Clinical Rule of Brink et al for Computed Tomography (CT) of the Chest in a Patient Following Blunt Trauma

 

Patient selection: blunt trauma

 

Parameters:

(1) age of the patient in years

(2) physical examination of the chest

(3) physical examination of the thoracic spine

(4) sensorium

(5) chest X-ray

(6) X-ray of the thoracic spine

(7) imaging studies of abdomen (ultrasound) and pelvis (X-ray)

(8) initial base excess in mmol/L (arterial blood gas)

(9) hemoglobin

Parameter	Finding	Points
age of the patient	< 55 years of age	0
	>= 55 years of age	1
exam of chest	normal	0
	abnormal	1
exam of thoracic spine	normal	0
	abnormal	1
sensorium	normal	0
	altered	1
chest X-ray	normal	0
	abnormal	1
X-ray of thoracic spine	normal	0
	abnormal	1
imaging studies of abdomen and pelvis	normal	0
	abnormal	1
base excess	>= -3 mmol/L	0
	< -3 mmol/L	1
hemoglobin	>= 6 g/dL	0
	< 6 g/dL	1

 

where:

• Abnormal chest exam: respiratory rate < 10 or > 29 per minute; oxygen saturation < 95% at presentation; decreased breathing sounds on auscultation; subcutaneous emphysema; tenderness to palpation on chest wall; laceration or hematoma of chest wall

• Altered sensorium: Glasgow coma score < 14 on presentation; orotracheal intubation required; suspicion of drug or alcohol intoxication

• Abnormal exam of thoracic spine: tenderness to palpation in the midline of the thoracic spine; lacerations or hematoma over spine; neurological deficits suggesting spinal cord injury

• Abnormal chest-Xray: pulmonary contusion; hemothorax or pneumothorax; subcutaneous emphysema; abnormal mediastinum suggesting aortic injury; spinal fracture; diaphragmatic rupture; rib fractures; scapular fractures; clavicular fractures

• Abnormal X-ray of thoracic spine: any fracture of vertebra, spinous process or transverse process; spinal malalignment

• Abnormal adominal ultrasound: presence of free fluid.

• Abnormal pelvic X-ray: any fracture of pelvis or proximal femur.

 

total score =

= SUM(points for all 9 parameters)

 

Interpretation:

• minimum score: 0

• maximum score: 9

• A patient with a score of 0 is unlikely to have a significant finding found on chest CT.

 

Performance:

• About 2% of patients with none of the risk factors had a injuries that were clinically relevant (would have resulted in additional diagnostic studies, increased the level of care, and/or an immediate intervention).

• Following the rule would reduce the number of chest CT performed by 18%.

• The area under the ROC curve was 0.85. The sensitivity was 95% but sensitivity was only 31%.