The aim of this prospective study was to evaluate whether early thoracic computed tomography (TCT) is superior to routine chest x-ray (CXR) in the diagnostic work-up of blunt thoracic
trauma and whether the additional information influences subsequent therapeutic decisions on the early management of severely injured patients.
PATIENTS AND METHODS: In a prospective study of 103 consecutive patients with clinical or radiologic signs of chest
trauma (94 multiple injured patients with chest
trauma, nine patients with isolated chest
trauma), an average Injury Severity Score of 30 and an average Abbreviated Injury Scale thorax score of 3, initial CXR and TCT were compared after initial assessment in our emergency department of a Level I trauma center.
RESULTS: In 67 patients (65%) TCT detected major chest
trauma complications that have been missed on CXR (lung
contusion (n = 33),
pneumothorax (n = 27), residual
pneumothorax after
chest tube placement (n = 7),
hemothorax (n = 21), displaced
chest tube (n = 5), diaphragmatic
rupture (n = 2), myocardial
rupture (n = 1)). In 11 patients only minor additional pathologic findings (dystelectasis, small
pleural effusion) were visualized on TCT, and in 14 patients CXR and TCT showed the same pathologic results. Eleven patients underwent both CXR and TCT without pathologic fundings. The TCT scan was significantly more effective than routine CXR in detecting lung
contusions (p < 0.001),
pneumothorax (p < 0.005), and
hemothorax (p < 0.05). In 42 patients (41%) the additional TCT findings resulted in a change of
therapy:
chest tube placement,
chest tube correction of pneumothoraces or large hemothoraces (n = 31), change in mode of ventilation and respiratory care (n = 14), influence on the management of fracture stabilization (n = 12),
laparotomy in cases of diaphragmatic
lacerations (n = 2), bronchoscopy for
atelectasis (n = 2), exclusion of
aortic rupture (n = 2), endotracheal intubation (n = 1), and pericardiocentesis (n = 1). To evaluate the efficacy of all those therapeutic changes after TCT the rates of
respiratory failure,
adult respiratory distress syndrome, and mortality in the subgroup of patients with Abbreviated Injury Scale thorax score of > 2 were compared with a historical control group, consisting of 84 patients with
multiple trauma and with blunt chest
trauma Abbreviated Injury Scale thorax score of > 2, prospectively studied between 1986 and 1992. Age (38 vs. 39 years), average Injury Severity Score (33 vs. 38), and the rate of
respiratory failure (36 vs. 56%) were not statistically different between the two groups, but the rates of
adult respiratory distress syndrome (8 vs. 20%; p < 0.05) and mortality (10 vs. 21%; p < 0.05) were significantly reduced in the TCT group.
CONCLUSIONS: TCT is highly sensitive in detecting
thoracic injuries after blunt chest
trauma and is superior to routine CXR in visualzing lung
contusions,
pneumothorax, and
hemothorax. Early TCT influences therapeutic management in a significant number of patients. We therefore recommend TCT in the initial diagnostic work-up of patients with
multiple injuries and with suspected chest
trauma because early and exact diagnosis of all
thoracic injuries along with sufficient therapeutic consequences may reduce complications and improve outcome of severely injured patients with blunt chest
trauma.