Screening performance of the chest X-ray in adult blunt trauma evaluation: Is it effective and what does it miss?

Although chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is unclear. Using chest CT as the referent standard, we sought to determine the screening performance of CXR for injury. We analyzed data from the NEXUS Chest...

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Published inThe American journal of emergency medicine Vol. 49; pp. 310 - 314
Main Authors Dillon, David G., Rodriguez, Robert M.
Format Journal Article
LanguageEnglish
Published Philadelphia Elsevier Inc 01.11.2021
Elsevier Limited
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Abstract Although chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is unclear. Using chest CT as the referent standard, we sought to determine the screening performance of CXR for injury. We analyzed data from the NEXUS Chest CT study, in which we prospectively enrolled blunt trauma patients older than 14 years who received chest imaging as part of their evaluation at nine level I trauma centers. For this analysis, we included patients who had both CXR and chest CT. We used CT as the referent standard and categorized injuries as clinically major or minor according to an a priori expert panel classification. Of 11,477 patients enrolled, 4501 had both CXR and chest CT; 1496 (33.2%) were found to have injury, of which 256 (17%) were classified as major injury. CXR missed injuries in 818 patients (54.7%), of which 63 (7.7%) were classified as major injuries. For injuries of major clinical significance, CXR had a sensitivity of 75.4% (95% confidence interval [CI] 69.6–80.4%), specificity of 86.2% (95% CI 85.1–87.2%), negative predictive value of 98.3 (95%CI 97.9–98.6%), and positive predictive value of 24.7 (95%CI 22.9–26.7%). For any injury CXR had a sensitivity of 45.3% (95% CI 42.8–47.9%), specificity of 96.6% (95% CI 95.9–97.2%), negative predictive value of 78% (95% CI 77.2–78.8%), and positive predictive value of 86.9% (95% CI 84.5–89.0%). The most common missed major injuries were pneumothorax (30/185; 16.2%), spinal fractures (19/39; 48.7%), and hemothorax (8/70; 11.4%). The most common missed minor injuries were rib fractures (381/836; 45.6%), pulmonary contusion (203/462; 43.9%), and sternal fractures (153/229; 66.8%). When used alone, without other trauma screening criteria, CXR has poor screening performance for blunt thoracic injury. •CXR had a sensitivity of 75.4% and a specificity of 86.2% for identifying major injury in patients with blunt thoracic trauma.•The most commonly missed major injuries were pneumothorax, spinal fractures, and hemothorax.•When used alone, without other trauma screening criteria, CXR has poor screening performance for blunt thoracic injury.
AbstractList BackgroundAlthough chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is unclear. Using chest CT as the referent standard, we sought to determine the screening performance of CXR for injury.MethodsWe analyzed data from the NEXUS Chest CT study, in which we prospectively enrolled blunt trauma patients older than 14 years who received chest imaging as part of their evaluation at nine level I trauma centers. For this analysis, we included patients who had both CXR and chest CT. We used CT as the referent standard and categorized injuries as clinically major or minor according to an a priori expert panel classification.ResultsOf 11,477 patients enrolled, 4501 had both CXR and chest CT; 1496 (33.2%) were found to have injury, of which 256 (17%) were classified as major injury. CXR missed injuries in 818 patients (54.7%), of which 63 (7.7%) were classified as major injuries. For injuries of major clinical significance, CXR had a sensitivity of 75.4% (95% confidence interval [CI] 69.6–80.4%), specificity of 86.2% (95% CI 85.1–87.2%), negative predictive value of 98.3 (95%CI 97.9–98.6%), and positive predictive value of 24.7 (95%CI 22.9–26.7%). For any injury CXR had a sensitivity of 45.3% (95% CI 42.8–47.9%), specificity of 96.6% (95% CI 95.9–97.2%), negative predictive value of 78% (95% CI 77.2–78.8%), and positive predictive value of 86.9% (95% CI 84.5–89.0%). The most common missed major injuries were pneumothorax (30/185; 16.2%), spinal fractures (19/39; 48.7%), and hemothorax (8/70; 11.4%). The most common missed minor injuries were rib fractures (381/836; 45.6%), pulmonary contusion (203/462; 43.9%), and sternal fractures (153/229; 66.8%).ConclusionsWhen used alone, without other trauma screening criteria, CXR has poor screening performance for blunt thoracic injury.
Although chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is unclear. Using chest CT as the referent standard, we sought to determine the screening performance of CXR for injury. We analyzed data from the NEXUS Chest CT study, in which we prospectively enrolled blunt trauma patients older than 14 years who received chest imaging as part of their evaluation at nine level I trauma centers. For this analysis, we included patients who had both CXR and chest CT. We used CT as the referent standard and categorized injuries as clinically major or minor according to an a priori expert panel classification. Of 11,477 patients enrolled, 4501 had both CXR and chest CT; 1496 (33.2%) were found to have injury, of which 256 (17%) were classified as major injury. CXR missed injuries in 818 patients (54.7%), of which 63 (7.7%) were classified as major injuries. For injuries of major clinical significance, CXR had a sensitivity of 75.4% (95% confidence interval [CI] 69.6–80.4%), specificity of 86.2% (95% CI 85.1–87.2%), negative predictive value of 98.3 (95%CI 97.9–98.6%), and positive predictive value of 24.7 (95%CI 22.9–26.7%). For any injury CXR had a sensitivity of 45.3% (95% CI 42.8–47.9%), specificity of 96.6% (95% CI 95.9–97.2%), negative predictive value of 78% (95% CI 77.2–78.8%), and positive predictive value of 86.9% (95% CI 84.5–89.0%). The most common missed major injuries were pneumothorax (30/185; 16.2%), spinal fractures (19/39; 48.7%), and hemothorax (8/70; 11.4%). The most common missed minor injuries were rib fractures (381/836; 45.6%), pulmonary contusion (203/462; 43.9%), and sternal fractures (153/229; 66.8%). When used alone, without other trauma screening criteria, CXR has poor screening performance for blunt thoracic injury. •CXR had a sensitivity of 75.4% and a specificity of 86.2% for identifying major injury in patients with blunt thoracic trauma.•The most commonly missed major injuries were pneumothorax, spinal fractures, and hemothorax.•When used alone, without other trauma screening criteria, CXR has poor screening performance for blunt thoracic injury.
Author Dillon, David G.
Rodriguez, Robert M.
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2021. Elsevier Inc.
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  publication-title: PLoS Med
  doi: 10.1371/journal.pmed.1001883
  contributor:
    fullname: Rodriguez
– volume: 22
  start-page: 663
  issue: 6
  year: 2015
  ident: 10.1016/j.ajem.2021.06.034_bb0015
  article-title: Trends in advanced computed tomography use for injured patients in United States emergency departments: 2007-2010
  publication-title: Acad Emerg Med
  doi: 10.1111/acem.12684
  contributor:
    fullname: Hussein
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Snippet Although chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is unclear. Using...
BackgroundAlthough chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is...
BACKGROUNDAlthough chest x-ray (CXR) is often used as a screening tool for thoracic injury in adult blunt trauma assessment, its screening performance is...
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elsevier
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StartPage 310
SubjectTerms Blunt trauma
Chest
Chest-xray
Computed tomography
Emergency medical care
Hemothorax
Injuries
Patients
Pneumothorax
Screening
Thorax
Trauma
Trauma centers
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Title Screening performance of the chest X-ray in adult blunt trauma evaluation: Is it effective and what does it miss?
URI https://dx.doi.org/10.1016/j.ajem.2021.06.034
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