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The SCRAP rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma

Published online by Cambridge University Press:  11 May 2015

Julien Payrastre*
Affiliation:
Division of Emergency Medicine, McMaster University, Hamilton, ON
Suneel Upadhye
Affiliation:
Division of Emergency Medicine, McMaster University, Hamilton, ON
Andrew Worster
Affiliation:
Division of Emergency Medicine, McMaster University, Hamilton, ON
Daren Lin
Affiliation:
Division of Emergency Medicine, McMaster University, Hamilton, ON
Kamyar Kahnamoui
Affiliation:
Department of Surgery, McMaster University, Hamilton, ON
Heather Patterson
Affiliation:
McMaster Hospital, McMaster University, Hamilton, ON
Layli Sanaee
Affiliation:
McMaster University Medical School, McMaster University, Hamilton, ON
Rob Clayden
Affiliation:
McMaster University Medical School, McMaster University, Hamilton, ON
*
C/O Abbotsford Regional Hospital and Cancer Centre, 32900 Marshall Road, Abbotsford, BC V2S 0C2; Payrastre@gmail.com.

Abstract

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Objective:

To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans.

Methods:

Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score > 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score ≤ 8, paralysis, or age < 16 years were excluded.

Results:

There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4–100], specificity 46.9% [95% CI 44.2–46.9], and negative likelihood ratio 0.00 [95% CI 0.00–0.04]). The five variables were oxygen saturation (< 95% on room air or < 98% on any supplemental oxygen), chest radiograph, respiratory rate ≥ 25, chest auscultation, and thoracic palpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2–100%), a specificity of 44.7% (95% CI 39.5–44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00–0.10).

Conclusions:

In major blunt trauma with a GCS score > 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting.

Type
Original Research • Recherche originale
Copyright
Copyright © Canadian Association of Emergency Physicians 2012

References

REFERENCES

1.Brink, M, Kool, DR, Dekker, HM, et al. Predictors of abnormal CT chest after blunt trauma: a critical appraisal of the literature. Clin Radiol 2005;64:272–83, doi:10.1016/j.crad.2008.09.004.CrossRefGoogle Scholar
2.Brink, M, Deunk, J, Dekker, HM, et al. Criteria for the selective use of chest computed tomography in blunt trauma patients. Eur Radiol 2010;20:818–28, doi:10.1007/s00330-009-1608-y.CrossRefGoogle ScholarPubMed
3.Stiell, IG, Greenberg, GH, McKnight, RD, et al. Decision rules for the use of radiography in acute ankle injuries. Refinement and prospective validation. JAMA 1993;269:1127–32, doi:10.1001/jama.269.9.1127.Google Scholar
4.Stiell, IG, Clement, CM, Grimshaw, J, et al. Implementation of the Canadian C-Spine Rule: prospective 12 centre cluster randomised trial. BMJ 2009;339:b4146, doi:10.1136/bmj.b4146.CrossRefGoogle ScholarPubMed
5.Stiell, IG, Wells, GA, Vandemheen, K, et al. The Canadian CT head rule for patient with minor head trauma. Lancet 2001;357:1391–6, doi:10.1016/S0140-6736(00)04561-X.CrossRefGoogle Scholar
6.Traub, M, Stevenson, M, McEvoy, S, et al. The use of chest computed tomography versus chest x-ray in patients with major blunt trauma. Injury 2007;38:43–7, doi:10.1016/j.injury.2006.07.006.Google Scholar
7.Bokhari, F, Brakenridge, S, Nagy, K, et al. Prospective evaluation of the sensitivity of physical examination in chest trauma. J Trauma 2002;53:1135–8, doi:10.1097/00005373-200212000-00017.CrossRefGoogle ScholarPubMed
8.Marts, B, Durham, R, Shapiro, M, et al. Computed tomography in the diagnosis of blunt thoracic injury. Am J Surg 1994;168:688–92, doi:10.1016/S0002-9610(05)80146-1.CrossRefGoogle ScholarPubMed
9.Johnson, JA, Cogbill, TH, Winga, ER. Determinants of outcome after pulmonary contusion. J Trauma 1986;26 :695–7, doi:10.1097/00005373-198608000-00002.CrossRefGoogle ScholarPubMed
10.Kwon, A, Sorrells, DL, Kurkchubasche, AG, et al. Isolated computed tomography diagnosis of pulmonary contusion does not correlate with increased morbidity. J Pediatr Surg 2006;41:7882, doi:10.1016/j.jpedsurg.2005.10.009.CrossRefGoogle Scholar
11.Bradley, LH, Paullus, WC, Howe, J, et al. Isolated transverse process fracture: spine service management not needed. J Trauma 2008;65:832–6, doi:10.1097/TA.0b013e318184d30e.Google Scholar
12.Cook, EF, Goldman, L. Empiric comparison of multivariate nalytic techniques: advantages and disadvantages of recursive partitioning analysis. J Chron Dis 1984;37:721–31, doi:10.1016/0021-9681(84)90041-9.CrossRefGoogle ScholarPubMed
13.Stiell, IG, Wells, GA. Methodologic standards for the development of clinical decision rules in emergency medicine. Ann Emerg Med 1999;33:437–47, doi:10.1016/S0196-0644(99)70309-4.CrossRefGoogle ScholarPubMed
14.Holtzman, SR, Yucel, EK, Rybicki, FJ, et al. American College of Radiology Appropriateness Criteria – suspected aortic injury (2009). Available at: http://acsearch.acr.org/default.aspx (accessed June 16, 2010).Google Scholar
15.Salim, A, Sangthong, B, Martin, M, et al. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury. Arch Surg 2006;141:468–75, doi:10.1001/archsurg.141.5.468.CrossRefGoogle ScholarPubMed
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.Google Scholar
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;47:415–8, doi:10.1016/j.annemergmed.2005.10.001.Google Scholar
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.Google Scholar
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.Google Scholar
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.Google ScholarPubMed
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.Google Scholar
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.Google ScholarPubMed
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.Google ScholarPubMed
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;15:153–8, doi:10.1258/jms.2008.008052.CrossRefGoogle Scholar
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.CrossRefGoogle ScholarPubMed
26.Tepel, M, Aspelin, P, Lameire, N. Contrast-induced nephropathy. Circulation 2006;113:1799–806, doi:10.1161/CIRCULATIONAHA.105.595090.CrossRefGoogle ScholarPubMed
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?pf=PFC1600&lang=en&media=0.Google Scholar
28.McGinn, TG, Guyatt, GH, Wyer, PC, et al. User’s guide to the medical literature – XXII: how to use articles about clinical decision rules. JAMA 2000;284:7984, doi:10.1001/jama.284.1.79.CrossRefGoogle Scholar