Study Type
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Study Quality
1. Karmy-Jones R, Jurkovich GJ, Nathens AB, et al. Timing of urgent thoracotomy for hemorrhage after trauma: a multicenter study. Arch Surg. 2001;136(5):513-518. Observational-Tx 157 patients Study hypothesized that it is possible to quantify an amount of thoracic hemorrhage, after blunt and penetrating injury, at which delay of thoracotomy is associated with increased mortality. Mortality correlated with mean (+/- SD) Injury Severity Score (38 +/- 19 vs 22 +/- 12.6 for survivors; P<.01) and mechanism (24 [67%] for blunt vs 21 [17%] for penetrating injuries; P<.01). Mortality increased as total chest blood loss increased, with the risk for death at blood loss of 1500 mL being 3 times greater than at 500 mL. Blunt-injured patients waited a significantly longer time to thoracotomy than penetrating-injured patients (4.4 +/- 9.0 h vs 1.6 +/- 3.0 h; P =.02) and also had a greater total chest tube output before thoracotomy (2220 +/- 1235 mL vs 1438 +/- 747 mL; P =.001). 2
2. World Health Organization. The top 10 cause of death. Available at: Accessed December 27, 2012. Review/Other-Dx N/A Fact sheet on the top 10 causes of death worldwide. N/A 4
3. Murphy SL, Xu J, Kochanek KD. Deaths: Preliminary Data for 2010. National vital statistics reports; vol 60 no 4. Hyattsville, MD: National Center for Health Statistics. 2010. Review/Other-Dx N/A A report to present preliminary U.S. data on deaths, death rates, life expectancy, leading causes of death, and infant mortality for 2010 by selected characteristics such as age, sex, race, and Hispanic origin. The age-adjusted death rate decreased from 749.6 deaths per 100,000 population in 2009 to 746.2 deaths per 100,000 population in 2010. From 2009 to 2010, age-adjusted death rates decreased significantly for 7 of the 15 leading causes of death: Diseases of heart, Malignant neoplasms, Chronic lower respiratory diseases, Cerebrovascular diseases, Accidents (unintentional injuries), Influenza and pneumonia, and Septicemia. Assault (homicide) fell from among the top 15 leading causes of death in 2010, replaced by Pneumonitis due to solids and liquids as the 15th leading cause of death. The age-adjusted death rate increased for five leading causes of death: Alzheimer’s disease; Nephritis, nephrotic syndrome and nephrosis; Chronic liver disease and cirrhosis; Parkinson’s disease; and Pneumonitis due to solids and liquids. Life expectancy increased by 0.1 year from 78.6 in 2009 to 78.7 in 2010. 4
4. Calhoon JH, Trinkle JK. Pathophysiology of chest trauma. Chest Surg Clin N Am. 1997;7(2):199-211. Review/Other-Dx N/A Review pathophysiology of chest trauma. No results stated in abstract. 4
5. Ungar TC, Wolf SJ, Haukoos JS, Dyer DS, Moore EE. Derivation of a clinical decision rule to exclude thoracic aortic imaging in patients with blunt chest trauma after motor vehicle collisions. J Trauma. 2006;61(5):1150-1155. Observational-Dx 1,096 patients To assess which patients with blunt chest trauma do not need aortic imaging. This article talks about a clinical decision rule. The decision rule incorporates findings on the CXR: sensitivity of 86% (95% CI, 65% to 97%), a specificity of 77% (95% CI, 75% to 80%), a PPV of 7% (95% CI, 4% to 11%), a NPV of 99.6% (95% CI, 99.0% to 99.9%), a positive likelihood ratio of 3.8 (95% CI, 1.1-12.9), and a negative likelihood ratio of 0.18 (95% CI, 0.05-0.61). This would potentially reduce aortic imaging by 76% (95% CI, 74% to 79%). This study is a more recent example in the literature showing the continued importance of the CXR in the initial evaluation of this group of patients. 3
6. Kaewlai R, Avery LL, Asrani AV, Novelline RA. Multidetector CT of blunt thoracic trauma. [Review] [50 refs]. Radiographics. 28(6):1555-70, 2008 Oct. Review/Other-Dx N/A To review and illustrate a spectrum of abnormalities encountered in blunt thoracic trauma at multidetector CT with multiplanar (two-dimensional) and volumetric (three-dimensional [3D]) reformation. Multidetector CT can quickly and accurately help diagnose a variety of thoracic injuries in trauma patients. These injuries can be clearly displayed with multiplanar and volumetric reformation. 4
7. Chung JH, Carr RB, Stern EJ. Extrapleural hematomas: imaging appearance, classification, and clinical significance. J Thorac Imaging. 26(3):218-23, 2011 Aug. Review/Other-Dx 13 cases To identify radiologic and clinical findings associated with extrapleural hematomas (EPHs), to formulate an imaging-based classification system for EPHs, and to identify any radiologic or clinical factors associated with surgical intervention. 92% of the patients (12/13) were male. The average age of the affected patients was 61 years. Most cases were related to blunt trauma (85%, 11/13). All these patients had additional injuries; rib fractures were most consistently present (81%, 9/11). All cases could be further categorized based on the appearance of their CT scan as biconvex or nonconvex. Biconvex EPHs tended to be larger than other types (average size of 4211 mL) and required surgical intervention in 80% of patients (4/5). No specific treatment was necessary in patients with nonconvex EPHs. 4
8. Bernardin B, Troquet JM. Initial management and resuscitation of severe chest trauma. Emerg Med Clin North Am. 2012;30(2):377-400, viii-ix. Review/Other-Dx N/A To provide a review of major thoracic injuries and to provide guidance in the initial management and resuscitation of victims of severe chest trauma. The incorporation of E-FAST will greatly facilitate the diagnostic approach. Therapeutic gestures such as tube thoracostomy and intubation play an important role in the initial stabilization of these patients. Further imaging with CT scanning allows for better definition of the majority of the injuries and has become the diagnostic modality of choice for aortic injuries. The majority of occult injuries (to CXR) can be easily observed. More than 80% of chest injuries may be managed nonoperatively, with supportive treatment. 4
9. Demehri S, Rybicki FJ, Desjardins B, et al. ACR Appropriateness Criteria() blunt chest trauma--suspected aortic injury. EMERG. RADIOL.. 19(4):287-92, 2012 Aug. Review/Other-Dx N/A To recommend appropriate imaging for patients with blunt chest trauma. Imaging largely focuses on the detection and exclusion of traumatic aortic injury; a large proportion of patients are victims of motor vehicle accidents. For those patients who survive the injury and come to emergency radiology, rapid, appropriate assessment of patients who require surgery is paramount. 4
10. Barrios C, Malinoski D, Dolich M, Lekawa M, Hoyt D, Cinat M. Utility of thoracic computed tomography after blunt trauma: when is chest radiograph enough?. Am Surg. 75(10):966-9, 2009 Oct. Observational-Dx 200 consecutive blunt trauma patients To identify the utility of TCT in blunt trauma patients with a normal admission CXR. 143 patients had a normal screening CXR; 36 of these patients (25%) had an abnormal TCT. TCT changed the management in only 9 of these patients (6%): 2 required serial CXR for occult pneumothorax, 4 received additional imaging of the spine, and 3 were admitted to a monitored bed. 57 patients had an abnormal initial CXR. Of these, 41 (81%) had an abnormal TCT. TCT changed management in 21 (37%) of these patients: 2 aortic injuries identified, 12 aortic injuries excluded, 2 chest tubes placed, 1 patient taken to the operating room, and 4 patients required further diagnostic evaluation. TCT was significantly more likely to alter management in patients with an abnormal admission CXR (6% vs 37%, P<0.001). 4
11. Brink M, Deunk J, Dekker HM, et al. Added value of routine chest MDCT after blunt trauma: evaluation of additional findings and impact on patient management. AJR. 2008;190(6):1591-1598. Observational-Dx 464 patients To evaluate the added value of a low-threshold routine thoracic MDCT algorithm compared with a selective MDCT algorithm in adult blunt trauma patients. Of all 464 patients within the routine MDCT group, 164 patients underwent selective MDCT, which resulted in detection of additional diagnoses compared with conventional radiography in 97 (59%) patients. The routine MDCT algorithm detected additional diagnoses compared with conventional radiography in 201 of 464 patients (43%). Compared with the selective MDCT algorithm, this was an absolute increase of 104 of 464 (22%) extra patients, resulting in a change in patient management in 34 (7%; 95% CI, 5-9.7%), mostly because of additional findings of pulmonary and mediastinal injury. 3
12. Tillou A, Gupta M, Baraff LJ, et al. Is the use of pan-computed tomography for blunt trauma justified? A prospective evaluation. J Trauma. 67(4):779-87, 2009 Oct. Observational-Dx 284 patients To determine whether a more selective approach could be justified in use the pan-CT scan for the evaluation of blunt trauma. Of the 284 patients, 48 (17%) had injuries on 52 unsupported CT scans. An immediate intervention was required in 2 of the 48 patients (4%). Injuries that would have been missed included 5 of 62 unsupported head scans (8%), 2 of 50 neck scans (4%), 33 of 116 chest scans (28%), and 12 of 83 abdominal scans (14%). These missed injuries represent 5 of the 61 patients with closed head injuries (8%) in the series, 2 of the 23 with C-spine injuries (9%), 33 of the 112 with chest injuries (29%), and 12 of the 86 with abdominal injuries (14%). In 19 patients, none of the four CT scans was supported; nine of these had an injury identified, and six were admitted to the hospital (1 to the intensive care unit). Injuries that would have been missed included intraventricular and intracerebral hemorrhage (4), subarachnoid hemorrhage (2), cerebral contusion (1), C1 fracture (1), spinous and transverse process fractures (3), vertebral fracture (6), lung lacerations (1), lung contusions (14), small pneumothoraces (7), grade II–III liver and splenic lacerations (6), and perinephric or mesenteric hematomas (2). 4
13. Omert L, Yeaney WW, Protetch J. Efficacy of thoracic computerized tomography in blunt chest trauma. Am Surg. 2001;67(7):660-664. Observational-Dx 169 patients; 110 enrolled in CTL group To determine whether thoracic CT provides additional information to routine CXR findings, whether the additional information results in a management change, and whether thoracic CT is more useful in patients with particular mechanisms of injury. Thoracic CT identified injuries not seen on CXR in 66 per cent of the Control (CTL) group and 39 per cent of the mechanism (MECH) group. Identification of these injuries resulted in a highly significant (P < 0.001) change in clinical management in 20 per cent of the CTL group and 5 per cent of the MECH group. TCT appears to be most helpful in the acute evaluation of trauma patients when roentgenographic evidence of chest injury exists and provides additional information impacting on the care of the patient 20 per cent of the time. In patients with severe mechanisms of injury and normal CXRs TCT expeditiously identifies occult chest injuries that require treatment in 5 per cent of this population. 3
14. McGonigal MD, Schwab CW, Kauder DR, Miller WT, Grumbach K. Supplemental emergent chest computed tomography in the management of blunt torso trauma. J Trauma. 1990;30(12):1431-1434; discussion 1434-1435. Observational-Dx 50 patients To examine the efficacy of conventional chest X-ray (CXR) in comparison to chest computed tomography (CCT) in acutely injured blunt trauma patients. Hemo- and/or pneumothorax (HPTX) was noted in 12 patients (five by CXR, 12 by CCT). Pulmonary contusion (PC) was identified in 10 patients (four by CXR, ten by CCT). Three additional false positive PC were diagnosed by CXR. Therapy changes based upon CCT findings occurred in seven of seven HPTX and five of six PC. The two imaging techniques were complementary in detecting fractures. Atelectasis was a common CCT finding (58% incidence). Chest X-ray is less sensitive than chest CT in the detection of HPTX (42% vs. 100%) and PC (40% vs. 100%). Emergent chest CT is recommended in stable patients with: 1) blunt high-energy torso trauma, 2) "cross-body" injury pattern, and/or 3) a mechanism of injury suggestive of chest trauma. 3
15. Bridges KG, Welch G, Silver M, Schinco MA, Esposito B. CT detection of occult pneumothorax in multiple trauma patients. J Emerg Med. 1993;11(2):179-186. Review/Other-Dx 90 trauma patients To assess the prevalence, initial detection, and management of trauma patients with occult pneumothoraces. In 35 cases (38.8%), initial supine chest x-ray study failed to detect a pneumothorax, and the diagnosis was made on CT scan of the chest or abdomen performed within 2 hours of admission. In 15 of these cases (42.8%), identification of the pneumothorax on CT scan resulted in alterations in management, including chest tube placement in 10 patients and intensified monitoring in 5 patients. 4
16. Traub M, Stevenson M, McEvoy S, et al. The use of chest computed tomography versus chest X-ray in patients with major blunt trauma. Injury. 2007;38(1):43-47. Observational-Dx 141 patients 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. The CT chest scan is significantly more likely to provide further diagnostic information for the management of blunt trauma compared to a chest X-ray in patients with chest wall tenderness (OR = 6.73, 95% CI = 2.56, 17.70, p < 0.001), reduced airentry (OR = 4.48, 95% CI = 1.33, 15.02, p = 0.015) and/or abnormal respiratory effort (OR = 4.05, 95% CI = 1.28, 12.66, p = 0.017). CT scan was significantly more effective than routine chest X-ray in detecting lung contusions, pneumothoraces, mediastinal haematomas, as well as fractured ribs, scapulas, sternums and vertebrae. 3
17. Ball CG, Kirkpatrick AW, Laupland KB, et al. Incidence, risk factors, and outcomes for occult pneumothoraces in victims of major trauma. J Trauma. 2005;59(4):917-924; discussion 924-915. Observational-Dx 761 patients To define the incidence, predictors, and outcomes for occult posttraumatic pneumothoraces (OPTXs) after trauma. Paired CXRs and CT scans were available for 338 of 761 (44%) patients (98.5% blunt trauma). One hundred three PTXs were present in 89 patients, 57 (55%) of which were occult; 6 (11%) were seen only on thoracic CT scan. Age, sex, length of stay, and survival were similar between all groups. OPTXs and PTXs were similar in comparative size index and number of images. Subcutaneous emphysema, pulmonary contusion, rib fracture(s), and female sex were independent predictors of OPTXs. Seventeen (35%) patients with OPTXs were ventilated, of whom 13 (76%) underwent thoracostomy. No complications resulted from observation, although 23% of patients with thoracostomy had tube-related complications or required repositioning. 3
18. Lopes JA, Frankel HL, Bokhari SJ, 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(1):31-34. Observational-Dx 157 patients To evaluate the need for trauma bay chest radiographs (CXR) in stable blunt-trauma patients who are scheduled for chest computed tomography (CCT). Among 95 patients with a "normal" CXR, 38 patients (40%) were found on CCT to have traumatic injuries. Among 62 patients with an "abnormal" CXR, 18 (29%) were found to be normal on CCT. Of the remaining 44 patients, 34 had additional findings on CCT. In 32 patients, CCT led to changes in management. CCT was more sensitive in diagnosing thoracic injuries and led to significant changes in management. 3
19. Ball CG, Kirkpatrick AW, Fox DL, et al. Are occult pneumothoraces truly occult or simply missed? J Trauma. 2006;60(2):294-298 discussion 298-299. Observational-Dx 44 patients To determine whether perceived occult pneumothoraces (OPTXs) were truly occult or simply missed and also address factors that contribute to the poor sensitivity of the supine CXR. Retrospective review identified only 12 to 24% of the OPTXs depending on radiology group. The kappa inter-observer agreement value was 0.55 to 0.56 (poor agreement). PTXs were most commonly identified via the deep sulcus sign (75-90%). CXRs were considered inadequate in 16 to 25% of OPTX images and in 0 to 18% of images without OPTXs. Thoracic CT scans were recommended in 18 to 33% of patients with inadequate CXRs, but 67 to 82% of patients with adequate CXRs. 3
20. Barrios C Jr, Pham J, Malinoski D, Dolich M, Lekawa M, Cinat M. Ability of a chest X-ray and an abdominal computed tomography scan to identify traumatic thoracic injury. Am J Surg. 200(6):741-4; discussion 744-5, 2010 Dec. Observational-Dx 200 patients To identify the utility of thoracic CT (TCT) in blunt trauma patients with a normal admission chest radiograph (CXR). 143 patients had a normal screening CXR; 36 of these patients (25%) had an abnormal TCT. TCT changed the management in only nine of these patients (6%): two required serial CXR for occult pneumothorax, four received additional imaging of the spine, and three were admitted to a monitored bed. 57 patients had an abnormal initial CXR. Of these, 41 (81%) had an abnormal TCT. TCT changed management in 21 (37%) of these patients: two aortic injuries identified, 12 aortic injuries excluded, two chest tubes placed, one patient taken to the Operating Room, and four patients required further diagnostic evaluation. TCT was significantly more likely to alter management in patients with an abnormal admission CXR (6% vs 37%, P < 0.001). 3
21. Smith CB, Barrett TW, Berger CL, Zhou C, Thurman RJ, Wrenn KD. Prediction of blunt traumatic injury in high-acuity patients: bedside examination vs computed tomography. Am J Emerg Med. 29(1):1-10, 2011 Jan. Observational-Dx 18 emergency physicians To prospectively evaluate the ability of emergency physicians (EPs) to exclude predefined clinically significant injuries on the basis of their initial bedside assessment. 400 patients were enrolled as a convenience sample; 71 were excluded. When a “very low” rating was considered negative and “low,” “intermediate,” “high,” and “very high” were considered positive, emergency physicianswere able to detect head, cervical spine, chest, abdominal/pelvic, and thoracic/lumbar spine injuries with sensitivities (95% CI) of 100% (98.6%-100%), 97.4% (94.9%-98.8%), 96.9% (94.2%-98.4%), 97.9% (95.5%-99.1%), and 97.0% (94.3%-98.5%), respectively. For overall diagnostic accuracy, areas under the receiver operating characteristics curve (95%CI) were 0.87 (0.82-0.92), 0.71 (0.62-0.81), 0.81 (0.76-0.86), 0.77(0.71-0.83), 0.74 (0.65-0.84), respectively. 2
22. Kaiser ML, Whealon MD, Barrios C Jr, et al. Risk factors for traumatic injury findings on thoracic computed tomography among patients with blunt trauma having a normal chest radiograph. Arch Surg. 146(4):459-63, 2011 Apr. Observational-Dx 2435 patients To identify risk factors that might predict acute traumatic injury findings on TCT among patients having a normal initial CXR. Multivariate logistic regression demonstrated that an abdominal Abbreviated Injury Score of 3 or higher (P=.001; odds ratio, 2.6), a pelvic or extremity Abbreviated Injury Score of 2 or higher (P<.001; odds ratio, 2.0), age >30 years (P=.004; odds ratio, 1.4), and male sex (P=.04; odds ratio, 1.3) were significantly associated with traumatic findings on TCT. No aortic injuries were diagnosed in patients with a normal CXR. Limiting TCT to patients with 1 or more risk factors predicting acute traumatic injury findings would have resulted in reduced radiation exposure and in a cost savings of almost $250,000 over the 2-year period. Limiting TCT to this degree would not have missed any clinically significant vertebral fractures or vascular injuries. 3
23. Plurad D, Green D, Demetriades D, Rhee P. The increasing use of chest computed tomography for trauma: is it being overutilized? J Trauma. 2007;62(3):631-635. Review/Other-Dx 2,326 CCT performed To determine the change in usage of CCT over time and the number of injuries missed on plain chest radiograph (CXR) with normal findings that required therapy. There were 2,326 CCT performed, and 1,873 (80.5%) of them were after negative CXRs. The percentage of patients studied with CCT increased incrementally from 2.7% to 28.7% for blunt and from 0.4% to 2.9% for penetrating injury. The identification of occult pneumothorax, hemothorax, rib fractures, and lung contusions significantly increased during the study period with the increased frequency of CCT use. There were 102 occult pneumothoraces and/or hemothoraces identified, but only 12 patients underwent tube thoracostomy during the 7-year period. There were 43 patients with blunt aortic injury (BAI) and 6 (13.9%) of these patients had normal CXR findings. There was no trend in increased BAI diagnosed during the study period, although the utilization of CCT was increased. 4
24. Millo NZ, Plewes C, Rowe BH, Low G. Appropriateness of CT of the chest, abdomen, and pelvis in motorized blunt force trauma patients without signs of significant injury. AJR Am J Roentgenol. 197(6):1393-8, 2011 Dec. Observational-Dx 108 patients To determine the frequency of clinically significant injuries detected on CT of the chest, abdomen, and pelvis in adult patients involved in motorized blunt force trauma with normal clinical examinations. 11 of the 108 patients (10%; 95% CI, 4.4-15.6%) had acute injuries detected on CT of the chest, abdomen, and pelvis. None of the injuries required direct medical intervention. Alcohol intoxication or distracting injuries were present in eight of these patients. The median time in hospital, from emergency department presentation to discharge, was 4.4 days (interquartile range, 2.5-8.5 days) for patients who were admitted and 6.7 hours (interquartile range, 4.8-10.3 hours) for those who were discharged. 3
25. 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(6):1173-1176. Observational-Dx 93 patients To evaluate the role of routine computed tomographic (CT) scan. 68 patients (73.1%) showed at least one pathologic sign on chest radiograph, and 25 patients (26.9%) had normal chest radiograph. In 13 (52.0%) of these 25 patients, the CT scan showed multiple injuries; among these were two aortic lacerations, three pleural effusions, and one pericardial effusion. 3
26. Brink M, Deunk J, Dekker HM, et al. Criteria for the selective use of chest computed tomography in blunt trauma patients. Eur Radiol. 20(4):818-28, 2010 Apr. Observational-Dx 508 patients To derive parameters that predict which high-energy blunt trauma patients should undergo CT for detection of chest injury. The authors included 1,047 patients , of whom 508 had chest injuries identified by CT. Using logistic regression, the authors identified nine predictors of chest injury presence on CT (age >or=55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <-3 mmol/l and haemoglobin <6 mmol/l). Of 855 patients with >or=1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant. 3
27. American College of Radiology. ACR Appropriateness Criteria®: Suspected spine trauma. Available at: Accessed October 23, 2012. Review/Other-Dx N/A ACR Appropriateness Criteria guideline on suspected spine trauma. N/A 4
28. Fleming S, Bird R, Ratnasingham K, Sarker SJ, Walsh M, Patel B. Accuracy of FAST scan in blunt abdominal trauma in a major London trauma centre. Int J Surg. 10(9):470-4, 2012. Observational-Dx 71 patients To determine how the results of FAST scans were used in a routine inner city emergency department and whether they influenced the subsequent treatment of adult, blunt trauma patients. 100 patients with BAT presented; 71 had complete data. The accuracy of FAST in BAT was 59.2%; in these 31 (43.7%) were confirmed by CT and 11 (15%) by laparotomy. There were 29 (40.8%) inaccurate FAST scans, all confirmed by CT. FAST had a specificity of 94.7% (95% CI: 0.75-0.99) and sensitivity of 46.2% (95% CI: 0.33-0.60). PPV of 0.96 (0.81-0.99) and NPV of 0.39 (0.26-0.54). Fisher's exact test shows positive FAST is significantly associated with Intra-abdominal pathology (p = 0.001). Cohen's chance corrected agreement was 0.3. 21 out of 28 who underwent laparotomies had positive FAST results indicating accuracy of 75% (95% CI: 57%-87%). 3
29. Matsushima K, Frankel HL. Beyond focused assessment with sonography for trauma: ultrasound creep in the trauma resuscitation area and beyond. Curr Opin Crit Care. 2011;17(6):606-612. Review/Other-Dx N/A Review role of focused assessment with sonography for trauma (FAST) in evaluation of the trauma patient. The indications for FAST and additional ultrasound studies in the injured patient continue to evolve. Application of sound clinical evidence will avoid unsubstantiated indications for ultrasound to creep into clinical practice. 4
30. Kirkpatrick AW, Sirois M, Laupland KB, et al. Hand-held thoracic sonography for detecting post-traumatic pneumothoraces: the Extended Focused Assessment with Sonography for Trauma (EFAST). Journal of Trauma-Injury Infection &#38; Critical Care. 57(2):288-95, 2004 Aug. Observational-Dx 225 patients To evaluate the diagnostic utility of hand-held US identifying occult pneumothoraces (OPTXs) missed by the AP supine chest radiograph (CXR). 225 eligible patients (207 blunt, 18 penetrating); 17 were excluded from the US examination because of battery failure or a lost probe. Sixty-five (65) PTXs were detected in 52 patients (22% of patients), 41 (63%) being occult to CXR in 33 patients (14.2% whole population, 24.6% of those with a CT). The US and CXR agreed in 186 (89.4%) of patients, EFAST was better in 16 (7.7%), and CXR better in 6 (2.9%). Compared with the composite standard, the sensitivity of EFAST was 58.9% with a likelihood ratio of a positive test (LR+) of 69.7 and a specificity of 99.1%. Comparing EFAST directly to CXR, by looking at each of 266 lung fields with the benefit of the CT gold standard, the EFAST showed higher sensitivity over CXR (48.8% versus 20.9%). Both exams had a very high specificity (99.6% and 98.7%), and very predictive LR+ (46.7 and 36.3). 3
31. Soldati G, Testa A, Pignataro G, et al. The ultrasonographic deep sulcus sign in traumatic pneumothorax. Ultrasound Med Biol. 2006;32(8):1157-1163. Observational-Dx 186 patients To validate the transthoracic ultrasonography in defining the presence, location and size of traumatic PNX in comparison with anteroposterior supine chest radiography and CT scan (gold standard) in emergency room. The prevalence of pneumothorax on CT scan was 56/186 (30.1%). Pneumothorax was proven on radiography in 30/56 cases without false positive results: "radiographic deep sulcus sign" was evident in 3/29 cases, 26/29 cases being occult. The ultrasound study demonstrated the presence of pneumothorax in 55/56 patients: one occult pneumothorax was missed and no false positive results were observed. The CT scan differed of +/-2.3 cm (range 1-5 cm) from the US study in evaluating size and location of pneumothorax. 2
32. Rowan KR, Kirkpatrick AW, Liu D, Forkheim KE, Mayo JR, Nicolaou S. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT--initial experience. Radiology. 2002;225(1):210-214. Observational-Dx 27 patients To prospectively compare the accuracy of US with that of supine chest radiography in the detection of traumatic pneumothoraces, with CT as the reference standard 11 of 27 patients had pneumothorax at CT. All 11 of these pneumothoraces were detected at US, and four were seen at supine chest radiography. In the one false-positive US case, the patient was shown to have substantial bullous emphysema at CT. Sensitivity and NPV of US were 100% (11 of 11 and 15 of 15 patients, respectively), specificity was 94% (15 of 16 patients), and PPV was 92% (11 of 12 patients). Chest radiography had 36% (4 of 11 patients) sensitivity, 100% (16 of 16 patients) specificity, a 100% (four of four patients) PPV, and a 70% (16 of 23 patients) NPV. 2
33. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and supine anteroposterior chest radiographs for the identification of pneumothorax after blunt trauma. [Review] [24 refs]. Academic Emergency Medicine. 17(1):11-7, 2010 Jan. Review/Other-Dx 4 observational studies; 606 patients Evidence-based review of the medical literature was performed to compare sensitivity of bedside US and AP chest radiographs in identifying pneumothorax after blunt trauma. Four prospective observational studies were identified, with a total of 606 subjects who met the inclusion and exclusion criteria. The sensitivity and specificity of US for the detection of pneumothorax ranged from 86% to 98% and 97% to 100%, respectively. The sensitivity of supine AP chest radiographs for the detection of pneumothorax ranged from 28% to 75%. The specificity of supine AP chest radiographs was 100% in all included studies. 4
34. Rothlin MA, Naf R, Amgwerd M, Candinas D, Frick T, Trentz O. Ultrasound in blunt abdominal and thoracic trauma. J Trauma. 1993;34(4):488-495. Observational-Dx 312 patients To examine the value of US in patients with blunt thoracic or abdominal injuries. The sensitivity for demonstration of intra-abdominal fluid and organ lesions was 98.1% and 41.4%, respectively. The overall sensitivity and specificity of the US examination were 90.0% and 99.5% respectivelly. 3
35. Brooks A, Davies B, Smethhurst M, Connolly J. Emergency ultrasound in the acute assessment of haemothorax. Emergency Medicine Journal. 21(1):44-6, 2004 Jan. Observational-Dx 61 patients To evaluate thoracic ultrasound for the detection of haemothorax in patients with thoracic trauma against established investigations. 61 patients, 54 (89%) after blunt trauma, underwent thoracic ultrasound evaluation during the study. Twelve patients had a haemothorax detected by ultrasound and confirmed by CT or by tube thoracostomy. Four haemothoraces detected on ultrasound were not apparent on trauma chest radiography. There were 12 true positives, 48 true negatives, no false positives, and one false negative scan. The sensitivity of ultrasound was 92% and specificity 100% with a PPV of 100% and NPV 98% for the detection of haemothorax after trauma. 3
36. Griffith JF, Rainer TH, Ching AS, Law KL, Cocks RA, Metreweli C. Sonography compared with radiography in revealing acute rib fracture. AJR Am J Roentgenol. 2001;176(2):429-432. Observational-Dx 50 patients To compare the sensitivities of sonography and radiography for revealing acute rib fracture. At presentation, radiographs revealed eight rib fractures in six (12%) of 50 patients and sonography revealed 83 rib fractures in 39 (78%) of 50 patients. Seventy-four (89%) of the 83 sonographically detected fractures were located in the rib, four (5%) were located at the costochondral junction, and five (6%) in the costal cartilage. Repeated sonography after 3 weeks showed evidence of healing in all reexamined fractures. Combining sonography at presentation and after 3 weeks, 88% of subjects had sustained a fracture. 3
37. Davis S, Affatato A. Blunt chest trauma: utility of radiological evaluation and effect on treatment patterns. Am J Emerg Med. 2006; 24(4):482-486. Observational-Dx 233 patients To evaluate the accuracy of emergency physicians in interpreting rib radiographs and to determine if that interpretation resulted in any variance in treatment patterns. The overall chi2 calculation showed no differences between the fractured group and the no fracture group (P=.072). From this, it can be concluded that there were no between group differences in drugs prescribed based on whether a fracture was diagnosed by the ED physician. Indicating that the interpretation of the rib series does not influence the physicians treatment plan. 3
38. Malghem J, Vande Berg B, Lecouvet F, Maldague B. Costal cartilage fractures as revealed on CT and sonography. AJR Am J Roentgenol. 2001;176(2):429-432. Review/Other-Dx 8 patients To describe the CT and sonographic appearance of 15 costal cartilage fractures observed in eight patients. On CT, fracture was seen as a low-density area through the costal cartilage, with surrounding calcifications present near old fractures, and gas density within the cleft in some cases. On sonography, cartilage fracture appeared as an interruption of the smooth anterior aspect of the cartilage. 4
39. Soldati G, Testa A, Silva FR, Carbone L, Portale G, Silveri NG. Chest ultrasonography in lung contusion. Chest. 2006;130(2):533-538. Observational-Dx 121 patients; 109 patients (group 1) and 12 patients (group 2) To examine the possible clinical applicability of chest ultrasonography for the diagnosis of lung contusion (LC) in the ED in comparison to radiography and CT. The diagnosis of LC was established by CT scan in 37 patients. If alveolointerstitial syndrome (AIS) is considered, the sensitivity of ultrasound study was 94.6%, specificity was 96.1%, positive and negative predictive values were 94.6% and 96.1%, respectively, and accuracy was 95.4%. If peripheral parenchymal lesion (PPL) is alternatively considered, sensitivity and negative predictive values drop to 18.9% and 63.0%, respectively, but both specificity and positive predictive values increased to 100%, with an accuracy of 65.9%. Radiography had sensitivity of 27% and specificity of 100%. 3
40. Bock JS, Benitez RM. Blunt cardiac injury. [Review]. Cardiol Clin. 30(4):545-55, 2012 Nov. Review/Other-Dx N/A To review some of the most common patterns of blunt cardiac injury (BCI). Blunt chest trauma represents a spectrum of injuries to the heart and aorta that vary markedly in character and severity. The setting, signs, and symptoms of chest trauma are often nonspecific, which represents a challenge to emergency providers. Individuals with suspected blunt chest trauma who have only mild or no symptoms, a normal electrocardiogram (ECG), and are hemodynamically stable typically have a benign course and rarely require further diagnostic testing or long periods of close observation. Individuals with pain, ECG abnormalities, or hemodynamic instability may require rapid evaluation of the heart by echocardiography and the great vessels by advanced imaging. 4
41. Rojas CA, Cruite DM, Chung JH. Traumatic ventricular septal defect: characterization with electrocardiogram-gated cardiac computed tomography angiography. J Thorac Imaging. 2012;27(6):W174-176. Review/Other-Dx N/A To report a case in which a ventricular septal defect caused by blunt chest trauma was characterized with electrocardiogram-gated computed tomography angiography and to review the current literature and theories of injury mechanism. No results stated in abstract. 4
42. Rollins MD, Koehler RP, Stevens MH, et al. Traumatic ventricular septal defect: case report and review of the English literature since 1970. J Trauma. 2005;58(1):175-180. Review/Other-Dx 1 To report a case for a traumatic ventricular septal defect. No abstract available. 4
43. Sohn JH, Song JW, Seo JB, et al. Case report: pericardial rupture and cardiac herniation after blunt trauma: a case diagnosed using cardiac MRI. Br J Radiol. 2005;78(929):447-449. Review/Other-Dx N/A To report a case of traumatic herniation of the heart for which a CT scan and MRI made a major contribution to the diagnosis is reported. No results stated in abstract. 4
44. Malbranque G, Serfaty JM, Himbert D, Steg PG, Laissy JP. Myocardial infarction after blunt chest trauma: usefulness of cardiac ECG-gated CT and MRI for positive and aetiologic diagnosis. Emerg Radiol. 2011;18(3):271-274. Review/Other-Dx 2 patients To determine usefulnes of cardiac ECG-gated CT and MRI for diagnosis of myocardial infarction after blunt chest trauma. Cardiac CT and MRI were useful to noninvasively explore these lesions. 4
45. Tepe SM, Glockner JF, Julsrud P. MRI demonstration of acute myocardial infarction due to posttraumatic coronary artery dissection. Int J Cardiovasc Imaging. 2006;22(1):97-100. Review/Other-Dx 1 patient To review MR imaging of myocardial infarction. No results stated in abstract. 4
46. Christensen MD, Nielsen PE, Sleight P. Prior blunt chest trauma may be a cause of single vessel coronary disease; hypothesis and review. Int J Cardiol. 2006;108(1):1-5. Review/Other-Dx 65 articles ; 77 patients To review the relation between blunt chest trauma (BCT) and angina pectoris, in addition to the relation with myocardial infarction. Angiography revealed 12 cases with completely normal vessels, which might be due to spasm or recanalisation; 31 cases showed occlusion but no atherosclerosis, which strongly suggested a causal relation between the trauma and subsequent occlusion. Acute myocardial infarction (AMI) should therefore be considered in patients suffering from chest pain after blunt chest trauma. Because traumatic AMI might often be the result of an intimal tear or dissection, thrombolytic therapy might worsen the situation and acute percutaneous coronary interventionmust be considered preferable. 4
47. Grosse A, Grosse C, Steinbach L, Anderson S. MRI findings of prolonged post-traumatic sternal pain. Skeletal Radiol. 2007;36(5):423-429. Review/Other-Dx 5 patients To characterize the different causes of prolonged sternal pain following thoracic trauma with involvement of the sternum and to define criteria for sternal nonunion diagnosis using MRI. Two patients (n = 2) revealed a sternal nonunion after sternal fracture. One patient had a sternal fracture with delayed union and minor displacement of the sternal halves. Abnormal signal intensity alterations adjacent to and within the manubrio-sternal joint were evident in 2 patients and considered due to trauma-related changes in the manubrio-sternal joint. The 3 patients who were not included in the study had no abnormalities of the sternum: 1 of them proved to have a well-healed sternal fracture and nonunion of a rib fracture, 1 had subtle Tietze's syndrome, and 1 patient revealed no pathological findings on imaging. 4
48. Subhas N, Kline MJ, Moskal MJ, White LM, Recht MP. MRI evaluation of costal cartilage injuries. AJR. 2008;191(1):129-132. Review/Other-Dx 13 patients with 14 injuries A report on MRI findings in a series of patients with costal cartilage injuries. MRI can be a useful technique in the diagnosis of costal cartilage. 4
49. Kwee TC, Takahara T, Niwa T. Diffusion-weighted whole-body imaging with background body signal suppression facilitates detection and evaluation of an anterior rib contusion. Clin Imaging. 2010;34(4):298-301. Review/Other-Dx 1 patient A report on MRI findings in a 29-year-old woman with anterior chest wall pain following blunt trauma, with special emphasis on the value of diffusion-weighted whole-body imaging with background body signal suppression (DWIBS). Although a rib contusion could be depicted at (fat-suppressed) T2-weighted MRI, anatomical localization and assessment of lesion extent were superior and more straightforward at DWIBS. 4
50. Shanmuganathan K, Mirvis SE, White CS, Pomerantz SM. MR imaging evaluation of hemidiaphragms in acute blunt trauma: experience with 16 patients. AJR. 1996;167(2):397-402. Review/Other-Dx 16 patients To evaluate the usefulness of MR imaging in excluding or confirming the diagnosis of diaphragmatic injury after blunt trauma. MR imaging studies confirmed diaphragmatic injury in seven patients (44%) and revealed an intact diaphragm in nine (66%). In seven patients MR imaging studies were able to correctly reveal the site of the diaphragmatic tear and the abdominal viscera that herniated into the thoracic cavity. None of the nine patients with intact diaphragms on MR imaging studies had delayed presentation of a diaphragmatic rupture on outpatient follow-up. 4
51. Maenza RL, Seaberg D, D'Amico F. A meta-analysis of blunt cardiac trauma: ending myocardial confusion. Am J Emerg Med. 1996;14(3):237-241. Meta-analysis 41 studies To use a meta-analysis of the current literature to identify which patients with blunt cardiac trauma develop complications. Results of the three meta-analyses were similar. Abnormal ECG and abnormal CPK-MB were found to correlate directly with complications requiring treatment. Conversely, normal ECG and CPK-MB correlated with the lack of clinically significant complications. Radionuclide scans did not correlate with complications. The results for echocardiogram were not congruent between the prospective and retrospective studies. The data support the use of ECG and CPK-MB in the diagnosis of clinically significant myocardial contusion. Radionuclide scanning is not useful in the evaluation of patients with blunt cardiac trauma. Further studies need to define the role of echocardiography. Inadequate
52. Pai M. Diagnosis of myocardial contusion after blunt chest trauma using 18F-FDG positron emission tomography. Br J Radiol. 2006;79(939):264-265. Review/Other-Dx 1 case To report a case of acute myocardial infarction without coronary artery injuries after a blunt chest trauma, in which myocardial viability status was evaluated by FDG PET combined with 201Tl perfusion SPECT. FDG PET helped to identify the contused myocardium as a result of perfusion-metabolism matching defect suggesting non-viable infarcted myocardium. FDG PET may be useful in early decision making for patients with blunt chest trauma in a case with indistinct laboratory and imaging findings. 4