Derivation of a Clinical Decision Rule to Exclude Thoracic Aortic Imaging in Patients With Blunt Chest Trauma After Motor Vehicle Collisions

Ungar, Todd C.; Wolf, Stephen J.; Haukoos, Jason S.; Dyer, Debra S.; Moore, Ernest E.

doi:10.1097/01.ta.0000239357.68782.30

Cited by 43 publications

(27 citation statements)

References 18 publications

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“…Published results reveal that approximately half of the thoracic CT scans obtained in blunt trauma are negative for major thoracic injury (61% in the previous study). 2,16 Studies of blunt trauma patients in need of advanced imaging have focused on identifying trauma patients at greatest risk for major thoracic injury and comparison of diagnostic performance between chest radiography and CT. 6,7,[17][18][19][20][21][22][23] One study did attempt to identify very low-risk patients who did not need chest CT, but it was only 95% sensitive. 2 Reducing the number of unnecessary CT scans is in the best interest of both the patient and the clinician for many reasons.…”

Section: Discussionmentioning

confidence: 99%

The SCRAP rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma

Payrastre

Upadhye

Worster

et al. 2012

CJEM

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Objective: To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans. Methods: Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score . 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score # 8, paralysis, or age , 16 years were excluded. Results: There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4-100], specificity 46.9% [95% CI 44.2-46.9], and negative likelihood ratio 0.00 [95% CI 0.00-0.04]). The five variables were oxygen saturation (, 95% on room air or , 98% on any supplemental oxygen), chest radiograph, respiratory rate $ 25, chest auscultation, and thoracic palpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2-100%), a specificity of 44.7% (95% CI 39.5-44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00-0.10). Conclusions: In major blunt trauma with a GCS score . 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting. RÉ SUMÉObjectif: L'é tude visait à obtenir par dé rivation et à valider par voie interne une rè gle de dé cision clinique permettant d'é carter la pré sence de blessures thoraciques graves chez des adultes ayant subi un traumatisme contondant, ce qui diminuerait la né cessité de recourir inutilement à la tomodensitomé trie (TDM) du thorax. Les patients é taient sé lectionné s s'ils avaient obtenu un ré sultat . 12 à l'Indice de gravité de la blessure et qu'une TDM avait é té effectué e à l'arrivé e ou encore s'ils pré sentaient une blessure thoracique grave avé ré e d'aprè s la base de donné es sur les traumatismes. Par contre, les patients é taient é carté s s'ils avaient subi une blessure par pé né tration, avaient obtenu un ré sultat # 8 sur l'é chelle de Glasgow (EG), é taient atteints de paralysie ou é taient â gé s de , 16 ans. Ré sultats: Quatre cent trente-quatre patients dans le groupe de dé rivation et 180 patients dans le groupe de validation ré pondaient aux critè res de sé lection. Cinq variables cliniques particuliè rement justes quant au caractè re pré visionnel des blessures se sont dé gagé es du partitionnement ré cursif. Lorsque ces variables é taient normales, aucun patient ne pré sentait de blessure thoracique grave (sensibilité ,...

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Section: Discussionmentioning

confidence: 99%

The SCRAP rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma

Payrastre

Upadhye

Worster

et al. 2012

CJEM

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“…It is included in most trauma center protocols in the initial evaluation of patients with polytrauma [7]. …”

Section: Summary Of Literature Reviewmentioning

confidence: 99%

ACR Appropriateness Criteria® blunt chest trauma—suspected aortic injury

et al. 2012

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The purpose of these guidelines is to recommend appropriate imaging for patients with blunt chest trauma. These patients are most often imaged in the emergency room, and thus emergency radiologists play a substantial role in prompt, accurate diagnoses that, in turn, can lead to life-saving interventions. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Imaging largely focuses on the detection and exclusion of traumatic aortic injury; a large proportion of patients are victims of motor vehicle accidents. For those patients who survive the injury and come to emergency radiology, rapid, appropriate assessment of patients who require surgery is paramount.

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“…Therefore, it is necessary to formulate a reliable strategy for selecting patients required chest radiography . Various decision‐making tools have been applied to determine the accuracy of clinical signs and symptoms in prediction of thoracic cavity injuries . These tools demonstrated on the acceptable sensitivity and specificity of clinical findings in rule in/out of thoracic injuries.…”

Section: Introductionmentioning

confidence: 99%

Clinical decision rule to prevent unnecessary chest X‐ray in patients with blunt multiple traumas

Forouzanfar

Safari

Niazazari

et al. 2014

Emerg Medicine Australasia

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Derivation of a Clinical Decision Rule to Exclude Thoracic Aortic Imaging in Patients With Blunt Chest Trauma After Motor Vehicle Collisions

Abstract: We report a clinical decision rule with a high NPV for exclusion of TAI. This may standardize the approach to such patients and may reduce the need for CT.

Cited by 43 publications

References 18 publications

The SCRAP rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma

The SCRAP rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma

ACR Appropriateness Criteria® blunt chest trauma—suspected aortic injury

Clinical decision rule to prevent unnecessary chest X‐ray in patients with blunt multiple traumas

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