Standard X-rays for the victims of severe trauma: time for a change

Introduction

International guidelines for trauma care still recommend the traditional advanced trauma life support investigations for the primary survey: plain radiographs of the chest, cervical spine and pelvis with FAST ultrasounds. However, an increasing amount of data suggest that plain X-rays have excessively low sensitivity. Cervical X-ray may miss up to 35% of the spine injuries, chest X-ray may miss as many as many as 50% of traumatic pneumothorax and a significant percentage of pelvic fractures may not be detected on the pelvis X-ray. CT scan and extended emergency ultrasound (EUs) have a much higher sensitivity if compared with plain X-rays. Moreover, EUs is even less time consuming. Therefore since 2004 we have adopted EUs and/or total body CT scan as the first-line diagnostic tools for major trauma (MT) victims. In a benchmarking analysis of Italian trauma centers (TCs), our hospital ranked first for patient mortality and long-term disability [1]. These results were associated with the shortest diagnostic time. The aim of this study is to assess whether these results were associated with a real change in the diagnostic process.

Methods

In order to evaluate the diagnostic approach to MT we retrospectively analyzed all MT cases (ISS >15) admitted to our TC over a 2-year time span. All investigations performed in the emergency department (ED) are entered in an electronic shift just before being performed. Data for all investigations requested within 2 hours from admission were analyzed.

Results

From 1 November 2007 to 31 October 2009, 743 MT patients were admitted to the ED. EUs was performed in 515 patients (69%), total body CT scan in 679 (91%). Patients who were not submitted to CT either died soon after admission or were rushed to the operating room on the basis of EUs results. Thirty-eight patients had a chest X-ray taken in the ED (5.1%), 11 (1.5%) a pelvic X-ray and only three a cervical spine X-ray.

Conclusions

Although many international guidelines for trauma care still recommend traditional plain radiographic investigations, our TC as well as many other European institutions with a high volume of trauma patients have adopted a different strategy based on the extended use of EUs and CT scan. This may improve the accuracy of the diagnosis in the stabilized patients and reduce time to the operating room in the highly instable ones. We suggest that a change in the recommended guidelines should be considered.