- Email: [email protected]
The significance of routine thoracic computed tomography in patients with blunt chest trauma
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JINJ-6024; No. of Pages 5 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
The significance of routine thoracic computed tomography in patients with blunt chest trauma Seref Kerem C¸orbacıog˘lu a,*, Erhan Er b, Sahin Aslan b, Meltem Seviner b, Go¨khan Aksel c, ¨ zgu¨r Dog˘an d, Sertac¸ Gu¨ler e, Aysen Bitir f Nurettin O a
Emergency Medicine Specialist, Kecioren Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey Emergency Medicine Specialist, Antakya State Hospital, Department of Emergency Medicine, Hatay, Turkey Emergency Medicine Specialist, Umraniye Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey d Emergency Medicine Specialist, Kocaeli University, Faculty of Medicine, Department of Emergency Medicine, Kocaeli, Turkey e Emergency Medicine Specialist, Ankara Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey f Thoracic Surgeon, Antakya State Hospital, Department of Chest Surgery, Hatay, Turkey b c
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 December 2014
Purpose: The purpose of this study is to investigate whether the use of thoracic computed tomography (TCT) as part of nonselective computed tomography (CT) guidelines is superior to selective CT during the diagnosis of blunt chest trauma. Subjects and methods: This study was planned as a prospective cohort study, and it was conducted at the emergency department between 2013 and 2014. A total of 260 adult patients who did not meet the exclusion criteria were enrolled in the study. All patients were evaluated by an emergency physician, and their primary surveys were completed based on the Advanced Trauma Life Support (ATLS) principles. Based on the initial findings and ATLS recommendations, patients in whom thoracic CT was indicated were determined (selective CT group). Routine CTs were then performed on all patients. Results: Thoracic injuries were found in 97 (37.3%) patients following routine TCT. In 53 (20%) patients, thoracic injuries were found by selective CT. Routine TCT was able to detect chest injury in 44 (16%) patients for whom selective TCT would not otherwise be ordered based on the EP evaluation (nonselective TCT group). Five (2%) patients in this nonselective TCT group required tube thoracostomy, while there was no additional treatment provided for thoracic injuries in the remaining 39 (15%). Conclusion: In conclusion, we found that the nonselective TCT method was superior to the selective TCT method in detecting thoracic injuries in patients with blunt trauma. Furthermore, we were able to demonstrate that the nonselective TCT method can change the course of patient management albeit at low rates. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Chest trauma CT Emergency radiology Thorax
Introduction Trauma is the third leading cause of death in populations around the world, and chest trauma contributes to approximately 25% of those [1–3]. Therefore, fast and accurate diagnosis of chest trauma as well as prompt and proper intervention is critical in reducing mortality and morbidity from such injuries. However, there is no consensus established yet in medical practice on the most beneficial methods of imaging, which are essential in the diagnostic process [4].
* Corresponding author. Tel.: +90 543 7656176. E-mail address: [email protected] (S.K. C¸orbacıog˘lu).
Based on the widely accepted recommendations of Advanced Trauma Life Support (ATLS) guidelines, after physical examination, conventional radiographies, chest X-ray (CXR), pelvic X-ray, and focused abdominal sonography in trauma (FAST) are obtained first during the management of blunt trauma, followed by computed tomography (CT) of the specific body region if indicated. This approach is called the selective CT method, and it has remained unchanged in the eighth and ninth editions of ATLS [5–7]. However, the criteria for thoracic computed tomography (TCT) have not been described clearly in the ATLS guidelines. Although some criteria are described for TCT such as clinical suspicion of severe chest injury and thoracolumbar vertebral injury on physical examination, subjective impression of abnormal mediastinum, fracture of more than three ribs, pulmonary consolidation suspected to be
http://dx.doi.org/10.1016/j.injury.2014.12.022 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: C¸orbacıog˘lu SK, et al. The significance of routine thoracic computed tomography in patients with blunt chest trauma. Injury (2015), http://dx.doi.org/10.1016/j.injury.2014.12.022
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JINJ-6024; No. of Pages 5 S.K. C¸orbacıog˘lu et al. / Injury, Int. J. Care Injured xxx (2015) xxx–xxx
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pulmonary contusion, and subcutaneous emphysema suspected to be pneumothorax on CXR, most physicians think that these criteria are very subjective. Many studies have reported that injuries such as haemothorax, pneumothorax, and lung contusion can remain undiagnosed by plain CXR [8,9]. In addition, some studies have reported that routine TCT as part of routine whole-body imaging in patients with blunt trauma – nonselective CT – is more sensitive than selective CT for detecting thoracic injury [10–12]. Therefore, many trauma centres prefer to use nonselective CT in the management of trauma and use routine TCT in patients with chest trauma. On the other hand, some concerns have been raised by researchers and clinicians about the use of nonselective CT. One such concern states that using routine TCT can increase the risk of cancer in young populations, is associated with substantial charges, costs, and expenditures, and increases time spent in the emergency department (ED) [13,14]. In addition, some studies have reported that, although routine TCT is superior to CXR in detecting thoracic injuries in patients with blunt trauma, these additional diagnoses do not change the management of patients significantly [15]. The purpose of the present study was to determine whether using routine TCT as a part of nonselective CT in the diagnosis process in patients with blunt chest trauma was superior to selective CT. In addition, we also aimed to determine if additional diagnoses detected by routine TCT would change the course of patient management. Materials and methods Study design This study was designed as a prospective cohort study, and it was conducted at the ED of the Antakya State Hospital (Turkey) between 1 July 2013 and 1 July 2014. Adult patients (18 years and older) who presented to the ED during the study period with complaints related to blunt chest trauma were enrolled in the study. The exclusion criteria are presented in Table 1. An informed consent form was signed by the patient and/or a family member. The approval of a local ethics committee was also obtained prior to the study. Clinical evaluation, imaging studies, and data collection All study patients were evaluated by one of the five emergency physicians (EPs) acting as team leaders. Upon arrival in the ED, an EP conducted a primary survey and patient examination; ordered CXR, other conventional radiographs, and laboratory tests as indicated; and performed a focused assessment with sonography for trauma (FAST). Patients who were found to have tension pneumothorax or those with free abdominal fluids with unstable haemodynamic parameters were directly referred for surgical evaluation and thus excluded from the study. Similarly, patients who developed cardiac arrest during the primary survey underwent cardiac resuscitation, and they were excluded from the study. After completing the primary survey, the responsible EP recorded the demographic information, vital signs, exam findings, as well as findings from CXR and FAST. Each one of the EPs also Table 1 Exclusion criteria. Age <18 years Requirement of urgent surgery or death before TCT Referral to another hospital Missing data Known pregnancy Patients who do not wish to participate in the study
decided if patients satisfied the criteria for TCT based on the ATLS selective CT recommendations. The criteria for selective TCT on physical examination were subcutaneous emphysema, asymmetric auscultative findings, tenderness in the chest wall on palpation, and neurological findings to be spinal injury. The criteria for selective TCT on CXR were fracture of more than three ribs, first or second rib fracture, scapular fracture, subjective impression of an abnormal mediastinum, suspicion of lung contusion, haemothorax, and pneumothorax. Following these evaluations, routine TCT was performed on all patients as part of the nonselective CT procedure. The selective TCT group consisted of the patients in whom CXR was abnormal and TCT was decided by the EP, and those with normal CXR but TCT was requested by the EP based on abnormal physical examination findings. On the other hand, the nonselective TCT group consisted of those with normal CXR and physical findings prompting no ordering of TCT by the EP. Indications of placing the chest tube were open pneumothorax, tension pneumothorax, and pneumothorax detected on CXR (overt pneumothorax) in the selective TCT group. The indications of placing the chest tube for occult pneumothorax (OP), which was not suspected on the basis of either clinical examination or initial CXR but is subsequently detected on a CT scan, were pneumothorax larger than 1 cm; need for positive pressure ventilation; and severe respiratory distress findings such as decreased oxygen saturation, tachypnea, hypoxia, and hypercapnia on arterial blood gases. Finally, we defined clinically significant thoracic injury as pneumothorax when placement of the chest tube or thoracotomy was required, haemothorax when surgical drainage was required, pulmonary contusion when mechanic ventilation including noninvasive mechanic ventilation was required (the clinical criteria for performing mechanic ventilation were as follows: persistent hypoxaemia despite high-flow oxygen supplementation, moderate or severe dyspnoea, acute respiratory acidosis, accessory respiratory muscle recruitment, and paradoxic abdominal movements), and sternum and multiple rib fracture when surgical intervention was required. All injuries, including thoracic injuries found after the nonselective TCT and corresponding treatment methods, were recorded. Similarly, the Injury Severity Scores (ISS), the ED course, and the patients’ length of stay (LOS) in hospital were also recorded. Statistical analysis Statistical analyses were performed using SPSS 11.0 (Chicago, IL, USA). The Kolmogorov–Smirnov test was used to assess the normal distribution of the variables. The independent variables were tested with the Mann–Whitney U test and expressed as medians with interquartile ranges. The categorical data were analyzed for significance with Pearson’s chi-squared test and expressed as numbers and percentiles. A p-value < 0.05 was considered statistically significant.
Results A total of 472 patients with blunt chest trauma were evaluated during the study period. Of these, 138 were excluded, because they were under 18 years of age. Similarly, 10 patients who died before the CT exams, 11 patients who underwent emergent surgery, and 32 patients who were referred to tertiary centres were excluded from the study. Another 21 patients were excluded because of incomplete documentation (Fig. 1). The demographic characteristics of the 260 patients included in the study are provided in Table 2. Of these patients, 113 (43.5%) were discharged from the ED, while 47 (18.1%) were admitted to the intensive care unit (ICU)
Please cite this article in press as: C¸orbacıog˘lu SK, et al. The significance of routine thoracic computed tomography in patients with blunt chest trauma. Injury (2015), http://dx.doi.org/10.1016/j.injury.2014.12.022
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The injuries detected following routine TCT in 44 (16% of all patients – 260) patients (nonselective TCT group), who were otherwise found to have no thoracic injury in selective TCT, included rib fractures in 15 (6%) patients, pulmonary contusion in 13 (5%) patients, pneumothorax in 11 (4%) patients (OP), sternum fracture in four (1.5%) patients, and pneumomediastinum in one (0.3%) patient. Five patients (2% of all patients) in this nonselective TCT group required tube thoracostomy, while there was no additional treatment provided for thoracic injuries in the remaining 39 (15%). Details of the patients who required interventions are summarized in Table 3. When comparing the selective TCT group with the nonselective TCT group, statistically significant differences were found in oxygen saturation, respiration, and LOS in patients. Furthermore, a significant difference was found in patients who required surgical intervention for the management of pulmonary injuries (Table 4). Discussion
Fig. 1. Patient flow chart.
and 89 (34.2%) were admitted to other hospital wards. Two (0.8%) patients died in the ED. Thoracic injuries were found in 97 (37.3%) patients following routine TCT. Of those, 50 (51.5%) sustained isolated chest injuries whereas 47 (48.5%) had accompanying severe injuries. Nine (9.3%) of the patients with thoracic injuries were discharged from the ED without any medical intervention for their injuries, 31 (32%) underwent tube thoracostomy, and 57 (58.8%) had no ED intervention but were admitted to the hospital for observation. When the patient outcomes were evaluated, 14 (14.4%) patients died in the hospital and 83 (85.6%) were discharged from the hospital. In 44 (16%) patients, thoracic injuries were found by CXR or FAST. On the other hand, in nine (4%) patients, TCT was requested by the EP based on the physical examination findings even though CXR and FAST revealed no pathology. As a result, thoracic injury was detected by selective TCT in 53 out of 260 patients (20%). The remaining 44 (16%) patients comprised the nonselective TCT group in which the thoracic injury would not detected by selective TCT; instead, a routine TCT was needed to detect their injuries. The sensitivity of selective TCT in determining thoracic injuries was found to be 54.6% (95% confidence interval (CI) 44.21–64.78). Table 2 Baseline characteristics of the study population – median (IQR 25–75%) or n (%). Age Male Female Trauma mechanism Traffic accident Fall from height Assault with fists/kicks Other Clinical findings Systolic blood pressure Diastolic blood pressure Oxygen saturation % Respiratory rate, breath/min Pulse rate, beats/min Glasgow Coma Scale Injury Severity Score (ISS)
32 (22–47) 196 (75.4) 64 (24.6) 147 89 6 18
(56.5) (34.2) (2.3) (6.9)
120 70 98 16 90 15 10
(110–130) (70–80) (96–99) (16–20) (80–100) (15–15) (3–18)
Although several CT rules of the head (e.g., New Orleans Head CT rules, Canadian Head CT rules), cervical spine (Nexus Rules, Canadian C-spine rules), abdomen, and pelvis have been described clearly, CT rules of thorax are not well described in the literature and ATLS guidelines. Although recently Rodriguez et al. developed the Nexus criteria for blunt chest trauma, these criteria have very low specificity and positive predictive value [16]. Therefore, most physicians prefer nonselective TCT (routine TCT in patients with thorax trauma) to selective TCT in the management of blunt thoracic trauma to prevent life-threatening injuries from being undiagnosed. Based on this concern, we aimed to compare nonselective TCT with selective TCT. The superiority of nonselective, routine TCT examination over CXR and physical examination findings in detecting thoracic injuries in patients with blunt trauma has been shown in recent studies [4,17]. Brink et al. reported that they diagnosed, by nonselective TCT, thoracic injury in 104 (22%) patients, who otherwise went undetected among the group of 464 patients with blunt trauma [17]. Similarly, in a study conducted on 589 patients with blunt trauma, Kea et al. detected, by routine TCT, thoracic injury in 106 (18%) patients, who otherwise were reported to have no injury based on CXR evaluation [18]. In another study, Chardoli et al. evaluated 200 patients with blunt trauma and they found that routine TCT was superior to conventional radiographies in detecting injuries such as rib fractures, pneumothorax, and haemothorax [19]. We found that the use of selective TCT guidelines during trauma evaluation was not sufficient to detect thoracic injuries. By using nonselective TCT, we were able to detect thoracic injuries in 16% (n = 44) of the patients who otherwise would go undetected after the selective TCT. However, the medical literature is mainly concerned whether the diagnoses made by nonselective TCT actually change the course of patient management. There are conflicting results found in the literature on this. Trupka et al. evaluated the value of routine TCT in the management of patients with thoracic trauma, and they reported that the course of treatment was changed in 42 (41%) patients out of 103 evaluated [20]. Similarly, Deunk et al. reported significant changes in the management of patient injuries following routine use of TCT [21]. On the other hand, Kea et al. reported that they were able to detect an injury severe enough to change the course of treatment in only 12 (2%) patients in their study group (n = 589) [18]. We found that nonselective TCT changed the management of five patients (2% of all patients with blunt chest trauma at inception) in whom selective TCT was misdiagnosed. They were all required to undergo a tube thoracostomy. OP is described as a pneumothorax identified on TCT but unidentifiable on CXR. There are different rates of
Please cite this article in press as: C¸orbacıog˘lu SK, et al. The significance of routine thoracic computed tomography in patients with blunt chest trauma. Injury (2015), http://dx.doi.org/10.1016/j.injury.2014.12.022
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Table 3 Features of the patients needing any intervention in the nonselective TCT group. Patients
Chest Injury
Other Injuries
Treatment and Outcome
18 years, male, traffic accident
Pnx
Femoral neck and tibia fx
24 years, male, traffic accident
Pnx + pulmonary contusions
Liver injury
26 years, male, traffic accident
Pnx + pulmonary contusions
ICH + Hand bone fx
20 years, male, fall from height
Pnx
ICH
66 years, male, fall from height
Pnx
–
Chest tube thoracostomy ISS = 19 LOS: 15 days Chest tube thoracostomy Only observation for liver injury ISS: 22 LOS: 7 days Chest tube thoracostomy ISS = 75 Died after two days Minimal Pnx but needed endotracheal intubation due to ICH. Thus, chest tube insertion for preventing the effect of positive pressure ISS = 75 LOS: 8 day Worsened Pnx on third day and insertion of chest tube, ISS = 12 LOS: 8 days
LOS: length of stay, Pnx: pneumothorax, Fx: fracture, ICH: intracranial haemorrhage.
Table 4 Comparison of the selective TCT group and nonselective TCT group regarding general characteristics, vital signs, and outcome – median (IQR 25–75%) or n (%).
Age (years) Male gender (n, %) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Oxygen saturation (%) Respiratory rate (breaths/min) Pulse rate (beats/min) Glasgow Coma Scale (GCS) score Injury Severity Scale (ISS) score Presence of other injuries Discharged from the ED Observation in the ED Surgical interventions a Hospital length of stay (days) a
Selective TCT group n = 53
Nonselective TCT group n = 44
p value
35 35 110 70 96 20 100 15 18 23 2 25 26 7
28 34 120 70 98 18 95 15 18 24 7 32 5 3
0.07 0.32 0.06 0.3 <0.001 <0.001 0.19 0.82 0.35 0.37 0.04 0.01 <0.001 0.01
(22–52) (66) (100–120) (60–80) (92–98) (16–26) (87–110) (14–15) (14–25) (44) (4) (47) (49) (2–10)
(20–46) (77) (110–130) (63–80) (96–99) (16–20) (80–110) (13–15) (10–25) (54) (16) (73) (11) (1–6)
Surgical interventions include chest tube insertion, thoracotomy, etc.
requirement for tube thoracostomy in patients with OP in the literature. In a study conducted on 569 patients with OP, Moore at al. reported that 21% of these patients required immediate tube thoracostomy [22]. In another study conducted on 307 patients with pneumothorax, Wilson et al. reported that 68 of these patients presented with OP and 35 (51%) of these patients with OP required tube thoracostomy [23]. In our study, five of 11 (45%) patients with OP required tube thoracostomy. Nevertheless, despite how the figures on change of patient management following nonselective TCT differ in various studies, we are reluctant to suggest these rates to be clinically insignificant or low. This is because there are no clear criteria to pronounce the TCT method significant based on the percentage of patients for whom the course of treatment is changed.
Conclusion In conclusion, we found that the nonselective TCT method is superior to the selective TCT method in detecting thoracic injuries in patients with blunt trauma. Furthermore, we were able to demonstrate that the nonselective TCT method can change the course of patient management albeit at low rates. Although it may be difficult to reach definite conclusions based on these findings, we suggest the use of the nonselective TCT method, as it has a low non-detection rate of thoracic injuries, and it can change the course of patient management in a small number of patients. Further studies with a greater number of patients would be helpful in drawing a clearer conclusion on the subject matter.
Limitations Our study has two important limitations. First, the initial evaluation of conventional radiography (CXR) and TCT was performed by an EP. In our ED, radiologists do not work 24/7. Thus, the power of initial CXR and TCT evaluation might be poor. However, we think this limitation is not significant because all imaging tests, such as TCT and CXR, were checked over by radiologists the following day, and there was general inter-rater agreement in results. In only one case, the EP interpreted a TCT result as minimal haemothorax, whereas the radiologist interpreted it as pleural thickening the next day. The second limitation is that the EPs were not blinded to the clinical information on patients. However, this is not a major concern, because due to the nature of the study, the clinicians decide whether or not selective TCTs are needed based on the clinical and radiological findings on the patients.
Conflict of interest statement The authors declare that there are no conflicts of interest.
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Please cite this article in press as: C¸orbacıog˘lu SK, et al. The significance of routine thoracic computed tomography in patients with blunt chest trauma. Injury (2015), http://dx.doi.org/10.1016/j.injury.2014.12.022
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[14] Korley FK, Pham JC, Kirsch TD. Use of advanced radiology during visits to US emergency departments for injury-related conditions, 1998–2007. JAMA 2010;304:1465–71. [15] Traub M, Stevenson M, McEvoy S, Briggs G, Lo SK, Leibman S, et al. The use of chest computed tomography versus chest X-ray in patients with major blunt trauma. Injury 2007;38:43–7. [16] Rodriguez RM, Anglin D, Langdorf MI, Baumann BM, Hendey GW, Bradley RN, et al. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg 2013;148:940–6. [17] Brink M, Deunk J, Dekker HM, Kool DR, Edwards MJ, Van Vugt AB, et al. Added value of routine chest MDCT after blunt trauma: evaluation of additional findings and impact on patient management. Am J Roentgenol 2008;190: 1591–8. [18] Kea B, Gamarallage R, Vairamuthu H, Fortman J, Lunney K, Hendey GW, et al. What is the clinical significance of chest CT when the chest X-ray result is normal in patients with blunt trauma? Am J Emerg Med 2013;31: 1268–73. [19] Chardoli M, Hasan-Ghaliaee T, Akbari H, Rahimi-Movaghar V. Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma. Chin J Traumatol 2013;16:351–4. [20] Trupka A, Waydhas C, Hallfeldt KK, Nast-Kolb D, Pfeifer KJ, Schweiberer L. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma 1997;43:405–11. [21] Deunk J, Brink M, Dekker HM, Kool DR, Blickman JG, van Vugt AB, et al. Routine versus selective multidetector-row computed tomography (MDCT) in blunt trauma patients: level of agreement on the influence of additional findings on management. J Trauma 2009;67:1080–6. [22] Moore FO, Goslar PW, Coimbra R, Velmahos G, Brown CV, Coopwood Jr TB, et al. Blunt traumatic occult pneumothorax: is observation safe? Results of a prospective, AAST multicenter study. J Trauma 2011;70:1019–23. [23] Wilson H, Ellsmere J, Tallon J, Kirkpatrick A. Occult pneumothorax in the blunt trauma patient: tube thoracostomy or observation? Injury 2009; 40:928–31.
Please cite this article in press as: C¸orbacıog˘lu SK, et al. The significance of routine thoracic computed tomography in patients with blunt chest trauma. Injury (2015), http://dx.doi.org/10.1016/j.injury.2014.12.022
JINJ-6024; No. of Pages 5 Injury, Int. J. Care Injured xxx (2015) xxx–xxx
Contents lists available at ScienceDirect
Injury journal homepage: www.elsevier.com/locate/injury
The significance of routine thoracic computed tomography in patients with blunt chest trauma Seref Kerem C¸orbacıog˘lu a,*, Erhan Er b, Sahin Aslan b, Meltem Seviner b, Go¨khan Aksel c, ¨ zgu¨r Dog˘an d, Sertac¸ Gu¨ler e, Aysen Bitir f Nurettin O a
Emergency Medicine Specialist, Kecioren Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey Emergency Medicine Specialist, Antakya State Hospital, Department of Emergency Medicine, Hatay, Turkey Emergency Medicine Specialist, Umraniye Training and Research Hospital, Department of Emergency Medicine, Istanbul, Turkey d Emergency Medicine Specialist, Kocaeli University, Faculty of Medicine, Department of Emergency Medicine, Kocaeli, Turkey e Emergency Medicine Specialist, Ankara Training and Research Hospital, Department of Emergency Medicine, Ankara, Turkey f Thoracic Surgeon, Antakya State Hospital, Department of Chest Surgery, Hatay, Turkey b c
A R T I C L E I N F O
A B S T R A C T
Article history: Accepted 19 December 2014
Purpose: The purpose of this study is to investigate whether the use of thoracic computed tomography (TCT) as part of nonselective computed tomography (CT) guidelines is superior to selective CT during the diagnosis of blunt chest trauma. Subjects and methods: This study was planned as a prospective cohort study, and it was conducted at the emergency department between 2013 and 2014. A total of 260 adult patients who did not meet the exclusion criteria were enrolled in the study. All patients were evaluated by an emergency physician, and their primary surveys were completed based on the Advanced Trauma Life Support (ATLS) principles. Based on the initial findings and ATLS recommendations, patients in whom thoracic CT was indicated were determined (selective CT group). Routine CTs were then performed on all patients. Results: Thoracic injuries were found in 97 (37.3%) patients following routine TCT. In 53 (20%) patients, thoracic injuries were found by selective CT. Routine TCT was able to detect chest injury in 44 (16%) patients for whom selective TCT would not otherwise be ordered based on the EP evaluation (nonselective TCT group). Five (2%) patients in this nonselective TCT group required tube thoracostomy, while there was no additional treatment provided for thoracic injuries in the remaining 39 (15%). Conclusion: In conclusion, we found that the nonselective TCT method was superior to the selective TCT method in detecting thoracic injuries in patients with blunt trauma. Furthermore, we were able to demonstrate that the nonselective TCT method can change the course of patient management albeit at low rates. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Chest trauma CT Emergency radiology Thorax
Introduction Trauma is the third leading cause of death in populations around the world, and chest trauma contributes to approximately 25% of those [1–3]. Therefore, fast and accurate diagnosis of chest trauma as well as prompt and proper intervention is critical in reducing mortality and morbidity from such injuries. However, there is no consensus established yet in medical practice on the most beneficial methods of imaging, which are essential in the diagnostic process [4].
* Corresponding author. Tel.: +90 543 7656176. E-mail address: [email protected] (S.K. C¸orbacıog˘lu).
Based on the widely accepted recommendations of Advanced Trauma Life Support (ATLS) guidelines, after physical examination, conventional radiographies, chest X-ray (CXR), pelvic X-ray, and focused abdominal sonography in trauma (FAST) are obtained first during the management of blunt trauma, followed by computed tomography (CT) of the specific body region if indicated. This approach is called the selective CT method, and it has remained unchanged in the eighth and ninth editions of ATLS [5–7]. However, the criteria for thoracic computed tomography (TCT) have not been described clearly in the ATLS guidelines. Although some criteria are described for TCT such as clinical suspicion of severe chest injury and thoracolumbar vertebral injury on physical examination, subjective impression of abnormal mediastinum, fracture of more than three ribs, pulmonary consolidation suspected to be
http://dx.doi.org/10.1016/j.injury.2014.12.022 0020–1383/ß 2014 Elsevier Ltd. All rights reserved.
Please cite this article in press as: C¸orbacıog˘lu SK, et al. The significance of routine thoracic computed tomography in patients with blunt chest trauma. Injury (2015), http://dx.doi.org/10.1016/j.injury.2014.12.022
G Model
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pulmonary contusion, and subcutaneous emphysema suspected to be pneumothorax on CXR, most physicians think that these criteria are very subjective. Many studies have reported that injuries such as haemothorax, pneumothorax, and lung contusion can remain undiagnosed by plain CXR [8,9]. In addition, some studies have reported that routine TCT as part of routine whole-body imaging in patients with blunt trauma – nonselective CT – is more sensitive than selective CT for detecting thoracic injury [10–12]. Therefore, many trauma centres prefer to use nonselective CT in the management of trauma and use routine TCT in patients with chest trauma. On the other hand, some concerns have been raised by researchers and clinicians about the use of nonselective CT. One such concern states that using routine TCT can increase the risk of cancer in young populations, is associated with substantial charges, costs, and expenditures, and increases time spent in the emergency department (ED) [13,14]. In addition, some studies have reported that, although routine TCT is superior to CXR in detecting thoracic injuries in patients with blunt trauma, these additional diagnoses do not change the management of patients significantly [15]. The purpose of the present study was to determine whether using routine TCT as a part of nonselective CT in the diagnosis process in patients with blunt chest trauma was superior to selective CT. In addition, we also aimed to determine if additional diagnoses detected by routine TCT would change the course of patient management. Materials and methods Study design This study was designed as a prospective cohort study, and it was conducted at the ED of the Antakya State Hospital (Turkey) between 1 July 2013 and 1 July 2014. Adult patients (18 years and older) who presented to the ED during the study period with complaints related to blunt chest trauma were enrolled in the study. The exclusion criteria are presented in Table 1. An informed consent form was signed by the patient and/or a family member. The approval of a local ethics committee was also obtained prior to the study. Clinical evaluation, imaging studies, and data collection All study patients were evaluated by one of the five emergency physicians (EPs) acting as team leaders. Upon arrival in the ED, an EP conducted a primary survey and patient examination; ordered CXR, other conventional radiographs, and laboratory tests as indicated; and performed a focused assessment with sonography for trauma (FAST). Patients who were found to have tension pneumothorax or those with free abdominal fluids with unstable haemodynamic parameters were directly referred for surgical evaluation and thus excluded from the study. Similarly, patients who developed cardiac arrest during the primary survey underwent cardiac resuscitation, and they were excluded from the study. After completing the primary survey, the responsible EP recorded the demographic information, vital signs, exam findings, as well as findings from CXR and FAST. Each one of the EPs also Table 1 Exclusion criteria. Age <18 years Requirement of urgent surgery or death before TCT Referral to another hospital Missing data Known pregnancy Patients who do not wish to participate in the study
decided if patients satisfied the criteria for TCT based on the ATLS selective CT recommendations. The criteria for selective TCT on physical examination were subcutaneous emphysema, asymmetric auscultative findings, tenderness in the chest wall on palpation, and neurological findings to be spinal injury. The criteria for selective TCT on CXR were fracture of more than three ribs, first or second rib fracture, scapular fracture, subjective impression of an abnormal mediastinum, suspicion of lung contusion, haemothorax, and pneumothorax. Following these evaluations, routine TCT was performed on all patients as part of the nonselective CT procedure. The selective TCT group consisted of the patients in whom CXR was abnormal and TCT was decided by the EP, and those with normal CXR but TCT was requested by the EP based on abnormal physical examination findings. On the other hand, the nonselective TCT group consisted of those with normal CXR and physical findings prompting no ordering of TCT by the EP. Indications of placing the chest tube were open pneumothorax, tension pneumothorax, and pneumothorax detected on CXR (overt pneumothorax) in the selective TCT group. The indications of placing the chest tube for occult pneumothorax (OP), which was not suspected on the basis of either clinical examination or initial CXR but is subsequently detected on a CT scan, were pneumothorax larger than 1 cm; need for positive pressure ventilation; and severe respiratory distress findings such as decreased oxygen saturation, tachypnea, hypoxia, and hypercapnia on arterial blood gases. Finally, we defined clinically significant thoracic injury as pneumothorax when placement of the chest tube or thoracotomy was required, haemothorax when surgical drainage was required, pulmonary contusion when mechanic ventilation including noninvasive mechanic ventilation was required (the clinical criteria for performing mechanic ventilation were as follows: persistent hypoxaemia despite high-flow oxygen supplementation, moderate or severe dyspnoea, acute respiratory acidosis, accessory respiratory muscle recruitment, and paradoxic abdominal movements), and sternum and multiple rib fracture when surgical intervention was required. All injuries, including thoracic injuries found after the nonselective TCT and corresponding treatment methods, were recorded. Similarly, the Injury Severity Scores (ISS), the ED course, and the patients’ length of stay (LOS) in hospital were also recorded. Statistical analysis Statistical analyses were performed using SPSS 11.0 (Chicago, IL, USA). The Kolmogorov–Smirnov test was used to assess the normal distribution of the variables. The independent variables were tested with the Mann–Whitney U test and expressed as medians with interquartile ranges. The categorical data were analyzed for significance with Pearson’s chi-squared test and expressed as numbers and percentiles. A p-value < 0.05 was considered statistically significant.
Results A total of 472 patients with blunt chest trauma were evaluated during the study period. Of these, 138 were excluded, because they were under 18 years of age. Similarly, 10 patients who died before the CT exams, 11 patients who underwent emergent surgery, and 32 patients who were referred to tertiary centres were excluded from the study. Another 21 patients were excluded because of incomplete documentation (Fig. 1). The demographic characteristics of the 260 patients included in the study are provided in Table 2. Of these patients, 113 (43.5%) were discharged from the ED, while 47 (18.1%) were admitted to the intensive care unit (ICU)
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The injuries detected following routine TCT in 44 (16% of all patients – 260) patients (nonselective TCT group), who were otherwise found to have no thoracic injury in selective TCT, included rib fractures in 15 (6%) patients, pulmonary contusion in 13 (5%) patients, pneumothorax in 11 (4%) patients (OP), sternum fracture in four (1.5%) patients, and pneumomediastinum in one (0.3%) patient. Five patients (2% of all patients) in this nonselective TCT group required tube thoracostomy, while there was no additional treatment provided for thoracic injuries in the remaining 39 (15%). Details of the patients who required interventions are summarized in Table 3. When comparing the selective TCT group with the nonselective TCT group, statistically significant differences were found in oxygen saturation, respiration, and LOS in patients. Furthermore, a significant difference was found in patients who required surgical intervention for the management of pulmonary injuries (Table 4). Discussion
Fig. 1. Patient flow chart.
and 89 (34.2%) were admitted to other hospital wards. Two (0.8%) patients died in the ED. Thoracic injuries were found in 97 (37.3%) patients following routine TCT. Of those, 50 (51.5%) sustained isolated chest injuries whereas 47 (48.5%) had accompanying severe injuries. Nine (9.3%) of the patients with thoracic injuries were discharged from the ED without any medical intervention for their injuries, 31 (32%) underwent tube thoracostomy, and 57 (58.8%) had no ED intervention but were admitted to the hospital for observation. When the patient outcomes were evaluated, 14 (14.4%) patients died in the hospital and 83 (85.6%) were discharged from the hospital. In 44 (16%) patients, thoracic injuries were found by CXR or FAST. On the other hand, in nine (4%) patients, TCT was requested by the EP based on the physical examination findings even though CXR and FAST revealed no pathology. As a result, thoracic injury was detected by selective TCT in 53 out of 260 patients (20%). The remaining 44 (16%) patients comprised the nonselective TCT group in which the thoracic injury would not detected by selective TCT; instead, a routine TCT was needed to detect their injuries. The sensitivity of selective TCT in determining thoracic injuries was found to be 54.6% (95% confidence interval (CI) 44.21–64.78). Table 2 Baseline characteristics of the study population – median (IQR 25–75%) or n (%). Age Male Female Trauma mechanism Traffic accident Fall from height Assault with fists/kicks Other Clinical findings Systolic blood pressure Diastolic blood pressure Oxygen saturation % Respiratory rate, breath/min Pulse rate, beats/min Glasgow Coma Scale Injury Severity Score (ISS)
32 (22–47) 196 (75.4) 64 (24.6) 147 89 6 18
(56.5) (34.2) (2.3) (6.9)
120 70 98 16 90 15 10
(110–130) (70–80) (96–99) (16–20) (80–100) (15–15) (3–18)
Although several CT rules of the head (e.g., New Orleans Head CT rules, Canadian Head CT rules), cervical spine (Nexus Rules, Canadian C-spine rules), abdomen, and pelvis have been described clearly, CT rules of thorax are not well described in the literature and ATLS guidelines. Although recently Rodriguez et al. developed the Nexus criteria for blunt chest trauma, these criteria have very low specificity and positive predictive value [16]. Therefore, most physicians prefer nonselective TCT (routine TCT in patients with thorax trauma) to selective TCT in the management of blunt thoracic trauma to prevent life-threatening injuries from being undiagnosed. Based on this concern, we aimed to compare nonselective TCT with selective TCT. The superiority of nonselective, routine TCT examination over CXR and physical examination findings in detecting thoracic injuries in patients with blunt trauma has been shown in recent studies [4,17]. Brink et al. reported that they diagnosed, by nonselective TCT, thoracic injury in 104 (22%) patients, who otherwise went undetected among the group of 464 patients with blunt trauma [17]. Similarly, in a study conducted on 589 patients with blunt trauma, Kea et al. detected, by routine TCT, thoracic injury in 106 (18%) patients, who otherwise were reported to have no injury based on CXR evaluation [18]. In another study, Chardoli et al. evaluated 200 patients with blunt trauma and they found that routine TCT was superior to conventional radiographies in detecting injuries such as rib fractures, pneumothorax, and haemothorax [19]. We found that the use of selective TCT guidelines during trauma evaluation was not sufficient to detect thoracic injuries. By using nonselective TCT, we were able to detect thoracic injuries in 16% (n = 44) of the patients who otherwise would go undetected after the selective TCT. However, the medical literature is mainly concerned whether the diagnoses made by nonselective TCT actually change the course of patient management. There are conflicting results found in the literature on this. Trupka et al. evaluated the value of routine TCT in the management of patients with thoracic trauma, and they reported that the course of treatment was changed in 42 (41%) patients out of 103 evaluated [20]. Similarly, Deunk et al. reported significant changes in the management of patient injuries following routine use of TCT [21]. On the other hand, Kea et al. reported that they were able to detect an injury severe enough to change the course of treatment in only 12 (2%) patients in their study group (n = 589) [18]. We found that nonselective TCT changed the management of five patients (2% of all patients with blunt chest trauma at inception) in whom selective TCT was misdiagnosed. They were all required to undergo a tube thoracostomy. OP is described as a pneumothorax identified on TCT but unidentifiable on CXR. There are different rates of
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Table 3 Features of the patients needing any intervention in the nonselective TCT group. Patients
Chest Injury
Other Injuries
Treatment and Outcome
18 years, male, traffic accident
Pnx
Femoral neck and tibia fx
24 years, male, traffic accident
Pnx + pulmonary contusions
Liver injury
26 years, male, traffic accident
Pnx + pulmonary contusions
ICH + Hand bone fx
20 years, male, fall from height
Pnx
ICH
66 years, male, fall from height
Pnx
–
Chest tube thoracostomy ISS = 19 LOS: 15 days Chest tube thoracostomy Only observation for liver injury ISS: 22 LOS: 7 days Chest tube thoracostomy ISS = 75 Died after two days Minimal Pnx but needed endotracheal intubation due to ICH. Thus, chest tube insertion for preventing the effect of positive pressure ISS = 75 LOS: 8 day Worsened Pnx on third day and insertion of chest tube, ISS = 12 LOS: 8 days
LOS: length of stay, Pnx: pneumothorax, Fx: fracture, ICH: intracranial haemorrhage.
Table 4 Comparison of the selective TCT group and nonselective TCT group regarding general characteristics, vital signs, and outcome – median (IQR 25–75%) or n (%).
Age (years) Male gender (n, %) Systolic blood pressure (mmHg) Diastolic blood pressure (mmHg) Oxygen saturation (%) Respiratory rate (breaths/min) Pulse rate (beats/min) Glasgow Coma Scale (GCS) score Injury Severity Scale (ISS) score Presence of other injuries Discharged from the ED Observation in the ED Surgical interventions a Hospital length of stay (days) a
Selective TCT group n = 53
Nonselective TCT group n = 44
p value
35 35 110 70 96 20 100 15 18 23 2 25 26 7
28 34 120 70 98 18 95 15 18 24 7 32 5 3
0.07 0.32 0.06 0.3 <0.001 <0.001 0.19 0.82 0.35 0.37 0.04 0.01 <0.001 0.01
(22–52) (66) (100–120) (60–80) (92–98) (16–26) (87–110) (14–15) (14–25) (44) (4) (47) (49) (2–10)
(20–46) (77) (110–130) (63–80) (96–99) (16–20) (80–110) (13–15) (10–25) (54) (16) (73) (11) (1–6)
Surgical interventions include chest tube insertion, thoracotomy, etc.
requirement for tube thoracostomy in patients with OP in the literature. In a study conducted on 569 patients with OP, Moore at al. reported that 21% of these patients required immediate tube thoracostomy [22]. In another study conducted on 307 patients with pneumothorax, Wilson et al. reported that 68 of these patients presented with OP and 35 (51%) of these patients with OP required tube thoracostomy [23]. In our study, five of 11 (45%) patients with OP required tube thoracostomy. Nevertheless, despite how the figures on change of patient management following nonselective TCT differ in various studies, we are reluctant to suggest these rates to be clinically insignificant or low. This is because there are no clear criteria to pronounce the TCT method significant based on the percentage of patients for whom the course of treatment is changed.
Conclusion In conclusion, we found that the nonselective TCT method is superior to the selective TCT method in detecting thoracic injuries in patients with blunt trauma. Furthermore, we were able to demonstrate that the nonselective TCT method can change the course of patient management albeit at low rates. Although it may be difficult to reach definite conclusions based on these findings, we suggest the use of the nonselective TCT method, as it has a low non-detection rate of thoracic injuries, and it can change the course of patient management in a small number of patients. Further studies with a greater number of patients would be helpful in drawing a clearer conclusion on the subject matter.
Limitations Our study has two important limitations. First, the initial evaluation of conventional radiography (CXR) and TCT was performed by an EP. In our ED, radiologists do not work 24/7. Thus, the power of initial CXR and TCT evaluation might be poor. However, we think this limitation is not significant because all imaging tests, such as TCT and CXR, were checked over by radiologists the following day, and there was general inter-rater agreement in results. In only one case, the EP interpreted a TCT result as minimal haemothorax, whereas the radiologist interpreted it as pleural thickening the next day. The second limitation is that the EPs were not blinded to the clinical information on patients. However, this is not a major concern, because due to the nature of the study, the clinicians decide whether or not selective TCTs are needed based on the clinical and radiological findings on the patients.
Conflict of interest statement The authors declare that there are no conflicts of interest.
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