Deferral of the rectal examination in blunt trauma patients: a clinical decision rule.
OBJECTIVE
To develop a clinical decision rule that would allow for the safe deferral of the digital rectal examination (DRE) in blunt trauma patients.


METHODS
The authors reviewed the medical records of all adult blunt trauma patients meeting trauma team activation criteria over a 14-month period. The results of the DRE and six predictor variables-abnormal neurologic examination, abdominal tenderness, pelvic stability, blood at the urethral meatus, blood pressure < 90 mm Hg, and age over 65 years-were recorded. Patients with abnormal DREs had their discharge summaries reviewed for specific criteria to determine if the abnormal DRE was a true- or false-positive examination. Predictor variables were entered into a classification and regression tree (CART) analysis designed to predict true-positive abnormal DREs.


RESULTS
Of the 579 patients, 53 had abnormal DREs, 34 of which were true positives. CART analysis retained three predictors, abnormal neurologic examination, blood at the urethral meatus, and age over 65 years, and accurately classified all patients with a true-positive abnormal DRE. The probability of a true-positive abnormal DRE in a patient with a normal neurologic examination, no blood at the urethral meatus, and age less than 65 years is between 0% and 0.8%.


CONCLUSIONS
Adult patients with blunt trauma and a normal neurologic examination, with no blood at the urethral meatus, and who are less than 65 years old have an exceedingly low likelihood of a true-positive abnormal DRE. If validated, patients who meet these three criteria may have the DRE safely deferred.
Guldner
Gregory
G
Department of Emergency Medicine, the School of Medicine, and the Department of Surgery, Division of Trauma Surgery, Loma Linda University, Loma Linda, CA 92354, USA. gguldner@ahs.llumc.edu
Babbitt
Jonathan
J
Boulton
Mike
M
O'Callaghan
Thomas
T
Feleke
Rehema
R
Hargrove
Jenny
J
D000007:Abdominal Injuries / Q000175:diagnosis*; D000328:Adult; D002985:Clinical Protocols; D003663:Decision Trees; D003938:Diagnostic Techniques, Digestive System; D004635:Emergency Medicine / Q000379:methods* / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D010043:Outcome and Process Assessment, Health Care; D010173:Palpation / Q000379:methods*; D011237:Predictive Value of Tests; D012007:Rectum; D012189:Retrospective Studies; D014949:Wounds, Nonpenetrating / Q000175:diagnosis*