Selective chest imaging for blunt trauma patients: The national emergency X-ray utilization studies (NEXUS-chest algorithm)

Abstract

Chest imaging plays a prominent role in blunt trauma patient evaluation, but indiscriminate imaging is expensive, may delay care, and unnecessarily exposes patients to potentially harmful ionizing radiation. To improve diagnostic chest imaging utilization, we conducted 3 prospective multicenter studies over 12 years to derive and validate decision instruments (DIs) to guide the use of chest x-ray (CXR) and chest computed tomography (CT). The first DI, NEXUS Chest x-ray, consists of seven criteria (Age > 60 years; rapid deceleration mechanism; chest pain; intoxication; altered mental status; distracting painful injury; and chest wall tenderness) and exhibits a sensitivity of 99.0% (95% confidence interval [CI] 98.2-99.4%) and a specificity of 13.3% (95% CI, 12.6%-14.0%) for detecting clinically significant injuries. We developed two NEXUS Chest CT DIs, which are both highly reliable in detecting clinically major injuries (sensitivity of 99.2%; 95% CI 95.4-100%). Designed primarily to focus on detecting major injuries, the NEXUS Chest CT-Major DI consists of six criteria (abnormal CXR; distracting injury; chest wall tenderness; sternal tenderness; thoracic spine tenderness; and scapular tenderness) and exhibits higher specificity (37.9%; 95% CI 35.8–40.1%). Designed to reliability detect both major and minor injuries (sensitivity 95.4%; 95% CI 93.6–96.9%) with resulting lower specificity (25.5%; 95% CI 23.5–27.5%), the NEXUS CT-All rule consists of seven elements (the six NEXUS CT-Major criteria plus rapid deceleration mechanism). The purpose of this review is to synthesize the three DIs into a novel, cohesive summary algorithm with practical implementation recommendations to guide selective chest imaging in adult blunt trauma patients.

Traumatic Internal Mammary Injury— A Literature Review and Guide for Management

“…After 2000, although diagnosis and treatment could be performed simultaneously by angiography, most physicians chose contrast-enhanced chest CT as the diagnostic tool because of its easy accessibility and ability to provide more comprehensive information. For blunt chest trauma, the National Emergency X-Radiography Utilization Study chest algorithm (NEXUS-chest) has already provided well-validated and practical recommendations for the implementation of chest imaging (39). For penetrating chest trauma, if an IMA injury is suspected according to the depth and route of injury, a contrast-enhanced chest CT scan is the reasonable rst choice as long as the patient's condition is suitable for the exam.…”

“…Immediate operation is indicated for patients with extremely unstable hemodynamics. The NEXUS CT-Major or All criteria were applied as selection criteria for CT in patients with blunt chest trauma (39). TAE should be considered for stable patients with active bleeding, while surgery should be considered for several situations, as shown in the algorithm.…”

Imaging Assessment of Thoracic Cage Injuries

“…It may be seen in high-energy motor vehicle collisions with impact of the shoulder and abnormal rotation. 7,12 These patients usually have other associated chest injuries and need MDCT evaluation (►Fig. 13).…”

Thoracic wall trauma—misdiagnosed lesions on radiographs and usefulness of ultrasound, multidetector computed tomography and magnetic resonance imaging

“…For instance, when performing after a normal chest radiograph, CT diagnoses only one major injury for every 67 studies (5). Rodriguez et al have designed a cohesive summary algorithm so-named NEXUS Chest X-ray, which consists of seven criteria (age >60 years; rapid deceleration mechanism; chest pain; intoxication; altered mental status; distracting painful injury; and chest wall tenderness) and exhibits a sensitivity of 99.0% [95% confidence interval (CI), 98.2-99.4%) and a specificity of 13.3% (95% CI, 12.6-14.0%) for detecting clinically significant injuries, reinforcing the efficacy of X-ray chest imaging in the evaluation of all blunt trauma patients (6). Ultrasonography (US) is increasingly being used for trauma patients to help identify fractures, haemothorax, pneumothorax and to evaluate cardiac function.…”

“…MDCT is considered the "gold-standard" for traumatic patients (especially polytraumatized patients), due to its fast acquisition covering the whole area of interest in axial plane (including other anatomic areas at the same time), reconstructing multiplanar (2D, 3D) volumerendered images with a superb quality and angiographic CT capabilities for evaluating vascular injury (1,3) with changing management in up to 20% of chest trauma patients (4). However, radiologists must be aware of unnecessarily MDCT scans expose patients to potentially harmful ionizing radiation (5,6). In front of subtle rib fractures and muscle-tendinous tears, complementary techniques such as US and MRI may improve the diagnostic accuracy (19,20,32,35,38,42).…”