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Nexus Chest CT Decision Rule in Blunt Trauma

Aka: Nexus Chest CT Decision Rule in Blunt Trauma
  1. Indications: Blunt Chest Trauma
    1. Evaluation for major chest injuries
      1. Great Vessel injury including aorta injury
      2. Diaphragmatic Rupture
      3. Pneumothorax or Hemothorax requiring evacuation (Chest Tube)
      4. Sternal Fracture, Scapular Fracture or Thoracic SpineFracture requiring surgical intervention
      5. Multiple Rib Fractures requiring surgery or epidural block
      6. Pulmonary Contusion requiring Mechanical Ventilation in first 24 hours
      7. Mediastinal or pericardial hematoma requiring drainage
      8. Esophageal, tracheal or Bronchial injury requiring surgical intervention
    2. Evaluation for minor chest injuries
      1. Pneumothorax or Hemothorax requiring observation >24 hours but NO drainage or evacuation
      2. Sternal Fracture, Scapular Fracture or Thoracic SpineFracture NOT requiring surgery
      3. Multiple Rib Fractures NOT requiring surgery or Nerve Block
      4. Pulmonary Contusion or Laceration requiring only observation >24 hours, but NO Mechanical Ventilation
      5. Mediastinal or pericardial hematoma requiring NO surgical intervention
      6. Esophageal, tracheal or Bronchial injury requiring NO surgical intervention
  2. Contraindications
    1. Does not apply to intubated patients or those who are hemodynamically unstable
  3. Criteria
    1. Abnormal Chest XRay
      1. Any Thoracic Injury (e.g. Clavicle Fracture, wide mediastinum)
    2. Distracting injury (same definition as used in NEXUS Cervical Spine Decision Rule)
      1. Long bone Fractures
      2. Visceral injury requiring Consultation
      3. Large Lacerations
      4. Degloving injury
      5. Crush injury
      6. Large Burn Injury
      7. Spinal Fractures or spinal cord injuries
      8. Injury causing acute functional Impairment
    3. Chest Wall Tenderness
    4. Sternal tenderness
    5. Thoracic Spine tenderness
    6. Scapula tenderness
    7. Rapid deceleration Mechanism (included for CT minor criteria)
      1. MVA at >40 MPH
      2. Fall >20 feet
  4. Interpretation
    1. Decision Rules
      1. Chest CT - All: Includes all criteria including rapid deceleration Mechanism
        1. Test Sensitivity for major injuries: 99%
        2. Test Sensitivity for minor injuries: 95%
      2. Chest CT - Major: Includes all criteria EXCEPT rapid deceleration Mechanism
        1. Test Sensitivity for major injuries: 99% (same as for Chest CT - All rule)
        2. Test Sensitivity for minor injuries: 90%
    2. Application
      1. Both decision rules are reassuring if negative and predict a CT Chest without major injury
        1. Negative likelihood for major injuries: 0.04
        2. Negative likelihood for all injuries: 0.18
        3. Reasonable to forego CT Chest if low to moderate probability cases and negative decision rule
          1. However, CT Chest may still be considered in high probability cases
      2. Positive decision rule does not mandate Chest CT
        1. Decision rules have poor Test Specificity and is useful only when negative
        2. Use clinical judgment to determine CT Chest indications
  5. References
    1. Lin and Rodriguez in Herbert (2016) EM:Rap 16(2): 10-11
    2. Rodriguez (2015) PLos Med 12(10): e1001883 +PMID:26440607 [PubMed]
      1. http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001883

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