American Journal of Emergency Medicine (2012) 30, 14

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
b
Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran

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 (March-
June 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 it is important to continually evaluate protocols to deter-

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: ghoddusih@yahoo.com (H.G. Johari).
mine 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

0735-6757/$ see front matter 2012 Elsevier Inc. All rights reserved.
doi:10.1016/j.ajem.2010.08.010
2 S. Paydar et al.

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 hemody-
namically 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
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 pro-
spectively entered into a computer-based database and were
further analyzed by an statistician.

This was a prospective cross-sectional study being

performed in Nemazee hospital trauma center (our level I
3. Results
trauma center) affiliated with Shiraz University of Medical
Sciences during a 4-month period (from March to June
Overall, 5091 blunt trauma patients referred to our center
2009). We included all the patients with blunt trauma who
during the study period out, of which 3598 (70.6%) were
were hemodynamically stable and had negative physical
men and 1493 (29.4%) were women, with mean (SD) age of
examination result. The study protocol was approved by both
30.82 (20.1) years. The most common mechanism of injury
institutional review board and ethics committee of the Shiraz
was motor vehicle accidents, which accounted for 3725
University of Medical Sciences, and all the participants gave
their informed written consents.
Patient care was in concordance with ATLS protocol
Table 1 Characteristics of 5091 patients with blunt trauma
including primary survey, followed by resuscitation and the referred to our trauma center from March to June 2009
secondary survey. Data were collected by means of standard
questionnaire, including demographic information (age, sex, Characteristic Value
area of residence), vital signs, and injury mechanism, and Age (y) 30.82 20.1
through history and physical examination findings. Hemo- Sex
dynamically unstable patients; those with positive chest Men (%) 3598 (70.6)
physical examination result; those younger than 18 years; Women (%) 1493 (29.4)
and those with penetrating trauma, isolated head trauma, and Mechanism of injury
Glasgow Coma Scale score less than 14 were all excluded Motor vehicle accident (%) 3725 (73.2)
Struck as pedestrian (%) 591 (11.6)
from the study. Considering the importance of effective
Fall (%) 575 (11.3)
relationship with patients in history taking and physical Blunt assault (%) 138 (2.7)
examination, we also excluded individuals who could not Other blunt injuries (%) 62 (1.2)
communicate due to language barrier. Stable hemody- Stability
namic condition was defined as systolic blood pressure Stable (%) 4195 (82.4)
higher than 90 mm Hg and heart rate less than 100 beats/ Unstable (%) 896 (17.6)
min. Positive chest physical examination result was Chest physical examination (CPE)
considered if any of the following criteria were met: Positive (%) 4074 (80.1)
decreased breathing sounds (determined by chest ausculta- Subjective chest pain (%) 1328 (26.1)
tion by both junior and senior residents), subcutaneous Chest wall tenderness (%) 809 (15.9)
emphysema, shortness of breath, respiratory distress Shortness of breath (%) 687 (13.5)
Ascultatory findings (%) 591 (11.6)
(determined according to suprasternal or intercostal retrac-
Subcutaneous emphysema (%) 397 (7.8)
tion accompanied by hypoxia and cyanosis), subjective Respiratory distress (%) 178 (3.5)
respiratory discomfort, positive squeeze test (palpation Others (%) 84 (1.7)
tenderness), subjective chest pain, hemoptysis, tenderness, Negative (%) 1017 (19.9)
deformity, crepitus, or auscultatory findings. All physical Hemodynamically stable with negative CPE 1008 (19.8)
examinations and history takings were performed by the
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) 34.3 16.8
Sex
Men (%) 656 (65)
Women (%) 352 (35)
Mechanism of injury
Motor vehicle accident (%) 819 (81.3)
Fall (%) 135 (13.4)
Struck as pedestrian (%) 32 (3.2)
Blunt assault (%) 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 exami-
nation, 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-year-
old 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 consis-
tent 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 life-
threatening 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 under-
went 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 signifi-
cantly 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 S. Paydar et al.
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, interob-
server 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.
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. Vali-
dity of a set of clinical criteria to rule out injury to the cervical spine
in patients with blunt trauma. National emergency X-radiography
utilization study group. N Engl J Med 2000;343:94-9.
[4] 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.
[5] Yugueros P, Sarmiento JM, Garcia AF, Ferrada R. Unnecessary use
of pelvic x-ray in blunt trauma. J Trauma 1995;39:722-5.
[6] 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.
[7] Omert L, Yeaney WW, Protetch J. Efficacy of thoracic computerized
tomography in chest trauma. Am Surg 2001;67:660-4.
[8] 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.
[9] 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.
[10] 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.
[11] 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.
[12] 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.
[13] 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.
[14] 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.
[15] 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.
Reproduced with permission of the copyright owner. Further reproduction prohibited without permission.