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A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST)

Franz E Babl1234*, Mark D Lyttle156, Silvia Bressan127, Meredith Borland8, Natalie Phillips9, Amit Kochar10, Stuart R Dalziel1112, Sarah Dalton13, John A Cheek1142, Jeremy Furyk15, Yuri Gilhotra16, Jocelyn Neutze17, Brenton Ward2, Susan Donath23, Kim Jachno23, Louise Crowe23, Amanda Williams23, Ed Oakley123 and On behalf of the PREDICT research network

Author Affiliations

1 Department of Emergency Medicine, Royal Children’s Hospital, Flemington Rd, Parkville Vic 3052, Australia

2 Murdoch Childrens Research Institute, Parkville, VIC, Australia

3 Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne VIC 3010, Australia

4 National Trauma Research Institute, Prahan, VIC, Australia

5 Bristol Royal Hospital for Children, Bristol, UK

6 Academic Department of Emergency Care, University of the West of England, Bristol, UK

7 University of Padova, Padova, Italy

8 Princess Margaret Hospital for Children, Perth, Australia

9 Royal Children's Hospital and Queensland Children's Medical Research Institute, Queensland University, Brisbane, Australia

10 Women’s & Children’s Hospital, Adelaide, Australia

11 Starship Hospital, Auckland, New Zealand

12 Liggins Institute, University of Auckland, Auckland, New Zealand

13 The Children’s Hospital at Westmead, Sydney, Australia

14 Monash Medical Centre, Clayton, VIC, Australia

15 Townsville Hospital, Townsville, Australia

16 Mater Children’s Hospital, Brisbane, Australia

17 Kidzfirst Middlemore Hospital, Auckland, New Zealand

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BMC Pediatrics 2014, 14:148  doi:10.1186/1471-2431-14-148

Published: 13 June 2014



Head injuries in children are responsible for a large number of emergency department visits. Failure to identify a clinically significant intracranial injury in a timely fashion may result in long term neurodisability and death. Whilst cranial computed tomography (CT) provides rapid and definitive identification of intracranial injuries, it is resource intensive and associated with radiation induced cancer. Evidence based head injury clinical decision rules have been derived to aid physicians in identifying patients at risk of having a clinically significant intracranial injury. Three rules have been identified as being of high quality and accuracy: the Canadian Assessment of Tomography for Childhood Head Injury (CATCH) from Canada, the Children’s Head Injury Algorithm for the Prediction of Important Clinical Events (CHALICE) from the UK, and the prediction rule for the identification of children at very low risk of clinically important traumatic brain injury developed by the Pediatric Emergency Care Applied Research Network (PECARN) from the USA. This study aims to prospectively validate and compare the performance accuracy of these three clinical decision rules when applied outside the derivation setting.


This study is a prospective observational study of children aged 0 to less than 18 years presenting to 10 emergency departments within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) research network in Australia and New Zealand after head injuries of any severity. Predictor variables identified in CATCH, CHALICE and PECARN clinical decision rules will be collected. Patients will be managed as per the treating clinicians at the participating hospitals. All patients not undergoing cranial CT will receive a follow up call 14 to 90 days after the injury. Outcome data collected will include results of cranial CTs (if performed) and details of admission, intubation, neurosurgery and death. The performance accuracy of each of the rules will be assessed using rule specific outcomes and inclusion and exclusion criteria.


This study will allow the simultaneous comparative application and validation of three major paediatric head injury clinical decision rules outside their derivation setting.

Trial registration

The study is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR)- ACTRN12614000463673 (registered 2 May 2014).

Head injury; Clinical decision rule; Computed tomography; Validation