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Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT).

Rodriguez RM, Langdorf MI, Nishijima D, Baumann BM, Hendey GW, Medak AJ, Raja AS, Allen IE, Mower WR - PLoS Med. (2015)

Bottom Line: During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results.Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury.We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs.

View Article: PubMed Central - PubMed

Affiliation: Department of Emergency Medicine, University of California, San Francisco, California, United States of America.

ABSTRACT

Background: Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients.

Methods and findings: From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients-6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 20.8% (95% CI 19.2%-22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%-100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%-96.9%), a specificity of 25.5% (95% CI 23.5%-27.5%), and a NPV of 93.9% (95% CI 91.5%-95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection.

Conclusions: We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population.

No MeSH data available.


Related in: MedlinePlus

NEXUS Chest CT decision instrument implementation.Abnormal CXR is any thoracic injury (including clavicle fracture) or a widened mediastinum. Rapid deceleration mechanism is a fall from >20 feet (6.1 m) or a motor vehicle accident at >40 miles (64.4 km) per hour with sudden deceleration. Thoracic injury is defined as pneumothorax, hemothorax, aortic or great vessel injury, multiple rib fractures, ruptured diaphragm, sternal fracture, scapular fracture, thoracic spine fracture, esophageal injury, tracheal/bronchial injury, or pulmonary contusion/laceration. *These four criteria may be evaluated together as any thoracic wall, sternal, spine, or scapular tenderness. Sen, sensitivity; Spec, specificity.
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pmed.1001883.g002: NEXUS Chest CT decision instrument implementation.Abnormal CXR is any thoracic injury (including clavicle fracture) or a widened mediastinum. Rapid deceleration mechanism is a fall from >20 feet (6.1 m) or a motor vehicle accident at >40 miles (64.4 km) per hour with sudden deceleration. Thoracic injury is defined as pneumothorax, hemothorax, aortic or great vessel injury, multiple rib fractures, ruptured diaphragm, sternal fracture, scapular fracture, thoracic spine fracture, esophageal injury, tracheal/bronchial injury, or pulmonary contusion/laceration. *These four criteria may be evaluated together as any thoracic wall, sternal, spine, or scapular tenderness. Sen, sensitivity; Spec, specificity.

Mentions: When designing this study, we were cognizant of distinct trauma practice variations and ideological differences in terms of injury diagnosis thresholds [24]. We therefore convened a multidisciplinary panel to classify injuries seen on CT and developed two distinct DIs. For clinicians who believe it is important to diagnose all (or nearly all) injuries, we developed Chest CT-All, which detects both major and minor injuries with high sensitivity and which may allow providers to forego unnecessary chest CT in approximately 25% of patients. For clinicians who seek to detect only those injuries that result in interventions, we recommend our second DI, Chest CT-Major, which maintains an equally high sensitivity for major injuries and has a greater specificity of over 37%, thereby sparing more patients from unnecessary CT. The only difference between the two DIs is the inclusion of the criterion of rapid decelerating mechanism in Chest CT-All, which allowed for greater detection of minor injuries. See Fig 2 for our recommended implementation of Chest CT-All and Chest CT-Major.


Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT).

Rodriguez RM, Langdorf MI, Nishijima D, Baumann BM, Hendey GW, Medak AJ, Raja AS, Allen IE, Mower WR - PLoS Med. (2015)

NEXUS Chest CT decision instrument implementation.Abnormal CXR is any thoracic injury (including clavicle fracture) or a widened mediastinum. Rapid deceleration mechanism is a fall from >20 feet (6.1 m) or a motor vehicle accident at >40 miles (64.4 km) per hour with sudden deceleration. Thoracic injury is defined as pneumothorax, hemothorax, aortic or great vessel injury, multiple rib fractures, ruptured diaphragm, sternal fracture, scapular fracture, thoracic spine fracture, esophageal injury, tracheal/bronchial injury, or pulmonary contusion/laceration. *These four criteria may be evaluated together as any thoracic wall, sternal, spine, or scapular tenderness. Sen, sensitivity; Spec, specificity.
© Copyright Policy
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4595216&req=5

pmed.1001883.g002: NEXUS Chest CT decision instrument implementation.Abnormal CXR is any thoracic injury (including clavicle fracture) or a widened mediastinum. Rapid deceleration mechanism is a fall from >20 feet (6.1 m) or a motor vehicle accident at >40 miles (64.4 km) per hour with sudden deceleration. Thoracic injury is defined as pneumothorax, hemothorax, aortic or great vessel injury, multiple rib fractures, ruptured diaphragm, sternal fracture, scapular fracture, thoracic spine fracture, esophageal injury, tracheal/bronchial injury, or pulmonary contusion/laceration. *These four criteria may be evaluated together as any thoracic wall, sternal, spine, or scapular tenderness. Sen, sensitivity; Spec, specificity.
Mentions: When designing this study, we were cognizant of distinct trauma practice variations and ideological differences in terms of injury diagnosis thresholds [24]. We therefore convened a multidisciplinary panel to classify injuries seen on CT and developed two distinct DIs. For clinicians who believe it is important to diagnose all (or nearly all) injuries, we developed Chest CT-All, which detects both major and minor injuries with high sensitivity and which may allow providers to forego unnecessary chest CT in approximately 25% of patients. For clinicians who seek to detect only those injuries that result in interventions, we recommend our second DI, Chest CT-Major, which maintains an equally high sensitivity for major injuries and has a greater specificity of over 37%, thereby sparing more patients from unnecessary CT. The only difference between the two DIs is the inclusion of the criterion of rapid decelerating mechanism in Chest CT-All, which allowed for greater detection of minor injuries. See Fig 2 for our recommended implementation of Chest CT-All and Chest CT-Major.

Bottom Line: During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results.Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury.We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs.

View Article: PubMed Central - PubMed

Affiliation: Department of Emergency Medicine, University of California, San Francisco, California, United States of America.

ABSTRACT

Background: Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients.

Methods and findings: From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients-6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 20.8% (95% CI 19.2%-22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%-100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%-96.9%), a specificity of 25.5% (95% CI 23.5%-27.5%), and a NPV of 93.9% (95% CI 91.5%-95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection.

Conclusions: We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population.

No MeSH data available.


Related in: MedlinePlus