The combined utility of extended focused assessment with sonography for trauma and chest X-ray in blunt thoracic trauma

BACKGROUND Portable chest X-ray (CXR) and extended focused assessment with sonography for trauma (EFAST) screen patients for thoracic injury in the trauma bay. It is unclear if one test alone is sufficient, if both are required, or if the two investigations are complementary. Study objectives were to define the combined diagnostic yield of EFAST and CXR among stable blunt thoracic trauma patients and to determine if a normal EFAST and CXR might obviate the need for computed tomography (CT) scan of the chest. METHODS All blunt trauma patients 15 years or older presenting to LAC+USC Medical Center in 2016 were screened. Only patients who underwent CT thorax were included. Patients were excluded if they presented more than 24 hours after injury, were transferred, or if they did not undergo EFAST and CXR. Demographics, physical examination (PEx) of the thorax, injury data, investigations, procedures, and outcomes were collected. The EFAST, CXR, and PEx findings were compared to the gold standard CT thorax to calculate the diagnostic yield of each investigation and combinations thereof in the assessment for clinically significant thoracic injury. RESULTS One thousand three hundred eleven patients met inclusion/exclusion criteria. Most common mechanisms of injury were motor vehicle collision (n = 385, 29%) and auto versus pedestrian trauma (n = 379, 29%). Mean Injury Severity Score was 11 (1-75), with mean Abbreviated Injury Scale chest score of 1.6 (1-6). The sensitivities of EFAST, CXR, and PEx, either individually or in combination, were less than 0.73 in the detection of clinically significant thoracic injury. The most common missed clinically significant injuries were sternal fractures, scapular fractures, clavicular fractures, and pneumothoraces. Motorcycle collisions and auto versus pedestrian traumas resulted in the highest rates of missed injury. CONCLUSION Even in conjunction with the physical examination, the sensitivity of EFAST+CXR in the detection of clinically significant thoracic injury is low. Therefore, if clinical suspicion for injury exists after blunt thoracic trauma, a normal EFAST+CXR is insufficient to exclude injury and CT scan of the chest should be performed. LEVEL OF EVIDENCE Diagnostic tests/criteria, level III.