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Original Investigation |

NEXUS Chest:  Validation of a Decision Instrument for Selective Chest Imaging in Blunt Trauma

Robert M. Rodriguez, MD1; Deirdre Anglin, MD, MPH2; Mark I. Langdorf, MD3; Brigitte M. Baumann, MD, MSCE4; Gregory W. Hendey, MD5; Richard N. Bradley, MD6; Anthony J. Medak, MD7; Ali S. Raja, MD, MPH8; Paul Juhn, MD2; Jonathan Fortman1; William Mulkerin2; William R. Mower, MD, PhD9
[+] Author Affiliations
1Department of Emergency Medicine, The University of California San Francisco School of Medicine, San Francisco General Hospital
2Department of Emergency Medicine, Keck School of Medicine of University of Southern California, Los Angeles
3Department of Emergency Medicine, University of California, Irvine
4Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey
5Department of Emergency Medicine, University of California, San Francisco, Fresno Medical Education Program
6Department of Emergency Medicine, The University of Texas Health Science Center at Houston
7Department of Emergency Medicine, University of California, San Diego School of Medicine
8Department of Emergency Medicine, Brigham and Women’s Hospital/Harvard Medical School, Boston, Massachusetts
9Department of Emergency Medicine, University of California, Los Angeles
JAMA Surg. 2013;148(10):940-946. doi:10.1001/jamasurg.2013.2757.
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Importance  Chest radiography (chest x-ray [CXR] and chest computed tomography [CT]) is the most common imaging in blunt trauma evaluation. Unnecessary trauma imaging leads to greater costs, emergency department time, and patient exposure to ionizing radiation.

Objective  To validate our previously derived decision instrument (NEXUS Chest) for identification of blunt trauma patients with very low risk of thoracic injury seen on chest imaging (TICI). We hypothesized that NEXUS Chest would have high sensitivity (>98%) for the prediction of TICI and TICI with major clinical significance.

Design, Setting, and Participants  From December 2009 to January 2012, we enrolled blunt trauma patients older than 14 years who received chest radiography in this prospective, observational, diagnostic decision instrument study at 9 US level I trauma centers. Prior to viewing radiographic results, physicians recorded the presence or absence of the NEXUS Chest 7 clinical criteria (age >60 years, rapid deceleration mechanism, chest pain, intoxication, abnormal alertness/mental status, distracting painful injury, and tenderness to chest wall palpation).

Main Outcomes and Measures  Thoracic injury seen on chest imaging was defined as pneumothorax, hemothorax, aortic or great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion or laceration seen on radiographs. An expert panel generated an a priori classification of clinically major, minor, and insignificant TICIs according to associated management changes.

Results  Of 9905 enrolled patients, 43.1% had a single CXR, 42.0% had CXR and chest CT, 6.7% had CXR and abdominal CT (without chest CT), 5.5% had multiple CXRs without CT, and 2.6% had chest CT alone in the emergency department. The most common trauma mechanisms were motorized vehicle crash (43.9%), fall (27.5%), pedestrian struck by motorized vehicle (10.7%), bicycle crash (6.3%), and struck by blunt object, fists, or kicked (5.8%). Thoracic injury seen on chest imaging was seen in 1478 (14.9%) patients with 363 (24.6%) of these having major clinical significance, 1079 (73.0%) minor clinical significance, and 36 (2.4%) no clinical significance. NEXUS Chest had a sensitivity of 98.8% (95% CI, 98.1%-99.3%), a negative predictive value of 98.5% (95% CI, 97.6%.6-99.1%), and a specificity of 13.3% (95% CI, 12.6%-14.1%) for TICI. The sensitivity and negative predictive value for TICI with clinically major injury were 99.7% (95% CI, 98.2%-100.0%) and 99.9% (95% CI, 99.4%-100.0%), respectively.

Conclusions and Relevance  We have validated the NEXUS Chest decision instrument, which may safely reduce the need for chest imaging in blunt trauma patients older than 14 years.

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NEXUS Chest Decision Instrument Implementation

Intrathoracic injury is defined as pneumothorax, hemothorax, aortic or great vessel injury; multiple rib fractures; ruptured diaphragm; sternal fracture; and pulmonary contusion or laceration. Intoxication, abnormal alertness, and distracting injury are defined in the same manner as in the NEXUS Cervical Spine Rule.11

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