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Ottawa Knee Rules Adult Clinical Decision Rules for Trauma William D. Hampton, DO Emergency Physician 26 March 2015 Learning Objectives 1. Explain statistical sensitivity & specificity and apply that knowledge in the evaluation of clinical decision rules (CDRs). 2. Discuss the various adult trauma clinical decision rules and how they were derived. 3. Compare and contrast the CDRs for head injury, cervical spine injury, and lower extremity injuries in adult trauma patients. 4. Explain the importance of CDRs in triage, selective diagnostic testing, and dispositioning trauma patients. Disclosure Statement • Faculty/Presenters/Authors/Content Reviewers/Planners disclose no conflict of interest relative to this educational activity. Successful Completion • To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session. • Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation. On a busy shift at a local emergency department, you are placed in triage and presented with a variety of patients… Or you work at a teaching hospital, and are particularly concerned about patient safety come every July… Or you work as a Nurse Practitioner at a critical access ED, and want to refine your telemedicine trauma referrals… Or you would simply like to become more comfortable in assessing and caring for critically injured patients… Statistical Definitions Definitions Imagine a study evaluating a new test that screens people for a disease. Each person taking the test either has or does not have the disease. The test can be positive (predicting that the person has the disease) or negative (predicting that the person does not have the disease). The test results for each subject may or may not match the subject's actual status. http://en.wikipedia.org/wiki/Sensitivity_and_specificity. Accessed last 9/5/2013. Definitions True positive Sick people correctly diagnosed as sick False positive Healthy people incorrectly identified as sick True negative Healthy people correctly identified as healthy False negative Sick people incorrectly identified as healthy http://en.wikipedia.org/wiki/Sensitivity_and_specificity. Accessed last 9/5/2013. Definitions In general Positive = identified Negative = rejected True positive = correctly identified False positive = incorrectly identified True negative = correctly rejected False negative = incorrectly rejected http://en.wikipedia.org/wiki/Sensitivity_and_specificity. Accessed last 9/5/2013. Sensitivity & Specificity Snout Spin Sensitivity Imagine that everyone in the audience came down with URI sx, and someone suggested that it might be Legionnaires’ Dz. You all have symptoms, but you want to know for certain you don’t have Legionnaire’s! A highly sensitive test would definitely catch anyone that is positive (for Legionnaires’ Dz). So if they’re not positive, you can be sure that they are negative. Negative results in a high sensitivity test are used to rule-out the disease. Snout – “Sensitivity rules it out” Specificity Imagine that everyone in the audience felt well, but you were told that you had been exposed to the SARS Virus. The CDC is offering treatment to everyone…but it will cost you $10,000. You would like to be certain that you actually have SARS before spending $10,000 on treatment! A highly specific test would definitively show everyone that is negative for the disease. So if you test positive (for SARS), you can be sure that you are not mistakenly positive! A positive result from a test with high specificity means a high probability of the presence of disease. Spin – “Specificity rules it in” Giddy-up Case #1 – 65-y/o ♂ fell off ladder CC: 65-y/o ♂ presents to UC after falling off stepladder 3 hours ago. Lost balance while fixing the roof. Admits “head pain” at site of impact. Denies vomiting, syncope, or other injuries. PE: Normal vitals. Small bruise noted above left eye. Prefers eyes closed throughout exam. Case #2 – 24-y/o ♀ slip & fall by pool CC: 24-y/o ♀ presents after slip and fall on pool deck last night. Friend attributes fall to “the wine.” Admits headache and one episode of vomiting after fall. Denies any other injuries. PE: Normal vitals. Tender hematoma noted above left ear. Left hemotympanum. GCS is 15. Cases #1 & 2 Which of these patients needs a CT Head? 65-y/o ♂ 24-y/o ♀ Neither Both New Orleans Criteria Computed tomography is required for patients with minor head injury with any one of the following findings. The criteria apply only to patients who also have a Glasgow Coma Scale score of 15. 1. Headache 2. Vomiting 3. Older than 60 years 4. Drug or alcohol intoxication 5. Persistent anterograde amnesia (deficits in short-term memory) 6. Visible trauma above the clavicle 7. Seizure Adults (> 16 years) with minor head injury. 5 Criteria for High-Risk for Neurologic Injury 2 Criteria for Medium Risk for Neurologic Injury Rule does not apply if any of the following: • Non-trauma case • GCS < 13 • Age < 16 years • Coumadin or bleeding d/o • Obvious open skull fx New Orleans Criteria Computed tomography is required for patients with minor head injury with any one of the following findings. The criteria apply only to patients who also have a Glasgow Coma Scale score of 15. 1. Headache 2. Vomiting 3. Older than 60 years 4. Drug or alcohol intoxication 5. Persistent anterograde amnesia (deficits in short-term memory) 6. Visible trauma above the clavicle 7. Seizure Canadian CT Head Rules Computed tomography is required for adults > 16 years with minor head injury (a history of a GCS score of 13 to 15 with witnessed LOC, amnesia, or confusion) and any one of the following findings: 1. Glasgow Coma Scale score < 15 at 2 hours after injury 2. Suspected open or depressed skull fracture 3. Any sign of basilar skull fracture CCHR 4. Two or more episodes of vomiting 5. 65 years or older 6. Amnesia before impact of 30 or more minutes 7. Dangerous mechanism Originally published in 2001 in The Lancet. Prospective cohort study in 10 large Canadian hospital EDs. n = 3,121 (consecutive adults) from 1996 to 1999 who presented with a GCS score of 13–15 after head injury. 2,078 (67%) patients underwent CT Scan to look for clinically important injury on CT; remainder had 14-day telephone F/U. Stiell IG, Wells GA, Vandemheen, K., et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357: 1391-1396. Canadian CT Head Rules Computed tomography is required for adults > 16 years with minor head injury (a history of a GCS score of 13 to 15 with witnessed LOC, amnesia, or confusion) and any one of the following findings: 1. Glasgow Coma Scale score < 15 at 2 hours after injury 2. Suspected open or depressed skull fracture 3. Any sign of basilar skull fracture CCHR 4. Two or more episodes of vomiting 5. 65 years or older 6. Amnesia before impact of 30 or more minutes 7. Dangerous mechanism 44 (1%) required neurological intervention. 254 (8%) patients were judged to have clinically important brain injury. 94 (4%) patients were judged to have clinically unimportant lesions— mainly localized SAH or isolated contusions < 5 mm in diameter. Stiell IG, Wells GA, Vandemheen, K., et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357: 1391-1396. Canadian CT Head Rules Computed tomography is required for adults > 16 years with minor head injury (a history of a GCS score of 13 to 15 with witnessed LOC, amnesia, or confusion) and any one of the following findings: 1. Glasgow Coma Scale score < 15 at 2 hours after injury 2. Suspected open or depressed skull fracture 3. Any sign of basilar skull fracture CCHR 4. Two or more episodes of vomiting 5. 65 years or older 6. Amnesia before impact of 30 or more minutes 7. Dangerous mechanism Results: The high-risk factors were 100% sensitive for predicting need for neurological intervention and would require only 32% of patients to undergo CT. The medium-risk factors were 98.4% sensitive and 49.6% specific for predicting clinically important brain injury, and would require only 54% of patients to undergo CT. Stiell IG, Wells GA, Vandemheen, K., et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001;357: 1391-1396. New Orleans Criteria Computed tomography is required for patients with minor head injury with any one of the following findings. The criteria apply only to patients who also have a GCS score of 15. NOC 1. Headache 2. Vomiting 3. Older than 60 years Originally published in 4. Drug or alcohol intoxication 5. Persistent anterograde amnesia (deficits in short-term memory) 2000 in NEJM. 6. Visible trauma above the clavicle 7. Seizure Single center study at a large, inner-city, level 1 trauma center from 1997 to 1999. Recursive Partitioning Analysis - Phase I: n = 520 consecutive patients (ages 3 – 97 years, mean age 36) with a GCS score 15 after minor head injury. Prosective Validation - Phase II: n = 909 consecutive patients (ages 3 – 94 years, mean age 36) with a GCS score 15 after minor head injury. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux PMC. Indications for computed tomography in patients with minor head injury. New England Journal of Medicine. 2000; 343: 100-105. New Orleans Criteria Computed tomography is required for patients with minor head injury with any one of the following findings. The criteria apply only to patients who also have a GCS score of 15. NOC 1. Headache 2. Vomiting 3. Older than 60 years 4. Drug or alcohol intoxication 5. Persistent anterograde amnesia (deficits in short-term memory) 6.
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