Prediction of blunt traumatic injury in high-acuity patients: bedside examination vs computed tomography

• Published in: The American journal of emergency medicine 2011, Vol.29 (1), p.1-10
• Main Authors: Smith, Clay B., MD, Barrett, Tyler W., MD, Berger, Craig L., MD, Zhou, Chuan, PhD, Thurman, R. Jason, MD, Wrenn, Keith D., MD
• Format: Article
• Language: English
• Subjects: Abdomen; Abdominal Injuries - diagnosis; Abdominal Injuries - diagnostic imaging; Accuracy; Adult; Anesthesia. Intensive care medicine. Transfusions. Cell therapy and gene therapy; Biological and medical sciences; Computed tomography; Confidence Intervals; Data collection; Emergency; Emergency medical care; Emergency Service, Hospital; Emergency services; Female; Head Injuries, Closed - diagnosis; Head Injuries, Closed - diagnostic imaging; Hospitals; Humans; Injuries; Injuries of the abdomen. Foreign bodies of the digestive system; Intensive care medicine; Male; Medical sciences; Middle Aged; Physical Examination; Point-of-Care Systems; Prospective Studies; Review boards; ROC Curve; Sensitivity and Specificity; Spinal Injuries - diagnosis; Spinal Injuries - diagnostic imaging; Spine; Thoracic Injuries - diagnosis; Thoracic Injuries - diagnostic imaging; Tomography, Spiral Computed; Traumas. Diseases due to physical agents; Wounds, Nonpenetrating - diagnosis; Wounds, Nonpenetrating - diagnostic imaging
• ISSN: 0735-6757; 1532-8171
• DOI: 10.1016/j.ajem.2009.05.025

Abstract Objective The addition of spiral computed tomography (SCT) to bedside assessment in patients with major trauma may improve detection of significant injury. We hypothesized that in high-acuity trauma patients, emergency physicians' ability to detect significant injuries based solely on bedside assessment would lack the sensitivity needed to exclude serious injuries when compared with SCT. Methods This was a prospective single-cohort study of high-acuity trauma patients routinely undergoing whole-body SCT at a level 1 trauma center from January to September 2006. Before SCT, emergency physicians assigned ratings for likelihood of injury to 5 body regions on the basis of bedside assessment. These ratings were compared with final SCT interpretations. Results We enrolled 400 patients as a convenience sample; 71 were excluded. When a “very low” rating was considered negative and “low,” “intermediate,” “high,” and “very high” were considered positive, emergency physicians were able to detect head, cervical spine, chest, abdominal/pelvic, and thoracic/lumbar spine injuries with sensitivities (95% confidence interval) of 100% (98.6%-100%), 97.4% (94.9%-98.8%), 96.9% (94.2%-98.4%), 97.9% (95.5%-99.1%), and 97.0% (94.3%-98.5%), respectively. For overall diagnostic accuracy, areas under the receiver operating characteristics curve (95% confidence interval) were 0.87 (0.82-0.92), 0.71 (0.62-0.81), 0.81 (0.76-0.86), 0.77(0.71-0.83), 0.74 (0.65-0.84), respectively. Conclusions Bedside assessment by emergency physicians before SCT was sensitive in ruling out serious injuries in high-acuity trauma patients with a “very low” rating for injury. However, overall diagnostic accuracy was low, suggesting that SCT should be considered in most high-acuity patients to prevent missing injuries.