Myint K S, French S, Williams-Johnson J, Williams E, Johnson P, Reid M O, Gordon-Strachan G
Department of Emergency Medicine, Faculty of Medical Sciences, The University of the West Indies, Kingston 7, Jamaica.
West Indian Med J. 2012 Jan;61(1):64-72.
The study sought to assess the test performance characteristics of clinical judgement in the evaluation of stable blunt chest trauma patients compared with chest radiography (CXR) in the determination of significant intra-thoracic injury.
We prospectively enrolled all adult patients (older than 16years) who were considered to have stable blunt chest trauma over a six-month period (May 1-October 31, 2009). We defined the latter as patients who were unintubated, normotensive (systolic blood pressure > 90 mm Hg) and without hypoxia (oxygen saturation> 95% at room air). Patients eligible for the study were sent for anteroposterior (AP) CXRs which were then interpreted by the same consultant radiologist throughout the study period. Both test (clinical judgement) and disease status (CXR) were assigned and correlated as binary measures. We compared the test performance characteristics such as sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV) and diagnostic likelihood ratios of clinical judgement to CXR findings in the determination of significant intra-thoracic injury.
During the six-month period, data were collected from 77 eligible stable blunt chest trauma patients (age over 16 years). Fifty-nine patients (76.6%) were male. Nine patients (11.7%) were radiologically confirmed to have significant blunt chest injuries including rib fractures, pneumothorax and an isolated case of pulmonary contusion. All nine (11.7%) patients had a positive (abnormal) radiograph for rib fractures. In addition, three (3.9%) of them also had both rib fracture and pneumothoraces and one (1.3%) had both a rib fracture and pulmonary contusion. Clinical judgementfor the diagnosis of significant blunt chest injuries matched with the CXR finding with 95% confidence intervals (CIs): sensitivity 100% (95% CI 66.4, 100), specificity 32.4% (95% CI 21.5, 44.8), prevalence 11.7%, PPV 16.4% (95% CI 7.77, 28.8), NPV100% (95% CI 84.6, 100), DLR+ 1.48 (95% CI 1.25, 1.74).
The majority ofpatients who sustained blunt chest injuries and were assessed as stable patients do not require CXR routinely. This study revealed that physicians in the local Emergency Department may be over-utilizing CXRfor patients who have stable blunt chest trauma.
本研究旨在评估在评估稳定型钝性胸部创伤患者时，临床判断相对于胸部X线摄影（CXR）在确定严重胸内损伤方面的检测性能特征。
我们前瞻性纳入了在六个月期间（2009年5月1日至10月31日）所有被认为患有稳定型钝性胸部创伤的成年患者（年龄大于16岁）。我们将后者定义为未插管、血压正常（收缩压>90 mmHg）且无缺氧（室内空气中氧饱和度>95%）的患者。符合研究条件的患者被送去进行前后位（AP）胸部X线摄影，在整个研究期间由同一位放射科顾问医生进行解读。测试（临床判断）和疾病状态（胸部X线摄影）均作为二元指标进行赋值和关联。我们比较了在确定严重胸内损伤时，临床判断与胸部X线摄影结果的检测性能特征，如敏感性、特异性、阳性预测值（PPV）、阴性预测值（NPV）和诊断似然比。
在六个月期间，从77例符合条件的稳定型钝性胸部创伤患者（年龄大于16岁）中收集了数据。59例患者（76.6%）为男性。9例患者（11.7%）经放射学证实有严重钝性胸部损伤，包括肋骨骨折、气胸和1例孤立的肺挫伤。所有9例（11.7%）患者的肋骨骨折X线片呈阳性（异常）。此外，其中3例（3.9%）同时有肋骨骨折和气胸，1例（1.3%）同时有肋骨骨折和肺挫伤。临床判断对严重钝性胸部损伤的诊断与胸部X线摄影结果相符，95%置信区间（CIs）为：敏感性100%（95% CI 66.4，100），特异性32.4%（95% CI 21.5，44.8），患病率11.7%，PPV 16.4%（95% CI 7.77，28.8），NPV 100%（95% CI 84.6，100），DLR+ 1.48（95% CI 1.25，1.74）。
大多数遭受钝性胸部损伤且被评估为稳定型的患者无需常规进行胸部X线摄影。本研究表明，当地急诊科的医生可能对患有稳定型钝性胸部创伤的患者过度使用了胸部X线摄影。
