title: Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT).
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.
  
  
  RESULTS
  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.
authors.affiliation: Department of Emergency Medicine, University of California, San Francisco, California, United States of America.
authors.forename: Robert M
authors.initials: RM
authors.lastname: Rodriguez
authors.affiliation: Department of Emergency Medicine, University of California, Irvine, California, United States of America.
authors.forename: Mark I
authors.initials: MI
authors.lastname: Langdorf
authors.affiliation: Department of Emergency Medicine, University of California, Davis, California, United States of America.
authors.forename: Daniel
authors.initials: D
authors.lastname: Nishijima
authors.affiliation: Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, New Jersey, United States of America.
authors.forename: Brigitte M
authors.initials: BM
authors.lastname: Baumann
authors.affiliation: Department of Emergency Medicine, UCSF Fresno Medical Education and Research, Fresno, California, United States of America.
authors.forename: Gregory W
authors.initials: GW
authors.lastname: Hendey
authors.affiliation: Department of Emergency Medicine, School of Medicine, University of California, San Diego, California, United States of America.
authors.forename: Anthony J
authors.initials: AJ
authors.lastname: Medak
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, Massachusetts, United States of America.
authors.forename: Ali S
authors.initials: AS
authors.lastname: Raja
authors.affiliation: University of California, San Francisco, California, United States of America.
authors.forename: Isabel E
authors.initials: IE
authors.lastname: Allen
authors.affiliation: Department of Emergency Medicine, University of California, Los Angeles, California, United States of America.
authors.forename: William R
authors.initials: WR
authors.lastname: Mower
mesh_terms: D000328:Adult; D000465:Algorithms; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D011446:Prospective Studies; D012680:Sensitivity and Specificity; D013898:Thoracic Injuries / Q000000981:diagnostic imaging*; D014057:Tomography, X-Ray Computed; D014481:United States; D014949:Wounds, Nonpenetrating / Q000000981:diagnostic imaging*