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Vasileiou G, Qian S, Al-ghamdi H, Pace D, Rattan R, Mulder M, Namias N, Dante Yeh D. Blunt Trauma: What Is Behind the Widened Mediastinum on Chest X-Ray (CXR)? J Surg Res 2019; 243:23-26. [DOI: 10.1016/j.jss.2019.04.079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Revised: 04/09/2019] [Accepted: 04/26/2019] [Indexed: 11/29/2022]
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Abstract
Blunt thoracic aortic injury remains a major cause of prehospital deaths. For patients who reach the hospital alive, diagnosis and management have undergone dramatic changes over the last 50 years. Computed tomography scanning is the imaging modality of choice for injury diagnosis and repair planning. Medical management with antihypertensives dramatically decreases the risk of rupture, allowing for delayed repair, while abnormal physiology and more immediately life-threatening injuries can be addressed. Endovascular techniques and endograft technology have reduced significantly the risks associated with repair. However, the incidence of late complications associated with the devices currently available is not known.
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Affiliation(s)
- Marc D Trust
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1501 Red River Street, Austin, TX 78712, USA
| | - Pedro G R Teixeira
- Department of Surgery and Perioperative Care, Dell Medical School, University of Texas at Austin, 1501 Red River Street, Austin, TX 78712, USA.
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Gutierrez A, Inaba K, Siboni S, Effron Z, Haltmeier T, Jaffray P, Reddy S, Lofthus A, Benjamin E, Dubose J, Demetriades D. The utility of chest X-ray as a screening tool for blunt thoracic aortic injury. Injury 2016; 47:32-6. [PMID: 26296454 DOI: 10.1016/j.injury.2015.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/29/2015] [Accepted: 08/01/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The early and accurate identification of patients with blunt thoracic aortic injury (BTAI) remains a challenge. Traditionally, a portable AP chest X-ray (CXR) is utilized as the initial screening modality for BTAI, however, there is controversy surrounding its sensitivity. The purpose of this study was to assess the sensitivity of CXR as a screening modality for BTAI. METHODS After IRB approval, all adult (≥18 yo) blunt trauma patients admitted to LAC+USC (01/2011-12/2013) who underwent CXR and chest CT were retrospectively reviewed. Final radiology attending CXR readings were reviewed for mediastinal abnormalities (widened mediastinum, mediastinal to chest width ratio greater than 0.25, irregular aortic arch, blurred aortic contour, opacification of the aortopulmonary window, and apical pleural haematoma) suggestive of aortic injury. Chest CT final attending radiologist readings were utilized as the gold standard for diagnosis of BTAI. The primary outcome analyzed was CXR sensitivity. RESULTS A total of 3728 patients were included in the study. The majority of patients were male (72.6%); mean age was 43 (SD 20). Median ISS was 9 (IQR 4-17) and median GCS was 15 (IQR 14-15). The most common mechanism of injury was MVC (48.0%), followed by fall (20.6%), and AVP (16.9%). The total number of CXRs demonstrating a mediastinal abnormality was 200 (5.4%). Widened mediastinum was present on 191 (5.1%) of CXRs, blurred aortic contour on 10 (0.3%), and irregular aortic arch on 4 (0.1%). An acute aortic injury confirmed by chest CT was present in 17 (0.5%) patients. Only 7 of these with CT-confirmed BTAI had a mediastinal abnormality identified on CXR, for a sensitivity of 41% (95% CI: 19-67%). CONCLUSION The results from this study suggest that CXR alone is not a reliable screening modality for BTAI. A combination of screening CXR and careful consideration of other factors, such as mechanism of injury, will be required to effectively discriminate between those who should and should not undergo chest CT.
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Affiliation(s)
- Adam Gutierrez
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA.
| | - Stefano Siboni
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Zachary Effron
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Tobias Haltmeier
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Paul Jaffray
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Sravanthi Reddy
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Alexander Lofthus
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Elizabeth Benjamin
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Joseph Dubose
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
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Payrastre J, Upadhye S, Worster A, Lin D, Kahnamoui K, Patterson H, Sanaee L, Clayden R. The SCRAP rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma. CAN J EMERG MED 2015; 14:344-53. [DOI: 10.2310/8000.2012.120738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTObjective:To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans.Methods:Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score > 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score ≤ 8, paralysis, or age < 16 years were excluded.Results:There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4–100], specificity 46.9% [95% CI 44.2–46.9], and negative likelihood ratio 0.00 [95% CI 0.00–0.04]). The five variables were oxygensaturation (< 95% on room air or < 98% on any supplemental oxygen),chest radiograph, respiratoryrate ≥ 25, chestauscultation, and thoracicpalpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2–100%), a specificity of 44.7% (95% CI 39.5–44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00–0.10).Conclusions:In major blunt trauma with a GCS score > 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting.
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Soult MC, Weireter LJ, Britt RC, Collins JN, Novosel TJ, Reed SF, Britt LD. Can Routine Trauma Bay Chest X-ray be Bypassed with an Extended Focused Assessment with Sonography for Trauma Examination? Am Surg 2015. [DOI: 10.1177/000313481508100420] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective of this study was to investigate the feasibility of using ultrasound (US) in place of portable chest x-ray (CXR) for the rapid detection of a traumatic pneumothorax (PTX) requiring urgent decompression in the trauma bay. All patients who presented as a trauma alert to a single institution from August 2011 to May 2012 underwent an extended focused assessment with sonography for trauma (FAST). The thoracic cavity was examined using four-view US imaging and were interpreted by a chief resident (Postgraduate Year 4) or attending staff. US results were compared with CXR and chest computed tomography (CT) scans, when obtained. The average age was 37.8 years and 68 per cent of the patients were male. Blunt injury occurred in 87 per cent and penetrating injury in 12 per cent of activations. US was able to predict the absence of PTX on CXR with a sensitivity of 93.8 per cent, specificity of 98 per cent, and a negative predictive value of 99.9 per cent compared with CXR. The only missed PTX seen on CXR was a small, low anterior, loculated PTX that was stable for transport to CT. The use of thoracic US during the FAST can rapidly and safely detect the absence of a clinically significant PTX. US can replace routine CXR obtained in the trauma bay and allow more rapid initiation of definitive imaging studies.
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Affiliation(s)
- Michael C. Soult
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | | | - Rebecca C. Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Jay N. Collins
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Timothy J. Novosel
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - Scott F. Reed
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
| | - L. D. Britt
- Department of Surgery, Eastern Virginia Medical School, Norfolk, Virginia
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Artigas Martín JM, Martí de Gracia M, Claraco Vega LM, Parrilla Herranz P. Radiology and imaging techniques in severe trauma. Med Intensiva 2015; 39:49-59. [PMID: 25438873 DOI: 10.1016/j.medin.2014.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/07/2014] [Accepted: 06/15/2014] [Indexed: 10/24/2022]
Affiliation(s)
- J M Artigas Martín
- Sección de Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - M Martí de Gracia
- Sección de Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario «La Paz», Madrid, España
| | - L M Claraco Vega
- Unidad de Cuidados Intensivos, Hospital Universitario Miguel Servet, Zaragoza, España
| | - P Parrilla Herranz
- Servicio de Urgencias, Hospital Universitario Miguel Servet, Zaragoza, España
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Martí de Gracia M, Artigas Martín JM, Soto JA. Evaluation of thoracic vascular trauma with multidetector computed tomography. Semin Roentgenol 2012; 47:342-51. [PMID: 22929693 DOI: 10.1053/j.ro.2012.05.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Milagros Martí de Gracia
- Emergency Radiology Unit from Department of Radiology, La Paz University Hospital, Madrid, Spain.
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Lai V, Tsang WK, Chan WC, Yeung TW. Diagnostic accuracy of mediastinal width measurement on posteroanterior and anteroposterior chest radiographs in the depiction of acute nontraumatic thoracic aortic dissection. Emerg Radiol 2012; 19:309-15. [PMID: 22415593 PMCID: PMC3396328 DOI: 10.1007/s10140-012-1034-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2011] [Accepted: 02/29/2012] [Indexed: 11/23/2022]
Abstract
We aimed to explore the diagnostic accuracy of various mediastinal measurements in determining acute nontraumatic thoracic aortic dissection with respect to posteroanterior (PA) and anteroposterior (AP) chest radiographs, which had received little attention so far. We retrospectively reviewed 100 patients (50 PA and 50 AP chest radiographs) with confirmed acute thoracic aortic dissection and 120 patients (60 PA and 60 AP chest radiographs) with confirmed normal aorta. Those who had prior history of trauma or aortic disease were excluded. The maximal mediastinal width (MW) and maximal left mediastinal width (LMW) were measured by two independent radiologists and the mediastinal width ratio (MWR) was calculated. Statistical analysis was then performed with independent sample t test. PA projection was significantly more accurate than AP projection, achieving higher sensitivity and specificity. LMW and MW were the most powerful parameters on PA and AP chest radiographs, respectively. The optimal cutoff levels were LMW = 4.95 cm (sensitivity, 90 %; specificity, 90 %) and MW = 7.45 cm (sensitivity, 90 %; specificity, 88.3 %) for PA projection and LMW = 5.45 cm (sensitivity, 76 %; specificity, 65 %) and MW = 8.65 cm (sensitivity, 72 %; specificity, 80 %) for AP projection. MWR was found less useful and less reliable. The use of LMW alone in PA film would allow more accurate prediction of aortic dissection. PA chest radiograph has a higher diagnostic accuracy when compared with AP chest radiograph, with negative PA chest radiograph showing less probability for aortic dissection. Lower threshold for proceeding to computed tomography aortogram is recommended however, especially in the elderly and patients with widened mediastinum on AP chest radiograph.
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Affiliation(s)
- Vincent Lai
- Department of Diagnostic Radiology, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Queen Mary Hospital, Pokfulam, Hong Kong.
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Demetriades D. Blunt thoracic aortic injuries: crossing the Rubicon. J Am Coll Surg 2012; 214:247-59. [PMID: 22265808 DOI: 10.1016/j.jamcollsurg.2011.11.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Accepted: 11/28/2011] [Indexed: 11/24/2022]
Affiliation(s)
- Demetrios Demetriades
- Department of Surgery, Division of Acute Care Surgery, University of Southern California, LAC+USC Medical Center, Los Angeles, CA 90033-4525, USA.
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