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European Journal of Trauma and Emergency Surgery Original Article

Is Routine Spiral CT-Chest Justified in


Evaluation of the Major Blunt Trauma Patients?
Abdel-Mohsen M. Hammad1, Mohamed A. Regal2

Abstract Eur J Trauma Emerg Surg 2009;35:314


Study: New generation spiral CT scanners permit DOI 10.1007/s00068-008-8025-9
multiple consecutive CT examinations on the same
trauma patient in a short period of time. The purpose
of this study was to evaluate the diagnostic role and Introduction
therapeutic impact of routine spiral CT chest in mul- Blunt chest injuries are common injuries in the poly-
tiply injured patients or patients with a suspicious traumatized patient, especially the entities of unstable
mechanism of injury. thorax and pulmonary contusion [14]. Furthermore,
Patients and Methods: This prospective study these injuries lead to a higher mortality in the multiple
included 443 patients with blunt chest trauma. All injured patients than isolated injuries of the same
patients underwent a spiral CT chest as part of their region [5]. In trauma patients, a clear history is rarely
routine evaluation. Radiological interpretation of chest available as most patients are confused, unconscious or
x-rays, CT scan findings, and changes in management even anesthetized and the clinical findings have been
plan guided by these findings were recorded. shown to be equivocal or misleading in 2050% of
Results: The mechanism of injury was road traffic acci- victims of blunt poly-trauma [6]. With the wide avail-
dents in 422 patients (95.26%). Out of the 167 patients ability of Spiral computed tomography (CT) scanner
with normal chest radiograph, 136 (81.43%) were found to overuse and perhaps overdependence on CT results for
have an abnormality on chest CT. The management was the management of patients with chest trauma has
changed in the form of additional investigations or occurred. Although CT is an excellent diagnostic tool
unplanned intervention in 92 patients (20.76%). Addi- for chest trauma, it is costly, requires radiation expo-
tional investigations included transoesophageal echo- sure; also, in a busy trauma or emergency facility,
cardiography (n = 7), bronchoscopy (n = 13), transfer to overuse of CT scans can lead to inappropriate delays in
higher center for aortography (n = 2). Intercostal tubes patient care [7]. The purpose of this study was to
(n = 55), thoracotomies (n = 4), fixation of sternal frac- evaluate the diagnostic role and therapeutic impact of
ture (n = 9), laparotomy (n = 1) and spinal fixation (n = 1) routine spiral CT chest in multiple injured patients or
were performed following the CT scan. patients with a suspicious mechanism of injury when it
Conclusion: Although the incidence of significant inju- is performed in addition to conventional X-ray chest.
ries identified by the chest CT scan was low, it did
prompt immediate intervention in a significant number Patients and Methods
of patients; some of them had potentially life-threat- This prospective observational study was conducted in
ening injuries. Routine use of CT scanning is warranted King Fahd Specialist Hospital (KFSH), Buraidah,
in early evaluation of polytrauma patients or patients Saudi Arabia, during the period from June 2004 to
with severe blunt chest trauma. May 2006. The protocol of the study was approved by
the ethical committee of the hospital; patient consent
Key Words was obtained before performance of CT as a routine.
Chest trauma Polytrauma Computed All patients with blunt chest trauma were included if
tomography they met the following criteria: (1) Polytrauma [injury

1
Thoracic Surgery Division, Padova University Hospital, Padova,
Italy,
2
Cardiothoracic Surgery Department, King Fahd Specialist Hospital,
Buraidah, Al Qassim, Saudi Arabia.

Received: February 14, 2008; revision accepted: June 11, 2008;


Published Online: July 17, 2008

Eur J Trauma Emerg Surg 2009 No. 1  URBAN & VOGEL 31


Hammad AMM, Regal MA. Is Routine Spiral CT-Chest Justified in Trauma Patients?

severity score (ISS) 16] [8]. (2) Isolated chest trauma More than half of patients 276 (62.3%) had a chest
with significant mechanisms of injury e.g., motor injury, diagnosed on X-ray film. Ninety-three percent of
vehicle crash, falls from heights greater than 3 m, or patients (n = 412) had at least one pathological finding
automobile, hitting a pedestrian . (3) Cases with assault on CT scan. Of the 167 (37.7%) with a normal chest
due to medicolegal reasons. radiograph, 136 patients (30.69%) were found to have an
Patients were assessed and managed along ATLS abnormality on chest CT. Seven percent of patients
guidelines [9]: primary survey, resuscitation, secondary (n = 31) had no abnormality on CT scan examination.
survey, including portable plain radiography of the Comparison of chest X-ray findings with those of
lateral cervical spine, chest and pelvis in the ED. the chest CT scan is presented in Table 1.
Necessary supportive treatments were commenced In this study, CT chest scanning was significantly
before transfer from the ED. Evaluation of the chest more effective in detecting pneumothorax, hemotho-
begins with assessment of the mechanism of injury, rax, hemo-pneumothorax, lung contusions and medi-
physical examination, and interpretation of chest astinal emphysema compared with a chest X-ray.
radiography. All patients underwent a CT chest, as Sternal fracture (p < 0.002) is detected better with CT
part of their evaluation. as well. Also CT scan was more effective in detecting
The following data were collected: patients demo- mediastinal hematoma, ruptured diaphragm and spinal
graphics, mechanisms of injury, clinical findings and and scapular fractures.
injuries sustained; interpretation of chest X-ray, CT In general, X-ray chest as compared to CT chest
scan findings, and changes in treatment based on these has a sensitivity of 66.9%, specificity of 100%, accuracy
findings and major operative procedures were recorded. of 69.3% and negative predictive value of 18.56%
An abnormal scan was defined as exhibiting any The clinical management was changed in 92 patients
traumatic abnormality. The intrathoracic findings (20.76%). Additional investigations and/or interventions
included pneumothorax, hemothorax, pulmonary con- following CT scan were performed and included
tusion, mediastinal abnormality suspicious for aortic transoesophageal echocardiography (n = 7), bronchos-
injury, mediastinal emphysema, rupture diaphragm and copy (n = 13) and patient transfer to higher center for
fracture of the ribs, scapula, sternum or dorsal spine. aortography (n = 2). Intercostal tubes were required in
Patient treatment changes were defined as altera- 55 patients following the CT scan for pneumothorax or
tions in the normal treatment plan as a direct result of the hemothorax that was not seen on a plain chest X-ray or
CT scan findings. These changes included performance for patient with mild hemo-pneumothorax undergoing
of additional diagnostic studies or interventions (e.g., general anesthesia or mechanical ventilation. Thoracot-
trans-esophageal echocardiography, angiography or omies were performed on four patients; three for rup-
bronchoscopy), and immediate operative intervention. tured diaphragm and one for a hemothorax and one
Comparison of data was performed by v2 test or laparotomy for ruptured diaphragm. Open fixation of
Fisher exact tests as appropriate. Statistical significance sternal fracture was performed in nine patients and
was considered at p < 0.05 for all comparisons. All dorsal spinal fixation in one patient.
statistical analyses were performed with SPSS version
13.0 (SPSS Inc, Chicago, IL). Table 1. Comparison between the chest X-ray and CT chest findings.

Radiological findings Chest X-ray CT scan p Value

Results Rib fracture 242 (54.6%) 256 (57.78%) 0.34


During the study period 443 patients with blunt chest Scapula fractures 15 (3.38%) 21 (4.7%) 0.30
trauma fulfilled the inclusion criteria for the study. Vertebra fractures 2 (0.45%) 7 (1.58%) 0.09
Most of the patients, 386 (87.13%) were involved in a Sternum fractures 1 (0.22%) 12 (2.7%) 0.002*
high-speed car crash, 36 (8.13%) were pedestrians in- Pneumothorax 75 (16.9%) 191 (43.1%) 0.00001*
volved in high-impact automobile collisions, 13 (2.93%) Hemo-pneumothorax 11 (2.48%) 92 (20.76%) 0.00001*
were assaulted and 8 (1.81%) fell from a height of more Hemothorax 39 (8.8%) 86 (19.4%) 0.00001*
Lung contusion 72 (16.25%) 169 (38.4%) 0.00001*
than 3 m. Most of the patients (92.1%) were male and
Mediastinal hematoma 16 (3.6%) 19 (4.28%) 0.60
the mean age was 39.8 years (range 1385 years).
Ruptured diaphragm 2 (0.45%) 6 (1.35%) 0.15
All patients had a supine chest film taken in the Mediastinal emphysema 10 (2.25%) 35 (7.9%) 0.00015*
emergency department and subsequently chest CT. Air way injury 0 (%) 2 (0.45%) 0.15
Most patients 358 (80.8%) had additional head and/or
abdominal CT. * Significant

32 Eur J Trauma Emerg Surg 2009 No. 1  URBAN & VOGEL


Hammad AMM, Regal MA. Is Routine Spiral CT-Chest Justified in Trauma Patients?

Discussion In contrast, several studies found changes in pa-


CT is considered to be one of the most valued tools in the tient management of up to 70% in situations where CT
diagnostic work-up of trauma patients. In most trauma chest scans were performed, such as insertion or cor-
centers, CT investigations to assess brain, thoracic, rection of a chest tube, a change in the mode of ven-
abdominal visceral and pelvic ring lesions are restricted to tilation, as well as further investigations and/or
hemodynamically stable patients and therefore, are mostly interventions [17]. Also, Salim et al. compared the
assigned to the secondary survey. Conventional CT was findings of the chest radiograph with those of the chest
time-consuming; today, spiral CT, and particularly multi- CT scan in 1,000 trauma patients. They found that 809
slice CT (MSCT), significantly reduced the time require- (80.9%) had a normal chest radiograph. Of these 809
ments for initial diagnostic evaluation [10, 11]. The patients with a normal chest radiograph, 64 patients
reduction of the scanning time is due to an increased speed (7.9%) were found to have an abnormality on chest CT
of image acquisition; entire sections of the body can be such as occult pneumothorax/hemothorax, pulmonary
rapidly imaged in the axial plane during a single breath contusion, rib fracture and aortic injury. In two pa-
hold [12]. These important aspects contribute to the more tients, who underwent aortography, CT scan was sug-
frequent use of CT and the potential introduction of gestive of an aortic injury, and an actual injury was
MSCT in the primary survey of polytrauma victims [13]. demonstrated in one patient [23].
The fear of missing an injury in a patient who Traub et al. reported that 90% of their patients
cannot be reliably examined has been pan scanned in (n = 127) had at least one pathological finding on CT
routine. Even in awake, evaluable patients, liberal scan compared to 58% of patients (n = 82) on plain chest
scanning is advocated because of the unreliability of X-ray. Additional investigations and/or interventions,
physical examination. In head and abdominal trauma, including aortic angiography (n = 4) and transoesoph-
the value of CT scanning is well recognized with many ageal echocardiography (n = 4), following CT scan were
changes in clinical management based on the results of performed on 19% of patients (n = 27) and two patients
these imaging studies [14]. However, for blunt thoracic required insertion of an endoluminal stent for aortic
trauma, the clinical utility of thoracic CT is less defined injuries. Thoracotomies were performed on two pa-
and is still open for debate. tients, one for a hemothorax and the other for a tran-
In this study, CT chest scanning was significantly sected thoracic aorta. Intercostal tubes were required in
more effective in detecting pneumothorax and hemo- 15 patients following the CT scan for a pneumothorax
pneumothorax, lung contusions and mediastinal that was not seen on a plain chest X-ray, and an addi-
emphysema, compared with a chest X-ray. This is in tional chest tube for a persisting pneumothorax [24].
accordance with several studies that have shown a There is growing concern that the overuse of CT is
greater sensitivity for a CT chest scan for detecting creating problems. Physicians are now becoming
intrathoracic injuries [15 20]. Moreover, chest CT increasingly dependent on CT scans for treatment
scan was better at detecting mediastinal hematoma, decisions, possibly even ignoring physical examinations.
rupture diaphragm, fractured ribs, scapulas, sternum This may lead to inappropriate intervention, or even
and dorsal vertebrae than a chest X-ray. delayed intervention [25]. The proliferation of CT
Although CT scans were more sensitive in diagnosis, scanning also introduces concerns that resources are
the question of whether the additional information inappropriately used in this cost-conscious medical era.
gained with CT scanning changes patient management in In a retrospective study looking at the clinical use of
this early phase remains controversial. In this study, only imaging in the acute trauma setting, nearly 52% of
20.79% (n = 92) of the patients with an abnormal CT patients had no clinically significant injuries seen on
scan had a subsequent investigation and/or intervention radiography [26, 27]. However, any financial analysis
as a direct result of the findings. Some studies have not should also take into account the costs (both health-
been able to demonstrate significant therapeutic conse- related and legal) associated with missed or delayed
quences and consequently, they do not recommend CT diagnoses that can be minimized by the routine use of CT.
chest scans as a routine first assessment [21]. Also, in a Besides the cost issue associated with liberal CT
study by Blostein & Hodgman of 40 patients, 76 injuries scanning, there is a general consensus that the current
were found on chest CT scan not seen on CXR; these levels of CT radiation may be associated with an in-
were mainly pneumothorax and lung contusions. How- creased risk of cancer, especially in children as com-
ever, only six patients (15%) had a change in therapy puted tomography examinations are associated with an
based on the results of the chest CT scan, five of which organ-specific radiation dose that is much higher than
were insertion of a chest tube [22]. with conventional radiographs [28, 29].

Eur J Trauma Emerg Surg 2009 No. 1  URBAN & VOGEL 33


Hammad AMM, Regal MA. Is Routine Spiral CT-Chest Justified in Trauma Patients?

Conclusion 18. Wilson D, Voystock JF, Sariego J. Role of computed tomography


Although the overall incidence of significant injuries scan in evaluating the widened mediastinum. Am Surg
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threatening injuries. A policy of routine use of CT routine computed tomographic scanning in the primary eval-
uation of blunt chest trauma in patients with normal chest
scanning is warranted in early evaluation of polytrauma radiograph? J Trauma 2001;51:11736.
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Acknowledgment Care Med 2000;28:13705.
We thank Dr. Giuseppe Marulli for the assistance in statistical work. 22. Blostein PA, Hodgman CG. Computed tomography of the
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