“NEXUS Chest – Validation of a Decision Instrument for Selective Chest Imaging in Blunt Trauma”
http://www.ncbi.nlm.nih.gov/pubmed/23925583
Clinical question / background:
- Low yield radiology is costly and exposes patients to unnecessary radiation. Can the previously described NEXUS Chest Imaging rules be validated for clinical use in cases of blunt chest trauma?
- Very low risk for chest trauma if none of the following are met:
- Older than 60 years old
- Rapid deceleration mechanism (fall> 20ft, MVC > 40mph)
- Chest Pain
- Intoxication
- Abnormal mental status
- Distracting injury
- Tenderness to chest wall palpation
Design:
- Prospective, observational validation study
- 9 US level I trauma centers
- Blunt trauma patients >14 years old
- Imaging studies ordered per individual physician (EP, Trauma). Prior to imaging results, MDs record presence or absense of NEXUS Chest 7 criteria.
Outcome:
- Thoracic injury on chest imaging (TICI) defined as pneumothorax, hemothorax, aortic/great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, pulmonary contusion/laceration.
- An expert panel was convened to determine which degree of injury clinically major, clinically minor and clinically insignificant injury.
- Outcomes stratified by major, minor and insignificant
Results:
- 9905 patients enrolled: 1478 with thoracic injury identified on chest imaging
- Sensitivity 98.8% for any thoracic injury
- Sensitivity 99.7% for injuries of major clinical significance.
- Cohort of 200 patients without chest imaging followed up to determine rate of thoracic injury in patients without chest imaging. Zero missed injuries.
Discussion:
- Clinical tool is validated for this patient population
- Very poor specificity: this is a rule-out tool, not rule in
