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    Chief Complaint


    Organ System


    Patent Pending

    Newsom Score for Non-traumatic Chest Pain

    Rules out need for chest x-ray in chest pain patients (non-traumatic).


    Use in patients presenting to the emergency department for non-traumatic chest pain.

    When to Use
    Why Use

    Patients presenting to the emergency department for non-traumatic chest pain.

    • Application of this decision tool would have missed five clinically relevant diagnoses in the study population: three pneumonias and two pleural effusions.

    • The prevalence of clinically relevant ED findings on chest x-ray in the study population was 6.4%. In populations where prevalence is higher, negative predictive value (98.4% in the study) would decrease (Newsom 2018).
    • Can potentially safely eliminate unnecessary x-ray in patients presenting to EDs with non-traumatic chest pain (92.9% sensitive, NPV 98.4% for clinically relevant ED findings on chest x-ray).
    • In the validation study, application of the score would have decreased chest x-ray usage by 28.9%.
    • The study authors estimate a potential decrease of $58 million per year in healthcare costs as a result of the potential decrease number of chest x-rays performed with application of the clinical decision tool. 

    Presence of ≥1 means the patient is not low risk:

    Diagnostic Result:

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    Next Steps
    Creator Insights

    Critical Actions

    • Consider prevalence of clinically significant chest x-ray findings in your population in comparison to the study population before applying the clinical decision tool to your practice. 
    • Though the criteria had excellent sensitivity and NPV for the study population, it did miss cases of pneumonia and pleural effusions. If clinical suspicion for these diagnosis is high despite absence of study criteria, consider performing chest x-ray. 


    Selection of the appropriate criteria:


    Age ≥60 years

    CHF history

    Smoking history


    Tuberculosis history

    Thromboembolic history

    Prior/current alcohol abuse

    Fever ≥100.4°F (38°C)

    Oxygen saturation <90%

    Respiratory rate >24

    Diminished breath sounds


    Facts & Figures


    Criteria present

    Risk group




    Chest x-ray not needed


    Not low

    Consider chest x-ray

    Evidence Appraisal

    Original, Derivation Rothrock Study (Rothrock 2002)

    • In 2002, investigators attempted to develop a clinical decision rule to identify criteria to predict clinically significant findings on chest x-ray in adult patients presenting to the ED with non-traumatic chest pain.

    • A prospective observational trial was performed at a single urban ED which enrolled 1,650 patients who underwent chest x-ray for non-traumatic chest pain.

    • 17% of the study population had a clinically significant finding on chest x-ray.

    • Using 10 criteria (all except CHF history and smoking history from Modified Rothrock Criteria), sensitivity was 95% and NPV 98%.

    Subsequent Studies (Newsom 2014, Hess 2010, Poku 2012)

    • In 2014, Newsom et al attempted to externally validate the Rothrock Criteria by performing a retrospective validation at a different ED.

    • However, the sensitivity was found to be only 79% for clinically significant chest x-ray findings in this population.

    • The NPV remained at 98%, consistent with the derivation study due to the significantly lower prevalence of pathology (5.2%) in the subsequent study population.

    • Despite not being able to validate the clinical decision tool, the investigators were able to determine that a history of CHF is highly influential in identifying which patients are at risk for having a clinically significant chest x-ray abnormality.

    • In 2014, another group (Hess et al) attempted to derive a different clinical decision tool to identify criteria to predict clinically significant findings on chest x-ray.

    • The derivation study showed promise as the absence of CHF history, smoking, and lung auscultation abnormalities was 100% sensitive for clinically significant chest x-ray abnormalities in their study population.

    • Unfortunately, attempts to validate this derivation rule were unsuccessful, with a sensitivity of 78.3% in the derivation study population.

    • However, this work demonstrated that a history of smoking was influential in identifying patients who are at risk for having a clinically significant chest x-ray abnormality.

    Newsom Study, Modified Rothrock Criteria (Newsom 2018)

    • In 2018, Newsom et al performed a prospective, observational study at three emergency departments in an attempt to validate a clinical decision tool to identify patients at risk for clinically relevant chest x-ray findings by modifying the Rothrock Criteria to add CHF and smoking history to the criteria.

    • In this study of 1,089 patients with non-traumatic chest pain, 6.4% had clinically significant chest x-ray abnormalities.

    • In this population, the Modified Rothrock Criteria were found to be 92.9% sensitive for clinically significant abnormalities found on CXR as well as having a NPV of 98.4%.

    • Implementation of these criteria would have decreased the amount of CXR performed by 28.9%.

    • The application of the rule would have resulted in five missed diagnoses of the 70 clinically significant ED diagnoses found:

      • Three cases of pneumonia missed (88.5% sensitive for pneumonia).

      • Two pleural effusions missed (94.1% sensitive for pleural effusions).

    • In this validation study, prevalence of pathology was much lower than in the derivation study, demonstrating impact of prevalence on NPV and the application of clinical decision tools in unique populations. 


    Dr. Case K. Newsom

    About the Creator

    Case K. Newsom, DO, is an emergency physician in the St. Luke's University Health Network in Bethlehem, Pennsylvania. Dr. Newsom’s primary research is focused on traumatic injuries.

    To view Dr. Case K. Newsom's publications, visit PubMed

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