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Emerg Med J. 2019 Jan;36(1):4-11. doi: 10.1136/emermed-2017-207435. Epub 2018 Aug 20.

Accuracy of NEXUS II head injury decision rule in children: a prospective PREDICT cohort study.

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Emergency Department, Royal Children's Hospital, Melbourne, Victoria, Australia.
Murdoch Children's Research Institute, Parkville, Victoria, Australia.
Department of Paediatrics, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Melbourne, Victoria, Australia.
Emergency Department, Starship Children's Health, Auckland, New Zealand.
Liggins Institute, University of Auckland, Auckland, New Zealand.
Emergency Department, Princess Margaret Hospital for Children, Perth, Western Australia, Australia.
Schools of Medicine, University of Western Australia, Crawley, Western Australia, Australia.
Emergency Department, Lady Cilento Children's Hospital, Brisbane and Child Health Research Centre, School of Medicine, The University of Queensland, South Brisbane, Queensland, Australia.
Emergency Department, Women's and Children's Hospital Adelaide, North Adelaide, South Australia, Australia.
Emergency Department, The Children's Hospital at Westmead, Sydney, New South Wales, Australia.
Emergency Department, Monash Children's Hospital, Parkville, Victoria, Australia.
Emergency Department, Townsville Hospital, Townsville, Queensland, Australia.
Emergency Department, Kidzfirst Middlemore Hospital, Auckland, New Zealand.
Department of Women's and Child's Health, University of Padova, Padova, Italy.
Academic Department of Emergency Care, University of the West of England, Bristol, UK.
Emergency Department, Bristol Royal Children's Hospital, Bristol, UK.



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.


emergency departments; imaging, ct/mri; paediatrics, paediatric emergency medicine; trauma, head

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