Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.
Murdoch Children's Research Institute, Parkville, Victoria, Australia.
Emerg Med J. 2019 Jan;36(1):4-11. doi: 10.1136/emermed-2017-207435. Epub 2018 Aug 20.
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.
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.
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%)).
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.
国家紧急放射学利用研究 II（NEXUS II）临床决策规则（CDR）可用于优化儿童头部创伤 CT 的使用。我们旨在对该 CDR 在大型队列中进行外部验证。
我们对澳大利亚/新西兰 10 家急诊室就诊的任何严重程度的头部创伤的<18 岁患者进行了前瞻性观察研究。在计划的二次分析中，我们评估了 NEXUS II CDR（95%CI）检测临床重要性颅内损伤（ICI）的准确性。我们还评估了没有规则的临床医生的准确性。
在 20137 名总患者中，我们排除了 28 例疑似穿透性损伤的患者。中位年龄为 4.2 岁。在 ED 中进行了 1962 次 CT 检查，其中 377 次（19.2%）根据 NEXUS II 定义有 ICI。74 例（ICI 的 19.6%）患者接受了神经外科手术。基于 NEXUS II CDR 的 ICI 敏感性为 379/383（99.0（95%CI 97.3%至 99.7%）），特异性为 9320/19726（47.2%（95%CI 46.5%至 47.9%））。在仅进行 CT 的队列中，敏感性相似。在 ED 中未进行 CT 的 18022 名儿童中，49.4%至少有一个 NEXUS II 风险标准。没有规则的临床医生检测 ICI 的敏感性为 377/377（100.0%（95%CI 99.0%至 100.0%）），特异性为 18147/19732（92.0%（95%CI 91.6%至 92.3%））。
NEXUS II 具有较高的敏感性，与推导研究相似。然而，大约一半未成像的患者对 NEXUS II 风险标准呈阳性；这可能会导致在具有高临床医生准确性的环境中 CT 率增加。
