Pneumothorax and Hemothorax in the Era of Frequent Chest Computed Tomography for the Evaluation of Adult Patients With Blunt Trauma

Robert M. Rodriguez, Karla Canseco, Brigitte M. Baumann, William R. Mower, Mark I. Langdorf, Anthony J. Medak, Deirdre R. Anglin, Gregory W. Hendey, Newton Addo, Daniel Nishijima, Ali S. Raja

Research output: Contribution to journalArticle

Abstract

Study objective: Although traditional teachings in regard to pneumothorax and hemothorax generally recommend chest tube placement and hospital admission, the increasing use of chest computed tomography (CT) in blunt trauma evaluation may detect more minor pneumothorax and hemothorax that might indicate a need to modify these traditional practices. We determine the incidence of pneumothorax and hemothorax observed on CT only and the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and describe the clinical implications of these injuries. Methods: This was a planned secondary analysis of 2 prospective, observational studies of adult patients with blunt trauma, NEXUS Chest (January 2009 to December 2012) and NEXUS Chest CT (August 2011 to May 2014), set in 10 Level I US trauma centers. Participants’ inclusion criteria were older than 14 years, presentation to the emergency department (ED) within 6 hours of blunt trauma, and receipt of chest imaging (chest radiograph, chest CT, or both) during their ED evaluation. Exposure(s) (for observational studies) were that patients had trauma and chest imaging. Primary measures and outcomes included the incidence of pneumothorax and hemothorax observed on CT only versus on both chest radiograph and chest CT, the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and admission rates, hospital length of stay, mortality, and frequency of chest tube placement for these injuries. Results: Of 21,382 enrolled subjects, 1,064 (5%) had a pneumothorax and 384 (1.8%) had a hemothorax. Of the 8,661 patients who received both a chest radiograph and a chest CT, 910 (10.5%) had a pneumothorax, with 609 (67%) observed on CT only; 319 (3.7%) had a hemothorax, with 254 (80%) observed on CT only. Of 1,117 patients with pneumothorax, hemothorax, or both, 108 (10%) had isolated pneumothorax or hemothorax. Patients with pneumothorax observed on CT only had a lower chest tube placement rate (30% versus 65%; difference in proportions [Δ] -35%; 95% confidence interval [CI] –28% to 42%), admission rate (94% versus 99%; Δ 5%; 95% CI 3% to 8%), and median length of stay (5 versus 6 days; difference 1 day; 95% CI 0 to 2 days) but similar mortality compared with patients with pneumothorax observed on chest radiograph and CT. Patients with hemothorax observed on CT had only a lower chest tube placement rate (49% versus 68%; Δ -19%; 95% CI –31% to -5%) but similar admission rate, mortality, and median length of stay compared with patients with hemothorax observed on chest radiograph and CT. Compared with patients with other thoracic injury, those with isolated pneumothorax or hemothorax had a lower chest tube placement rate (20% versus 43%; Δ -22%; 95% CI –30% to -13%), median length of stay (4 versus 5 days; difference -1 day; 95% CI –3 to 1 days), and admission rate (44% versus 97%; Δ -53%; 95% CI –62% to -43%), with an admission rate comparable to that of patients without pneumothorax or hemothorax (49%). Conclusion: Under current imaging protocols for adult blunt trauma evaluation, most pneumothoraces and hemothoraces are observed on CT only and few occur as isolated thoracic injury. The clinical implications (admission rates and frequency of chest tube placement) of pneumothorax and hemothorax observed on CT only and isolated pneumothorax or hemothorax are lower than those of patients with pneumothorax and hemothorax observed on chest radiograph and CT and of those who have other thoracic injury, respectively.

Original languageEnglish (US)
JournalAnnals of Emergency Medicine
DOIs
StateAccepted/In press - Jan 1 2018

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Hemothorax
Pneumothorax
Thorax
Tomography
Wounds and Injuries
Chest Tubes
Thoracic Injuries
Confidence Intervals
Length of Stay
Incidence
Observational Studies
Mortality
Hospital Emergency Service

ASJC Scopus subject areas

  • Emergency Medicine

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Pneumothorax and Hemothorax in the Era of Frequent Chest Computed Tomography for the Evaluation of Adult Patients With Blunt Trauma. / Rodriguez, Robert M.; Canseco, Karla; Baumann, Brigitte M.; Mower, William R.; Langdorf, Mark I.; Medak, Anthony J.; Anglin, Deirdre R.; Hendey, Gregory W.; Addo, Newton; Nishijima, Daniel; Raja, Ali S.

In: Annals of Emergency Medicine, 01.01.2018.

Research output: Contribution to journalArticle

Rodriguez, Robert M. ; Canseco, Karla ; Baumann, Brigitte M. ; Mower, William R. ; Langdorf, Mark I. ; Medak, Anthony J. ; Anglin, Deirdre R. ; Hendey, Gregory W. ; Addo, Newton ; Nishijima, Daniel ; Raja, Ali S. / Pneumothorax and Hemothorax in the Era of Frequent Chest Computed Tomography for the Evaluation of Adult Patients With Blunt Trauma. In: Annals of Emergency Medicine. 2018.
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title = "Pneumothorax and Hemothorax in the Era of Frequent Chest Computed Tomography for the Evaluation of Adult Patients With Blunt Trauma",
abstract = "Study objective: Although traditional teachings in regard to pneumothorax and hemothorax generally recommend chest tube placement and hospital admission, the increasing use of chest computed tomography (CT) in blunt trauma evaluation may detect more minor pneumothorax and hemothorax that might indicate a need to modify these traditional practices. We determine the incidence of pneumothorax and hemothorax observed on CT only and the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and describe the clinical implications of these injuries. Methods: This was a planned secondary analysis of 2 prospective, observational studies of adult patients with blunt trauma, NEXUS Chest (January 2009 to December 2012) and NEXUS Chest CT (August 2011 to May 2014), set in 10 Level I US trauma centers. Participants’ inclusion criteria were older than 14 years, presentation to the emergency department (ED) within 6 hours of blunt trauma, and receipt of chest imaging (chest radiograph, chest CT, or both) during their ED evaluation. Exposure(s) (for observational studies) were that patients had trauma and chest imaging. Primary measures and outcomes included the incidence of pneumothorax and hemothorax observed on CT only versus on both chest radiograph and chest CT, the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and admission rates, hospital length of stay, mortality, and frequency of chest tube placement for these injuries. Results: Of 21,382 enrolled subjects, 1,064 (5{\%}) had a pneumothorax and 384 (1.8{\%}) had a hemothorax. Of the 8,661 patients who received both a chest radiograph and a chest CT, 910 (10.5{\%}) had a pneumothorax, with 609 (67{\%}) observed on CT only; 319 (3.7{\%}) had a hemothorax, with 254 (80{\%}) observed on CT only. Of 1,117 patients with pneumothorax, hemothorax, or both, 108 (10{\%}) had isolated pneumothorax or hemothorax. Patients with pneumothorax observed on CT only had a lower chest tube placement rate (30{\%} versus 65{\%}; difference in proportions [Δ] -35{\%}; 95{\%} confidence interval [CI] –28{\%} to 42{\%}), admission rate (94{\%} versus 99{\%}; Δ 5{\%}; 95{\%} CI 3{\%} to 8{\%}), and median length of stay (5 versus 6 days; difference 1 day; 95{\%} CI 0 to 2 days) but similar mortality compared with patients with pneumothorax observed on chest radiograph and CT. Patients with hemothorax observed on CT had only a lower chest tube placement rate (49{\%} versus 68{\%}; Δ -19{\%}; 95{\%} CI –31{\%} to -5{\%}) but similar admission rate, mortality, and median length of stay compared with patients with hemothorax observed on chest radiograph and CT. Compared with patients with other thoracic injury, those with isolated pneumothorax or hemothorax had a lower chest tube placement rate (20{\%} versus 43{\%}; Δ -22{\%}; 95{\%} CI –30{\%} to -13{\%}), median length of stay (4 versus 5 days; difference -1 day; 95{\%} CI –3 to 1 days), and admission rate (44{\%} versus 97{\%}; Δ -53{\%}; 95{\%} CI –62{\%} to -43{\%}), with an admission rate comparable to that of patients without pneumothorax or hemothorax (49{\%}). Conclusion: Under current imaging protocols for adult blunt trauma evaluation, most pneumothoraces and hemothoraces are observed on CT only and few occur as isolated thoracic injury. The clinical implications (admission rates and frequency of chest tube placement) of pneumothorax and hemothorax observed on CT only and isolated pneumothorax or hemothorax are lower than those of patients with pneumothorax and hemothorax observed on chest radiograph and CT and of those who have other thoracic injury, respectively.",
author = "Rodriguez, {Robert M.} and Karla Canseco and Baumann, {Brigitte M.} and Mower, {William R.} and Langdorf, {Mark I.} and Medak, {Anthony J.} and Anglin, {Deirdre R.} and Hendey, {Gregory W.} and Newton Addo and Daniel Nishijima and Raja, {Ali S.}",
year = "2018",
month = "1",
day = "1",
doi = "10.1016/j.annemergmed.2018.08.423",
language = "English (US)",
journal = "Annals of Emergency Medicine",
issn = "0196-0644",
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TY - JOUR

T1 - Pneumothorax and Hemothorax in the Era of Frequent Chest Computed Tomography for the Evaluation of Adult Patients With Blunt Trauma

AU - Rodriguez, Robert M.

AU - Canseco, Karla

AU - Baumann, Brigitte M.

AU - Mower, William R.

AU - Langdorf, Mark I.

AU - Medak, Anthony J.

AU - Anglin, Deirdre R.

AU - Hendey, Gregory W.

AU - Addo, Newton

AU - Nishijima, Daniel

AU - Raja, Ali S.

PY - 2018/1/1

Y1 - 2018/1/1

N2 - Study objective: Although traditional teachings in regard to pneumothorax and hemothorax generally recommend chest tube placement and hospital admission, the increasing use of chest computed tomography (CT) in blunt trauma evaluation may detect more minor pneumothorax and hemothorax that might indicate a need to modify these traditional practices. We determine the incidence of pneumothorax and hemothorax observed on CT only and the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and describe the clinical implications of these injuries. Methods: This was a planned secondary analysis of 2 prospective, observational studies of adult patients with blunt trauma, NEXUS Chest (January 2009 to December 2012) and NEXUS Chest CT (August 2011 to May 2014), set in 10 Level I US trauma centers. Participants’ inclusion criteria were older than 14 years, presentation to the emergency department (ED) within 6 hours of blunt trauma, and receipt of chest imaging (chest radiograph, chest CT, or both) during their ED evaluation. Exposure(s) (for observational studies) were that patients had trauma and chest imaging. Primary measures and outcomes included the incidence of pneumothorax and hemothorax observed on CT only versus on both chest radiograph and chest CT, the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and admission rates, hospital length of stay, mortality, and frequency of chest tube placement for these injuries. Results: Of 21,382 enrolled subjects, 1,064 (5%) had a pneumothorax and 384 (1.8%) had a hemothorax. Of the 8,661 patients who received both a chest radiograph and a chest CT, 910 (10.5%) had a pneumothorax, with 609 (67%) observed on CT only; 319 (3.7%) had a hemothorax, with 254 (80%) observed on CT only. Of 1,117 patients with pneumothorax, hemothorax, or both, 108 (10%) had isolated pneumothorax or hemothorax. Patients with pneumothorax observed on CT only had a lower chest tube placement rate (30% versus 65%; difference in proportions [Δ] -35%; 95% confidence interval [CI] –28% to 42%), admission rate (94% versus 99%; Δ 5%; 95% CI 3% to 8%), and median length of stay (5 versus 6 days; difference 1 day; 95% CI 0 to 2 days) but similar mortality compared with patients with pneumothorax observed on chest radiograph and CT. Patients with hemothorax observed on CT had only a lower chest tube placement rate (49% versus 68%; Δ -19%; 95% CI –31% to -5%) but similar admission rate, mortality, and median length of stay compared with patients with hemothorax observed on chest radiograph and CT. Compared with patients with other thoracic injury, those with isolated pneumothorax or hemothorax had a lower chest tube placement rate (20% versus 43%; Δ -22%; 95% CI –30% to -13%), median length of stay (4 versus 5 days; difference -1 day; 95% CI –3 to 1 days), and admission rate (44% versus 97%; Δ -53%; 95% CI –62% to -43%), with an admission rate comparable to that of patients without pneumothorax or hemothorax (49%). Conclusion: Under current imaging protocols for adult blunt trauma evaluation, most pneumothoraces and hemothoraces are observed on CT only and few occur as isolated thoracic injury. The clinical implications (admission rates and frequency of chest tube placement) of pneumothorax and hemothorax observed on CT only and isolated pneumothorax or hemothorax are lower than those of patients with pneumothorax and hemothorax observed on chest radiograph and CT and of those who have other thoracic injury, respectively.

AB - Study objective: Although traditional teachings in regard to pneumothorax and hemothorax generally recommend chest tube placement and hospital admission, the increasing use of chest computed tomography (CT) in blunt trauma evaluation may detect more minor pneumothorax and hemothorax that might indicate a need to modify these traditional practices. We determine the incidence of pneumothorax and hemothorax observed on CT only and the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and describe the clinical implications of these injuries. Methods: This was a planned secondary analysis of 2 prospective, observational studies of adult patients with blunt trauma, NEXUS Chest (January 2009 to December 2012) and NEXUS Chest CT (August 2011 to May 2014), set in 10 Level I US trauma centers. Participants’ inclusion criteria were older than 14 years, presentation to the emergency department (ED) within 6 hours of blunt trauma, and receipt of chest imaging (chest radiograph, chest CT, or both) during their ED evaluation. Exposure(s) (for observational studies) were that patients had trauma and chest imaging. Primary measures and outcomes included the incidence of pneumothorax and hemothorax observed on CT only versus on both chest radiograph and chest CT, the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and admission rates, hospital length of stay, mortality, and frequency of chest tube placement for these injuries. Results: Of 21,382 enrolled subjects, 1,064 (5%) had a pneumothorax and 384 (1.8%) had a hemothorax. Of the 8,661 patients who received both a chest radiograph and a chest CT, 910 (10.5%) had a pneumothorax, with 609 (67%) observed on CT only; 319 (3.7%) had a hemothorax, with 254 (80%) observed on CT only. Of 1,117 patients with pneumothorax, hemothorax, or both, 108 (10%) had isolated pneumothorax or hemothorax. Patients with pneumothorax observed on CT only had a lower chest tube placement rate (30% versus 65%; difference in proportions [Δ] -35%; 95% confidence interval [CI] –28% to 42%), admission rate (94% versus 99%; Δ 5%; 95% CI 3% to 8%), and median length of stay (5 versus 6 days; difference 1 day; 95% CI 0 to 2 days) but similar mortality compared with patients with pneumothorax observed on chest radiograph and CT. Patients with hemothorax observed on CT had only a lower chest tube placement rate (49% versus 68%; Δ -19%; 95% CI –31% to -5%) but similar admission rate, mortality, and median length of stay compared with patients with hemothorax observed on chest radiograph and CT. Compared with patients with other thoracic injury, those with isolated pneumothorax or hemothorax had a lower chest tube placement rate (20% versus 43%; Δ -22%; 95% CI –30% to -13%), median length of stay (4 versus 5 days; difference -1 day; 95% CI –3 to 1 days), and admission rate (44% versus 97%; Δ -53%; 95% CI –62% to -43%), with an admission rate comparable to that of patients without pneumothorax or hemothorax (49%). Conclusion: Under current imaging protocols for adult blunt trauma evaluation, most pneumothoraces and hemothoraces are observed on CT only and few occur as isolated thoracic injury. The clinical implications (admission rates and frequency of chest tube placement) of pneumothorax and hemothorax observed on CT only and isolated pneumothorax or hemothorax are lower than those of patients with pneumothorax and hemothorax observed on chest radiograph and CT and of those who have other thoracic injury, respectively.

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