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Diagnostic accuracy of the Scandinavian guidelines for minor and moderate head trauma in children : a prospective, pragmatic, validation study

Wickbom, Fredrik LU orcid ; Bremell, Rakel ; Thornberg, Sarah ; Sotoca Fernandez, Jorge LU ; Magnusson, Beatrice ; Silfver, Rasmus ; Chaudhry, Aqeel ; Kjellröier, Kristoffer ; Farahnoosh Afsan, Hanna and Bergman, Marcus , et al. (2025) In The Lancet Regional Health - Europe 51.
Abstract

Background: Current guidelines for initial management of traumatic brain injury (TBI) support decision making, but they are rarely validated. The Scandinavian guideline for management of children with TBI (SNC16) was developed to minimise the use of cranial computed tomography (cCT) without compromising safety, but the performance of the guideline in a real-world population is unknown. We aimed to determine the diagnostic accuracy for the SNC16 in a large, pragmatic cohort of children. Methods: In this prospective, observational, international cohort study in 16 Swedish and Norwegian emergency departments (EDs), children (aged <18 years) with blunt head trauma, presenting within 24 h of injury and a Glasgow Coma Scale of 9–15, were... (More)

Background: Current guidelines for initial management of traumatic brain injury (TBI) support decision making, but they are rarely validated. The Scandinavian guideline for management of children with TBI (SNC16) was developed to minimise the use of cranial computed tomography (cCT) without compromising safety, but the performance of the guideline in a real-world population is unknown. We aimed to determine the diagnostic accuracy for the SNC16 in a large, pragmatic cohort of children. Methods: In this prospective, observational, international cohort study in 16 Swedish and Norwegian emergency departments (EDs), children (aged <18 years) with blunt head trauma, presenting within 24 h of injury and a Glasgow Coma Scale of 9–15, were prospectively enrolled. The primary outcome measure was presence of a composite variable (clinically important intracranial injury (CIII) comprised of death, neurosurgery, admission to hospital ward ≥2 days due to head injury, or intubation ≥1 day due to pathological cCT findings), all within one week from trauma. Secondary outcome measures were neurosurgery and significant trauma related findings on cCT. Findings: A total of 3012 children were enrolled from April 2018 to May 2024. Nine patients fulfilled the primary variable CIII (0.30%; 9/3012), two patients required neurosurgery (0.07%; 2/3012), and 27 patients showed significant trauma related findings on cCT (0.90%; 27/3012). Point sensitivities to detect CIII, neurosurgery and significant cCT findings were 100% (CI 95% 70%–100% [9/9]; 34%–100% [2/2]; and 87%–100% [27/27]). Point specificity was 41.3%, 41.2%, and 41.6% (CI 95% 40%–43% [1241/3003]; 39%–43% [1241/3010]; and 40%–43% [1241/2985]). Negative predictive values were 100% for CIII, neurosurgery and significant cCT findings (CI 95% 99.7%–100.0% for all). Application of the SNC16 guidelines would have resulted in a mandatory cCT rate of 3.4% (101/3012) and immediate discharge from the ED for 41.2% (1241/3012) of children. No children with a discharge recommendation were positive for any primary or secondary outcomes. Interpretation: Validation of the SNC16 guideline showed adequate diagnostic performance in a real-world cohort, supporting formal implementation. Funding: Non-commercially (Swedish state) funded by Sӧdra Sjukvårdsregionen and Vetenskapliga Rådet, Hallands Hospital and Forskning och Utveckling, Halland.

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publication status
published
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keywords
Children, Clinical decision rule, Computed tomography, Diagnostic accuracy, Guidelines, Scandinavia, Traumatic brain injury, Validation
in
The Lancet Regional Health - Europe
volume
51
article number
101233
publisher
Elsevier
external identifiers
  • scopus:85217375707
ISSN
2666-7762
DOI
10.1016/j.lanepe.2025.101233
language
English
LU publication?
yes
id
d6cd27a6-d623-4f5a-9cc4-54bff49ce640
date added to LUP
2025-03-17 15:23:39
date last changed
2025-04-14 18:38:52
@article{d6cd27a6-d623-4f5a-9cc4-54bff49ce640,
  abstract     = {{<p>Background: Current guidelines for initial management of traumatic brain injury (TBI) support decision making, but they are rarely validated. The Scandinavian guideline for management of children with TBI (SNC16) was developed to minimise the use of cranial computed tomography (cCT) without compromising safety, but the performance of the guideline in a real-world population is unknown. We aimed to determine the diagnostic accuracy for the SNC16 in a large, pragmatic cohort of children. Methods: In this prospective, observational, international cohort study in 16 Swedish and Norwegian emergency departments (EDs), children (aged &lt;18 years) with blunt head trauma, presenting within 24 h of injury and a Glasgow Coma Scale of 9–15, were prospectively enrolled. The primary outcome measure was presence of a composite variable (clinically important intracranial injury (CIII) comprised of death, neurosurgery, admission to hospital ward ≥2 days due to head injury, or intubation ≥1 day due to pathological cCT findings), all within one week from trauma. Secondary outcome measures were neurosurgery and significant trauma related findings on cCT. Findings: A total of 3012 children were enrolled from April 2018 to May 2024. Nine patients fulfilled the primary variable CIII (0.30%; 9/3012), two patients required neurosurgery (0.07%; 2/3012), and 27 patients showed significant trauma related findings on cCT (0.90%; 27/3012). Point sensitivities to detect CIII, neurosurgery and significant cCT findings were 100% (CI 95% 70%–100% [9/9]; 34%–100% [2/2]; and 87%–100% [27/27]). Point specificity was 41.3%, 41.2%, and 41.6% (CI 95% 40%–43% [1241/3003]; 39%–43% [1241/3010]; and 40%–43% [1241/2985]). Negative predictive values were 100% for CIII, neurosurgery and significant cCT findings (CI 95% 99.7%–100.0% for all). Application of the SNC16 guidelines would have resulted in a mandatory cCT rate of 3.4% (101/3012) and immediate discharge from the ED for 41.2% (1241/3012) of children. No children with a discharge recommendation were positive for any primary or secondary outcomes. Interpretation: Validation of the SNC16 guideline showed adequate diagnostic performance in a real-world cohort, supporting formal implementation. Funding: Non-commercially (Swedish state) funded by Sӧdra Sjukvårdsregionen and Vetenskapliga Rådet, Hallands Hospital and Forskning och Utveckling, Halland.</p>}},
  author       = {{Wickbom, Fredrik and Bremell, Rakel and Thornberg, Sarah and Sotoca Fernandez, Jorge and Magnusson, Beatrice and Silfver, Rasmus and Chaudhry, Aqeel and Kjellröier, Kristoffer and Farahnoosh Afsan, Hanna and Bergman, Marcus and Jumppanen, Amel and Johansson, Malin and Östberg, Sascha and Kamis, Christian and Ölund, Mihai and Jeppsson, Emma and Modin, Albert and Santoft, Anders and Borg, Lovisa and Gatzinsky, Cathrine and Lönn, Maria and Calcagnile, Olga and Astrand, Ramona and Sundstrøm, Terje and Marklund, Niklas and Undén, Johan}},
  issn         = {{2666-7762}},
  keywords     = {{Children; Clinical decision rule; Computed tomography; Diagnostic accuracy; Guidelines; Scandinavia; Traumatic brain injury; Validation}},
  language     = {{eng}},
  publisher    = {{Elsevier}},
  series       = {{The Lancet Regional Health - Europe}},
  title        = {{Diagnostic accuracy of the Scandinavian guidelines for minor and moderate head trauma in children : a prospective, pragmatic, validation study}},
  url          = {{http://dx.doi.org/10.1016/j.lanepe.2025.101233}},
  doi          = {{10.1016/j.lanepe.2025.101233}},
  volume       = {{51}},
  year         = {{2025}},
}