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    Patent Pending

    NEXUS Chest Decision Instrument for Blunt Chest Trauma

    Determines which patients require chest imaging after blunt trauma.
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    INSTRUCTIONS

    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).

    When to Use
    Pearls/Pitfalls
    Why Use
    • 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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    Next Steps
    Evidence
    Creator Insights

    Advice

    • In patients who get chest x-ray and CT is being considered, the NEXUS creators recommend using the NEXUS Chest CT Decision Instrument.
    • Adequate pain control is always important in patients with trauma.
    • Consider initial evaluation with chest x-ray in stable patients with isolated chest trauma.
    • CT will obviously find many more injuries than x-ray, regardless of their true clinical significance.
    • CT may be more useful in patients with multiple injuries or those who are sicker.
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    About the Creator
    Dr. Robert Rodriguez
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