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'Loma Linda rule' predicted need for emergent surgery.

NEW ORLEANS -- A simple clinical decision rule using prehospital vital signs may predict which trauma patients will need emergent surgical intervention upon arriving in the emergency department.

"Use of this rule may improve the effectiveness and efficiency of trauma triage," Dr. Richard L. Byyny observed at the annual meeting of the Society for Academic Emergency Medicine.

Dr. Byyny presented the first external validation study of the "Loma Linda rule" that was developed by physicians at that California medical center in 2006 (Ann. Emerg. Med. 2006;47:135).


The decision rule has three criteria: a penetrating mechanism of injury, initial systolic blood pressure less than 100 mm Hg, and initial heart rate greater than 100 bpm. The presence of any one of those criteria predicts the possibility that the affected trauma patient may need either general surgery within 1 hour of ED arrival or a thoracotomy or cricothyrotomy performed in the ED.

On the other hand, the rule predicts that, in the absence of any of those criteria, there is no need for a trauma surgeon to be at the bedside when the patient arrives at the ED, explained Dr. Byyny, an emergency physician at Denver Health Medical Center.

The Loma Linda rule validation study was carried out using data from Denver Health's prospective level I trauma center registry. During 1993-2006, 17,080 consecutive adult trauma patients presented to the regional trauma center and were entered in the registry, of whom 864 patients required emergent operative or procedural intervention.

About 39% of all adult trauma patients met one or more criteria for the clinical decision rule. Application of the rule had 94% sensitivity and 64% specificity for emergent operative or procedural intervention, a 12% positive predictive value, and a 99% negative predictive value.

American College of Surgeons (ACS) secondary trauma triage guidelines state that a 10% undertriage rate is acceptable and a 50% overtriage or false-positive rate is unavoidable in order to capture as many at-risk patients as possible, Dr. Byyny said. "The Loma Linda rule exceeds these standards," he noted.

The ACS has recommended a major resuscitation trauma triage scheme of its own. It has the following components: initial systolic blood pressure below 90 mm Hg; respiratory compromise; a gunshot wound to the neck or torso; patient transfer to another hospital with need for blood products to maintain vital signs; a Glasgow Coma Scale score below 8; and the catch-all category of emergency physician's discretion.

Applying the ACS rule to Denver Health's trauma registry, it provided 82% sensitivity and 80% specificity for emergent operative or procedural intervention. "Our n.fie identifies more of the patients [requiring emergent operative intervention] at the expense of a slightly decreased specificity," he noted.

Asked by audience members what sort of reception the decision rule has had from trauma surgeons, Dr. Byyny replied that it actually reduces the number of times a resident or attending trauma surgeon needs to be present in the ED. Previously, they had to show up for all lights-and-sirens ambulance arrivals.

The study was funded by grants from the Emergency Medicine Foundation, Colorado ACEP, and the Agency for Healthcare Research and Quality.

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Title Annotation:CLINICAL ROUNDS
Comment:'Loma Linda rule' predicted need for emergent surgery.(CLINICAL ROUNDS)
Author:Jancin, Bruce
Publication:Family Practice News
Geographic Code:1USA
Date:Jun 15, 2009
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