Highlights
- •Thoracic trauma is an important cause of morbidity and mortality in children exposed to blast and early recognition of these injuries is vital.
- •No studies have investigated the sensitivity of chest X-ray (CXR) for the detection of chest injury in paediatric blast casualties.
- •CXR findings were compared to the ‘gold standard’ of CT for detection of significant thoracic injuries in 103 children who were injured by blast.
- •CXR has low sensitivity for detecting thoracic injury in children exposed to blast, necessitating a low threshold for the use of CT for such patients.
Abstract
Introduction
Thoracic trauma is an important cause of morbidity and mortality in children exposed
to blast and early recognition of these injuries is vital. While numerous studies
have investigated the sensitivity of chest X-ray (CXR) for the detection of chest
injury in blunt trauma, none have evaluated its performance in paediatric blast injury.
Methods
CXR and Computed Tomography (CT) thorax findings were compared for 105 children who
were injured by blast and presented to the UK Role 3 Hospital, Camp Bastion, Helmand
Province, during the recent conflict in Afghanistan from 2011 to 2013. CXR performance
was evaluated compared to the ‘gold standard’ of CT for the detection of significant
thoracic injuries, defined as pneumothorax, haemothorax, aortic or great vessel injury,
2 or more rib fractures, ruptured diaphragm, sternal fracture, penetrating fragments
and pulmonary contusion or laceration.
Results
The sensitivity of CXR for the detection of significant injuries was: pneumothorax
43%, haemothorax 40%, contusion 44%, laceration 100%, blast lung 80% and subdermal
metallic fragments 75%. CXR missed all cases of diaphragm injury, ≥2 rib fractures,
clavicle fracture and pleural effusion, although numbers of each were small. Specificity
for CXR injury detection was 94% for contusion and 93% for fragment, and 100% otherwise.
The sensitivity and specificity of CXR for identifying an abnormality that would prompt
CT imaging was 72% (95% CI 55–85%) and 82% (95% CI 70–90%).
Conclusions
CXR has a poor sensitivity for the identification of significant thoracic injury in
children exposed to blast. We argue that, given the challenge of clinical assessment
of injured children and the potential for serious adverse consequences of missed thoracic
injuries, there should be a low threshold for the use of CT chest in the evaluation
of children exposed to blast.
Keywords
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References
Denselow J., Edwards J., Salarkia K. Blast Injuries: the impact of explosive weapons on children in conflict. 2019.
Eastern Ukraine one of the areas most contaminated by landmines in the world. United Nations Office for the Coordination of Humanitarian Affairs. https://www.unocha.org/story/eastern-ukraine-one-areas-most-contaminated-landmines-world 2019.
Ukraine: civilian casualty update 22 August 2022. Office of the high commissioner for human rights. https://www.ohchr.org/en/news/2022/08/ukraine-civilian-casualty-update-22-august-2022
- Management of chest trauma in children.Paediatr Respir Rev. 2013; 14 (2013/06//): 86-91https://doi.org/10.1016/j.prrv.2013.02.011
- Blast injuries in children: a mixed-methods narrative review.BMJ Paediatr Open. 2019; 3e000452https://doi.org/10.1136/bmjpo-2019-000452
- Primary blast lung injury - a review.Br J Anaesth. 2017; 118 (Mar 1): 311-316https://doi.org/10.1093/bja/aew385
- Not just little adults' - a pediatric trauma primer.R I Med J. 2013; 97 (Jan 3 2014): 27-30
Paediatric trauma protocols. Ref No. BFCR(14)8 ed: The royal college of radiologists; 2014.
- Plain radiography may be safely omitted for selected major trauma patients undergoing whole body CT: database study.Emerg Med Int. 2012; 2012432537https://doi.org/10.1155/2012/432537
- Accuracy of chest radiography versus chest computed tomography in hemodynamically stable patients with blunt chest trauma.Chin J Traumatol. 2013; 16: 351-354
- Added value of routine chest MDCT after blunt trauma: evaluation of additional findings and impact on patient management.AJR Am J Roentgenol. 2008; 190 (Jun): 1591-1598https://doi.org/10.2214/ajr.07.3277
- Epidemiological study of child casualties of landmines and unexploded ordnances: a national study from Iran.Prehosp Disaster Med. 2015; 30: 472-477https://doi.org/10.1017/S1049023X15005105
- Focused assessment with sonography in trauma (FAST) performance in paediatric conflict injury.Clin Radiol. 2022; 77 (Jul): 529-534https://doi.org/10.1016/j.crad.2022.04.001
- NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma.JAMA Surg. 2013; 148 (Oct): 940-946https://doi.org/10.1001/jamasurg.2013.2757
- CT findings in blast lung injury.BMJ Case Rep. 2012; (Mar 202012)https://doi.org/10.1136/bcr.08.2011.4713
Diagnostic test evaluation calculator. MedCalc software Ltd. Accessed November 2nd, 2021.
Trauma ACoSCo. Advanced trauma life support student course manual. Tenth edition ed. 2018.
- Practice management guidelines for management of hemothorax and occult pneumothorax.J Trauma Acute Care Surg. 2011; 70
- Chest X-rays in detecting injuries caused by blunt trauma.World J Emerg Med. 2016; 7: 55-58https://doi.org/10.5847/wjem.j.1920-8642.2016.01.010
- Efficacy of thoracic computerized tomography in blunt chest trauma.Am Surg. 2001; 67 (Jul): 660-664
- Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study.J Trauma. 1997; 43 (Sepdiscussion 411-2): 405-411https://doi.org/10.1097/00005373-199709000-00003
- Do we really need routine computed tomographic scanning in the primary evaluation of blunt chest trauma in patients with "normal" chest radiograph?.J Trauma. 2001; 51 (Dec): 1173-1176https://doi.org/10.1097/00005373-200112000-00025
- CT as a first-line modality in elderly patients with stable blunt chest trauma.Chin J Traumatol. 2021; 24 (Sep): 255-260https://doi.org/10.1016/j.cjtee.2021.03.009
Article info
Publication history
Published online: December 03, 2022
Accepted:
December 1,
2022
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2022 Elsevier Ltd. All rights reserved.
