Augustin Pascal, Guivarch Elise, Tran-Dinh Alexy, Pellenc Quentin, Tanaka Sebastien, Montravers Philippe
Département d'Anesthésie et Réanimation Chirurgicale, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, 46 rue Henri Huchard, 75018, Paris, France.
INSERM, UMR 1148, Paris, France.
Eur J Trauma Emerg Surg. 2020 Dec;46(6):1385-1391. doi: 10.1007/s00068-019-01203-4. Epub 2019 Aug 12.
The management of chest stab wounds necessitates to perform an efficient imaging strategy. Compared to chest X-ray, computed tomography (CT) scan has a higher sensitivity. Nevertheless, the utility of diagnosing occult injuries remains controversial. Previous studies reported very different rates of management modifications induced by CT-scan. Indeed, no study specifically addressed the issue of ruling out traumatic diaphragmatic injury (TDI) in the specific population of chest stab trauma. The aim of the study was to evaluate the rate of thoracic procedures induced or guided by the results of thoracic CT-scan in the specific population of chest stab wounds. Secondary objective was to evaluate the utility of CT-scan for the diagnosis of TDI.
We conducted a prospective observational study. All consecutive patients referred to the acute care unit were included. We recorded the general characteristics of patients, the localization of wounds, all imaging tests, the final injury diagnosis, and the patients' management. We compared patients with modifications of management induced by CT-scan results to other patients. We evaluated the performance of CT-scan for the diagnosis of TDI by calculating its sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV).
153 patients were included. There were 92 patients with normal chest X-ray. 67 of them received a CT-scan. 34 (51%) patients had an abnormal CT-scan, including 19 (21%) patients with thoracic new findings, with 3 (4.5%) modification of management. There were 50 patients who had an abnormal chest X-ray. 31 of them received a CT-scan, and 31 (100%) had an abnormal CT-scan, including 19 thoracic new findings, with 11 (36%) modifications of management. The diagnostic performance of CT-scan for TDI was: sensitivity 50%; specificity 95%; NPV 72%; PPV 88%.
In chest stab trauma, CT-scans may be unnecessary outside the thoracoabdominal zone when chest X-ray is normal. In other cases, CT-scan seems to have an impact on the decision-making. In case of thoracoabdominal wounds, CT-scan helps to detect intra-abdominal injuries. The performance of CT-scan to diagnose TDI is not high enough to reliably rule out all TDI.
胸部刺伤的处理需要实施有效的影像学检查策略。与胸部X线相比，计算机断层扫描（CT）的敏感性更高。然而，其对隐匿性损伤的诊断价值仍存在争议。既往研究报道CT扫描导致的处理方式改变率差异很大。实际上，尚无研究专门探讨在胸部刺伤这一特定人群中排除创伤性膈肌损伤（TDI）的问题。本研究的目的是评估在胸部刺伤这一特定人群中，胸部CT扫描结果所引发或引导的胸部手术发生率。次要目的是评估CT扫描对TDI诊断的价值。
我们开展了一项前瞻性观察研究。纳入所有转诊至急诊病房的连续患者。我们记录患者的一般特征、伤口位置、所有影像学检查、最终损伤诊断以及患者的处理方式。我们将因CT扫描结果导致处理方式改变的患者与其他患者进行比较。通过计算其敏感性、特异性、阴性预测值（NPV）和阳性预测值（PPV）来评估CT扫描对TDI诊断的性能。
共纳入153例患者。92例患者胸部X线正常。其中67例接受了CT扫描。34例（51%）患者CT扫描异常，包括19例（21%）有胸部新发现的患者，其中3例（4.5%）处理方式改变。50例患者胸部X线异常。其中31例接受了CT扫描，且31例（100%）CT扫描异常，包括19例胸部新发现，其中11例（36%）处理方式改变。CT扫描对TDI诊断的性能为：敏感性50%；特异性95%；NPV 72%；PPV 88%。
在胸部刺伤中，当胸部X线正常时，胸腹部区域以外可能无需进行CT扫描。在其他情况下，CT扫描似乎会对决策产生影响。对于胸腹部伤口，CT扫描有助于检测腹腔内损伤。CT扫描诊断TDI的性能不足以可靠地排除所有TDI。
