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Scanning the aged to minimize missed injury: An Eastern Association for the Surgery of Trauma multicenter study
Vanessa P Ho1, Sami K Kishawi, Hannah Hill
1From the Department of Surgery (V.P.H., S.K.K., J.O., J.A.C.), MetroHealth Medical Center; Department of Surgery (S.K.K.), University Hospitals Cleveland Medical Center; Departments of Surgery (V.P.H.), and Population and Quantitative Health Sciences (V.P.H.), Case Western Reserve University School of Medicine; Biostatistics and Data Sciences Group (H.H.), Population Health and Equity Research Institute, MetroHealth Medical Center, Cleveland, Ohio; Department of Surgery (A.R., S.S.S., T.H.T.), Crozer-Chester Medical Center, Upland; Department of Surgery (C.A.B., A.M., B.F.D.), Reading Hospital, West Reading, Pennsylvania; Department of Surgery (G.A.B., P.P., T.B.S.P.), NYU Langone Hospital-Long Island, Mineola, New York; Department of Surgery (S.M., T.C., J.B.), Conemaugh Memorial Medical Center, Johnstown, Pennsylvania; Trauma Administration (L.E.J., J.M.W., C.S.N.), Ascension St. Vincent Hospital, Indianapolis, Indiana; Department of Surgery (P.O.U., K.T., C.P.), WakeMed Health and Hospitals, Raleigh, North Carolina; Department of Surgery (J.M.V., T.J.C., E.J.K.), Creighton University Medical Center - Bergan Mercy, Omaha, Nebraska; Department of Surgery (L.M.K., S.M.M., D.A.), Yale School of Medicine, New Haven, Connecticut; Department of Surgery (C.M., N.D., R.B.), Spartanburg Medical Center, Spartanburg, South Carolina; Department of Surgery (A.E., S.D., E.V.), OhioHealth Grant Medical Center, Columbus, Ohio; Department of Surgery (M.C.W., J.K.D., E.W.), Loma Linda University Medical Center, Loma Linda, California; Department of Trauma and Acute Care Surgery (M.L.M., B.P., K.H.), Kettering Health Main Campus, Kettering, Ohio; Department of Surgery (T.E., J.W.), Cooper University Hospital, Camden, New Jersey; Department of Surgery (J.H., K.L.), Ascension Via Christi Saint Francis, Wichita, Kansas; Department of Trauma Surgery (K.P.C., M.L.H.), Essentia Health-St. Mary's Medical Center; Essentia Institute of Rural Health (M.L.H.), Essentia Health, Duluth, Minnesota; Department of Surgery (J.N., E.T.-L.), University of California, Irvine Medical Center, Orange; and Department of Surgery (J.C., C.J.H.), Zuckerberg San Francisco General Hospital and Trauma Center, San Francisco, California.
Background:
Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a pan-scan (head/cervical spine [C-spine]/torso) or a selective scan (head/C-spine ± torso). We hypothesized that a patient's initial history and examination could be used to guide imaging.
Methods:
We prospectively studied blunt trauma patients 65 years or older at 18 Level I/II trauma centers. Patients presenting >24 hours after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of head/C-spine or Torso (chest, abdomen/pelvis, and thoracolumbar spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our data set. Our priority was to identify a simple rule, which could be applied at the bedside, maximizing sensitivity and negative predictive value (NPV) to minimize missed injuries.
Results:
We enrolled 5,498 patients with 3,082 injuries. Nearly half (n = 2,587 [47.1%]) had an injury within the defined CT body regions. No rule to guide a pan-scan could be identified with suitable sensitivity/NPV for clinical use. A clinical algorithm to identify patients for pan-scan, using a combination of physical examination findings and specific high-risk criteria, was identified and had a sensitivity of 0.94 and NPV of 0.86. This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT.
Conclusion:
Our findings advocate for head/C-spine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population.
Level Of Evidence:
Diagnostic Tests or Criteria; Level II.
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