Department of Emergency Medicine, Lewis Katz School of Medicine at Temple University, 1314 West Ontario Street, Jones Hall, 10(th) Floor, Philadelphia, PA 19130, United States of America.
Am J Emerg Med. 2022 Apr;54:326.e5-326.e8. doi: 10.1016/j.ajem.2021.10.024. Epub 2021 Oct 25.
Given the many causes of seizures, emergency physicians often utilize brain computed tomography (CT) to evaluate for intracranial pathology. Previously, we have validated the LIMIT (Let's Image Malignancy, Intracranial Hemorrhage, and Trauma) clinical decision instrument (CDI) study to determine which patients with recurrent seizures require emergent neuroimaging. The LIMIT CDI had a negative predictive value (NPV) of 99.9%. Here, we seek to compare the LIMIT CDI to unstructured physician judgement.
This was an observational study of patients who presented with a complaint of seizure. A research assistant reviewed the electronic medical record (EMR) for each patient and applied the LIMIT CDI. Brain CT was used as a proxy for physician judgement. If no brain CT was ordered and the patient was discharged from the emergency department (ED), the EMR was searched to determine whether patient had any medical visits within one year of the index visit. If the patient had no new neurological findings on follow up or abnormalities on follow up neuroimaging, this was considered a patient who did not require a brain CT in the ED. Patients who did not have a CT on their ED visit and had no follow up visits were excluded.
1739 patients were screened and 1108 patients were in the final analysis. 24 patients who did not have a brain CT and no follow up visits were excluded. 10 patients (0.9%) had positive CTs. 9/10 of the patients were identified by the CDI resulting in a sensitivity of 90%, specificity of 81.1% and a negative predictive value (NPV) of 99.9%, and a negative likelihood ratio (LR) of 0.12. Clinician judgement identified all 10 patients with a positive brain CT for a sensitivity of 100%, specificity of 67.8%, and a NPV and negative LR of 100% and 0, respectively. Using unstructured clinical judgement, EPs ordered 364 brain CTs while only 217 brain CTs would have been ordered using the CDI, a reduction of 13.3%.
When compared to unstructured physician judgement, the LIMIT CDI would have reduced brain CT usage by more than 13%. Although the LIMIT CDI needs to be validated in a larger set of patients, it performed better than unstructured physician judgement for evaluating need for emergent neuroimaging after recurrent seizures.
鉴于癫痫发作的多种原因，急诊医师常利用脑计算机断层扫描（CT）评估颅内病变。此前，我们已经验证了 LIMIT（让我们识别恶性肿瘤、颅内出血和创伤）临床决策工具（CDI）研究，以确定哪些复发性癫痫患者需要紧急神经影像学检查。LIMIT CDI 的阴性预测值（NPV）为 99.9%。在此，我们旨在比较 LIMIT CDI 与非结构化医生判断。
这是一项关于以癫痫发作就诊的患者的观察性研究。一名研究助理查阅了每位患者的电子病历（EMR），并应用了 LIMIT CDI。脑 CT 作为医生判断的替代指标。如果未开脑 CT 且患者从急诊部（ED）出院，则在 EMR 中搜索以确定患者在索引就诊后的一年内是否有任何就诊。如果患者在随访中没有新的神经学发现或随访神经影像学异常，则认为该患者在 ED 不需要进行脑 CT。未在 ED 就诊时进行 CT 检查且无随访就诊的患者被排除。
共筛选了 1739 例患者，最终有 1108 例患者纳入分析。排除了 24 例未行脑 CT 检查且无随访就诊的患者。10 例（0.9%）患者 CT 阳性。CDI 识别出 9/10 例阳性 CT 患者，其敏感性为 90%，特异性为 81.1%，阴性预测值（NPV）为 99.9%，阴性似然比（LR）为 0.12。临床判断确定了所有 10 例阳性脑 CT 患者，敏感性为 100%，特异性为 67.8%，NPV 和阴性 LR 分别为 100%和 0。使用非结构化临床判断，EP 开出了 364 例脑 CT 检查，而使用 CDI 仅开出 217 例脑 CT 检查，减少了 13.3%。
与非结构化医生判断相比，LIMIT CDI 将减少超过 13%的脑 CT 检查。尽管 LIMIT CDI 需要在更大的患者群体中进行验证，但它在评估复发性癫痫后是否需要紧急神经影像学检查方面的表现优于非结构化医生判断。
