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Imaging in Trauma
TRAUMA/BRIEF COMMENTARY
Imaging in Trauma David L. Schriger, MD, MPH
From the University of California, Los Angeles, Emergency Medicine Center, University of California, Los Angeles, School of Medicine, Los Angeles, CA.
0196-0644/$-see front matter Copyright © 2006 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2006.03.008
SEE RELATED ARTICLES, P. 415, 420, 422. [Ann Emerg Med. 2006;47:419.] This section on Trauma begins with an article by Rodriguez et al, who report the results of a pilot study to determine the feasibility of developing a decision rule for the use of plain chest radiography in trauma.1 In a single-site study of 492 blunt trauma patients, they found no significant thoracic injuries among the 266 patients who had neither tenderness to chest wall palpation nor hypoxia. However, because there were only 31 patients with important thoracic injuries, the lower bound of the confidence interval for their sensitivity calculation is around 90%, too low to establish that the rule identifies all patients with important injuries. Readers might wonder why this journal would publish a single-site decision-rule study that is too small to establish safety within the derivation set and makes no attempt at independent validation. There are 2 answers. First, the study is well done, and the authors take great care to emphasize that theirs is a pilot study. Such a pilot study in necessary before substantial funding can be committed to the large multicenter study required to derive and validate a definitive rule. Second, and perhaps more important, this study highlights controversies about the value of imaging in trauma patients. In less than a decade, many trauma centers have moved from the selective use of plain neck, chest, and pelvis radiography and cranial, cervical, thoracic, abdominal, and pelvic computer tomographic imaging to the virtually automatic use of all of these—the “PAN scan”— on any patient who is rolled into the trauma suite. Although explanations for this shift abound, the only certainty is that there is virtually no evidence to support or refute it. It is for this reason that the Rodriquez article is so important. It begins a dialogue on this important issue. To further this debate, I asked 2 of my colleagues at the University of California, Los Angeles, Henry M. Cryer, MD,
Volume , . : May
professor of surgery and director of trauma services, and William R. Mower, MD, PhD, professor of emergency medicine, to offer their views on the use of radiographic imaging in trauma. Their editorials in this issue nicely frame the controversy and provide a context for understanding why investigations into the appropriate use of plain radiographs and computed tomography are so important.2,3 I find it fascinating that 2 colleagues who work side by side caring for patients could have such disparate views. At our institution, the trauma surgeons’ imaging wishes are typically honored because the surgeons accept full responsibility for the patient once the emergency department (ED) care is complete. As a result, many patients get more imaging than the ED faculty would order if they treated the patient independently. Given the importance of this controversy, it is my hope that the emergency medicine literature will soon be filled with high-quality trials that provide guidance about the appropriate use of these modalities. Supervising editor: Michael L. Callaham, MD Funding and support: Dr. Schriger did not receive any funding or support for the writing of this editorial. Reprints not available from the author. Address for correspondence: David L. Schriger, MD, MPH, UCLA Emergency Medicine Center, 924 Westwood Blvd, Suite 300, Los Angeles, CA 90024-2924; E-mail [email protected].
REFERENCES 1. Rodriguez RM, Hendey GW, Marek G, et al. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med. 2006;47:415-418. 2. Cryer HM. Chest radiography in blunt trauma patients: is it necessary? Ann Emerg Med. 2006;47:422-423. 3. Mower WR. Selective chest radiography in blunt trauma: who cares? Ann Emerg Med. 2006;47:420-421.
Annals of Emergency Medicine 419
Imaging in Trauma David L. Schriger, MD, MPH
From the University of California, Los Angeles, Emergency Medicine Center, University of California, Los Angeles, School of Medicine, Los Angeles, CA.
0196-0644/$-see front matter Copyright © 2006 by the American College of Emergency Physicians. doi:10.1016/j.annemergmed.2006.03.008
SEE RELATED ARTICLES, P. 415, 420, 422. [Ann Emerg Med. 2006;47:419.] This section on Trauma begins with an article by Rodriguez et al, who report the results of a pilot study to determine the feasibility of developing a decision rule for the use of plain chest radiography in trauma.1 In a single-site study of 492 blunt trauma patients, they found no significant thoracic injuries among the 266 patients who had neither tenderness to chest wall palpation nor hypoxia. However, because there were only 31 patients with important thoracic injuries, the lower bound of the confidence interval for their sensitivity calculation is around 90%, too low to establish that the rule identifies all patients with important injuries. Readers might wonder why this journal would publish a single-site decision-rule study that is too small to establish safety within the derivation set and makes no attempt at independent validation. There are 2 answers. First, the study is well done, and the authors take great care to emphasize that theirs is a pilot study. Such a pilot study in necessary before substantial funding can be committed to the large multicenter study required to derive and validate a definitive rule. Second, and perhaps more important, this study highlights controversies about the value of imaging in trauma patients. In less than a decade, many trauma centers have moved from the selective use of plain neck, chest, and pelvis radiography and cranial, cervical, thoracic, abdominal, and pelvic computer tomographic imaging to the virtually automatic use of all of these—the “PAN scan”— on any patient who is rolled into the trauma suite. Although explanations for this shift abound, the only certainty is that there is virtually no evidence to support or refute it. It is for this reason that the Rodriquez article is so important. It begins a dialogue on this important issue. To further this debate, I asked 2 of my colleagues at the University of California, Los Angeles, Henry M. Cryer, MD,
Volume , . : May
professor of surgery and director of trauma services, and William R. Mower, MD, PhD, professor of emergency medicine, to offer their views on the use of radiographic imaging in trauma. Their editorials in this issue nicely frame the controversy and provide a context for understanding why investigations into the appropriate use of plain radiographs and computed tomography are so important.2,3 I find it fascinating that 2 colleagues who work side by side caring for patients could have such disparate views. At our institution, the trauma surgeons’ imaging wishes are typically honored because the surgeons accept full responsibility for the patient once the emergency department (ED) care is complete. As a result, many patients get more imaging than the ED faculty would order if they treated the patient independently. Given the importance of this controversy, it is my hope that the emergency medicine literature will soon be filled with high-quality trials that provide guidance about the appropriate use of these modalities. Supervising editor: Michael L. Callaham, MD Funding and support: Dr. Schriger did not receive any funding or support for the writing of this editorial. Reprints not available from the author. Address for correspondence: David L. Schriger, MD, MPH, UCLA Emergency Medicine Center, 924 Westwood Blvd, Suite 300, Los Angeles, CA 90024-2924; E-mail [email protected].
REFERENCES 1. Rodriguez RM, Hendey GW, Marek G, et al. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med. 2006;47:415-418. 2. Cryer HM. Chest radiography in blunt trauma patients: is it necessary? Ann Emerg Med. 2006;47:422-423. 3. Mower WR. Selective chest radiography in blunt trauma: who cares? Ann Emerg Med. 2006;47:420-421.
Annals of Emergency Medicine 419