Escolar Documentos
Profissional Documentos
Cultura Documentos
EM Advances
RESUME
From the *Division of Emergency Medicine, 3Department of Surgery, 4McMaster Hospital, and 1McMaster University Medical School, McMaster
University, Hamilton, ON.
The abstract was presented at the Canadian Association of Emergency Physicians conference in Montreal, QC, in June 2010.
Correspondence to: Dr. Julien Payrastre, C/O Abbotsford Regional Hospital and Cancer Centre, 32900 Marshall Road, Abbotsford, BC V2S 0C2;
Payrastre@gmail.com.
This article has been peer reviewed.
Canadian Association of Emergency Physicians
344
2012;14(6)
CJEM 2012;14(6):344-353
CJEM N JCMU
DOI 10.2310/8000.2012.120738
SCRAP chest CT
Patient population
METHODS
Study design
This study was a retrospective medical record review of
trauma patients at a single trauma centre in southern
Ontario from 2005 to 2008. The study was designed to
derive and validate a clinical decision rule that
identified patients at low risk for major thoracic injury.
Ethics
This study was approved by the Research Ethics Board
at Hamilton Health Sciences.
CJEM N JCMU
2012;14(6)
345
SCRAP chest CT
Patient population
METHODS
Study design
This study was a retrospective medical record review of
trauma patients at a single trauma centre in southern
Ontario from 2005 to 2008. The study was designed to
derive and validate a clinical decision rule that
identified patients at low risk for major thoracic injury.
Ethics
This study was approved by the Research Ethics Board
at Hamilton Health Sciences.
CJEM N JCMU
2012;14(6)
345
Payrastre et al
Data collection
Three data collectors (L.S., R.C., and H.P.) independently abstracted the study variable data for all
included trauma patients seen during the study period.
These clinical variables were derived from published
studies and local expert opinion. The data were
abstracted from the patients electronic records and
entered onto a study-specific data abstraction form. As
there were multiple sources of data in the patient
charts, a priori we established the hierarchy of data
sources. The trauma staff or fellows dictated note was
the primary source of information as this was the
physician making the decision whether to obtain a
chest CT scan. If this was unavailable or incomplete,
the abstractors were to refer to notes from other
physicians who participated in the trauma resuscitation
and then the nursing notes.
Although the data abstractors were not blinded to
the study objectives, they had no knowledge of which
variables were likely to be included in the final rule.
The abstractors were not blinded to patient outcomes
or CT results as these are generally included in the
trauma chart and admission note. The variables
collected included age, sex, mechanism, extraction
time, seat belt use, air bag deployment, patient
ejection from vehicle, heart rate at the time of
assessment, respiratory rate, oxygen saturation, supplemental oxygen use, systolic blood pressure, abnormal auscultation of the chest, abnormal findings on
thoracic palpation (anteriorly or posteriorly), acute
abnormalities on a chest radiograph, findings on a
chest CT scan, GCS score at arrival, intubation on
arrival, intubation after initial assessment, tube
thoracostomy insertion (initial or delayed), specific
thoracic injuries diagnosed, length of stay in hospital,
ISS, ICD-9 data, and patient identification number.
We calculated interrater reliability between the data
abstractors using a percent agreement score for each
of the clinical variables on the first 91 charts (10% of
total charts). Disagreements between the abstractors
were resolved by consensus or adjudication by the
principal investigator (J.P.).
Outcome measures
The primary outcome measure was the presence of a
major thoracic injury noted on a CT scan, at discharge,
or at clinic follow-up. We defined a major thoracic
346
2012;14(6)
CJEM N JCMU
SCRAP chest CT
Patient characteristics
A total of 614 patients (434 in the derivation and 180 in
the validation) were included in this study (Figure 1).
CJEM N JCMU
2012;14(6)
347
Payrastre et al
Derivation (n 5 434)
Validation (n 5 180)
43 (1695)
Median 5 44
72.3
43 (1687)
Median 5 44
70.5
52.3
9.4
2.8
5.1
22.1
1.4
6.9
22 (1359)
274/434 (63.1)
70/434 (16)
160/434 (36.9)
49.4
7.8
3.3
8.3
22.2
0.6
8.3
23 (1550)
104/180 (57.8)
33/180 (18.3)
76/180 (42.2)
tenderness; this may have been a product of underreporting in this retrospective review. We conducted a
post hoc sensitivity analysis with the assumption that
patients who had rib fractures would have been positive
for tenderness on palpation. Using recursive partitioning, the same five variables were found to predict major
thoracic injury with the following characteristics for
predicting major thoracic injury: sensitivity 100%
(95% CI 98.4100), specificity 35.7% (95% CI 32.9
35.7), and LR 0.00 (95% CI 0.000.05). Again, no
causes of major thoracic injury were missed, but
including these patients as SCRAP positive yielded
an 11% absolute reduction in CT scans.
The test characteristics of the SCRAP rule for the
sole outcome of blunt aortic traumatic injury in the
derivation group was sensitivity 100% (95% CI 66.2
100), specificity 17.7% (95% CI 16.917.7), and LR
0.00 (95% CI 0.002.00).
To compare an alternative method to recursive
partitioning for creating the rule, forward stepwise
logistic regression analysis yielded a four-variable
model from the derivation group (abnormal chest
radiograph, respiratory rate . 20 breaths/min, abnormal auscultation, and abnormal palpation), with a
sensitivity of 98% (95% CI 9699) and a specificity of
45% (95% CI 3952).
Sensitivity analysis
DISCUSSION
Validation set
348
2012;14(6)
CJEM N JCMU
SCRAP chest CT
Table 2. Odds ratios for major thoracic injury in derivation group (95% CI)
Unadjusted
(univariate)
odds ratio, p
Three-person
% agreement
Clinical variable
SCRAP variables
SpO2 , 95% on room air or , 98% on supplement oxygen (n 5 81)
Abnormal chest radiograph (n 5 165)
RR . 24 (n 5 69)
Abnormal chest auscultation (n 5 154)
Abnormal thorax palpation anteriorly or posteriorly (n 5 201)
Variables not included in SCRAP
Age $ 55 yr (n 5 140)
Age $ 60 yr (n 5 110)
Age $ 65 yr (n 5 76)
Age $ 70 yr (n 5 57)
Age $ 80 (n 5 28)
Male sex (n 5 314)
Mechanism
MVC (n 5 227)
Motorcycle (n 5 41)
Pedestrian (n 5 22)
Bicycle (n 5 12)
Blunt assault (n 5 6)
Fall (n 5 96)
MVC
Ejected (n 5 24)
Air bag deployed (n 5 46)
Seat belt used (n 5 140)
Extrication . 5 min (n 5 70)
Oxygen saturation
, 98% (n 5 117)
, 95% (n 5 51)
Heart rate (beats/min)
$ 100 (n 5 144)
$ 110 (n 5 91)
Respiratory rate (breaths/min)
$ 21 (n 5 169)
$ 30 (n 5 27)
Systolic BP (mm Hg)
, 110 (n 5 64)
, 100 (n 5 35)
, 90 (n 5 17)
GCS score
913 (n 5 60)
. 13 (n 5 374)
(0.822.39), 0.25
(6.1018.58), , 0.0001
(1.073.40), 0.04
(2.307.86), , 0.0001
(2.686.29), , .0001
Significance in
RP
model, p
84.7
97.8
90.0
86.6
76.6
1.37
10.65
1.91
4.85
4.11
, 0.001
, 0.001
, 0.001
0.001
, 0.001
100
100
100
100
100
100
1.06
1.10
0.99
0.70
0.51
0.84
(0.701.60),
(0.701.72),
(0.601.65),
(0.401.22),
(0.241.10),
(0.541.30),
0.89
0.76
0.92
0.26
0.12
0.49
N/A
N/A
N/A
N/A
N/A
N/A
99.6
99.6
99.6
99.6
99.6
99.6
1.50
0.61
0.72
0.60
0.30
1.03
(1.022.21),
(0.321.17),
(0.311.70),
(0.191.91),
(0.061.66),
(0.641.64),
0.05
0.19
0.61
0.54
0.20
0.92
N/A
N/A
N/A
N/A
N/A
N/A
95.1
94.0
96.3
92.6
1.58
0.58
1.07
1.14
(0.604.16),
(0.301.13),
(0.611.89),
(0.632.09),
0.48
0.15
0.92
0.77
N/A
N/A
N/A
N/A
84.7
88.1
N/A
N/A
89.9
89.9
N/A
N/A
84.0
92.9
N/A
N/A
95.1
95.5
96.6
N/A
N/A
N/A
92.9
92.9
N/A
N/A
BP 5 blood pressure; GCS 5 Glasgow Coma Scale; MVC 5 motor vehicle collision; N/A 5 not available; RP 5 recursive partitioning; RR 5 respiratory rate; SCRAP 5 abnormal oxygen
saturation, chest radiograph, respiratory rate, chest auscultation, and thoracic palpation; SpO2 5 saturated oxygen.
CJEM N JCMU
2012;14(6)
349
Payrastre et al
Validation group
SCRAP
positive
(n 5 359)
SCRAP
negative
(n 5 34)
SCRAP
positive
(n 5 146)
Total
(N 5 614)
0
0
0
0
0
0
0
0
0
0
10
6
28
0
196
54
3
41
48
59
0
0
0
0
0
0
0
0
0
0
3
2
17
0
83
26
1
19
12
19
13
8
45
0
279
80
4
60
60
78
2
19
19
2
0
48
227
219
21
34
1
6
4
0
0
19
111
81
12
9
70
366
323
35
43
CT 5 computed tomography; SCRAP 5 abnormal oxygen saturation, chest radiograph, respiratory rate, chest auscultation and thoracic palpation.
2012;14(6)
CJEM N JCMU
SCRAP chest CT
SCRAP positive
SCRAP negative
Present
Absent
274
0
85
75
CJEM N JCMU
2012;14(6)
351
Payrastre et al
SCRAP positive
SCRAP negative
Present
Absent
104
0
42
34
2012;14(6)
REFERENCES
1. Brink M, Kool DR, Dekker HM, et al. Predictors of
abnormal CT chest after blunt trauma: a critical appraisal of
CJEM N JCMU
SCRAP chest CT
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16. Tillou A, Gupta M, Baraff L, et al. Is the use of pancomputed tomography for blunt trauma justified? A prospective evaluation. J Trauma 2009;67:779-87, doi:10.1097/
TA.0b013e3181b5f2eb.
17. Rodgriguez RM, Hendey GW, Marek G, et al. A pilot study
to derive clinical variables for the selective chest radiography
in blunt chest trauma patients. Ann Emerg Med 2006;47:4158, doi:10.1016/j.annemergmed.2005.10.001.
18. Ungar TC, Wolf SJ, Haukoos JS, et al. Derivation of a
clinical decision rule to exclude thoracic aortic imaging in
patients with blunt chest trauma after motor vehicle
collisions. J Trauma 2006;61:1150-5, doi:10.1097/01.ta.
0000239357.68782.30.
19. Deunk J, Dekker HM, Brink M, et al. The value of indicated
computed tomography scan of the chest and abdomen in
addition to the conventional radiologic work-up for blunt
trauma. J Trauma 2007;63:757-63, doi:10.1097/01.ta.
0000235878.42251.8d.
20. Ekeh AP, Perterson W, Woods RJ, et al. Is chest x-ray an
adequate screening tool for the diagnosis of blunt thoracic
aortic injury? J Trauma 2008;65:1088-92, doi:10.1097/
TA.0b013e31812f60bf.
21. Exadaktylos AK, Sclabas G, Schmid SW, et al. Do we really
need routine computed tomographic scanning in the primary
evaluation of blunt chest trauma in patients with normal
chest radiograph? J Trauma 2001;51:1173-6, doi:10.1097/
00005373-200112000-00025.
22. Livingston DH, Shogan B, John P, et al. CT diagnosis of rib
fractures and the prediction of acute respiratory failure. J
Trauma 2008;64:905-11, doi:10.1097/TA.0b013e3181668ad7.
23. Fosse JP, Cohen Y, Karoubi P, et al. Initial evaluation of
thoracic injuries. Comparison of pulmonary radiography and
x-ray computed tomography. Presse Med 1997;26:1232-5.
24. Berrington de Gonzales A, Kim KP, Berg CD. Low-dose
lung computed tomography screening before age 55:
estimates of the mortality reduction required to outweigh
the radiation-induced cancer risk. J Med Screen 2008;15:1538, doi:10.1258/jms.2008.008052.
25. Onzuka J, Worster A, McCreadie B. Is computerized
tomography of trauma patients associated with a transfer
delay to a regional trauma centre? CJEM 2008;10:205-8.
26. Tepel M, Aspelin P, Lameire N. Contrast-induced nephropathy. Circulation 2006;113:1799-806, doi:10.1161/CIRC
ULATIONAHA.105.595090.
27. Canadian Institute for Health Information. National Trauma
Registry 2011 report: Hospitalizations for Major Injury in Canada.
2008-2009 data. Available at: https://secure.cihi.ca/estore/
productFamily.htm?pf5PFC1600&lang5en&media50.
28. McGinn TG, Guyatt GH, Wyer PC, et al. Users guide to
the medical literature XXII: how to use articles about
clinical decision rules. JAMA 2000;284:79-84, doi:10.1001/
jama.284.1.79.
CJEM N JCMU
2012;14(6)
353