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Discussion in 'Emergency Medicine' started by alfonzarel, Jan 1, 2009.
to all you aspiring EM docs, what are your feelings on CT criteria using nexus vs. BEAN BASH?
Well, I'm a board certified ER doc and all I know is that Nexus had over 34,000 patients, and Bean Bash.... Bean Bash....
Who am I kidding? I had to google it! Apparently it's an annual 5K race. Feel free to educate me (us?) but it isn't a commonly cited study in ER academic circles.
Whichever criteria you follow, for any condition, you should do two things:
1) Analyze the methods to determine if the study conditions are appropriate for your patient population, and decide if the numbers in the study really do support the point they're trying to make
2) Remember that they're criteria -- the word decision "rule" is actually a misnomer. The authors of the NEXUS study, even to this day, tell a story of how they wanted to call it a decision aid (or some such label) so as to avoid the verbage decision "rule". The publishers over ruled them.
http://www.medscape.com/viewarticle/547419_3 this is the url, but it doesn't seem to work as a link here. just google this: nexus vs. BEAN BASH ACEP and you should get the hit
Trauma 2006: The Year in ReviewSwaminatha Mahadevan, MD, FACEP, Assistant Professor of Surgery/Emergency Medicine and Associate Chief Emergency Medicine at Stanford University, provided an update on diagnostic and management modalities for the multitrauma patient. Dr. Mahadevan reviewed the trauma management literature that has been published since the 2004 Scientific Assembly and culled the ones he felt might possibly alter the ED physician's clinical practice.
BEAN BASH and BEN BASH Criteria
The first study discussed was by Mower and colleagues for the Nexus II investigators. Emergency physicians request head CTs to rule out unrecognized intracranial injury (ICI) which can lead to brain damage, disability, and death. Mahadevan stated that this concern is the leading reason for obtaining head CTs in the United States, where over 1 million are obtained annually with 94% showing no significant injury.
The authors of this study set out to develop an instrument that would identify patients at risk for significant ICI after blunt head trauma. This was a prospective, multicenter observational study of 13,728 patients with blunt head trauma who would have received a head CT anyway. All were assessed for 20 specific variables. The head CT obtained was assessed for significant injury, defined as any injury that led to neurosurgical intervention, rapid clinical deterioration, or had the potential for long-term neurologic impairment.
The authors identified 917 patients with significant ICI. After recursive portioning, they found 8 high-sensitivity criteria that predicted significant ICI. The mnemonic "BEAN BASH" was proposed as follows, where BEAN refers to the head and BASH refers to a blow to the head:
B Behavior abnormal
E Emesis intractable
A Age > 65 years
N Neurologic deficit
B Bleeding disorder
A Altered mental status
S Skull fracture
H Hematoma scalp
Of the 917 injuries studied, these criteria identified 901 significant ICIs with a miss of 16 injuries for a sensitivity of 98.3% and a negative predictive value of 99%. Of the 16 missed injuries, only 1 required neurosurgical intervention. Of interest, noted Mahadevan, was that loss of consciousness did not come up as one of the criteria. The study requires prospective validation.
The authors then applied BEAN BASH to children, eliminating the A and reducing the mnemonic to BEN BASH. The authors enrolled 1666 children, including 138 with clinically important ICI. BEN BASH correctly identified 136 out of 138 cases. Of the 2 cases missed, neither required neurosurgical intervention. When the criteria were applied to 309 children under the age of 3 years, including 25 with significant ICI, BEN BASH successfully identified all. In children, these criteria had a sensitivity of 98.6% and a negative predictive value of 99.1%. This study also requires prospective validation.
Thanks - Yes I saw it once I googled it, too. But the key line is the last one. No prospective validation. I wonder, did the group decide they would try and prospectively validate it?
I gotta admit, the time, energy, resources that would need to be invested to prospectively validate something like this would far outweight the benefits (IMHO). Hell, a lot of people think the funding for the NEXUS study was outlandishly disproportionate to the benefit (listen to some of the EM Abstract needling that goes on between Rick and Jerry).
For me, NEXUS as a clinical aid works just fine.
clinical gestalt until something shown better
yeah i like it too... less criteria to have to remember
I haven't read the BEAN BASH stuff, but it seems from what you all are saying, we're comparing apples to oranges here. NEXUS is an aid for cervical spine injury, whereas BEAN BASH is for closed head injury. Two different, yet related injury patterns. I do like the mnemonic, though.