Prehosp Emerg Care. 2020 Jan-Feb;24(1):8-14. doi: 10.1080/10903127.2019.1597954. Epub 2019 Apr 23.
To evaluate the accuracy of emergency medical services (EMS) provider judgment for traumatic intracranial hemorrhage (tICH) in older patients following head trauma in the field. We also compared EMS provider judgment with other sets of field triage criteria. This was a prospective observational cohort study conducted with five EMS agencies and 11 hospitals in Northern California. Patients 55 years and older who experienced blunt head trauma were transported by EMS between August 1, 2015 and September 30, 2016, and received an initial cranial computed tomography (CT) imaging, were eligible. EMS providers were asked, "What is your suspicion for the patient having intracranial hemorrhage (bleeding in the brain)?" Responses were recorded as ordinal categories (<1%, 1-5%, >5-10%, >10-50%, or >50%) and the incidences of tICH were recorded for each category. The accuracy of EMS provider judgment was compared to other sets of triage criteria, including current field triage criteria, current field triage criteria plus multivariate logistical regression risk factors, and actual transport. Among the 673 patients enrolled, 319 (47.0%) were male and the median age was 75 years (interquartile range 64-85). Seventy-six (11.3%) patients had tICH on initial cranial CT imaging. The increase in EMS provider judgment correlated with an increase in the incidence of tICH. EMS provider judgment had a sensitivity of 77.6% (95% CI 67.1-85.5%) and a specificity of 41.5% (37.7-45.5%) when using a threshold of 1% or higher suspicion for tICH. Current field triage criteria (Steps 1-3) was poorly sensitive (26.3%, 95% CI 17.7-37.2%) in identifying tICH and current field trial criteria plus multivariate logistical regression risk factors was sensitive (97.4%, 95% CI 90.9-99.3%) but poorly specific (12.9%, 95% CI 10.4-15.8%). Actual transport was comparable to EMS provider judgment (sensitivity 71.1%, 95% CI 60.0-80.0%; specificity 35.3%, 95% CI 31.6-38.3%). As EMS provider judgment for tICH increased, the incidence for tICH also increased. EMS provider judgment, using a threshold of 1% or higher suspicion for tICH, was more accurate than current field triage criteria, with and without additional risk factors included.
评估在头外伤后现场对老年创伤性颅内出血（tICH）的急救医疗服务（EMS）提供者的判断准确性。我们还比较了 EMS 提供者的判断与其他几套现场分诊标准。 这是一项前瞻性观察队列研究，涉及北加利福尼亚州的五个 EMS 机构和 11 家医院。2015 年 8 月 1 日至 2016 年 9 月 30 日期间，年龄在 55 岁及以上经历过钝性头部外伤的患者通过 EMS 进行了转运，且他们接受了初始颅脑 CT（计算机断层扫描）成像，符合条件。我们询问 EMS 提供者：“您对患者颅内出血（脑内出血）的怀疑程度如何？”将回答记录为分类类别（<1%、1-5%、>5-10%、>10-50%或>50%），并记录每个类别的 tICH 发生率。将 EMS 提供者的判断准确性与其他几套分诊标准进行了比较，包括当前现场分诊标准、当前现场分诊标准加多变量逻辑回归风险因素，以及实际转运。 在纳入的 673 名患者中，319 名（47.0%）为男性，中位年龄为 75 岁（四分位距 64-85）。76 名（11.3%）患者在初始颅脑 CT 成像上有 tICH。EMS 提供者判断的增加与 tICH 发生率的增加相关。当使用 1%或更高的 tICH 怀疑阈值时，EMS 提供者判断的敏感性为 77.6%（95%置信区间 67.1-85.5%），特异性为 41.5%（37.7-45.5%）。当前现场分诊标准（步骤 1-3）在识别 tICH 方面的敏感性较差（26.3%，95%置信区间 17.7-37.2%），而当前现场试验标准加多变量逻辑回归风险因素的敏感性较高（97.4%，95%置信区间 90.9-99.3%），但特异性较差（12.9%，95%置信区间 10.4-15.8%）。实际转运与 EMS 提供者判断相当（敏感性 71.1%，95%置信区间 60.0-80.0%；特异性 35.3%，95%置信区间 31.6-38.3%）。随着 EMS 提供者对 tICH 的判断增加，tICH 的发生率也随之增加。EMS 提供者判断，使用 1%或更高的 tICH 怀疑阈值，比当前的现场分诊标准更准确，包括和不包括额外的风险因素。
Prehosp Emerg Care. 2019-4-23
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