Chest CT in trauma - rational thinking

Short Attention Span Summary

To determine which patients with blunt trauma need chest CT, the NEXUS CT chest rule may help.  In this study, if one criterion (excluding abnormal CXR) was present, it was worth discussing the risk of CT vs the very small risk of clinically major injury (1.1% prevalence).  But if the CXR was abnormal (13% prevalence major injury) or there was >1 NEXUS criterion (~3% prevalence major injury), the risk of CT was warranted.


FOAM Report


Abstract

Acad Emerg Med. 2016 May 10. doi: 10.1111/acem.13010. [Epub ahead of print]

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

Raja AS1, Mower WR2, Nishijima DK3, Hendey GW4, Baumann BM5, Medak AJ6, Rodriguez RM7.

Author information:

1Departments of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA.

2Department of Emergency Medicine, University of California, Los Angeles, CA.

3Department of Emergency Medicine, University of California, Davis, CA.

4Department of Emergency Medicine, San Francisco Fresno Medical Education Program, San Francisco, CA.

5Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ.

6Department of Emergency Medicine, University of California, San Diego School of Medicine, San Diego, CA.

7Department of Emergency Medicine, University of California, San Francisco, CA.

 

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. This article is protected by copyright. All rights reserved.

This article is protected by copyright. All rights reserved.

PMID: 27163732 [PubMed - as supplied by publisher]