The use of chest computed tomography versus chest X-ray in patients with major blunt trauma
Introduction
Two-thirds of patients with multiple injuries suffer from blunt chest trauma and severe thoracic trauma is associated with multiple injuries in 70–90% of cases.5, 7 Among blunt injuries to the chest, lung contusion is considered one of the most important factors contributing to the increased morbidity and mortality of patients with multiple injuries.2, 9
The usual diagnostic work-up in the emergency department for blunt injuries to the chest includes a routine chest X-ray taken in the supine position and an ultrasound. Despite this approach, significant injuries, such as pneumothoraces, haemothoraces, and lung contusions can be missed during the initial trauma assessment.1, 8, 11 Another investigation that is relevant to assess blunt trauma to the chest is computed tomography (CT) scanning. Several studies have shown that CT scanning is accurate in visualising intrathoracic injuries, such as pneumothoraces, haemothoraces, and lung contusions.3, 6, 10 In addition, the availability, reliability, and low complication rate of CT scans has led to its widespread use in the evaluation of blunt trauma.
A number of authors have suggested that the CT chest scan should be routinely considered in the initial assessment of chest trauma.6, 12 However, this suggestion remains controversial. For example, some studies have reported clinical changes in management after CT scans in up to 70% of cases,10 whereas others have suggested that routine CT scans do not have a major impact on the management of blunt trauma to the chest.8, 6
With the wide availability of CT scanners and with the technical improvements in image quality and speed over the past decade, overuse and perhaps overdependence on CT results for the management of patients with chest trauma has occurred. Although CT is an excellent diagnostic tool for chest trauma, it is costly, requires radiation exposure, and removes the patient briefly from direct clinical care at a time when close monitoring of the patient is critical. In a busy trauma or emergency facility, overuse of CT scans can lead to inappropriate delays in patient care.
The purpose of the study is to identify the clinical features associated with further diagnostic information obtained on a CT chest scan compared with a routine chest X-ray in patients sustaining blunt trauma to the chest. This will help to guide decisions about the further investigation and management of blunt trauma to the chest; which is important given that two-thirds of patients with multiple injuries sustain blunt chest trauma.5, 7
Section snippets
Study design
A retrospective review of patients with blunt chest trauma who were treated in a Level 1 trauma centre between January 2002 and December 2003 and who had received both CT chest scan and chest X-ray as part of their initial assessment.
Data collection from medical records and the trauma registry was approved by the Northern Sydney Health Human Research Ethics Committee.
Patients
Patients were identified from the hospital's trauma registry. The trauma registry collects data on all trauma patients with
Results
Of the 141 patients, 75% (n = 106) were men with the patients ranging in age from 17 to 89 years (mean = 47.2 years). The most common mechanism of blunt trauma to the chest was as a result of a motor vehicle crash (37%, n = 52), a motorcycle crash (8.5%, n = 12), a fall (23%, n = 33) or pedestrian injury (17%, n = 24). The mean ISS was 24 (range 3–59).
Almost a third of the patients (n = 45) arrived intubated or were intubated in the emergency department. Eighteen percent (n = 26) of the patients had a chest
Discussion
In this study, CT chest scanning was significantly more effective in detecting pneumothoraces and haemopneumothoraces, lung contusions and mediastinal haematomas compared with a chest X-ray. This is in accordance with several studies that have shown a greater sensitivity for a CT chest scan for detecting intrathoracic injuries.6, 12 Furthermore CT chest scan was significantly better at detecting fractured ribs, scapulas, sternums and vertebrae than a chest X-ray.
CT scanning was more sensitive
Conclusion
The findings from this research highlight that a CT scan is significantly more likely to yield additional information than a CXR alone under the following circumstances: presence of chest wall tenderness, reduced air-entry and abnormal respiratory effort. Therefore, in alert patients and in the absence of those clinical findings, the results suggest that selective use of CT chest scanning can be considered. This is supported by the fact that most chest injuries can be treated with simple
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