Newgard C D, Hedges J R, Stone J V, Lenfesty B, Diggs B, Arthur M, Mullins R J
Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon 97239-3098, USA.
Emerg Med J. 2005 Dec;22(12):855-60. doi: 10.1136/emj.2004.020206.
To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care.
We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18-65 years with a serious head injury (AIS > or =3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based "high therapeutic intensity" measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule.
504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation.
This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.
推导一个针对创伤性脑损伤（TBI）患者的临床决策规则，以便早期识别需要专科创伤护理的患者。
我们收集了1999年至2003年的数据，这些数据来自一个回顾性队列，该队列中的患者为连续的18 - 65岁严重头部损伤（简明损伤定级[AIS]≥3）患者，他们从受伤现场直接转运而来，并在急诊科接受评估。收集了22个人口统计学、生理学、影像学和实验室变量的信息。预先确定了在急诊科就诊后72小时内出现的基于资源的“高治疗强度”措施（结局指标），包括：神经外科干预、剖腹探查术、重症监护干预或死亡。我们使用分类和回归树分析来推导并交叉验证该决策规则。
504例连续创伤患者被确定为严重头部损伤：246例（49%）至少需要一项高治疗强度措施。五个急诊科变量（格拉斯哥昏迷量表[GCS]、呼吸频率、年龄、体温和脉搏率）在推导样本中识别出需要至少一项高治疗强度措施的受试者，灵敏度为94%（95%置信区间91%至97%），特异度为63%（95%置信区间57%至69%），交叉验证时灵敏度为90%，特异度为55%。
该决策规则在急诊科评估的一组头部受伤患者中识别出了大多数急需专科创伤护理的患者。在推荐实施之前，该规则需要在非三级护理医院就诊的受伤患者中进行前瞻性验证。
