NEXUS Chest Decision Instrument for Blunt Chest Trauma
Applies to patients ≥15 years old with blunt trauma within the past 24 hours in the ED. May be used sequentially with NEXUS Chest CT Decision Instrument (see Next Steps for details).
- Pregnant patients with minor trauma
- Patients who are of indeterminate risk
- Young patients, in whom radiation exposure is more risky
- The NEXUS Chest Decision Instrument can rapidly identify “very low-risk” patients with blunt thoracic trauma who would not benefit from chest imaging.
- It was developed due to the concern of radiation from Chest CT that is now common in the evaluation of trauma patients, and was developed at 3 Level 1 trauma centers in over 2600 patients.
- It uses 7 criteria to identify this low-risk cohort who have a <2% chance of having any thoracic injury (and 1% chance of having clinically significant thoracic injuries).
- It was designed to not miss any injuries, but is not very specific -- just because a patient may not meet low-risk criteria does not mean the patient must be imaged.
Points to keep in mind:
- 1 isolated rib fracture was not included as a “thoracic injury.”
- Some providers may disagree with the study's definitions of “clinically significant.”
- Clavicular tenderness is not included as “chest wall tenderness.”
- Distracting injury is purposefully vaguely defined and is at the discretion of the provider: “any condition thought by the clinician to be producing sufficient pain to distract the patient from a second (intrathoracic) injury.” From the original paper:
- Long bone fractures;
- Visceral injuries requiring surgical consultation;
- Large lacerations, degloving injuries, or crush injuries;
- Large burns, and
- Any other injury producing acute functional impairment.
- Physicians may also classify any injury as distracting if it is thought to have the potential to impair the patient’s ability to appreciate other injuries.
- Intoxication is also similarly intentionally vague:
- A history of intoxication or recent intoxicating ingestion is provided by a patient or observer;
- Test of bodily secretions positive for alcohol or drugs;
- Patient has physical evidence suggesting intoxication (odor of alcohol, slurred speech, ataxia, dysmetria, or other cerebellar findings), or behavior consistent with intoxication and unexplained by medical or psychiatric illness.
This decision instrument can help reduce unnecessary imaging by identifying patients at low risk of thoracic injury, which reduces radiation exposure and provides faster evaluation for emergency providers and their patients, allowing them to focus on treatment, evaluation of other injuries or problems, or education and reassurance.
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From the Creator
- Why did you develop the NEXUS Chest Decision Instrument for Blunt Chest Trauma? Was there a clinical experience that inspired you to create this tool for clinicians?
- I began this line of research over a decade ago, when (during a shift) I noticed that we were getting so many negative chest X-rays (CXRs) in blunt trauma patients. The CXR appeared to be a completely reflexive thing and the vast majority of our studies were non-diagnostic. With an EM resident (Anna Bjoring), I started a pilot study and recruited NEXUS colleagues from UCLA (Bill Mower) and UCSF-Fresno (Greg Hendey). We have followed the path and methods put forth by our mentor Jerry Hoffman in his landmark NEXUS C-Spine work.
- What pearls, pitfalls and/or tips do you have for users of the NEXUS Chest Decision Instrument for Blunt Chest Trauma? Are there cases in which it has been applied, interpreted, or used inappropriately?
- This is a great question. Misapplication of decision rules can paradoxically lead to greater imaging. As with essentially all imaging decision rules, NEXUS Chest was derived and validated only for the purpose of ruling out injury, not ruling it in. In other words, finding one or more NEXUS Chest criteria does not mean you must image that patient. We suggest using NEXUS Chest only in patients whom you were planning to image. Then apply NEXUS Chest to find out whether you can safely forego imaging.
- What recommendations do you have for health care providers once they have applied the NEXUS Chest Decision Instrument for Blunt Chest Trauma? Are there any adjustments or updates you would make to the instrument given recent changes in medicine?
- NEXUS Chest is easy to implement in conjunction with NEXUS C-Spine. Three criteria (altered alertness, intoxication and distracting injury) are the same and a fourth (chest wall tenderness) is analogous to the midline cervical spine tenderness criterion. We suggest that you use them in tandem for rapid evaluation of blunt trauma patients.
- Other comments? Any new research or papers on this topic in the pipeline?
- We have recently completed multicenter derivation and validation of our next rules in this line of research--the NEXUS Chest CT Decision Instruments. Using simple clinical criteria, these rules will allow trauma providers to forego chest CT in approximately 25-37% of blunt trauma patients who would otherwise get it. We hope to publish the manuscript describing this important study within the next 3 months.
About the Creator
Robert Rodriguez, MD, is a professor of clinical emergency medicine and the residency research director at UCSF School of Medicine. He is also an attending emergency room physician. Dr. Rodriguez's research interests include deriving decision instruments for imaging in blunt trauma, critical care in the ED, infectious disease presentations to the ED, homeless and immigrant population access and care in the ED, and defensive medicine.
To view Dr. Robert Rodriguez's publications, visit PubMed