ORIGINAL ARTICLE

Derivation of a clinical decision rule to guide the interhospital transfer of patients with blunt traumatic brain injury

C D Newgard¹, J R Hedges¹, J V Stone², B Lenfesty², B Diggs², M Arthur², R J Mullins²

¹ Center for Policy and Research in Emergency Medicine, Department of Emergency Medicine, Oregon Health & Science University, Portland, Oregon, USA
² Department of Surgery, Trauma/Critical Care Section, Oregon Health & Science University, Portland, Oregon, USA

Correspondence to:
Correspondence to:
Craig D Newgard
Assistant Professor, Department of Emergency Medicine, Center for Policy and Research in Emergency Medicine, Oregon Health & Science University, 3181 SW Sam Jackson Park Road, Mail Code CR-114, Portland, Oregon, USA 97239-3098; newgardc{at}ohsu.edu

Objective: To derive a clinical decision rule for people with traumatic brain injury (TBI) that enables early identification of patients requiring specialised trauma care.

Methods: We collected data from 1999 through 2003 on a retrospective cohort of consecutive people aged 18–65 years with a serious head injury (AIS 3), transported directly from the scene of injury, and evaluated in the ED. Information on 22 demographical, physiological, radiographic, and lab variables was collected. Resource based "high therapeutic intensity" measures occurring within 72 hours of ED arrival (the outcome measure) were identified a priori and included: neurosurgical intervention, exploratory laparotomy, intensive care interventions, or death. We used classification and regression tree analysis to derive and cross validate the decision rule.

Results: 504 consecutive trauma patients were identified as having a serious head injury: 246 (49%) required at least one of the HTI measures. Five ED variables (GCS, respiratory rate, age, temperature, and pulse rate) identified subjects requiring at least one of the HTI measures with 94% sensitivity (95% CI 91 to 97%) and 63% specificity (95% CI 57 to 69%) in the derivation sample, and 90% sensitivity and 55% specificity using cross validation.

Conclusions: This decision rule identified among a cohort of head injured patients evaluated in the ED the majority of those who urgently required specialised trauma care. The rule will require prospective validation in injured people presenting to non-tertiary care hospitals before implementation can be recommended.

Abbreviations: AIS, Abbreviated Injury Scale; ED, emergency department; GCS, Glasgow Coma Scale; HTI, high therapeutic intensity; INR, international normalised ratio; TBI, traumatic brain injury

Keywords: traumatic brain injury; decision rule

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