Another doom and gloom trauma article that wants to take one of our most cherished tools away from us regarding the evaluation of the blunt trauma patients. Certainly, nothing is sacred, but these authors want to take NEXUS out to the woodshed and make sure every trauma patient gets a CT of the c-spine.
The premise of their argument is reasonable – NEXUS was derived in an era of plain films for radiographic clearance of the cervical spine, and now, many studies have observed that CT with 3D reconstruction picks up potentially significant injuries that could be missed by plain x-rays. Therefore, the gold standard incorporating plain radiography for NEXUS renders it invalid due to missed injuries.
These authors performed a prospective evaluation of the NEXUS rules by applying them to 2,606 adult trauma patients, all of whom underwent 16 multidetector CT scanning with 2mm thick axial cuts. They found 157 patients with a total of 258 fractures – and note that 26 patients had fractures identified despite meeting NEXUS criteria. Of these 26, 16 were managed in a c-collar, 2 underwent operative stabilization, and 1 had a halo placed. Therefore, they simply conclude that NEXUS is not externally valid to their trauma population and everyone should receive a CT of the c-spine based on mechanism.
Finding flaws with NEXUS – excellent, let’s identify the subset at higher-risk so we can prevent missed injuries. However, this article doesn’t help us at all. They don’t do any sort of descriptive analysis of the NEXUS-negative patients who end up with significant injuries with which to educate our practice. They simply conclude with the blanket statement that the dollar cost of performing all the CTs is less than the dollar cost of potential malpractice payouts.
In an era where we’re trying to cut healthcare costs and reduce the practices of defensive medicine, this is precisely the sort of article that we don’t need. This is fantastic data presented in a non-constructive fashion that will likely, as the authors seem to intend, ensure the 97% of NEXUS-negative patients who had no injuries get their CT of the c-spine.
“National Emergency X-Radiography Utilization Study Criteria Is Inadequate to Rule Out Fracture After Significant Blunt Trauma Compared With Computed Tomography”
http://www.ncbi.nlm.nih.gov/pubmed/21610391
It's already hard enough to order a plain film of the neck in a young MVC patient! I have heard some of the authors of NEXUS talk about their conscientious search for "false-negative" patients, and it reassured me greatly about the safety of their approach.
From 2,606 patients with blunt trauma, they find 26 with "NEXUS-negative" injuries, of which 3 had intensive intervention. 1 in a thousand – pretty good odds, actually, even if you never examined the patient & were only looking at the film!
It's already hard enough to order a plain film of the neck in a young MVC patient! I have heard some of the authors of NEXUS talk about their conscientious search for "false-negative" patients, and it reassured me greatly about the safety of their approach.
From 2,606 patients with blunt trauma, they find 26 with "NEXUS-negative" injuries, of which 3 had intensive intervention. 1 in a thousand – pretty good odds, actually, even if you never examined the patient & were only looking at the film!
The problem is, the further we get into the era of NEXUS and CCR, the more reasonable literature we see identifying patients missed by the rules. And, this makes sense – these are mostly successful simplifications of complex clinical questions, but they have holes. I'm just afraid this literature is going to lead us into a dark age of pan-scanning before we can develop better complex decision instruments we can run through the decision-support engine of our electronic health records to guide our clinical acumen.
The problem is, the further we get into the era of NEXUS and CCR, the more reasonable literature we see identifying patients missed by the rules. And, this makes sense – these are mostly successful simplifications of complex clinical questions, but they have holes. I'm just afraid this literature is going to lead us into a dark age of pan-scanning before we can develop better complex decision instruments we can run through the decision-support engine of our electronic health records to guide our clinical acumen.
When we actually look at the NEXUS rules as written, they are far more demanding than the simple version we have memorized. I doubt the docs in the study applied them in the way the original study outlined; if they did, there probably would have been no misses. But far fewer patients would have been cleared.
When we actually look at the NEXUS rules as written, they are far more demanding than the simple version we have memorized. I doubt the docs in the study applied them in the way the original study outlined; if they did, there probably would have been no misses. But far fewer patients would have been cleared.
The specific minutiae of NEXUS definitely expand the simple criteria we all have memorized. But, what's more relevant – NEXUS as defined, or NEXUS as clinically applied? If clinicians apply it too narrowly in general practice, that's the appropriate measure of its effectiveness – e.g., TPA NINDS vs. TPA Cleveland Experience (with all their protocol deviations).
Well this is really awesome post. I really like it. Thanks for sharing.
USMLE
Well this is really awesome post. I really like it. Thanks for sharing.
USMLE