Laurent Zieleskiewicz1, Raphaelle Fresco2, Gary Duclos2, François Antonini2, Calypso Mathieu3, Sophie Medam2, Coralie Vigne2, Marion Poirier2, Pierre-Hugues Roche4, Pierre Bouzat5, François Kerbaul6, Ugo Scemama7, Thierry Bège8, Pascal Alexandre Thomas9, Xavier Flecher10, Emmanuelle Hammad2, Marc Leone11. 1. Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France; Aix Marseille Univiversity, INSERM, INRA, C2VN, Marseille, France. Electronic address: Laurent.zieleskiewicz@ap-hm.fr. 2. Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France. 3. Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France; Aix-Marseille University, Marseille, France. 4. Aix-Marseille University, Marseille, France; Department of Neurosurgery, North university hospital, AP-HM, Marseille, France. 5. Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France; Grenoble Alps University, Grenoble, France. 6. Aix-Marseille University, Marseille, France; Pole RUSH, Assistance-Publique Hôpitaux de Marseille, Marseille, France. 7. Department of Radiology, Hôpital Nord, Marseille, France. 8. Aix-Marseille University, Marseille, France; Department of General Surgery, Marseille, France; Laboratoire de Biomécanique Appliquée, UMR T24, Marseille, France. 9. Aix-Marseille University, Marseille, France; Department of Thoracic and Esophageal Surgery, Hôpital Nord, Marseille, France. 10. Aix-Marseille University, Marseille, France; Department of Orthopaedic Surgery, Institut du Mouvement et de l'Appareil Locomoteur, UMR CNRS 7287 /AMU, Centre Hospitalo-Universitaire Sud, Hôpital Sainte Marguerite, Marseille, France. 11. Department of Anesthesiology and Critical Care, North university hospital, AP-HM, Marseille, France; Aix-Marseille University, Marseille, France; Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes, UMR 63, Marseille, France.
Abstract
BACKGROUND: Before total body computed tomography scan, an initial rapid imaging assessment should be conducted in the trauma bay. It generally includes a chest x-ray, pelvic x-ray, and an extended focused ultrasonography assessment for trauma. This initial imaging assessment has been poorly described since the increase in the use of ultrasound. Therefore, our study aimed to evaluate the diagnostic accuracy and therapeutic impact of this initial imaging work-up in severe trauma patients. A secondary aim was to assess the therapeutic impact of a chest x-ray according to the lung ultrasonography findings. METHODS: Patients with severe trauma who were admitted directly to our level 1 trauma center were consecutively included in this retrospective single center study. The diagnostic accuracy, therapeutic impact, and appropriate decision rate were calculated according to the initial assessment results of the whole body computed tomography scan and surgery reports. RESULTS: Among the 1315 trauma patients admitted, 756 were included in this research. Lung ultrasound showed a higher diagnostic accuracy for haemothorax and pneumothorax cases than the chest x-ray. Sensitivity and specificity of the abdominal ultrasound to detect intraperitoneal effusion were 70% and 96%, respectively. The initial assessment had a therapeutic impact in 76 (10%) of the patients, including 16 (2%) immediate laparotomies and 58 (7%) chest tube insertions. The pelvic x-ray had no therapeutic impact, and when the lung ultrasound was normal, the chest x-ray had a therapeutic impact of only 0.13%. Combining the chest x-ray and lung ultrasound allowed adequate management of all the pneumothorax and haemothorax cases. Only one of the 756 patients had initial management that was judged as inappropriate. This patient had a missed pelvic disjunction with active retroperitoneal bleeding, and underwent an inappropriate immediate laparotomy. CONCLUSIONS: In our cohort, the initial imaging assessment allowed appropriate decisions in 755 of 756 patients, with a global therapeutic impact of 10%. The pelvic x-ray had a minimal therapeutic impact, and in the patients with normal lung ultrasounds, the chest x-ray marginally affected the management of our patients. The potential consequences of abandoning systematic chest and pelvic x-rays should be investigated in future randomized prospective studies.
BACKGROUND: Before total body computed tomography scan, an initial rapid imaging assessment should be conducted in the trauma bay. It generally includes a chest x-ray, pelvic x-ray, and an extended focused ultrasonography assessment for trauma. This initial imaging assessment has been poorly described since the increase in the use of ultrasound. Therefore, our study aimed to evaluate the diagnostic accuracy and therapeutic impact of this initial imaging work-up in severe traumapatients. A secondary aim was to assess the therapeutic impact of a chest x-ray according to the lung ultrasonography findings. METHODS:Patients with severe trauma who were admitted directly to our level 1 trauma center were consecutively included in this retrospective single center study. The diagnostic accuracy, therapeutic impact, and appropriate decision rate were calculated according to the initial assessment results of the whole body computed tomography scan and surgery reports. RESULTS: Among the 1315 traumapatients admitted, 756 were included in this research. Lung ultrasound showed a higher diagnostic accuracy for haemothorax and pneumothorax cases than the chest x-ray. Sensitivity and specificity of the abdominal ultrasound to detect intraperitoneal effusion were 70% and 96%, respectively. The initial assessment had a therapeutic impact in 76 (10%) of the patients, including 16 (2%) immediate laparotomies and 58 (7%) chest tube insertions. The pelvic x-ray had no therapeutic impact, and when the lung ultrasound was normal, the chest x-ray had a therapeutic impact of only 0.13%. Combining the chest x-ray and lung ultrasound allowed adequate management of all the pneumothorax and haemothorax cases. Only one of the 756 patients had initial management that was judged as inappropriate. This patient had a missed pelvic disjunction with active retroperitoneal bleeding, and underwent an inappropriate immediate laparotomy. CONCLUSIONS: In our cohort, the initial imaging assessment allowed appropriate decisions in 755 of 756 patients, with a global therapeutic impact of 10%. The pelvic x-ray had a minimal therapeutic impact, and in the patients with normal lung ultrasounds, the chest x-ray marginally affected the management of our patients. The potential consequences of abandoning systematic chest and pelvic x-rays should be investigated in future randomized prospective studies.
Keywords:
Chest x-ray; Diagnostic accuracy; Focused assessment with sonography for trauma; Pelvic x-ray; Point of care ultrasound; Severe trauma; Trauma bay; Whole body computed tomography
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