Journal Club November 2016 - Bedside Imaging Decisions in Trauma

This Journal Club was done in concert with the trauma attendings and residents with articles chosen and presented by the EM residents. 

The Hamada article was a prospective interventional study of blunt trauma patients who were deemed “stable” and had an e-FAST prior to whole body CT (as opposed to routine plain films).  With this pathway there were no clinically significant missed injuries.  This analysis also showed that this algorithm decreased time spent in the trauma bay, as well as cost and radiation savings.

The Kirkpatrick article attempted to define the test characteristics of bedside thoracic ultrasound as performed by trauma surgeons (training and experience not explained) on blunt and penetrating trauma patients.  The study demonstrated a higher sensitivity for EFAST compared to CXR (49% vs. 21%), but overall reported a lower sensitivity for EFAST than the Wilkerson paper.

The Guilliamondegui article challenged the ATLS protocol that all blunt trauma patients require a pelvic x-ray before CT.  The consensus in the article and during the group discussion was that pelvic plain films should not be ordered routinely, but instead in 3 specific instances: 1. unstable patients in whom you are trying to determine the source of blood loss, 2. patients in whom there is concern for hip dislocation that would require reduction prior to CT or 3. sick patients who are bypassing CT and headed to the OR or for other procedure.

The Wilkerson article was a literature review of the sensitivity of bedside thoracic ultrasound vs. a single supine chest x-ray for the detection of pneumothorax in blunt trauma patients that included 4 prospective observational studies.  This study found a much higher sensitivity of ultrasound (sensitivity 86-98% with a specificity 97-100% compared to CXR with sensitivity 28-75% and specificity 100%) than the Kirkpatrick article. The images in this study were done by EM physicians and we surmised that this may have been due to more experienced operators given that the studies occurred many years later.

 

Written by Casey MacVane, MD


Edited and Posted by Jeff Holmes, MD

Articles Reviewed

1.  Hamada et al. Integrating eFAST in the initial management of stable trauma patients: the end of plain film radiography. Annals of Intensive Care (2016) 6:62.

2.  Kirkpatrick et al. Hand-Held Thoracic Sonography for Detecting Post-Traumatic Pneumothoraces: The Extended Focused Assessment With Sonography For Trauma (EFAST). The Journal of TRAUMA. August 2004, Volume 57, No. 2,  288-295.

3.  Guilliamondegui et al. Pelvic Radiography in Blunt Trauma Resuscitation: A Diminishing Role. The Journal of TRAUMA. Volume 53, No. 6, 1043-1047.

4.  Wilkerson et al. Sensitivity of Bedside Ultrasound and Supine Anteroposterior Chest Radiographs for the Identification of Pneumothorax After Blunt Trauma. Acad Emerg Med. January 2010, Vol 17, No. 1.

 

Download Article Summaries

 HAMADA

HAMADA

 Kirkpatrick

Kirkpatrick