Evaluating validity of clinical criteria for requesting chest X-rays in trauma patients referred to emergency room


1 Department of Emergency Medicine, Tehran University of Medical Sciences, Tehran, Iran

2 Department of Emergency Medicine, Mazandaran University of Medical Sciences, Mazandaran, Iran

3 Department of Emergency Medicine, Isfahan University of Medical Sciences, Isfahan, Iran

4 Department of Radiology, Tehran University of Medical Sciences, Tehran, Iran

5 Department of Surgery, Isfahan University of Medical Sciences, Isfahan, Iran


Background: Our goal was to identify the clinical criteria for requesting the chest X-ray in patients with blunt trauma and whether its findings such as clinical signs with a high sensitivity could be used to codify the final criteria.
Materials and Methods: 386 patients with multiple trauma or blunt chest trauma examined by a physician and the injury mechanism, vital signs, O 2 saturation, auscultation findings, abrasions and ecchymosis, crepitation, tenderness on palpation, and pain on lateral compression were noted. The physician's clinical judgment on the necessity of a chest X-ray was also noted in a questionnaire. After taking the X-ray, a digital photo was taken and showed to a radiologist to report any significant chest injury. Data were collected and the positive and negative predictive values, sensitivity and specificity were estimated.
Results: 350 males (90.9%) and 35 females (9.1%) with the mean age of 47.1 ± 15.5 years old were evaluated. Falling down (37.7%) was the major mechanism of injury and chest pain (48%) the first complaint of patients. In 87.3% of the chest X-rays, there was no abnormal finding. Among several pathological findings in the chest X-rays, hemothorax, and rib fracture (each with 3.4% prevalence) had a higher prevalence. Tenderness on palpation with clinical judgment had a higher sensitivity about 95% and higher specificity about 100% in crepitation detected.
Conclusion: Results showed the combination of positive chest pain and tachypnea in the patients could identify a significant chest injury with 100% sensitivity. More studies on this issue are warranted.


1. Bokhari F, Brakenridge S, Nagy K, Roberts R, Smith R, Joseph K, et al. Prospective evaluation of the sensitivity of physical examination in chest trauma. J Trauma 2002;53:1135-8.  Back to cited text no. 1
2. Rossen B, Laursen NO, Just S. Chest radiography after minor chest trauma. Acta Radiol 1987;28:53-4.  Back to cited text no. 2
3. Hoffman JR, Mower WR, Wolfson AB. Validity of a set of criteria to rule out injury to the cervical spine in patients with blunt trauma. N Eng J Med 2000;343:94-9.  Back to cited text no. 3
4. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, et al. The Canadian C-Spine Rule for radiography in alert and stable trauma patients. JAMA 2001;286;1841-8.  Back to cited text no. 4
5. Stiell IG, Greenberg GH, McKnight RD, Nair RC, McDowell I, Reardon M, et al. Decision rules for the use of radiography in acute ankle injuries: Refinement and prospective validation. JAMA 1993;269:1127-32.  Back to cited text no. 5
6. Stiell IG, Greenberg GH, Wells GA, McDowell I, Cwinn AA, Smith NA, et al. Prospective validation of a decision rule for the use of radiography in acute knee injuries. JAMA 1996;275:611-5.  Back to cited text no. 6
7. Dubinsky I, Low A. Non-life threatening bunt chest trauma: Appropriate investigation and treatment. Am J Emerg Med 1997;15:240-3.  Back to cited text no. 7
8. McLellan BA, Ali J, Towers MJ, Sharkey PW. Role of the trauma room chest X-ray film in assessing the patient with severe blunt traumatic injury. Can J Surg 1996;39:36-41.  Back to cited text no. 8
9. Rodriguez RM, Hendey GW, Marek G, Dery RA, Bjoring A. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med 2006;47:415-8.  Back to cited text no. 9
10. Holmes JF, Sokolove PE, Brant WE, Kuppermann N. A clinical decision rule for identifying children with thoracic injuries after blunt torso trauma. Ann Emerg Med 2002;39:492-9.  Back to cited text no. 10
11. Sears BW, Luchette FA, Esposito TJ, Dickson EL, Grant M, Santaniello JM, et al. Old fashion clinical judgment in the era of protocols: Is mandatory chest X-ray necessary in injured patients?. J Trauma 2005;59:324-32.  Back to cited text no. 11