是否进行头部CT扫描：疑似蛛网膜下腔出血的临床困境；渥太华蛛网膜下腔出血规则的验证研究

To Head CT Scan or Not: The Clinical Quandary in Suspected Subarachnoid Hemorrhage; a Validation Study on Ottawa Subarachnoid Hemorrhage Rule.

作者信息

Pathan Abdul-Sajjad, Chakarova Eleonora, Tarique Aamir

机构信息

Department of Emergency Medicine, Luton and Dunstable NHS University Hospital Trust, Luton, UK.

出版信息

Adv J Emerg Med. 2018 Apr 1;2(3):e28. doi: 10.22114/AJEM.v0i0.73. eCollection 2018 Summer.

DOI:10.22114/AJEM.v0i0.73

PMID:31172091

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC6549203/

Abstract

INTRODUCTION

The Ottawa Subarachnoid Hemorrhage rule (OSR) is a clinical decision tool identified for ruling out subarachnoid hemorrhage (SAH) in those patient above 15 years of age who present to the emergency department (ED) with acute onset atraumatic headache.

OBJECTIVE

The primary objective of this study was to externally validate the OSR in a single national health service (NHS) setting in the UK and secondly, to compare it with our current practice without using a decision rule.

METHOD

A retrospective review of computerized medical records was done for all patients registered with headaches from January to December 2016. The data were manually charted on a data sheet from individual patient records. Patients fulfilling the preset inclusion and exclusion criteria as per the OSR were enrolled in the analysis. According to the OSR, if patient had any of the 6 criteria enlisted (age > 40 years, neck stiffness/pain, witnessed loss of consciousness, onset during exertion, thunderclap headache, limited neck flexion on examination), further diagnostic decision was required. All patients were followed up for 6 months on the computer system as it gets highlighted if the patient is represented again to the ED or is deceased.

RESULTS

A total of 737 ED visits with acute headache were reviewed for potential eligibility. Out of these, 649 were estimated to be eligible. On excluding 485 patients that could not meet the predetermined inclusion criteria and 19 patients as per the exclusion criteria, 145 (19.7%) patients were included in the analysis. There were 5 cases of SAH, yielding an incidence of 3.4 % (95% CI 1.3 % - 8.3 %). The sensitivity for SAH was 100% (95% CI, 46.3 % - 100 %); specificity of 44.2 % (95% CI, 36 % - 53 %); positive predictive value of 6.02 % (95% CI 2.2 % - 14.1 %); and negative predictive value of 100% (95% CI, 92.7 % - 100%).

CONCLUSION

Although being poorly specific, the OSR is a highly sensitive, simple tool for ruling out SAH in alert patients with a headache in ED settings.

摘要

引言

渥太华蛛网膜下腔出血规则（OSR）是一种临床决策工具，用于排除那些15岁以上因急性非创伤性头痛就诊于急诊科（ED）的患者的蛛网膜下腔出血（SAH）。

目的

本研究的主要目的是在英国单一的国民医疗服务体系（NHS）环境中对OSR进行外部验证，其次，将其与我们目前不使用决策规则的做法进行比较。

方法

对2016年1月至12月所有登记有头痛症状的患者的计算机化病历进行回顾性分析。数据从个体患者记录手动绘制到数据表上。符合OSR预设纳入和排除标准的患者纳入分析。根据OSR，如果患者有列出的6项标准中的任何一项（年龄>40岁、颈部僵硬/疼痛、目击意识丧失、用力时发作、霹雳样头痛、检查时颈部屈曲受限），则需要进一步的诊断决策。所有患者在计算机系统上随访6个月，因为如果患者再次到急诊科就诊或死亡，系统会突出显示。

结果

共审查了737次因急性头痛到急诊科就诊的病例以确定其潜在适用性。其中，估计有649例符合条件。排除485例不符合预定纳入标准的患者和19例符合排除标准的患者后，145例（19.7%）患者纳入分析。有5例SAH病例，发病率为3.4%（95%CI 1.3%-8.3%）。SAH的敏感性为100%（95%CI，46.3%-100%）；特异性为44.2%（95%CI，36%-53%）；阳性预测值为6.02%（95%CI 2.2%-14.1%）；阴性预测值为100%（95%CI，92.7%-100%）。