A clinical decision rule for cranial computed tomography in minor pediatric head trauma
A clinical decision rule for cranial computed tomography in minor pediatric head trauma
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DOI：
10.1001/archpedi.162.5.439
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发表时间：
2008-05-01
影响因子：
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通讯作者：
Chamberlain, James M.
中科院分区：
文献类型：
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作者：
Atabaki, Shireen M.;Stiell, Ian G.;Chamberlain, James M.
目的：为了开发一种敏感的临床决策规则，具有较高的阴性预测值，用于在小儿轻微头部创伤中使用颅骨计算机断层扫描（CT），以识别预测神经外科干预的临床特征，并评估临床医生的预测能力，仅根据病史和体格检查确定是否存在颅内损伤。设计：前瞻性观察研究。四个一级儿科创伤中心。参与者：1000名年龄小于21岁的轻微头部创伤患者接受头颅CT检查。主要结果测量：CT和神经外科干预证实的颅内损伤。结果：在研究的1000名患者中，平均年龄为8.9岁，64.1%为男性; 6.5%（65/1000）的患者在CT上有阳性结果，其中9.2%（6/65）需要神经外科干预。递归划分确定了决策规则中的以下变量：头晕、颅骨缺损、感觉缺陷、精神状态改变、自行车相关损伤、年龄小于2岁、格拉斯哥昏迷量表评分小于15分以及基底部颅骨骨折的证据。对于颅内损伤的检测，决策规则的敏感性为95.4%（95%置信区间[CI]，86.2%-98.8%），特异性为48.9%（95% CI，46.6%-52.1%），阴性预测值为99.3%结论：我们开发了一种敏感的临床决策规则，具有高NPV，用于检测小儿轻微头部创伤中的颅内损伤。如果得到验证，该规则可以通过减少实践中的变化和不必要的头颅CT来为医生的临床评估提供有用的辅助。
Objectives: To develop a sensitive clinical decision rule with a high negative predictive value for the use of cranial computed tomography (CT) in minor pediatric head trauma, to identify clinical features predictive of neurosurgical intervention, and to assess clinicians' predictive abilities to determine the presence or absence of intracranial injury based on history and physical examination alone.Design: Prospective observational study.Setting: Four level I pediatric trauma centers.Participants: One thousand patients younger than 21 years with minor head trauma undergoing cranial CT.Main Outcome Measure: Intracranial injury as demonstrated by CT and neurosurgical intervention.Results: Of 1000 patients in the study, the mean age was 8.9 years, and 64.1% were male; 6.5% (65 of 1000) had positive findings on CT, and 9.2% (6 of 65) of these required neurosurgical intervention. Recursive partitioning identified the following variables in the decision rule: dizziness, skull defect, sensory deficit, mental status change, bicycle-related injury, age younger than 2 years, Glasgow Coma Scale score less than 15, and evidence of a basilar skull fracture. For detection of intracranial injury, the decision rule had a sensitivity of 95.4% (95% confidence interval [CI], 86.2%-98.8%), a specificity of 48.9% (95% CI, 46.6%-52.1%), and a negative predictive value of 99.3% (95% CI, 98.1%-99.8%).Conclusions: We developed a sensitive clinical decision rule with a high NPV for detection of intracranial injury in minor pediatric head trauma. If validated, this rule could provide a useful adjunct to the physician's clinical assessment by reducing variations in practice and unnecessary cranial CT.