Lit of the Week- 5/17/16

“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

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