Sun Benjamin C, Hoffman Jerome R, Mower William R
Robert Wood Johnson Clinical Scholars Program, University of California at Los Angeles, Los Angeles, CA, USA.
Ann Emerg Med. 2007 Mar;49(3):325-32, 332.e1. doi: 10.1016/j.annemergmed.2006.08.032. Epub 2007 Jan 8.
We evaluate the effect of a modification of the University of California-Davis Pediatric Head Injury Rule on the ability of the decision instrument for pediatric head injury to predict clinically important intracranial injury in an external cohort.
We analyzed data prospectively recorded in 1,666 pediatric patients enrolled in the derivation set of the National Emergency X-Radiography Utilization Study II (NEXUS II). Treating physicians at 21 emergency departments recorded the presence or absence of clinical predictors on all patients who received a head computed tomography (CT) scan after experiencing blunt head trauma. Predictors included 3 exact elements of the University of California-Davis Rule (abnormal mental status, signs of skull fracture, and scalp hematoma in children < or = 2 years of age), some with different wording, and 2 modified elements with new definitions (the presence of high-risk vomiting or severe headache, rather than any vomiting or headache).
A significant intracranial injury was identified by CT in 138 (8.3%) patients. Sensitivity of the modified instrument to detect significant intracranial injury was 90.4% (95% confidence interval [CI] 85.4% to 95.4%); 13 children with such an injury were misclassified as low risk. Specificity of the modified instrument was 42.7% (95% CI 40.1% to 45.3%).
In the NEXUS II cohort, a modified version of the University of California-Davis Rule misclassified a substantial proportion of pediatric patients with clinically important blunt head injury. Although we cannot evaluate the exact University of California-Davis Rule, we demonstrate that using stricter definitions of "headache" and "vomiting" and different wording than in the original study may have unintended or negative consequences. We emphasize the importance of careful attention to precise definitions of clinical predictors when a decision instrument is used.
我们评估了对加利福尼亚大学戴维斯分校小儿头部损伤规则进行修改后，该小儿头部损伤决策工具在外部队列中预测具有临床重要性的颅内损伤能力的影响。
我们分析了前瞻性记录在全国急诊X线摄影利用研究II（NEXUS II）推导集中的1666例儿科患者的数据。21个急诊科的治疗医师记录了所有钝性头部外伤后接受头部计算机断层扫描（CT）的患者是否存在临床预测因素。预测因素包括加利福尼亚大学戴维斯分校规则的3个确切要素（意识状态异常、颅骨骨折体征以及2岁及以下儿童的头皮血肿），有些表述有所不同，还有2个修改后的要素及新定义（存在高危呕吐或严重头痛，而非任何呕吐或头痛）。
CT检查发现138例（8.3%）患者存在显著颅内损伤。修改后的工具检测显著颅内损伤的敏感性为90.4%（95%置信区间[CI] 85.4%至95.4%）；13例有此类损伤的儿童被误分类为低风险。修改后工具的特异性为42.7%（95% CI 40.1%至45.3%）。
在NEXUS II队列中，加利福尼亚大学戴维斯分校规则的修改版本将相当一部分具有临床重要性的钝性头部损伤的儿科患者误分类。虽然我们无法评估确切的加利福尼亚大学戴维斯分校规则，但我们证明，与原始研究相比，使用更严格的“头痛”和“呕吐”定义以及不同的表述可能会产生意外或负面后果。我们强调在使用决策工具时仔细关注临床预测因素精确定义的重要性。
