative predictive value of 97.9%, with an AUC of 0.90 (P=0.01). Although the observed sensitivity was lower than the near 100% sensitivity reported in the original validation study by Kuppermann et al. [2], it is consistent with subsequent international validation studies reporting sensitivities ranging from 80% to 97% [15–18]. The modest reduction in sensitivity may reflect differences in sample size, inclusion criteria, and case mix. Notably, no cases requiring neurosurgical intervention were missed, supporting the clinical safety of the rule in our setting.

The incidence of ciTBI (10.6%) observed in this cohort is comparable to rates reported in other Asian and middle-income settings (8%–12%) [16,17]. Children aged ≥2 years demonstrated a significantly higher incidence of ciTBI than those aged <2 years (13.4% vs. 1.8%, P<0.05), which may reflect increased mobility and environmental exposure among older children. The most common mechanism of injury was object-related trauma (50.6%), consistent with regional data indicating that domestic and community injuries predominate [19].

Several clinical variables, including GCS score, mechanism of injury, vomiting, loss of consciousness, and signs of basilar skull fracture, were significantly associated with ciTBI (all P<0.001). Although clinical signs of basilar skull fracture were associated with ciTBI, radiological confirmation was not consistently obtained, possibly due to overlapping soft-tissue findings or subtle fracture patterns, as reported previously [20,21]. A multicenter Korean validation study similarly demonstrated that PECARN retained good discriminatory ability for ciTBI in pediatric emergency populations [22].

The clinical implications of these findings reinforce the utility of PECARN in the South Indian pediatric emergency context. The high negative predictive value supports safely deferring CT imaging in low-risk patients, thereby reducing unnecessary radiation exposure and optimizing resource utilization. However, children categorized as intermediate risk, particularly those with unwitnessed injuries, should undergo careful observation, given the small but clinically relevant risk of delayed ciTBI observed in this cohort.

Incorporating PECARN into local triage protocols may enhance evidence-based decision-making, particularly in resource-limited settings where imaging availability and follow-up may be constrained. Future multicenter studies across India are warranted to further validate these findings and to explore region-specific injury mechanisms, healthcare access barriers, and follow-up practices. Such research will be critical for establishing a context-appropriate framework for pediatric head injury management in South Asia.

Strengths and limitations

This study represents one of the few investigations assessing the diagnostic performance of the PECARN clinical decision rule in identifying pediatric patients at risk of ciTBI in a South Indian setting. Additionally, this study is among the limited body of literature examining the incidence of ciTBI separately in children aged <2 years and those aged ≥2 years within an Indian population.

Despite its strengths, this study has several limitations. First, due to the observational study design, causal inferences cannot be made. The findings were generalizable primarily to similar tertiary care settings, as the study was conducted at a single center in South India. Second, follow-up was limited to 48 hours, whereas longer follow-up durations were reported in other validation studies. Consequently, cases of TBI presenting after 48 hours may have been missed. Lastly, the final analysis combined both age groups because the sample size of children aged <2 years was small, and only one case of ciTBI occurred in this subgroup.

Conclusions

This study adds to the growing body of evidence supporting the diagnostic utility of the PECARN clinical decision rule in children with minor head trauma presenting to the emergency department. The rule demonstrated high sensitivity for identifying ciTBI, thereby facilitating timely intervention while reducing unnecessary CT imaging in low-risk patients. However, these findings should be interpreted in light of the inherent limitations of clinical decision rules, underscoring the need for continued validation and refinement to ensure optimal performance across diverse clinical settings.

ARTICLE INFORMATION

Author contributions

Conceptualization: SS, KMKK; Data curation: NP; Formal analysis: SS; Investigation: AMJ; Methodology: LSM, VSV; Project administration: KMKK; Visualization: AMJ; Writing–original draft: KMKK; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Fig. 1.

Receiver operating characteristic curve showing diagnostic performance of the PECARN (Pediatric Emergency Care Applied Research Network) rule for predicting clinically important traumatic brain injury. The area under the curve (AUC) indicates high accuracy (AUC, 0.90; P=0.01); clinically important traumatic brain injury confirmed by imaging or clinical outcomes served as the reference standard.

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Figure & Data

References

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