UCLA Department of Emergency Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, CA.
Antelope Valley Hospital Emergency Department, Lancaster, CA.
Acad Emerg Med. 2018 Jul;25(7):729-737. doi: 10.1111/acem.13431. Epub 2018 Jun 8.
Data suggest that clinicians, when evaluating pediatric patients with blunt head trauma, may be overordering head computed tomography (CT). Prior decision instruments (DIs) aimed at aiding clinicians in safely forgoing CTs may be paradoxically increasing CT utilization. This study evaluated a novel DI that aims for high sensitivity while also improving specificity over prior instruments.
We conducted a planned secondary analysis of the NEXUS Head CT DI among patients less than 18 years old. The rule required patients satisfy seven criteria to achieve "low-risk" classification. Patients were assigned "high-risk" status if they fail to meet one or more criteria. Our primary outcome was the ability of the rule to identify all patients requiring neurosurgical intervention.
The study enrolled 1,018 blunt head injury pediatric patients. The DI assigned high-risk status to 27 of 27 patients requiring neurosurgical intervention (sensitivity = 100.0%, 95% confidence interval [CI] = 87.2%-100%]). The instrument assigned low-risk status to 330 of 991 patients who did not require neurosurgical intervention (specificity = 33.3%, 95% CI = 30.3%-36.3%). None of the 991 low-risk patients required neurosurgical intervention (negative predictive value [NPV] = 100%, 95% CI = 99.6%-100%). The DI correctly assigned high-risk status to 48 of the 49 patients with significant intracranial injuries, yielding a sensitivity of 98.0% (95% CI = 89.1%-99.9%). The instrument assigned low-risk status to 329 of 969 patients who did not have significant injuries to yield a specificity of 34.0% (95% CI = 31.0%-37.0%). Significant injuries were absent in 329 of the 330 patients assigned low-risk status to yield a NPV of 99.7% (95% CI = 98.3%-100%).
The Pediatric NEXUS Head CT DI reliably identifies blunt trauma patients who require head CT imaging and could significantly reduce the use of CT imaging.
数据表明，临床医生在评估患有钝性头部创伤的儿科患者时，可能会过度进行头部计算机断层扫描（CT）检查。旨在帮助临床医生安全避免 CT 检查的先前决策工具（DI）可能会适得其反，增加 CT 的使用。本研究评估了一种旨在提高敏感性的新型 DI，同时也提高了与先前工具相比的特异性。
我们对小于 18 岁的 NEXUS 头部 CT DI 患者进行了计划的二次分析。该规则要求患者满足七个标准才能达到“低风险”分类。如果患者未能满足一个或多个标准，则被分配为“高风险”状态。我们的主要结果是该规则识别所有需要神经外科干预的患者的能力。
该研究共纳入 1018 例钝性头部损伤儿科患者。该规则将 27 例需要神经外科干预的患者分配为高风险状态（敏感性为 100.0%，95%置信区间[CI]为 87.2%-100%）。该仪器将 991 例不需要神经外科干预的患者分配为低风险状态（特异性为 33.3%，95%CI为 30.3%-36.3%）。991 例低风险患者中无一例需要神经外科干预（阴性预测值[NPV]为 100%，95%CI为 99.6%-100%）。该 DI 正确地将高风险状态分配给 49 例有明显颅内损伤的患者中的 48 例，敏感性为 98.0%（95%CI为 89.1%-99.9%）。该仪器将 969 例无明显损伤的患者分配为低风险状态，特异性为 34.0%（95%CI为 31.0%-37.0%）。329 例低风险状态的患者中没有明显的损伤，NPV 为 99.7%（95%CI为 98.3%-100%）。
儿科 NEXUS 头部 CT DI 可可靠地识别需要头部 CT 成像的钝性创伤患者，并可显著减少 CT 成像的使用。
