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We evaluated the existing decision rules and developed our own decision rule for use with pediatric patients having head injuries to see how good they are for identifying serious complications.In a retrospective survey covering 5 years, we tested 3 decision rules on all the 485 children with head trauma admitted to the Department of Pediatrics at Oulu University Hospital in Finland.Four hundred two (83%) of our 485 patients had uncomplicated head trauma, 55 (11%) had complicated trauma, and 28 (6%) had severely complicated trauma. We found the 3 existing decision rules to be applicable with 96% to 99% sensitivities in identifying patients with at least complicated head trauma and 100% sensitivity in identifying severely complicated cases, but the specificities were low, from 5% to 21%. Use of the best National Emergency X-Radiography Utilization Study (NEXUS) II decision rule would have resulted in 89 (18%) less hospital admissions, 216 (14%) less days in the hospital, and annual savings of $30,600 without compromising the prognosis for our patients. A decision rule developed on the basis of our own series had a sensitivity of 94% for patients with at least complicated head trauma and 96% for patients with severely complicated head trauma and a specificity of 29% in both groups.All the 3 existing decision rules tested had high sensitivities for at least complicated head trauma, but rather low specificity. Because the most optimal decision rule based on the present data was not superior to the existing ones, we conclude that it is difficult to develop a rule that would be markedly better than that of NEXUS II. Use of the NEXUS II rule would have resulted in reduced hospitalization and imaging rates in our hospital, where no decision rules are currently used.