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NEXUS Chest Decision Instrument for Blunt Chest Trauma

Calculators  Respiratory
The NEXUS Chest Decision Instrument for Blunt Chest Trauma calculator identifies which patients require chest imaging after blunt trauma.
Age >60 years
No 0
Yes 1
Rapid deceleration mechanism
Fall from >20 ft (>6m)|MVC >40 mph (>64km/h)
No 0
Yes 1
Chest pain
No 0
Yes 1
Intoxication
No 0
Yes 1
Altered mental status
No 0
Yes 1
Distracting painful injury
No 0
Yes 1
Tenderness to chest wall palpation
No 0
Yes 1
Result:

Background

Measured Factor
Risk of significant thoracic injury that requires thoracic imaging
Measured Factor Disease
  • Significant thoracic injury
Measured Factor Detail
The NEXUS Chest Decision Instrument for Blunt Chest Trauma calculator identifies which patients require chest imaging after blunt trauma. Due to the risk of radiation exposure, trauma patients who would not benefit from chest imaging should not receive it, especially when they are young or pregnant. The calculator uses seven criteria (age, rapid deceleration mechanism, chest pain, intoxication, altered mental status, distracting painful injury, and chest wall tenderness) to identify clinically significant thoracic injuries that require chest imaging. Chest imaging can be either chest X-ray and/or chest computed tomography (CT) depending on how the patient look and evidence of organ injury.
Speciality
Emergency Medicine Physician
Body System
Respiratory
Measured Factor High Impact
  • Significant thoracic injury

Result Interpretation

Ranges Ranges
  • Critical High: Score ≥1
  • Normal: Score 0
  • Normal Adult Male: Score 0
  • Normal Adult Female: Score 0
  • Normal Geriatric Male: Score 0
  • Normal Geriatric Female: Score 0
Result High Conditions
  • Significant thoracic injury
Test Limitations
This calculator should not yet be used alone to direct imaging decisions and larger populations are needed to confirm its performance. Moreover, the calculator provides no information about injuries that do not show up on imaging. Lastly, the calculator can't be used in patients younger than 15 years old.
References: 1

Studies

Study Validation 1
This prospective, observational, diagnostic decision instrument study evaluated the sensitivity of the NEXUS Chest Decision Instrument for Blunt Chest Trauma in predicting the thoracic injury seen on chest imaging (TICI) and TICI with major clinical significance. A total of 9905 patients older than 14 years with blunt trauma were enrolled from December 2009 to January 2012 at 9 United States level I trauma centers. Physicians recorded the presence or absence of the NEXUS Chest 7 clinical criteria prior to viewing radiographic results. Thoracic injury seen on chest imaging was seen in 1478 (14.9%) patients with 363 (24.6%) of these having major 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. The authors concluded that the NEXUS Chest decision instrument may safely reduce the need for chest imaging in blunt trauma patients older than 14 years.
References: 2
Study Validation 2
This review looked at 3 prospective multicenter studies over 12 years that derived and validated 3 decision instruments to guide the use of chest x-ray (CXR) and chest computed tomography (CT) in blunt trauma patients. The decision instruments were the NEXUS Chest x-ray,  NEXUS Chest CT-Major, the NEXUS CT-All rule. The NEXUS Chest x-ray consisted of seven criteria (Age > 60 years; rapid deceleration mechanism; chest pain; intoxication; altered mental status; distracting painful injury; and chest wall tenderness) and had a sensitivity of 99.0% and a specificity of 13.3% for detecting clinically significant injuries. The NEXUS Chest CT-Major consists of six criteria (abnormal CXR; distracting injury; chest wall tenderness; sternal tenderness; thoracic spine tenderness; and scapular tenderness) and had  a sensitivity of 99.2% and a specificity of 37.9%. The NEXUS CT-All rule consisted of six NEXUS CT-Major criteria plus rapid deceleration mechanism and had a sensitivity of 95.4% and a specificity of 25.5%. The authors recommended to incorporate these  3 decision instruments into chart templates and electronic medical records in order to safely avoid unnecessary imaging.
References: 3
Study Validation 3
This study described the criteria of the NEXUS chest decision instrument. A total of 21,382 patients older than 14 years with blunt trauma from 9 United States Level I trauma centers were enrolled. Sensitivities of criteria ranged from 15% to 56% for major clinical injuries and 14% to 53% for thoracic injuries observed on chest imaging. The specificities varied from 71% to 84% for major clinical injuries and 67% to 84% for thoracic injuries observed on chest imaging. Individual criteria were associated with a prevalence of major clinical injury between 1.9% and 3.8% and of thoracic injury between 5.3% and 11.5% observed on chest imaging. The study concluded that criteria-specific risks could be used to inform the need for imaging.
References: 4

Authors

Robert Rodriguez, MD, is a professor of clinical emergency medicine, the associate chair for clinical research, and the residency research director at University of California, San Francisco (UCSF) School of Medicine. His research focused on decision instruments for imaging in blunt trauma, critical care in the emergency medicine, infectious disease presentations to the emergency medicine, homeless and immigrant population access and care in the emergency medicine, and defensive medicine
https://emergency.ucsf.edu/people/robert-rodriguez-md

References

  1. Rodriguez RM, Hendey GW, Mower W, Kea B, Fortman J, Merchant G, et al. Derivation of a decision instrument for selective chest radiography in blunt trauma. J Trauma. 2011 Sep;71(3):549-53.
  2. Rodriguez RM, Anglin D, Langdorf MI, Baumann BM, Hendey GW, Bradley RN, et al. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg. 2013 Oct;148(10):940-6.
  3. Rodriguez RM, Hendey GW, Mower WR. Selective chest imaging for blunt trauma patients: The national emergency X-ray utilization studies (NEXUS-chest algorithm). Am J Emerg Med. 2017 Jan;35(1):164-170.
  4. Raja AS, Lanning J, Gower A, Langdorf MI, Nishijima DK, Baumann BM, et al. Prevalence of Chest Injury With the Presence of NEXUS Chest Criteria: Data to Inform Shared Decisionmaking About Imaging Use. Ann Emerg Med. 2016 Aug;68(2):222-6.