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The role of routine chest radiography in initial evaluation of stable blunt trauma patients
American Journal of Emergency Medicine (2012) 30, 1–4
www.elsevier.com/locate/ajem
Original Contribution
The role of routine chest radiography in initial evaluation of stable blunt trauma patients☆ Shahram Paydar MD a , Hamed Ghoddusi Johari MD a,⁎, Fariborz Ghaffarpasand MD b , Danial Shahidian MD a , Afsaneh Dehbozorgi MD a , Bijan Ziaeian MD a , Shahram Bolandparvaz MD a , Hamid Reza Abbasi MD a , Maryam Sharifian MD a a
Department of General Surgery, Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
b
Received 24 June 2010; revised 12 August 2010; accepted 19 August 2010
Abstract Background: Radiology plays an important role in evaluation of a trauma patient. Although chest radiography is recommended for initial evaluation of the trauma patient by the Advanced Trauma Life Support course, we hypothesized that precise physical examinations and history taking accurately identify those blunt trauma patients at low risk for chest injury, making routine radiographs unnecessary. Thus, this study was performed to investigate the role of chest radiography in initial evaluation of those trauma patients with normal physical examination. Methods: In this prospective cross-sectional study, all the hemodynamically stable blunt trauma patients with negative physical examination result referred to our trauma center during a 4-month period (MarchJune 2009) were included. Chest radiographies were performed and reviewed for abnormalities. Results: During the study period, 5091 blunt trauma patients referred to our center, out of which, 1008 were hemodynamically stable and had negative physical examination result. Only 1 (0.1%) patient had abnormal chest radiography that showed perihilar lymphadenopathy, unrelated to trauma. Conclusion: Performing routine chest radiography in stable blunt trauma patients is of low clinical value. Thus, decision making for performing chest radiography in blunt trauma patients based on clinical findings would be efficacious and resource saving. © 2012 Elsevier Inc. All rights reserved.
1. Introduction Trauma is one of the leading causes of death and a major worldwide public health problem in both industrialized and developing countries. In this era of cost containment,
☆ The work was performed in: Nemazee Hospital affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. ⁎ Corresponding author. Tel.: +98 917 713 1640; fax: +98 711 2330724. E-mail address: [email protected] (H.G. Johari).
0735-6757/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2010.08.010
it is important to continually evaluate protocols to determine possible diagnostic and therapeutic interventions that may be safely eliminated. The trauma resuscitation is no exception [1]. Radiology plays a major role in evaluation of the trauma patient. Previously, the Advanced Trauma Life Support (ATLS) course recommended performing the plain film radiography of the chest, abdomen, and cervical spine in all the blunt trauma patients. However, in recent years, ATLS plain radiographies of the cervical spine and pelvic have been limited to hemodynamically unstable patients or those
2 with normal physical examination [2] probably based on previous evidences [1,3-5]. In the other hands, these days, most trauma centers in industrialized countries use spiral computed tomography (CT) for evaluating head, neck, chest, abdomen, and pelvis in trauma patients [6-8]. The ATLS still recommends chest radiography in all trauma patients [2]. Recently, several studies have shown that also chest radiography has limited value in initial assessment of the blunt trauma patients who are hemodynamically stable or have negative physical examination result [9-11]. However, evidence regarding this issue is still scarce. Thus, we performed this study to evaluate the usefulness of chest radiography in hemodynamically stable blunt trauma patients.
2. Methods This was a prospective cross-sectional study being performed in Nemazee hospital trauma center (our level I trauma center) affiliated with Shiraz University of Medical Sciences during a 4-month period (from March to June 2009). We included all the patients with blunt trauma who were hemodynamically stable and had negative physical examination result. The study protocol was approved by both institutional review board and ethics committee of the Shiraz University of Medical Sciences, and all the participants gave their informed written consents. Patient care was in concordance with ATLS protocol including primary survey, followed by resuscitation and the secondary survey. Data were collected by means of standard questionnaire, including demographic information (age, sex, area of residence), vital signs, and injury mechanism, and through history and physical examination findings. Hemodynamically unstable patients; those with positive chest physical examination result; those younger than 18 years; and those with penetrating trauma, isolated head trauma, and Glasgow Coma Scale score less than 14 were all excluded from the study. Considering the importance of effective relationship with patients in history taking and physical examination, we also excluded individuals who could not communicate due to language barrier. Stable hemodynamic condition was defined as systolic blood pressure higher than 90 mm Hg and heart rate less than 100 beats/ min. Positive chest physical examination result was considered if any of the following criteria were met: decreased breathing sounds (determined by chest auscultation by both junior and senior residents), subcutaneous emphysema, shortness of breath, respiratory distress (determined according to suprasternal or intercostal retraction accompanied by hypoxia and cyanosis), subjective respiratory discomfort, positive squeeze test (palpation tenderness), subjective chest pain, hemoptysis, tenderness, deformity, crepitus, or auscultatory findings. All physical examinations and history takings were performed by the
S. Paydar et al. junior and senior surgical residents. However, the final judgment was adjudicated by the attending trauma surgeon. A chest radiography was performed for all the included patients. A portable anteroposterior technique was used for performing chest radiography. The supine patient was placed in a semiupright position achieved by tilting the stretcher approximately 30° in the head-up position. The trauma surgery team members have completed their clinical judgment and data collection before viewing the chest radiography. All the chest radiographies were interpreted by an attending radiologist unaware of the clinical findings of the patients. The chest radiography findings were recorded in a separate questionnaire identified by the patients' admission code. The results of the study including both the clinical findings (determined by trauma surgery team) and radiology findings (determined by attending radiologist) were prospectively entered into a computer-based database and were further analyzed by an statistician.
3. Results Overall, 5091 blunt trauma patients referred to our center during the study period out, of which 3598 (70.6%) were men and 1493 (29.4%) were women, with mean (SD) age of 30.82 (20.1) years. The most common mechanism of injury was motor vehicle accidents, which accounted for 3725
Table 1 Characteristics of 5091 patients with blunt trauma referred to our trauma center from March to June 2009 Characteristic
Value
Age (y) Sex Men (%) Women (%) Mechanism of injury Motor vehicle accident (%) Struck as pedestrian (%) Fall (%) Blunt assault (%) Other blunt injuries (%) Stability Stable (%) Unstable (%) Chest physical examination (CPE) Positive (%) Subjective chest pain (%) Chest wall tenderness (%) Shortness of breath (%) Ascultatory findings (%) Subcutaneous emphysema (%) Respiratory distress (%) Others (%) Negative (%) Hemodynamically stable with negative CPE
30.82 ± 20.1 3598 (70.6) 1493 (29.4) 3725 (73.2) 591 (11.6) 575 (11.3) 138 (2.7) 62 (1.2) 4195 (82.4) 896 (17.6) 4074 (80.1) 1328 (26.1) 809 (15.9) 687 (13.5) 591 (11.6) 397 (7.8) 178 (3.5) 84 (1.7) 1017 (19.9) 1008 (19.8)
Blunt trauma patient evaluation using chest radiography Table 2 Characteristics of 1008 hemodynamically stable blunt trauma patients with negative physical examination Characteristic
Value
Age (y) Sex Men (%) Women (%) Mechanism of injury Motor vehicle accident (%) Fall (%) Struck as pedestrian (%) Blunt assault (%)
34.3 ± 16.8 656 (65) 352 (35) 819 (81.3) 135 (13.4) 32 (3.2) 22 (2.1)
(73.2%) of the referrals. Among the patients, there were 896 (17.6%) unstable and 4074 (80.1%) with positive physical examination finding. The most common finding in chest physical examination was subjective chest pain detected in 1328 (26.1%) followed by chest wall tenderness in 809 (15.9%) and shortness of breath in 687 (13.5%). Of the patients, 1017 (19.9%) had negative chest physical examination, of which 9 were found to be hemodynamically unstable. Thus, the final study population who was stable and had negative chest physical examination finding was 1008 (19.8%). Table 1 summarizes the characteristics of these 5091 patients with blunt trauma. Table 2 demonstrates the characteristics of the 1008 included patients. The mean (SD) age of the patients was 34.3 (16.8) years. Among these patients, only 1 (0.1%) patient had abnormal chest radiography. He was a 61-yearold man with perihilar lymphadenopathy, which was unrelated to his trauma.
4. Discussion Several modalities are now being used for initial assessment of trauma patients for increasing the speed and accuracy of the diagnosis and treatment. For instance, focused abdominal sonography for trauma is now being used extensively and has replaced diagnostic peritoneal lavage in the initial assessment of abdominal trauma patients [12,13]. Furthermore, most trauma centers now use spiral CT scan for trauma evaluation. Chest radiography is another modality being recommended by ATLS for initial assessment of blunt trauma patients [2]; however, its role is rapidly diminishing in these days [9-11]. In this regard, we showed that chest radiography is of no value in hemodynamically stable blunt trauma patients who have negative physical examination. Our findings are consistent with previous studies [9-11,14,15] that questioned the role of chest radiography in initial assessment of blunt trauma patients. The ATLS course is developed by the American College of Surgeons Committee on Trauma and was introduced in the
3 late 1970s. It includes 3 steps of patient evaluation including primary survey, resuscitation, and secondary survey. The importance of physical examination in the primary survey for prompt diagnosis is always accentuated by ATLS. The course curriculum also encourages the liberal use of adjunctive tests for the early diagnosis of potentially lifethreatening thoracic injuries during the secondary survey. Traditionally, ATLS recommends 3 sets of radiographs including cross-table cervical spine, anterior-posterior chest, and anterior-posterior pelvis for evaluation of trauma patients [2]. However, ATLS has changed dramatically regarding both diagnostic capabilities and treatment options. In this era of cost containment, it is important to continually evaluate protocols to determine possible diagnostic and therapeutic interventions that may be safely eliminated. The trauma resuscitation is no exception [1]. According to our experience in our high-turnover level I trauma center (Nemazee Hospital) in Shiraz, it appears that chest radiography is unnecessary and to is of no value in the initial evaluation of hemodynamically stable trauma patients with a negative physical examination finding. Previously, Wisbach et al [11] demonstrated that in stable trauma patients with a normal chest physical examination result, chest radiography appears to be unnecessary in their initial evaluation. They recommended that chest radiography be relegated to a role similar to cervical spine and pelvis radiographs in the initial evaluation of hemodynamically stable trauma patients with a normal physical examination result and be limited to use only for clear clinical indications. In the same way, it was shown by Sears et al [9] that mandatory chest radiography for all trauma patients has a low yield for abnormal findings. They also recommended that a selective policy relying on surgical judgment guided by clinical indicators would be safe and efficacious while reducing cost and conserving resources. In our study, between March and June 2009, all blunt trauma patients who were hemodynamically stable with negative history and physical examination findings underwent routine chest x-ray. The most important premise of this trial was that the patient's history and physical examination are reliable. Therefore, we used a Glasgow Coma Scale score of more than 14 as the limit of reliability. Also, we excluded individuals who could not communicate due to language barrier. It was interesting that of 1008 patients who included in this study, only 1 (0.1%) patient had an abnormal chest radiography, which was unrelated to his recent trauma. In recent years, using CT scan techniques has significantly increased both the speed and accuracy of the initial evaluation of trauma patients. With these techniques, whole chest, abdomen, and pelvis can easily be scanned for detailed injuries and anatomical findings in just minutes. Thus, several authors have questioned the role of initial chest radiography [6,7,10]. Lopes et al [10] showed that chest radiography could safely be eliminated in favor of chest CT scan in hemodynamically stable blunt trauma patients.
4 We note some limitation to our study. First, our study period was limited and included only a 4-month period; however, because of high rate of trauma in our region, 5091 patients referred to our center, of which -1008 fulfilled the inclusion criteria. Larger studies are now being undertaken in our center to elucidate the role of routine radiographies in the initial evaluation of trauma patients. Second, the study may be underpowered due to the low incidence of positive chest radiography (0.1%) in hemodynamically stable blunt trauma patients, which may lead to type II error; however, this is consistent with our hypothesis, questioning the role of chest radiography in initial evaluation of trauma patients. The third limitation was the variability in the examiners and decision makers. During the study period, 5 junior and 3 senior residents attended the trauma center besides an attending trauma surgeon as their rotations. Thus, interobserver variability was inevitable. In conclusion, performing routine chest radiography in stable blunt trauma patients is of low clinical value. Thus, decision making and case selection for performing chest radiography in blunt trauma patients based on clinical and surgical findings would be efficacious and resource saving.
S. Paydar et al.
[4]
[5] [6]
[7] [8]
[9]
[10]
[11]
[12]
References [1] Duane TM, Tan BB, Golay D, Cole Jr FJ, Weireter Jr LJ, Britt LD. Blunt trauma and the role of routine pelvic radiographs: a prospective analysis. J Trauma 2002;53(3):463-8. [2] American College of Surgeons. Advanced Trauma Life Support for Doctors. Student Course Manual. 7th Ed. Chicago, IL: American College of Surgeons; 2004. [3] Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine
[13]
[14]
[15]
in patients with blunt trauma. National emergency X-radiography utilization study group. N Engl J Med 2000;343:94-9. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998;32:461-9. Yugueros P, Sarmiento JM, Garcia AF, Ferrada R. Unnecessary use of pelvic x-ray in blunt trauma. J Trauma 1995;39:722-5. Exadaktylos AK, Sclabas G, Schmid SW, Schaller B, Zimmermann H. Do we really need routine computed tomographic scanning in the primary evaluation of blunt chest trauma in patients with “normal” chest radiograph? J Trauma 2001;51:1173-6. Omert L, Yeaney WW, Protetch J. Efficacy of thoracic computerized tomography in chest trauma. Am Surg 2001;67:660-4. Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma 2005;58:890-6. Sears BW, Luchette FA, Esposito TJ, Dickson EL, Grant M, Santaniello JM, et al. Old fashion clinical judgment in the era of protocols: is mandatory chest x-ray necessary in injured patients? J Trauma 2005;59:324-32. Lopes JO, Frankel HL, Jamal Bokhari S, Bank M, Tandon M, Rabinovici R. The trauma bay chest radiograph in stable blunt-trauma patients: do we really need it? Am Surg 2006;72:31-4. Wisbach GG, Sise MJ, Sack DI, Swanson SM, Sundquist SM, Paci GM, et al. What is the role of chest x-ray in the initial assessment of stable trauma patients? J Trauma 2007;62(1):74-8. Peytel E, Menegaux F, Cluzel P, Langeron O, Coriat P, Riou B. Initial imaging assessment of severe blunt trauma. Intensive Care Med 2001;27:1756-61. Ollerton JE, Sugrue M, Balogh Z, D'Amours SK, Giles A, Wyllie P. Prospective study to evaluate the influence of FAST on trauma patient management. J Trauma 2006;60:785-91. Rodriguez RM, Hendey GW, Marek G, Dery RA, Bjoring A. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med 2006;47: 415-8. Bokhari F, Brakenridge S, Nagy K, Roberts R, Smith R, Joseph K, et al. Prospective evaluation of the sensitivity of physical examination in chest trauma. J Trauma 2002;53(6):1135-8.
www.elsevier.com/locate/ajem
Original Contribution
The role of routine chest radiography in initial evaluation of stable blunt trauma patients☆ Shahram Paydar MD a , Hamed Ghoddusi Johari MD a,⁎, Fariborz Ghaffarpasand MD b , Danial Shahidian MD a , Afsaneh Dehbozorgi MD a , Bijan Ziaeian MD a , Shahram Bolandparvaz MD a , Hamid Reza Abbasi MD a , Maryam Sharifian MD a a
Department of General Surgery, Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
b
Received 24 June 2010; revised 12 August 2010; accepted 19 August 2010
Abstract Background: Radiology plays an important role in evaluation of a trauma patient. Although chest radiography is recommended for initial evaluation of the trauma patient by the Advanced Trauma Life Support course, we hypothesized that precise physical examinations and history taking accurately identify those blunt trauma patients at low risk for chest injury, making routine radiographs unnecessary. Thus, this study was performed to investigate the role of chest radiography in initial evaluation of those trauma patients with normal physical examination. Methods: In this prospective cross-sectional study, all the hemodynamically stable blunt trauma patients with negative physical examination result referred to our trauma center during a 4-month period (MarchJune 2009) were included. Chest radiographies were performed and reviewed for abnormalities. Results: During the study period, 5091 blunt trauma patients referred to our center, out of which, 1008 were hemodynamically stable and had negative physical examination result. Only 1 (0.1%) patient had abnormal chest radiography that showed perihilar lymphadenopathy, unrelated to trauma. Conclusion: Performing routine chest radiography in stable blunt trauma patients is of low clinical value. Thus, decision making for performing chest radiography in blunt trauma patients based on clinical findings would be efficacious and resource saving. © 2012 Elsevier Inc. All rights reserved.
1. Introduction Trauma is one of the leading causes of death and a major worldwide public health problem in both industrialized and developing countries. In this era of cost containment,
☆ The work was performed in: Nemazee Hospital affiliated with Shiraz University of Medical Sciences, Shiraz, Iran. ⁎ Corresponding author. Tel.: +98 917 713 1640; fax: +98 711 2330724. E-mail address: [email protected] (H.G. Johari).
0735-6757/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.ajem.2010.08.010
it is important to continually evaluate protocols to determine possible diagnostic and therapeutic interventions that may be safely eliminated. The trauma resuscitation is no exception [1]. Radiology plays a major role in evaluation of the trauma patient. Previously, the Advanced Trauma Life Support (ATLS) course recommended performing the plain film radiography of the chest, abdomen, and cervical spine in all the blunt trauma patients. However, in recent years, ATLS plain radiographies of the cervical spine and pelvic have been limited to hemodynamically unstable patients or those
2 with normal physical examination [2] probably based on previous evidences [1,3-5]. In the other hands, these days, most trauma centers in industrialized countries use spiral computed tomography (CT) for evaluating head, neck, chest, abdomen, and pelvis in trauma patients [6-8]. The ATLS still recommends chest radiography in all trauma patients [2]. Recently, several studies have shown that also chest radiography has limited value in initial assessment of the blunt trauma patients who are hemodynamically stable or have negative physical examination result [9-11]. However, evidence regarding this issue is still scarce. Thus, we performed this study to evaluate the usefulness of chest radiography in hemodynamically stable blunt trauma patients.
2. Methods This was a prospective cross-sectional study being performed in Nemazee hospital trauma center (our level I trauma center) affiliated with Shiraz University of Medical Sciences during a 4-month period (from March to June 2009). We included all the patients with blunt trauma who were hemodynamically stable and had negative physical examination result. The study protocol was approved by both institutional review board and ethics committee of the Shiraz University of Medical Sciences, and all the participants gave their informed written consents. Patient care was in concordance with ATLS protocol including primary survey, followed by resuscitation and the secondary survey. Data were collected by means of standard questionnaire, including demographic information (age, sex, area of residence), vital signs, and injury mechanism, and through history and physical examination findings. Hemodynamically unstable patients; those with positive chest physical examination result; those younger than 18 years; and those with penetrating trauma, isolated head trauma, and Glasgow Coma Scale score less than 14 were all excluded from the study. Considering the importance of effective relationship with patients in history taking and physical examination, we also excluded individuals who could not communicate due to language barrier. Stable hemodynamic condition was defined as systolic blood pressure higher than 90 mm Hg and heart rate less than 100 beats/ min. Positive chest physical examination result was considered if any of the following criteria were met: decreased breathing sounds (determined by chest auscultation by both junior and senior residents), subcutaneous emphysema, shortness of breath, respiratory distress (determined according to suprasternal or intercostal retraction accompanied by hypoxia and cyanosis), subjective respiratory discomfort, positive squeeze test (palpation tenderness), subjective chest pain, hemoptysis, tenderness, deformity, crepitus, or auscultatory findings. All physical examinations and history takings were performed by the
S. Paydar et al. junior and senior surgical residents. However, the final judgment was adjudicated by the attending trauma surgeon. A chest radiography was performed for all the included patients. A portable anteroposterior technique was used for performing chest radiography. The supine patient was placed in a semiupright position achieved by tilting the stretcher approximately 30° in the head-up position. The trauma surgery team members have completed their clinical judgment and data collection before viewing the chest radiography. All the chest radiographies were interpreted by an attending radiologist unaware of the clinical findings of the patients. The chest radiography findings were recorded in a separate questionnaire identified by the patients' admission code. The results of the study including both the clinical findings (determined by trauma surgery team) and radiology findings (determined by attending radiologist) were prospectively entered into a computer-based database and were further analyzed by an statistician.
3. Results Overall, 5091 blunt trauma patients referred to our center during the study period out, of which 3598 (70.6%) were men and 1493 (29.4%) were women, with mean (SD) age of 30.82 (20.1) years. The most common mechanism of injury was motor vehicle accidents, which accounted for 3725
Table 1 Characteristics of 5091 patients with blunt trauma referred to our trauma center from March to June 2009 Characteristic
Value
Age (y) Sex Men (%) Women (%) Mechanism of injury Motor vehicle accident (%) Struck as pedestrian (%) Fall (%) Blunt assault (%) Other blunt injuries (%) Stability Stable (%) Unstable (%) Chest physical examination (CPE) Positive (%) Subjective chest pain (%) Chest wall tenderness (%) Shortness of breath (%) Ascultatory findings (%) Subcutaneous emphysema (%) Respiratory distress (%) Others (%) Negative (%) Hemodynamically stable with negative CPE
30.82 ± 20.1 3598 (70.6) 1493 (29.4) 3725 (73.2) 591 (11.6) 575 (11.3) 138 (2.7) 62 (1.2) 4195 (82.4) 896 (17.6) 4074 (80.1) 1328 (26.1) 809 (15.9) 687 (13.5) 591 (11.6) 397 (7.8) 178 (3.5) 84 (1.7) 1017 (19.9) 1008 (19.8)
Blunt trauma patient evaluation using chest radiography Table 2 Characteristics of 1008 hemodynamically stable blunt trauma patients with negative physical examination Characteristic
Value
Age (y) Sex Men (%) Women (%) Mechanism of injury Motor vehicle accident (%) Fall (%) Struck as pedestrian (%) Blunt assault (%)
34.3 ± 16.8 656 (65) 352 (35) 819 (81.3) 135 (13.4) 32 (3.2) 22 (2.1)
(73.2%) of the referrals. Among the patients, there were 896 (17.6%) unstable and 4074 (80.1%) with positive physical examination finding. The most common finding in chest physical examination was subjective chest pain detected in 1328 (26.1%) followed by chest wall tenderness in 809 (15.9%) and shortness of breath in 687 (13.5%). Of the patients, 1017 (19.9%) had negative chest physical examination, of which 9 were found to be hemodynamically unstable. Thus, the final study population who was stable and had negative chest physical examination finding was 1008 (19.8%). Table 1 summarizes the characteristics of these 5091 patients with blunt trauma. Table 2 demonstrates the characteristics of the 1008 included patients. The mean (SD) age of the patients was 34.3 (16.8) years. Among these patients, only 1 (0.1%) patient had abnormal chest radiography. He was a 61-yearold man with perihilar lymphadenopathy, which was unrelated to his trauma.
4. Discussion Several modalities are now being used for initial assessment of trauma patients for increasing the speed and accuracy of the diagnosis and treatment. For instance, focused abdominal sonography for trauma is now being used extensively and has replaced diagnostic peritoneal lavage in the initial assessment of abdominal trauma patients [12,13]. Furthermore, most trauma centers now use spiral CT scan for trauma evaluation. Chest radiography is another modality being recommended by ATLS for initial assessment of blunt trauma patients [2]; however, its role is rapidly diminishing in these days [9-11]. In this regard, we showed that chest radiography is of no value in hemodynamically stable blunt trauma patients who have negative physical examination. Our findings are consistent with previous studies [9-11,14,15] that questioned the role of chest radiography in initial assessment of blunt trauma patients. The ATLS course is developed by the American College of Surgeons Committee on Trauma and was introduced in the
3 late 1970s. It includes 3 steps of patient evaluation including primary survey, resuscitation, and secondary survey. The importance of physical examination in the primary survey for prompt diagnosis is always accentuated by ATLS. The course curriculum also encourages the liberal use of adjunctive tests for the early diagnosis of potentially lifethreatening thoracic injuries during the secondary survey. Traditionally, ATLS recommends 3 sets of radiographs including cross-table cervical spine, anterior-posterior chest, and anterior-posterior pelvis for evaluation of trauma patients [2]. However, ATLS has changed dramatically regarding both diagnostic capabilities and treatment options. In this era of cost containment, it is important to continually evaluate protocols to determine possible diagnostic and therapeutic interventions that may be safely eliminated. The trauma resuscitation is no exception [1]. According to our experience in our high-turnover level I trauma center (Nemazee Hospital) in Shiraz, it appears that chest radiography is unnecessary and to is of no value in the initial evaluation of hemodynamically stable trauma patients with a negative physical examination finding. Previously, Wisbach et al [11] demonstrated that in stable trauma patients with a normal chest physical examination result, chest radiography appears to be unnecessary in their initial evaluation. They recommended that chest radiography be relegated to a role similar to cervical spine and pelvis radiographs in the initial evaluation of hemodynamically stable trauma patients with a normal physical examination result and be limited to use only for clear clinical indications. In the same way, it was shown by Sears et al [9] that mandatory chest radiography for all trauma patients has a low yield for abnormal findings. They also recommended that a selective policy relying on surgical judgment guided by clinical indicators would be safe and efficacious while reducing cost and conserving resources. In our study, between March and June 2009, all blunt trauma patients who were hemodynamically stable with negative history and physical examination findings underwent routine chest x-ray. The most important premise of this trial was that the patient's history and physical examination are reliable. Therefore, we used a Glasgow Coma Scale score of more than 14 as the limit of reliability. Also, we excluded individuals who could not communicate due to language barrier. It was interesting that of 1008 patients who included in this study, only 1 (0.1%) patient had an abnormal chest radiography, which was unrelated to his recent trauma. In recent years, using CT scan techniques has significantly increased both the speed and accuracy of the initial evaluation of trauma patients. With these techniques, whole chest, abdomen, and pelvis can easily be scanned for detailed injuries and anatomical findings in just minutes. Thus, several authors have questioned the role of initial chest radiography [6,7,10]. Lopes et al [10] showed that chest radiography could safely be eliminated in favor of chest CT scan in hemodynamically stable blunt trauma patients.
4 We note some limitation to our study. First, our study period was limited and included only a 4-month period; however, because of high rate of trauma in our region, 5091 patients referred to our center, of which -1008 fulfilled the inclusion criteria. Larger studies are now being undertaken in our center to elucidate the role of routine radiographies in the initial evaluation of trauma patients. Second, the study may be underpowered due to the low incidence of positive chest radiography (0.1%) in hemodynamically stable blunt trauma patients, which may lead to type II error; however, this is consistent with our hypothesis, questioning the role of chest radiography in initial evaluation of trauma patients. The third limitation was the variability in the examiners and decision makers. During the study period, 5 junior and 3 senior residents attended the trauma center besides an attending trauma surgeon as their rotations. Thus, interobserver variability was inevitable. In conclusion, performing routine chest radiography in stable blunt trauma patients is of low clinical value. Thus, decision making and case selection for performing chest radiography in blunt trauma patients based on clinical and surgical findings would be efficacious and resource saving.
S. Paydar et al.
[4]
[5] [6]
[7] [8]
[9]
[10]
[11]
[12]
References [1] Duane TM, Tan BB, Golay D, Cole Jr FJ, Weireter Jr LJ, Britt LD. Blunt trauma and the role of routine pelvic radiographs: a prospective analysis. J Trauma 2002;53(3):463-8. [2] American College of Surgeons. Advanced Trauma Life Support for Doctors. Student Course Manual. 7th Ed. Chicago, IL: American College of Surgeons; 2004. [3] Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to rule out injury to the cervical spine
[13]
[14]
[15]
in patients with blunt trauma. National emergency X-radiography utilization study group. N Engl J Med 2000;343:94-9. Hoffman JR, Wolfson AB, Todd K, Mower WR. Selective cervical spine radiography in blunt trauma: methodology of the National Emergency X-Radiography Utilization Study (NEXUS). Ann Emerg Med 1998;32:461-9. Yugueros P, Sarmiento JM, Garcia AF, Ferrada R. Unnecessary use of pelvic x-ray in blunt trauma. J Trauma 1995;39:722-5. Exadaktylos AK, Sclabas G, Schmid SW, Schaller B, Zimmermann H. Do we really need routine computed tomographic scanning in the primary evaluation of blunt chest trauma in patients with “normal” chest radiograph? J Trauma 2001;51:1173-6. Omert L, Yeaney WW, Protetch J. Efficacy of thoracic computerized tomography in chest trauma. Am Surg 2001;67:660-4. Brown CV, Antevil JL, Sise MJ, Sack DI. Spiral computed tomography for the diagnosis of cervical, thoracic, and lumbar spine fractures: its time has come. J Trauma 2005;58:890-6. Sears BW, Luchette FA, Esposito TJ, Dickson EL, Grant M, Santaniello JM, et al. Old fashion clinical judgment in the era of protocols: is mandatory chest x-ray necessary in injured patients? J Trauma 2005;59:324-32. Lopes JO, Frankel HL, Jamal Bokhari S, Bank M, Tandon M, Rabinovici R. The trauma bay chest radiograph in stable blunt-trauma patients: do we really need it? Am Surg 2006;72:31-4. Wisbach GG, Sise MJ, Sack DI, Swanson SM, Sundquist SM, Paci GM, et al. What is the role of chest x-ray in the initial assessment of stable trauma patients? J Trauma 2007;62(1):74-8. Peytel E, Menegaux F, Cluzel P, Langeron O, Coriat P, Riou B. Initial imaging assessment of severe blunt trauma. Intensive Care Med 2001;27:1756-61. Ollerton JE, Sugrue M, Balogh Z, D'Amours SK, Giles A, Wyllie P. Prospective study to evaluate the influence of FAST on trauma patient management. J Trauma 2006;60:785-91. Rodriguez RM, Hendey GW, Marek G, Dery RA, Bjoring A. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med 2006;47: 415-8. Bokhari F, Brakenridge S, Nagy K, Roberts R, Smith R, Joseph K, et al. Prospective evaluation of the sensitivity of physical examination in chest trauma. J Trauma 2002;53(6):1135-8.