Checklist can help avoid CT chest scans in a third of blunt trauma cases
BMJ 2015; 351 doi: https://doi.org/10.1136/bmj.h5381 (Published 08 October 2015) Cite this as: BMJ 2015;351:h5381Using a simple checklist can help to avoid computed tomography (CT) scans of the chest in a third of people admitted to emergency departments with blunt trauma without increasing the risk of missing major injury, a US study has shown.
The study, published in PLOS Medicine,1 investigated more than 11 000 patients aged 15 or over who were treated at eight major US trauma centres. The patients all had blunt trauma injuries generally resulting from road accidents and falls, which account for most trauma cases seen in hospital emergency departments.
The researchers used data collected on 6002 patients in the first part of their study to develop two sets of criteria: firstly, to identify patients with injuries of any severity that could be detected by CT scans and, secondly, major injuries. They recorded the presence or absence of 14 clinical criteria and then viewed each patient’s chest imaging results and refined the criteria in line with those that best predicted injury.
The first set of criteria to detect major and minor injuries were: abnormal chest x ray; tenderness in the chest wall, breastbone, shoulder blade, or thoracic spine; injury caused by rapid deceleration—either a fall of 20 feet or more or a vehicle accident while travelling at 40 or more miles per hour; and the presence of distracting injuries, such as a broken thigh bone, that could make patients less aware of pain from internal injuries. The second set of criteria to detect major injury were the same but excluded rapid deceleration.
The researchers then validated these two sets of criteria while observing the care of 5475 patients with blunt trauma injuries. They found that both sets identified patients with significant thoracic injuries with high sensitivity. The more comprehensive set of criteria had a sensitivity of 99.2% (95% confidence interval 95.4% to 100%) for major injury. The shorter set had a similar sensitivity for major injury but was less sensitive in determining whether the patient had either a major or minor injury.
With a specificity for major or minor injury of 25.5% (23.5% to 27.5%), the comprehensive set of criteria would correctly avoid around 25% of non-diagnostic chest CT scans. The set for major injury would correctly avoid more than a third of chest CT scans, with a specificity for major or minor injury of 37.9% (35.8% to 40.1%).
“We prospectively derived and validated two . . . decision instruments, which consist of simple, readily available criteria that detect clinically significant thoracic and intrathoracic injury with very high sensitivity,” said the researchers, led by Robert Rodriguez, professor of emergency medicine at the University of California, San Francisco, USA.
Rodriguez explained, “CT scans deliver radiation dosages to the body that elevate cancer risk, especially in the young, and they are expensive, so we want to be sure to use them only when they are likely to provide a diagnostic benefit.
“Except for the chest x ray, the clinical criteria we incorporated into the decision making tools are simple, straightforward components of the routine trauma history and physical exam. Healthcare providers will not need to spend more time, money or effort to implement them.”
Notes
Cite this as: BMJ 2015;351:h5381
References
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