Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients
Abstract Background Timely and accurate identification of life- and limb-threatening injuries (LLTIs) is a fundamental objective of trauma care that directly informs triage and treatment decisions. However, the diagnostic accuracy of clinical examination to detect LLTIs is largely unknown, due to th...
| Main Authors: | , , , , , , , , , , |
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| Format: | Article |
| Language: | English |
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BMC
2023-04-01
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| Series: | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine |
| Subjects: | |
| Online Access: | https://doi.org/10.1186/s13049-023-01083-z |
| _version_ | 1827970266174586880 |
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| author | Jared M. Wohlgemut Max E. R. Marsden Rebecca S. Stoner Erhan Pisirir Evangelia Kyrimi Gareth Grier Michael Christian Thomas Hurst William Marsh Nigel R. M. Tai Zane B. Perkins |
| author_facet | Jared M. Wohlgemut Max E. R. Marsden Rebecca S. Stoner Erhan Pisirir Evangelia Kyrimi Gareth Grier Michael Christian Thomas Hurst William Marsh Nigel R. M. Tai Zane B. Perkins |
| author_sort | Jared M. Wohlgemut |
| collection | DOAJ |
| description | Abstract Background Timely and accurate identification of life- and limb-threatening injuries (LLTIs) is a fundamental objective of trauma care that directly informs triage and treatment decisions. However, the diagnostic accuracy of clinical examination to detect LLTIs is largely unknown, due to the risk of contamination from in-hospital diagnostics in existing studies. Our aim was to assess the diagnostic accuracy of initial clinical examination for detecting life- and limb-threatening injuries (LLTIs). Secondary aims were to identify factors associated with missed injury and overdiagnosis, and determine the impact of clinician uncertainty on diagnostic accuracy. Methods Retrospective diagnostic accuracy study of consecutive adult (≥ 16 years) patients examined at the scene of injury by experienced trauma clinicians, and admitted to a Major Trauma Center between 01/01/2019 and 31/12/2020. Diagnoses of LLTIs made on contemporaneous clinical records were compared to hospital coded diagnoses. Diagnostic performance measures were calculated overall, and based on clinician uncertainty. Multivariate logistic regression analyses identified factors affecting missed injury and overdiagnosis. Results Among 947 trauma patients, 821 were male (86.7%), median age was 31 years (range 16–89), 569 suffered blunt mechanisms (60.1%), and 522 (55.1%) sustained LLTIs. Overall, clinical examination had a moderate ability to detect LLTIs, which varied by body region: head (sensitivity 69.7%, positive predictive value (PPV) 59.1%), chest (sensitivity 58.7%, PPV 53.3%), abdomen (sensitivity 51.9%, PPV 30.7%), pelvis (sensitivity 23.5%, PPV 50.0%), and long bone fracture (sensitivity 69.9%, PPV 74.3%). Clinical examination poorly detected life-threatening thoracic (sensitivity 48.1%, PPV 13.0%) and abdominal (sensitivity 43.6%, PPV 20.0%) bleeding. Missed injury was more common in patients with polytrauma (OR 1.83, 95% CI 1.62–2.07) or shock (systolic blood pressure OR 0.993, 95% CI 0.988–0.998). Overdiagnosis was more common in shock (OR 0.991, 95% CI 0.986–0.995) or when clinicians were uncertain (OR 6.42, 95% CI 4.63–8.99). Uncertainty improved sensitivity but reduced PPV, impeding diagnostic precision. Conclusions Clinical examination performed by experienced trauma clinicians has only a moderate ability to detect LLTIs. Clinicians must appreciate the limitations of clinical examination, and the impact of uncertainty, when making clinical decisions in trauma. This study provides impetus for diagnostic adjuncts and decision support systems in trauma. |
| first_indexed | 2024-04-09T18:51:15Z |
| format | Article |
| id | doaj.art-07383103673d4e5fa080ba971cdc6e77 |
| institution | Directory Open Access Journal |
| issn | 1757-7241 |
| language | English |
| last_indexed | 2024-04-09T18:51:15Z |
| publishDate | 2023-04-01 |
| publisher | BMC |
| record_format | Article |
| series | Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine |
| spelling | doaj.art-07383103673d4e5fa080ba971cdc6e772023-04-09T11:25:36ZengBMCScandinavian Journal of Trauma, Resuscitation and Emergency Medicine1757-72412023-04-0131111210.1186/s13049-023-01083-zDiagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patientsJared M. Wohlgemut0Max E. R. Marsden1Rebecca S. Stoner2Erhan Pisirir3Evangelia Kyrimi4Gareth Grier5Michael Christian6Thomas Hurst7William Marsh8Nigel R. M. Tai9Zane B. Perkins10Centre for Trauma Sciences, Blizard Institute, Queen Mary University of LondonCentre for Trauma Sciences, Blizard Institute, Queen Mary University of LondonCentre for Trauma Sciences, Blizard Institute, Queen Mary University of LondonDepartment of Electrical Engineering and Computer Science, Queen Mary University of LondonDepartment of Electrical Engineering and Computer Science, Queen Mary University of LondonLondon’s Air Ambulance, Royal London Hospital, Barts Health NHS TrustLondon’s Air Ambulance, Royal London Hospital, Barts Health NHS TrustLondon’s Air Ambulance, Royal London Hospital, Barts Health NHS TrustDepartment of Electrical Engineering and Computer Science, Queen Mary University of LondonCentre for Trauma Sciences, Blizard Institute, Queen Mary University of LondonCentre for Trauma Sciences, Blizard Institute, Queen Mary University of LondonAbstract Background Timely and accurate identification of life- and limb-threatening injuries (LLTIs) is a fundamental objective of trauma care that directly informs triage and treatment decisions. However, the diagnostic accuracy of clinical examination to detect LLTIs is largely unknown, due to the risk of contamination from in-hospital diagnostics in existing studies. Our aim was to assess the diagnostic accuracy of initial clinical examination for detecting life- and limb-threatening injuries (LLTIs). Secondary aims were to identify factors associated with missed injury and overdiagnosis, and determine the impact of clinician uncertainty on diagnostic accuracy. Methods Retrospective diagnostic accuracy study of consecutive adult (≥ 16 years) patients examined at the scene of injury by experienced trauma clinicians, and admitted to a Major Trauma Center between 01/01/2019 and 31/12/2020. Diagnoses of LLTIs made on contemporaneous clinical records were compared to hospital coded diagnoses. Diagnostic performance measures were calculated overall, and based on clinician uncertainty. Multivariate logistic regression analyses identified factors affecting missed injury and overdiagnosis. Results Among 947 trauma patients, 821 were male (86.7%), median age was 31 years (range 16–89), 569 suffered blunt mechanisms (60.1%), and 522 (55.1%) sustained LLTIs. Overall, clinical examination had a moderate ability to detect LLTIs, which varied by body region: head (sensitivity 69.7%, positive predictive value (PPV) 59.1%), chest (sensitivity 58.7%, PPV 53.3%), abdomen (sensitivity 51.9%, PPV 30.7%), pelvis (sensitivity 23.5%, PPV 50.0%), and long bone fracture (sensitivity 69.9%, PPV 74.3%). Clinical examination poorly detected life-threatening thoracic (sensitivity 48.1%, PPV 13.0%) and abdominal (sensitivity 43.6%, PPV 20.0%) bleeding. Missed injury was more common in patients with polytrauma (OR 1.83, 95% CI 1.62–2.07) or shock (systolic blood pressure OR 0.993, 95% CI 0.988–0.998). Overdiagnosis was more common in shock (OR 0.991, 95% CI 0.986–0.995) or when clinicians were uncertain (OR 6.42, 95% CI 4.63–8.99). Uncertainty improved sensitivity but reduced PPV, impeding diagnostic precision. Conclusions Clinical examination performed by experienced trauma clinicians has only a moderate ability to detect LLTIs. Clinicians must appreciate the limitations of clinical examination, and the impact of uncertainty, when making clinical decisions in trauma. This study provides impetus for diagnostic adjuncts and decision support systems in trauma.https://doi.org/10.1186/s13049-023-01083-zTraumatic injuriesDiagnostic accuracyClinical examinationUncertaintyPre-hospital diagnosis |
| spellingShingle | Jared M. Wohlgemut Max E. R. Marsden Rebecca S. Stoner Erhan Pisirir Evangelia Kyrimi Gareth Grier Michael Christian Thomas Hurst William Marsh Nigel R. M. Tai Zane B. Perkins Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine Traumatic injuries Diagnostic accuracy Clinical examination Uncertainty Pre-hospital diagnosis |
| title | Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients |
| title_full | Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients |
| title_fullStr | Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients |
| title_full_unstemmed | Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients |
| title_short | Diagnostic accuracy of clinical examination to identify life- and limb-threatening injuries in trauma patients |
| title_sort | diagnostic accuracy of clinical examination to identify life and limb threatening injuries in trauma patients |
| topic | Traumatic injuries Diagnostic accuracy Clinical examination Uncertainty Pre-hospital diagnosis |
| url | https://doi.org/10.1186/s13049-023-01083-z |
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