Objective The National Emergency X-Radiography Utilisation Study II (NEXUS II) clinical decision rule (CDR) can be used to optimise the use of CT in children with head trauma. We set out to externally validate this CDR in a large cohort.
Methods We performed a prospective observational study of patients aged <18 years presenting with head trauma of any severity to 10 Australian/New Zealand EDs. In a planned secondary analysis, we assessed the accuracy of the NEXUS II CDR (with 95% CI) to detect clinically important intracranial injury (ICI). We also assessed clinician accuracy without the rule.
Results Of 20 137 total patients, we excluded 28 with suspected penetrating injury. Median age was 4.2 years. CTs were obtained in ED for 1962 (9.8%), of whom 377 (19.2%) had ICI as defined by NEXUS II. 74 (19.6% of ICI) patients underwent neurosurgery.
Sensitivity for ICI based on the NEXUS II CDR was 379/383 (99.0 (95% CI 97.3% to 99.7%)) and specificity was 9320/19 726 (47.2% (95% CI 46.5% to 47.9%)) for the total cohort. Sensitivity in the CT-only cohort was similar. Of the 18 022 children without CT in ED, 49.4% had at least one NEXUS II risk criterion. Sensitivity for ICI by the clinicians without the rule was 377/377 (100.0% (95% CI 99.0% to 100.0%)) and specificity was 18 147/19 732 (92.0% (95% CI 91.6% to 92.3%)).
Conclusions NEXUS II had high sensitivity, similar to the derivation study. However, approximately half of unimaged patients were positive for NEXUS II risk criteria; this may result in an increased CT rate in a setting with high clinician accuracy.
- trauma, head
- emergency departments
- imaging, ct/mri
- paediatrics, paediatric emergency medicine
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Contributors FEB: conceived the study, obtained grant funding, designed the study, provided overall supervision, interpreted the data, wrote the initial draft of the paper, gave final approval to be published and agreed to be accountable for all aspects of the work. MLB, NP, AK, SD, JAC, YG, JF, JN, MDL, MA, SH, SB, LMC, EO, SRD: designed the study, obtained the data, provided supervision, interpreted the data, drafted or revised it critically, gave final approval to be published and agreed to be accountable for all aspects of the work. SD: designed the study, supervised the analysis of the data, contributed to the interpretation of the data, revised the paper critically, gave final approval to be published and agreed to be accountable for all aspects of the work.
Funding The study was funded by grants from the National Health and Medical Research Council (project grant GNT1046727, Centre of Research Excellence for Paediatric Emergency Medicine GNT1058560), Canberra, Australia; the Murdoch Childrens Research Institute, Melbourne, Australia; the Emergency Medicine Foundation (EMPJ-11162), Brisbane, Australia; Perpetual Philanthropic Services (2012/1140), Australia; Auckland Medical Research Foundation (No. 3112011) and the A + Trust (Auckland District Health Board), Auckland, New Zealand; WA Health Targeted Research Funds 2013, Perth, Australia; the Townsville Hospital and Health Service Private Practice Research and Education Trust Fund, Townsville, Australia and supported by the Victorian Government’s Infrastructure Support Program, Melbourne, Australia. FEB’s time was part funded by a grant from the Royal Children’s Hospital Foundation, Melbourne, Australia, an NHMRC Practitioner Fellowship GNT1124466 and a Melbourne Children’s Clinician Scientist Fellowship. SRD’s time was part funded by the Health Research Council of New Zealand (HRC13/556).
Competing interests None declared.
Patient consent Not required.
Ethics approval The study was approved by the Royal Children’s Hospital, Melbourne, Australia.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement There are no additional data available.
Press Release Yes.
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