NEXUS Chest decision criteria sensitive for thoracic injury

Image: PD

1. The NEXUS (National Emergency X-Radiography Utilization Study) Chest decision instrument demonstrated high sensitivity for detecting thoracic injury on chest imaging (TICI), and for TICI with clinically major injury (98.8% and 99.7% respectively). 

2. The negative predictive value of NEXUS Chest for TICI and TICI with clinically major injury was also high (98.5% and 99.9% respectively). 

Evidence Rating Level: 1 (Excellent) 

Study Rundown: Imaging of the chest is a commonly used diagnostic technique in evaluating blunt trauma patients. Chest x-ray and CT are two of the most commonly used imaging methods, and both expose patients to harmful ionizing radiation, increase the cost of healthcare, and increase the length of stay in the emergency department. This study sought to validate a clinical rule that could exclude clinically significant thoracic injury (TICI), and thus eliminate unnecessary chest imaging. The criteria demonstrated high sensitivity, high negative predictive value, and poor specificity, characteristics which are useful for ruling out clinically significant trauma. One disadvantage of this study was the use of convenience sampling for personnel availability, only assessing patients admitted from 0700 to 2300. The study was conducted at nine level I trauma centers in the US, which could potentially produce different results than if performed at community hospitals with less traumatic chest injury experience. Moreover, the study excluded patients younger than 14 years of age, making the decision rule inapplicable to pediatric populations.

Click to read the study in JAMA Surgery

Relevant Reading: A Pilot Study to Derive Clinical Variables for Selective Chest Radiography in Blunt Trauma Patients

In-Depth [prospective study]: This multicenter prospective cohort validation study was conducted at nine level I trauma centers in the US. Enrolled patients had sustained blunt trauma within 24 hours of presentation to the emergency department, and received either chest x-ray or chest CT for evaluation. Treating physicians were asked to fill out a questionnaire before viewing the images or imaging reports, on which they indicated the presence or absence of the NEXUS Chest criteria: (1) age greater than 60 years, (2) rapid deceleration mechanism, (3) chest pain, (4) intoxication, (5) abnormal alertness/mental status, (6) distracting painful injury, and (7) tenderness to chest wall palpation. Interpreting radiologists were blinded from patient enrollment. A panel of trauma surgeons and emergency physicians classified thoracic injuries to levels of clinical significance (none, minor, and major).

Of 9905 enrolled patients, 1478 (14.9%) had thoracic injury on chest imaging. Of those, 363 were of major clinical significance, and 1079 were of minor clinical significance. The NEXUS Chest criteria were 98.8% sensitive and had NPV of 98.5% for TICI, regardless of clinical significance. For clinically major TICI, the criteria were 99.7% sensitive and had NPV of 99.9%. For either major or minor clinical significance, the criteria were 99.0% sensitive (95% CI: 98.2%-99.4%) and had 98.7% NPV (95% CI: 98.1-99.3%). Of the false negatives, 13 of 17 missed TICI occurred at a single site, where the sensitivity was 97.1%, lower than the other sites.

By James Jiang and Chaz Carrier

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