National Emergency X-Radiography Utilization Study Research Articles

Effectiveness of implementation strategies for increasing clinicians' use of five validated imaging decision rules for musculoskeletal injuries: a systematic review.

Strategies to enhance clinicians' adherence to validated imaging decision rules and increase the appropriateness of imaging remain unclear. To evaluate the effectiveness of various implementation strategies for increasing clinicians' use of five validated imaging decision rules (Ottawa Ankle Rules, Ottawa Knee Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study and Canadian Computed Tomography Head Rule). Systematic review. The inclusion criteria were experimental, quasi-experimental study designs comprising randomised controlled trials (RCTs), non-randomised controlled trials, and single-arm trials (i.e. prospective observational studies) of implementation interventions in any care setting. The search encompassed electronic databases up to March 11, 2024, including MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane CENTRAL, Web of Science, and Scopus. Two reviewers assessed the risk of bias of studies independently using the Cochrane Effective Practice and Organization of Care Group (EPOC) risk of bias tool. The primary outcome was clinicians' use of decision rules. Secondary outcomes included imaging use (indicated, non-indicated and overall) and knowledge of the rules. We included 22 studies (5-RCTs, 1-non-RCT and 16-single-arm trials), conducted in emergency care settings in six countries (USA, Canada, UK, Australia, Ireland and France). One RCT suggested that reminders may be effective at increasing clinicians' use of Ottawa Ankle Rules but may also increase the use of ankle radiography. Two RCTs that combined multiple intervention strategies showed mixed results for ankle imaging and head CT use. One combining educational meetings and materials on Ottawa Ankle Rules reduced ankle injury imaging among ED physicians, while another, with similar efforts plus clinical practice guidelines and reminders for the Canadian CT Head Rule, increased CT imaging for head injuries. For knowledge, one RCT suggested that distributing guidelines had a limited short-term impact but improved clinicians' long-term knowledge of the Ottawa Ankle Rules. Interventions such as pop-up reminders, educational meetings, and posters may improve adherence to the Ottawa Ankle Rules, Ottawa Knee Rule, and Canadian CT Head Rule. Reminders may reduce non-indicated imaging for knee and ankle injuries. The uncertain quality of evidence indicates the need for well-conducted RCTs to establish effectiveness of implementation strategies.

Blunt Head Injury in the Elderly: Analysis of the NEXUS II Injury Cohort

Changes with aging make older patients vulnerable to blunt head trauma and alter the potential for injury and the injury patterns seen among this expanding cohort. High-quality care requires a clear understanding of the factors associated with blunt head injuries in the elderly. Our objective was to develop a detailed assessment of the injury mechanisms, presentations, injury patterns, and outcomes among older blunt head trauma patients. We conducted a planned secondary analysis of patients aged 65 or greater who were enrolled in the National Emergency X-Radiography Utilization Study (NEXUS) Head Computed Tomography validation study. We performed a detailed assessment of the demographics, mechanisms, presentations, injuries, interventions, and outcomes among older patients. We identified 3,659 patients aged 65 years or greater, among the 11,770 patients enrolled in the NEXUS validation study. Of these older patients, 325 (8.9%) sustained significant injuries, as compared with significant injuries in 442 (5.4%) of the 8,111 younger patients. Older females (1,900; 51.9%) outnumbered older males (1,753; 47.9%), and occult presentations (exhibiting no high-risk clinical criteria beyond age) occurred in 48 (14.8%; 95% confidence interval (CI) 11.1 to 19.1) patients with significant injuries. Subdural hematomas (377 discreet lesions in 299 patients) and subarachnoid hemorrhages (333 discreet instances in 256 patients) were the most frequent types of injuries occurring in our elderly population. A ground-level fall was the most frequent mechanism of injury among all patients (2,211; 69.6%), those sustaining significant injuries (180; 55.7%), and those who died of their injuries (37; 46.3%), but mortality rates were highest among patients experiencing a fall from a ladder (11.8%; 4 deaths among 34 cases [95% CI 3.3% to 27.5%]) and automobile versus pedestrian events (10.7%; 16 deaths among 149 cases [95% CI 6.3% to 16.9%]). Among older patients who required neurosurgical intervention for their injuries, only 16.4% (95% CI 11.1% to 22.9%) were able to return home, 32.1% (95% CI 25.1% to 39.8%) required extended facility care, and 41.8% (95% CI 34.2% to 49.7%) died from their injuries. Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.

Awareness and use of five imaging decision rules for musculoskeletal injuries: a systematic review.

Several validated decision rules are available for clinicians to guide the appropriate use of imaging for patients with musculoskeletal injuries, including the Canadian CT Head Rule, Canadian C-Spine Rule, National Emergency X-Radiography Utilization Study (NEXUS) guideline, Ottawa Ankle Rules and Ottawa Knee Rules. However, it is unclear to what extent clinicians are aware of the rules and are using these five rules in practice. To determine the proportion of clinicians that are aware of five imaging decision rules and the proportion that use them in practice. Systematic review. This was a systematic review conducted in accordance with the 'Preferred reporting items for systematic reviews and meta-analyses' (PRISMA) statement. We performed searches in MEDLINE (via Ovid), CINAHL (via EBSCO), EMBASE (via Ovid), Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science and Scopus databases to identify observational and experimental studies with data on the following outcomes among clinicians related to five validated imaging decision rules: awareness, use, attitudes, knowledge, and barriers and facilitators to implementation. Where possible, we pooled data using medians to summarise these outcomes. We included 39 studies. Studies were conducted in 15 countries (e.g. the USA, Canada, the UK, Australasia, New Zealand) and included various clinician types (e.g. emergency physicians, emergency nurses and nurse practitioners). Among the five decision rules, clinicians' awareness was highest for the Canadian C-Spine Rule (84%, n = 3 studies) and lowest for the Ottawa Knee Rules (18%, n = 2). Clinicians' use was highest for NEXUS (median percentage ranging from 7 to 77%, n = 4) followed by Canadian C-Spine Rule (56-71%, n = 7 studies) and lowest for the Ottawa Knee Rules which ranged from 18 to 58% (n = 4). Our results suggest that awareness of the five imaging decision rules is low. Changing clinicians' attitudes and knowledge towards these decision rules and addressing barriers to their implementation could increase use.

Clinical decision rules in predicting computed tomography scan findings and need for neurosurgical intervention in mild traumatic brain injury: a prospective observational study.

In this study, we will compare the diagnostic values of head CT decision rules in predicting the findings of CT scans in a prospective multicenter study in university emergency departments in Iran. The primary outcome was any traumatic lesion findings in brain CT scans, and the secondary outcomes were death, the need for mechanical ventilation, and neurosurgical intervention. Decision rules including the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), National Institute for Health and Clinical Excellence (NICE), National Emergency X-Radiography Utilization Study (NEXUS), and Neurotraumatology Committee of the World Federation of Neurosurgical Societies (NCWFNS) were compared for the main outcomes. In total, 434 mild TBI patients were enrolled in the study. The NCWFNS had the highest sensitivity (91.14%) and the lowest specificity (39.42%) for predicting abnormal finding in CT scan compared to other models. While the NICE obtained the lowest sensitivity (79.75%), it was associated with the highest specificity (66.67%). All model performances were improved when administered to predict neurosurgical intervention among patients with GCS 13-15. NEXUS (AUC 0.862, 95% CI 0.799-0.924) and NCWFNS (AUC 0.813, 95% CI 0.723-0.903) had the best performance among all evaluated models. The NCWFNS and the NEXUS decision rules performed better than the CCHR and NICE guidelines for predicting any lesion in the CT imaging and neurosurgical intervention among patients with mTBI with GCS 13-15. For a subset of mTBI patients with GCS 15, the NOC criteria havehigher sensitivity for abnormal CT imaging, but lower specificity and more requested CTs.

Comparative study of National Emergency X-Radiography Utilization Study (NEXUS) chest algorithm and extended focused assessment with sonography for trauma (E-FAST) in the early detection of blunt chest injuries in polytrauma patients.

Chest imaging plays a prominent role in the assessment of patients with blunt trauma. Selection of the right approach at the right time is fundamental in the management of patients with blunt chest trauma.[1] A reliable, economic, bedside, and rapidly accomplished screening test can be pivotal. [2]. The aim of this study was to compare the accuracy of extended- focused assessment with sonography for trauma (E-FAST) to that of the National Emergency X-Radiography Utilisation Study (NEXUS) chest algorithm in detecting blunt chest injuries. This descriptive cross-sectional study included 50 polytrauma patients with blunt chest trauma from the emergency centre of Suez Canal University Hospital. E-FAST and computed tomography (CT) were conducted, followed by reporting of NEXUS criteria for all patients. Blinding of the E-FAST performer and CT reporter were confirmed. The results of both the NEXUS algorithm and E-FAST were compared with CT chest results. The NEXUS algorithm had 100% sensitivity and 15.3% specificity, and E-FAST had 70% sensitivity and 96.7% specificity, in the detection of pneumothorax.In the detection of hemothorax, the sensitivity and specificity of the NEXUS algorithm were 90% and 7.5%, respectively, whereas E-FAST had a lower sensitivity of 80% and a higher specificity of 97.5%. E-FAST is highly specific for the detection of hemothorax, pneumothorax, and chest injuries compared with the NEXUS chest algorithm, which demonstrated the lowest specificity. However, the NEXUS chest algorithm showed a higher sensitivity than E-FAST and hence can be used effectively to rule out thoracic injury.

Effect of the Extended Focused Assessment With Sonography for Trauma on the Screening Performance of the National Emergency X-Radiography Utilization Study Chest Decision Instrument.

Developed to decrease unnecessary thoracic computed tomography use in adult blunt trauma patients, the National Emergency X-Radiography Utilization Study (NEXUS) Chest clinical decision instrument does not include the extended Focused Assessment with Sonography in Trauma (eFAST). We assessed whether eFAST improves the NEXUS Chest clinical decision instrument's diagnostic performance and may replace the chest radiograph (CXR) as a predictor variable. We performed a secondary analysis of prospective data from 8 Level I trauma centers from 2011-2014. We compared performance of modified clinical decision instruments that (1) added eFAST as a predictor (eFAST-added clinical decision instrument), and (2) replaced CXR with eFAST (eFAST-replaced clinical decision instrument), in screening for blunt thoracic injuries. One thousand nine hundred fifty-seven patients had documented computed tomography, CXR, clinical NEXUS criteria, and adequate eFAST; 624 (31.9%) patients had blunt thoracic injuries, and 126 (6.4%) had major injuries. Compared to the NEXUS Chest clinical decision instrument, the eFAST-added clinical decision instrument demonstrated unchanged screening performance for major injury (sensitivity 0.98 [0.94 to 1.00], specificity 0.28 [0.26 to 0.30]) or any injury (sensitivity 0.97 [0.95 to 0.98], specificity 0.21 [0.19 to 0.23]). The eFAST-replaced clinical decision instrument demonstrated unchanged sensitivity for major injury (sensitivity 0.93 [0.87 to 0.97], specificity 0.31 [0.29 to 0.34]) and decreased sensitivity for any injury (0.93 [0.91 to 0.951] versus 0.97 [0.953 to 0.98]). In our secondary analysis, adding eFAST as a predictor variable did not improve the diagnostic screening performance of the original NEXUS Chest clinical decision instrument; eFAST cannot replace the CXR criterion of the NEXUS Chest clinical decision instrument.

Current status of imaging studies and application of clinical decision rules for pediatric blunt cervical spine injury

Purpose: We investigated the current status of imaging studies for pediatric blunt cervical spine injury, and applied 3 clinical decision rules to children with blunt trauma of the head or neck in a pediatric emergency center in Korea. The rules included National Emergency X-Radiography Utilization Study (NEXUS) criteria, Canadian Cervical Spine Rule, and Pediatric Emergency Care Applied Research Network risk factors.Methods: This was a retrospective study conducted on 399 children aged 15 years or younger who visited the center after the blunt trauma, and underwent cervical spine radiographs from January 2020 through December 2021. We examined the clinical characteristics per age groups (0-1, 2-5, 6-12, and 13-15 years). Using the 3 rules, we selected children with a potential need for imaging studies (PNI). For this purpose, we analyzed the absence of low-risk variables and the presence of high-risk variables. Predictive performances of the rules were measured for the imaging-confirmed cervical spine injury.Results: The study population (n = 399) had a median age of 5.0 years (interquartile range, 2.0-9.0) and a 64.2% boys’ proportion. Fall (36.6%) was the most common injury mechanism. Two children had the cervical spine injuries. As per NEXUS criteria, Canadian Cervical Spine Rule, and Pediatric Emergency Care Applied Research Network risk factors, 72 (18.0%), 289 (72.4%), and 74 children (18.5%) were classified as those with PNI, respectively. Resultantly, 291 children (72.9%) were classified as having PNI whereas the other 108 (27.1%) were deemed to undergo unnecessary imaging. The 3 rules had nearly 100% sensitivity and negative predictive value, except a 50% sensitivity of NEXUS criteria.Conclusion: Imaging studies can be minimized for children with blunt trauma of the head or neck who are deemed without PNI per the 3 current clinical decision rules. More elaborate criteria are needed to make a timely diagnosis.

Physical Examination Sensitivity for Skull Fracture in Pediatric Patients With Blunt Head Trauma: A Secondary Analysis of the National Emergency X-Radiography Utilization Study II Head Computed Tomography Validation Study.

We evaluated the emergency department (ED) providers' ability to detect skull fractures in pediatric patients presenting with blunt head trauma. This was a secondary analysis of the National Emergency X-Radiography Utilization Study (NEXUS) Head computed tomography (CT) validation study. Demographics and clinical characteristics were analyzed for pediatric patients. Radiologist interpretations of head CT imaging were abstracted and cataloged. Detection of skull fractures was evaluated through provider response to specific clinical decision instrument criteria (NEXUS or Canadian head CT rules) at the time of initial patient evaluation. The presence of skull fracture was determined by formal radiologist interpretation of CT imaging. Between April 2006, and December 2015, 1,018 pediatric patients were enrolled. One hundred twenty-eight (12.5%) children had a notable injury reported on CT head. Skull fracture was present in most (66.4%) children with intracranial injuries. The sensitivity and specificity of provider physical examination to detect skull fractures was 18.5% (95% confidence interval 10.5% to 28.7%) and 96.6% (95.3% to 97.7%), respectively. The most common injuries associated with skull fractures were subarachnoid hemorrhage (27%) and subdural hematoma (22.3%). Skull fracture is common in children with intracranial injury after blunt head trauma. Despite this, providers were found to have poor sensitivity for skull fractures in this population, and these injuries may be missed on initial emergency department assessment.

Frequency and Outcomes of Cervical Spine Computed Tomography Imaging on Alcohol-Intoxicated Patients in the Emergency Department

BackgroundCervical spinal (c-spine) injuries range greatly in severity from minor ligamentous injuries to osteoligamentous instability with spinal cord injuries. Initial evaluation begins with stabilization as needed and immediate immobilization. Current practice as to whether the c-spine can be cleared clinically without radiographic evaluation is often guided by using the National Emergency X-Radiography Utilization Study Low-Risk Criteria and the Canadian C-Spine Rule. Under these clinical decision guidelines, stable trauma patients presenting with alcohol intoxication cannot have the c-spine cleared clinically and imaging should be “considered.” ObjectiveThis study aimed to assess the frequency of computed tomography (CT) c-spine scans ordered for patients presenting with alcohol intoxication to the emergency department (ED), the timing of the studies, and subsequently determine the proportion of which showed a clinically significant result that required intervention. MethodsIn this retrospective medical record review, all clinically alcohol-intoxicated patients presenting to two academic EDs were included. Overall demographic characteristics, time to order of CT imaging, radiology reads, and outcomes of patient visits were determined. ResultsThere were 8008 patient visits included in the study. Of these visits, 5 patients scanned in ≤3 h had acute findings on CT scan and no patients with a deferred timing of CT scan after patients metabolized had an acute finding on CT scan. No patients required operative management. ConclusionsThis study's results suggest that it is a safe clinical practice to defer CT imaging for patients presenting to the ED with alcohol intoxication and low suspicion for c-spine injury per history and examination.

NEXUS vs. Canadian C-Spine Rule (CCR) in Predicting Cervical Spine Injuries; a Systematic Review and Meta-analysis.

Clinical decision tools have been shown to reduce imaging rates for clearance of suspected cervical spine injury (CSI). This review provides more comprehensive evidence on the diagnostic capabilities of National Emergency X-Radiography Utilization Study (NEXUS) and Canadian C-spine rule (CCR) in this regard. A systematic review of the current literature was performed on studies published until Jan 26th, 2023, in databases of Medline, Scopus, Web of Science, and Embase, investigating the performance of NEXUS and CCR in blunt trauma patients. QUADAS-2 and GRADE guidelines were used to assess the quality and certainty of evidence. All analyses were performed using the STATA 14.0 statistical analysis software. 35 articles comprising 70000 patients for NEXUS and 33000 patients for CCR were included in this review. NEXUS and CCR were evaluated to have a sensitivity of 0.94 (95% confidence interval (CI): 0.88 to 0.98) and 1.00 (95% CI: 0.98 to 1.00) in the detection of any CSI and 0.95 (95% CI: 0.89 to 0.98) and 1.00 (95% CI: 0.95 to 1.00) in the detection of clinically important CSI. The area under the curve (AUC) of NEXUS and CCR was 0.85 and 0.97 for any CSI and 0.78 (95% CI: 0.74 to 0.81) and 0.94 (95% CI: 0.91 to 0.96) for clinically important CSI. Our study demonstrates that both NEXUS and CCR can be used in ruling out patients with low risk of CSI, and CCR was shown to have superior performance. Even though these tools have low specificity, their application can still greatly reduce the number of radiographic imaging performed in emergency departments.

Canadian C-spine Rule versus NEXUS in Screening of Clinically Important Traumatic Cervical Spine Injuries; a systematic review and meta-analysis.

The Canadian C-spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) are two criteria designed to rule-out clinically important traumatic cervical Spinal Cord Injury (SCI). In this systematic review and meta-analysis, we reviewed the articles comparing the performance of these two models. Search was done in Medline, Embase, Scopus and Web of Science until June 2022. Observational studies with direct comparison of CCR and NEXUS criteria in detection of clinically important cervical SCI were included. Two independent reviewers screened the relevant articles and summarized the data. Certainty of evidence was assessed based on QUADAS-2. Data were recorded as true positive, true negative, false positive, and false negative. Then, using "diagma" package and applying weighted random effect model, area under the receiver operating characteristic (ROC) curve (AUC), sensitivity, specificity, negative likelihood ratio, positive likelihood ratio, and diagnostic odds ratio (DOR) were calculated with 95% confidence interval (95% CI). We included 5 studies with direct comparison. Area under the ROC curve of NEXUS in screening of patients with clinically important cervical SCI was 0.708 (95% CI: 0.647 to 0.762). Pooled sensitivity and specificity of NEXUS criteria in screening of patients with clinically important cervical SCI were 0.899 (95% CI: 0.845 to 0.936) and 0.398 (95% CI: 0.315 to 0.488). The positive and negative likelihood ratios of NEXUS were 1.494 (95% CI: 1.146 to 1.949) and 0.254 (95% CI: 1.155 to 1.414), respectively. Diagnostic odds ratio of NEXUS was 5.894 (95% CI: 3.372 to 10.305). Furthermore, area under the ROC curve of CCR in screening of clinically important cervical SCI was 0.793 (95% CI: 0.657 to 0.884). Meta-analysis results showed that pooled sensitivity of CCR criteria in screening of patients with clinically important cervical SCI was 0.987 (95% CI: 0.957 to 0.996) and specificity was 0.167 (95% CI: 0.073 to 0.336). The positive and negative likelihood ratios of CCR were 1.184 (95% CI: 0.837 to 1.675) and 0.081 (95% CI: 0.021 to 0.308), respectively. Diagnostic odds ratio of CCR was 14.647 (95% CI: 3.678 to 58.336). Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.

Retrospective analysis of efficacy of the National Emergency X-Radiography Utilization Study low-risk criteria and the Canadian cervical spine rules for cervical spine trauma

Background: With increasing road traffic accidents, cervical spine injuries are a major health hazard in the developed as well as the developing world. Over the years, the National Emergency X-radiography Utilization Study (NEXUS) low-risk criteria and the Canadian cervical spine rules (CCRs) have acted as primary guidelines in emergency departments around the world to decide on the need for cervical spine X-ray in emergency settings. The aim of this study was to retrospectively analyze the efficiency of both the NEXUS low-risk criteria and CCR in confirming positive cervical spine injuries in emergency department settings. Aims and Objectives: The aim was to retrospectively analyze the efficiency of both the NEXUS low-risk criteria and CCR in confirming positive cervical spine injuries. Methods: A retrospective study involving 631 patients for 4 years aged above 18 years, who underwent a cervical spine X-ray from June 2018 to June 2022, were included in the study. From the eligible case records, the data pertaining to the NEXUS low-risk criteria and CCR were recorded. Along with this, the final diagnosis regarding the cervical spine injury, confirmed by subsequent computed tomography (CT) scan or magnetic resonance imaging (MRI), was also recorded. Results: The NEXUS low-risk criteria and CCR were met in 92.7% and 98.6% of the patients, respectively. The cervical spine X-rays were normal in 87.8% of the patients, fractures were recorded in 9.5% of the patients, and in 2.7% of the patients, doubtful lesions were present, which needed additional investigations in the form of CT scan or MRI or both. Conclusion: Both the Nexus and CCR guidelines act as a good guiding light in deciding about the need for the cervical spine X-ray in the emergency setup. Both guidelines are effective in ruling out cervical spine injuries in the majority of cases.

Cervical Spine Computed Tomography in Adolescent Blunt Trauma Patients: Are They Being Overutilized?

IntroductionCervical spine computed tomography (CSCT) scans are used to evaluate cervical spine traumatic injuries; however, recent evidence demonstrates that adult trauma centers (ATCs) overutilize CSCT when evaluating adolescent patients. This leads to unnecessary radiation exposure. The aim of this study is to review a level 1 ATC's use of CSCT in the adolescent blunt trauma population. MethodsA retrospective chart review was conducted of a level 1 ATC's trauma database. Blunt trauma patients between the ages of 11 and 18 who receive a CSCT between January 2015 to December 2019 were included. The primary outcome was the prevalence of positive findings on CSCT scans. Data were analyzed using Fischer-Exact analysis and multivariate logistic regression where appropriate. ResultsThree-hundred thirty-seven of 546 (61.7%) adolescent blunt trauma patients received CSCT. Of those, 68.2% (230) were male; the mean age was 16.6 ± 1.0 y old. Twenty-eight patients (8.3%) had a positive finding on CSCT. All patients with a positive CSCT failed the National Emergency X-Radiography Utilization study (NEXUS) criteria while 123 patients (36.5%) with a negative CSCT met NEXUS criteria. ConclusionsCSCT was overutilized in our trauma center. There is a low positive CSCT scan rate among adolescent patients, which aligns with the current literature. All patients with positive CSCT passed NEXUS criteria suggesting that a quality improvement project focusing on the use of the NEXUS criteria to assess the risk of cervical spine injury could potentially reduce the use of CSCT scans by nearly 40%.

Implementation of National Emergency X-Radiography Utilization Study (NEXUS) Criteria in Pediatrics: A Systematic Review.

Since its introduction in 1992, the National Emergency X-Radiography Utilization Study (NEXUS) criteria have been used in trauma to decide whether a patient requires radiographic imaging. The tool is important in reducing radiation exposure. However, applying the NEXUS criteria for cervical spine imaging in pediatric patients is poorly supported compared to their use in adults. The objective of this review was to examine the effectiveness of using the NEXUS criteria in the diagnostic management of pediatric cervical spine injuries (CSI). The following databases were searched for studies focused on applying the NEXUS criteria for CSI in pediatric patients: Cochrane, PubMed, Google Scholar, EMBASE, ELSEVIER, and ScienceDirect. Additional studies were found through reference lists of primary sources and previous systematic and meta-analyses.The search focused on randomized controlled trials (RCTs), cohort studies, retrospective studies, prospective studies, and other uncontrolled trials published from 2000 to 2022. There were seven included studies with a total of 4502 pediatric patients. Five of the included studies were retrospective studies, while the remaining were prospective and case studies. Our results show that the sensitivity ranged from 43% to 100%, while the specificity ranged from 12.93% to 96%. The sensitivity increased with age, with those under the age of two or under the age of eight reporting poorer outcomes than the older pediatric patients. One study also shows that the proportion of patients undergoing cervical spine CT increased from 18% to 61% in the initial period before the implementation of clearance guidelines. The implementation of guidelines led to a 23% decrease in CT scans clearable by NEXUS criteria after 12 months. One of the studies reported that NEXUS criteria were a cost-effective option when used along with X-rays and CT. Overall, the studies do not strongly support the application of the NEXUS criteria to image pediatric patients for CSI. In conclusion, there is weak support in the literature for applying the NEXUS criteria in determining the need for cervical spine imaging in pediatric trauma patients. The practice and research implications of the findings are also discussed.

Factors which affect the application and implementation of a spinal motion restriction protocol by prehospital providers in a low resource setting: A scoping review.

The safety and effectiveness of prehospital clinical c-spine clearance or spinal motion restriction (SMR) decision support tools are unclear. The present study aimed to examine the available literature on clinical cervical spine clearance and selective SMR decision support tools to identify possible barriers to implementation, safety, and effectiveness when used by emergency medical service (EMS) practitioners. We performed a focused scoping review of published literature on the prehospital use of clinical c-spine clearance and SMR decision tools in adult blunt trauma patients. The Medline, Embase, Cochrane Library, Cumulative Index of Nursing and Allied Health Literature, Web of Science, Turning Research into Practice and EBSCOhost online databases were searched (February 2021). The type of decision support tool and facilitators and barriers to its use were extracted from each included publication in accordance with a modified descriptive-analytical framework. Extracted data were subjected to thematic analysis. Following screening, forty-two articles were included in this scoping review. No studies conducted specifically in low resource settings were found. The majority of articles (57%) evaluated the use of specific SMR decision support tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) and the Canadian C-spine Rule (CCR). Potential facilitators of safe and effective use were identified in 60%, and potential barriers to safe and effective use in 55% of included articles. Only one study evaluated the CCR when used by EMS practitioners, making it difficult to determine its appropriateness for implementation in the prehospital setting. This is the first scoping review, to our knowledge, that has attempted to identify the possible barriers and facilitators to their implementation, safety, and effectiveness when used by EMS practitioners. Key issues identified included terminology, guideline compliance and implementation, and a lack of context-specific evidence. These may provide important considerations for future guideline development.

Variability of Pediatric Cervical Spine Clearance Protocols: A Systematic Review.

The objective of this study was to better understand the variability that exists in the contemporary pediatric cervical spine (c-spine) clearance protocols and how this variability affects clinical practice and outcomes. Pediatric c-spine injury is a rare but potentially devastating event. In the adult population, validated tools, such as the National Emergency X-Radiography Utilization Study (NEXUS) criteria and the Canadian C-spine Rule, are available to aid in safely clearing the c-spine clinically while reducing the utilization of radiography. In the pediatric population, no standardized, validated tool exists, leading to variability in protocols that are put to use. A systematic literature search was conducted in Cochrane, Embase, PubMed/MEDLINE, and Web of Science electronic databases from January 1, 2009 until April 30, 2021. Data were extracted from studies that met inclusion criteria. Quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) criteria. There were 19 studies included in this systematic review. From these 19 studies, there were 16 unique protocols, 12 of which (75%) utilized some or all NEXUS criteria. Of the protocols that provided a detailed imaging algorithm (N=14), 12 (85.7%) utilized x-rays as the initial imaging modality. Indications for computed tomography and magnetic resonance imaging varied widely across the protocols. The rate of x-rays, computed tomography, and magnetic resonance imaging utilization ranged from 16.7% to 97.8%, 5.4% to 100%, and 0% to 100%, respectively. Ten studies evaluated the efficacy of protocol implementation, with 9 (90%) of these studies showing an overall reduction of imaging rates in the postprotocol period. No clinically significant missed injuries were reported in the included studies. Details of c-spine clearance protocols differed significantly across the included studies, but many applied some or all NEXUS criteria. Overall, while variable, protocols served to safely treat pediatric patients without missing any clinically significant c-spine injuries, while reducing radiation exposure.

Evaluation of Glial and Neuronal Blood Biomarkers Compared With Clinical Decision Rules in Assessing the Need for Computed Tomography in Patients With Mild Traumatic Brain Injury

In 2018, the combination of glial fibrillary acidic protein (GFAP) and ubiquitin C-terminal hydrolase (UCH-L1) levels became the first US Food and Drug Administration-approved blood test to detect intracranial lesions after mild to moderate traumatic brain injury (MTBI). How this blood test compares with validated clinical decision rules remains unknown. To compare the performance of GFAP and UCH-L1 levels vs 3 validated clinical decision rules for detecting traumatic intracranial lesions on computed tomography (CT) in patients with MTBI and to evaluate combining biomarkers with clinical decision rules. This prospective cohort study from a level I trauma center enrolled adults with suspected MTBI presenting within 4 hours of injury. The clinical decision rules included the Canadian CT Head Rule (CCHR), New Orleans Criteria (NOC), and National Emergency X-Radiography Utilization Study II (NEXUS II) criteria. Emergency physicians prospectively completed data forms for each clinical decision rule before the patients' CT scans. Blood samples for measuring GFAP and UCH-L1 levels were drawn, but laboratory personnel were blinded to clinical results. Of 2274 potential patients screened, 697 met eligibility criteria, 320 declined to participate, and 377 were enrolled. Data were collected from March 16, 2010, to March 5, 2014, and analyzed on August 11, 2021. The presence of acute traumatic intracranial lesions on head CT scan (positive CT finding). Among enrolled patients, 349 (93%) had a CT scan performed and were included in the analysis. The mean (SD) age was 40 (16) years; 230 patients (66%) were men, 314 (90%) had a Glasgow Coma Scale score of 15, and 23 (7%) had positive CT findings. For the CCHR, sensitivity was 100% (95% CI, 82%-100%), specificity was 33% (95% CI, 28%-39%), and negative predictive value (NPV) was 100% (95% CI, 96%-100%). For the NOC, sensitivity was 100% (95% CI, 82%-100%), specificity was 16% (95% CI, 12%-20%), and NPV was 100% (95% CI, 91%-100%). For NEXUS II, sensitivity was 83% (95% CI, 60%-94%), specificity was 52% (95% CI, 47%-58%), and NPV was 98% (95% CI, 94%-99%). For GFAP and UCH-L1 levels combined with cutoffs at 67 and 189 pg/mL, respectively, sensitivity was 100% (95% CI, 82%-100%), specificity was 25% (95% CI, 20%-30%), and NPV was 100%; with cutoffs at 30 and 327 pg/mL, respectively, sensitivity was 91% (95% CI, 70%-98%), specificity was 20% (95% CI, 16%-24%), and NPV was 97%. The area under the receiver operating characteristic curve (AUROC) for GFAP alone was 0.83; for GFAP plus NEXUS II, 0.83; for GFAP plus NOC, 0.85; and for GFAP plus CCHR, 0.88. The AUROC for UCH-L1 alone was 0.72; for UCH-L1 plus NEXUS II, 0.77; for UCH-L1 plus NOC, 0.77; and for UCH-L1 plus CCHR, 0.79. The GFAP biomarker alone (without UCH-L1) contributed the most improvement to the clinical decision rules. In this cohort study, the CCHR, the NOC, and GFAP plus UCH-L1 biomarkers had equally high sensitivities, and the CCHR had the highest specificity. However, using different cutoff values reduced both sensitivity and specificity of GFAP plus UCH-L1. Use of GFAP significantly improved the performance of the clinical decision rules, independently of UCH-L1. Together, the CCHR and GFAP had the highest diagnostic performance.

274 Characteristics of Intracranial Injury in Pediatric Patients in the National Emergency X-Radiography Utilization Study

Blunt head trauma remains an important and costly mechanism of injury in the pediatric population. This study aimed to investigate the characteristics of pediatric patients presenting to National Emergency X-Radiography Utilization Study (NEXUS) study centers with blunt head trauma and acute cranial injury, as well as determine the screening performance characteristics of physical exam for the detection of skull fracture. We performed a secondary analysis of pediatric computed tomography (CT) data from a previous NEXUS cohort. Demographic data, criteria for two well-established CT imaging decision instruments, and whether patients received neurosurgical interventions were analyzed for the 1018 enrolled patients under the age of 18 years. Radiologist interpretations of CT head results including classification of injury type, location of injury, mass effect, and associated injuries were abstracted for 128 injured patients. Provider detection of skull fractures was determined by response to a specific question on the decision instruments inquiring about signs of these injuries. Contingency tables were used to evaluate provider sensitivity to detect skull fracture. Between April 2006 and December 2015, 1018 pediatric patients were enrolled as part of the NEXUS validation study. 128 (12.5%) of children had a notable injury reported on CT head, 49 (4.8%) were deemed to have a significant injury, and 27 (2.7%) patients received neurosurgical intervention. The median age for injured patients was 9.96 (IQR 3.27 – 15.22) years old. Midline shift was observed in 7 children (5.4% of injuries), and none were observed to have herniation. The most common intracranial injuries were subdural hematomas (28.9%) and subarachnoid hemorrhage (29.7%). The majority of injuries were superior to the tentorium; 3 cerebellar injuries and no brainstem injuries were observed. Incidence of subarachnoid hemorrhage and parenchymal injuries was greater in teenage children (44% and 24%, respectively) than in school age (22.9% and 14.6%) and in infants and toddlers (16.7% and 6.7%). Patients with subarachnoid hemorrhage and parenchymal injuries more frequently presented with abnormal alertness or abnormal behavior. Skull fracture was present in the majority (66.4%) of children with intracranial injuries. The sensitivity and specificity of provider physical exam to detect skull fractures was 18.5% and 96.6%, respectively. Sensitivity and specificity for the detection of basilar or depressed skull fractures was 11.1% and 96.6%. These data suggest that while few pediatric patients presenting with blunt head trauma have a significant intracranial injury or require neurosurgical intervention, skull fracture may be present in a large proportion of children with intracranial hemorrhage. Despite its integration into head injury decision instruments, providers have poor sensitivity for detecting skull fractures in pediatric patients.

Prevalence of midline cervical spine tenderness in the non-trauma population

ObjectiveThe Canadian C-Spine Rule (CCR) and the National Emergency X-Radiography Utilization Study (NEXUS) criteria are two commonly used clinical decision rules which use midline cervical spine (c-spine) tenderness on palpation...

ALGORITHMS FOR CLINICAL ASSESSMENT OF THE CERVICAL SPINE IN PATIENTS WITH SEVERE TRAUMA: A MIXED-METHOD ANALYZIS

ABSTRACT Objective: Cervical trauma is an important cause of morbidity and mortality, affecting 2% of patients admitted to emergency units. Therefore, this study aims to compare the use of two clinical cervical spine evaluation algorithms, the Canadian C-Spine Rule (CCR) and the National Emergency X-radiography Utilization Study (NEXUS). Methods: A descriptive study of the use of the two algorithms by medical residents in the initial assessment of severely traumatized patients admitted to the regional emergency unit was conducted. The evaluation of the indication for imaging tests and the positive predictive value of the algorithms were the parameters analyzed. Finally, the residents answered a questionnaire evaluating the applicability, degree of confidence and advantages of both flowcharts. Results: There was no significant difference between the number of indications for imaging or their predictive values. In the analysis of the questionnaires, the CCR proved to be more reliable and the NEXUS more applicable, and the positive and negative points of applying each of them were highlighted. Conclusion: It is concluded that the two methods are similar in detecting injuries and optimizing the use of imaging exams, being equally indicated to evaluate cervical trauma. However, the technical specifics of each must be taken into account when deciding which to use. Level of evidence IV; Descriptive Study.