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

Schellenberg, Morgan MD; Inaba, Kenji MD; Bardes, James M. MD; Orozco, Nicholas MD; Chen, Jessica; Park, Caroline MD; Kang, Tarina MD; Demetriades, Demetrios MD, PhD

Journal of Trauma and Acute Care Surgery: July 2018 - Volume 85 - Issue 1 - p 113–117
doi: 10.1097/TA.0000000000001868
EAST Quickshot Presentations

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.

From the Division of Trauma and Surgical Critical Care (M.S., K.I., J.M.B., C.P., D.D.), Department of Emergency Medicine (N.O., T.K.), LAC+USC Medical Center, and Keck School of Medicine (J.C.), University of Southern California, Los Angeles, California.

Submitted: November 30, 2017, Revised: December 31, 2017, Accepted: February 24, 2018, Published online: March 9, 2018.

The results of this study were presented at the Eastern Association for the Surgery of Trauma (EAST) Annual Meeting in Lake Buena Vista, FL on January 9–13, 2018.

Address for reprints: Kenji Inaba, MD, Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, University of Southern California, 2051 Marengo St, Inpatient Tower, C5L100, Los Angeles, CA 90033; email:

© 2018 Lippincott Williams & Wilkins, Inc.