Prevalence and Diagnostic Performance of Isolated and Combined NEXUS Chest CT Decision Criteria

Abstract

Objectives

The use of chest computed tomography (CT) to evaluate emergency department (ED) patients with adult blunt trauma is rising. The NEXUS Chest CT decision instruments are highly sensitive identifiers of adult blunt trauma patients with thoracic injuries. However, many patients without injury exhibit one of more of the criteria so cannot be classified “low-risk.” We sought to determine screening performance of both individual and combined NEXUS Chest CT criteria as predictors of thoracic injury to inform chest CT imaging decisions in “non-low-risk” patients.

Methods

This secondary analysis of data on patients in the derivation and validation cohorts of the prospective, observational NEXUS Chest CT study was performed September 2011-May 2014 in eleven Level 1 trauma centers. Institutional Review Board approval was obtained at all study sites. Adult blunt trauma patients receiving chest CT were included. The primary outcome was injury and major clinical injury prevalence and screening performance in patients with combinations of one, two or three of seven individual NEXUS Chest CT criteria.

Results

Across the eleven study sites, rates of chest CT performance ranged from 15.5% to 77.2% (median 43.6%). We found injuries in 1,493/5,169 patients (28.9%) who had chest CT; 269 patients (5.2%) had major clinical injury (e.g., pneumothorax requiring chest tube). With sensitivity of 73.7 (95% confidence interval [CI] 68.1-78.6) and specificity of 83.9 (95% CI 83.6-84.2) for major clinical injury, abnormal CXR was the single most important screening criterion. When patients had only abnormal CXR, injury and major clinical injury prevalence were 60.7% (95% CI 52.2-68.6) and 12.9% (95% CI 8.3-19.4), respectively. Injury and major clinical injury prevalence when any other single criterion alone (other than abnormal CXR) was present were 16.8% (95% CI 15.2-18.6) and 1.1% (95% CI 0.1-1.8) respectively. Injury and major clinical injury prevalence among patients when two and three criteria (not abnormal CXR) were present were 25.5% (95% CI 23.1-28.0) and 3.2% (95% CI 2.3-4.4), and 34.9% (95% CI 31.0-39.0) and 2.7% (95% CI 1.6-4.5) respectively.

Conclusions

We recommend that clinicians check for the six clinical NEXUS Chest CT criteria and review the CXR (if obtained). If patients have one clinical criterion (other than abnormal CXR), they will have a very low risk of clinically major injury. We recommend that clinicians discuss the potential risks and benefit of chest CT in these cases. The risks of injury and major clinical injury rise incrementally with more criteria, rendering the risk/benefit ratio toward performing CT in most cases. If the patient has an abnormal CXR, the risks of major clinical injury and minor injury are considerably higher than with the other criteria—chest CT may be indicated in cases requiring greater anatomical detail and injury characterization.

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