World Journal o f Surgery

World Journal o f Surgery ;

Prospective Evaluation of Early Follow-up Chest Radiography after Penetrating Thoracic Injury
Regan J. Berg • Kenji Inaba • Gustavo Recinos • Galinos Barmparas • Pedro G. Teixeira • Chrysanthos Georgiou • David Shatz • Peter Rhee • Demetrios Demetriades
Published online: 28 March 2013 © Societe Internationale de Chirurgie 2013
Abstract Background In asymptomatic patients with penetrating thoracic trauma and a normal initial chest x-ray, successive prospective trials have decreased the minimum observation period required for exclusion of significant injury from 6 to 3 h. Despite the quality of these studies, this interval remains arbitrary and the true requisite observation time for safe discharge remains unknown. The current study eval-uates the ability of “early” repeat chest x-ray, at intervals approaching 1 h, to exclude clinically significant injury. Methods Eighty-eight, asymptomatic patients with pene-trating chest trauma and normal initial chest radiographs were prospectively enrolled in this study. All patients received an “early” follow-up chest x-ray, at a median interval of 1 h and 34 min (interquartile range: 1 h 35 min to 2 h 22 min), and a second repeat x-ray at a “delayed” interval no earlier than 3 h postadmission. Radiographic abnormalities in clinically stable patients were followed with serial examination and repeat imaging for a minimum of 6 h. All patients received both “early” and “delayed” repeat CXRs with no patient discharged before full assessment.
R. J. Berg • K. Inaba (2) • G. Recinos • G. Barmparas • P. G. Teixeira • C. Georgiou • D. Demetriades Division of Trauma and Surgical Critical Care, LAC+USC Medical Center, 1200 North State Street, Inpatient Tower (C)—Room C5L100, Los Angeles, CA 90033, USA e-mail:
D. Shatz Department of Surgery, UC Davis Medical Center, Sacramento, CA, USA
P. Rhee Division of Trauma, Critical Care and Emergency Surgery, The University of Arizona Medical Center, Tucson, AZ, USA
Results One of the 88 patients with initially normal chest x-ray underwent tube thoracostomy at the discretion of the attending surgeon before any repeat imaging. Of the remaining patients, 4 of 87 (4.6 %) demonstrated radio-graphic abnormalities on “early” repeat imaging. Two patients had pneumothoraces, successfully managed with-out intervention; the remaining two demonstrated evidence of hemothorax, subsequently undergoing tube thoracos-tomy. Two more patients (2.3 %) developed pneumotho-races on “delayed” imaging, both successfully observed without intervention. Conclusions In asymptomatic patients with penetrating thoracic trauma and normal initial chest radiographs, “early” repeat chest x-ray, at intervals approaching 1 h, appears sufficient to exclude clinically significant pathol-ogy and to allow safe patient discharge.
During the past three decades, the management of asymptomatic patients with penetrating torso injury has undergone considerable change, shifting from policies of mandatory hospital admission and observation [1, 2], to evidence-based strategies of selective emergency depart-ment discharge after repeat interval radiography [3-5]. In 1982, Weigelt et al. [5] reported no significant clinical progression between chest films performed at 6 and 24 h postinjury, in 110 asymptomatic patients with thoracic stab wounds. Subsequent replication of these findings prompted wide adoption of a “6-h rule” for observation, repeat imaging, and discharge of stable patients [3]. Need for 6 h observation was initially challenged by retrospective review, suggesting equivalency of a 3 h interval for injury exclusion in both blunt and penetrating