Prediction of blunt traumatic injury in high-acuity patients: bedside examination vs computed tomography

OBJECTIVE

The addition of spiral computed tomography (SCT) to bedside assessment in patients with major trauma may improve detection of significant injury. We hypothesized that in high-acuity trauma patients, emergency physicians' ability to detect significant injuries based solely on bedside assessment would lack the sensitivity needed to exclude serious injuries when compared with SCT.

METHODS

This was a prospective single-cohort study of high-acuity trauma patients routinely undergoing whole-body SCT at a level 1 trauma center from January to September 2006. Before SCT, emergency physicians assigned ratings for likelihood of injury to 5 body regions on the basis of bedside assessment. These ratings were compared with final SCT interpretations.

RESULTS

We enrolled 400 patients as a convenience sample; 71 were excluded. When a "very low" rating was considered negative and "low," "intermediate," "high," and "very high" were considered positive, emergency physicians were able to detect head, cervical spine, chest, abdominal/pelvic, and thoracic/lumbar spine injuries with sensitivities (95% confidence interval) of 100% (98.6%-100%), 97.4% (94.9%-98.8%), 96.9% (94.2%-98.4%), 97.9% (95.5%-99.1%), and 97.0% (94.3%-98.5%), respectively. For overall diagnostic accuracy, areas under the receiver operating characteristics curve (95% confidence interval) were 0.87 (0.82-0.92), 0.71 (0.62-0.81), 0.81 (0.76-0.86), 0.77(0.71-0.83), 0.74 (0.65-0.84), respectively.

CONCLUSIONS

Bedside assessment by emergency physicians before SCT was sensitive in ruling out serious injuries in high-acuity trauma patients with a "very low" rating for injury. However, overall diagnostic accuracy was low, suggesting that SCT should be considered in most high-acuity patients to prevent missing injuries.