Imaging in Trauma Patients

Hemodynamically Unstable Patients

In hemodynamically unstable trauma patients, the American College of Surgeons recommends obtaining chest and pelvic X-rays immediately alongside E-FAST during resuscitation, as immediate X-ray imaging is essential when patients cannot undergo CT scanning due to ongoing resuscitation needs 1, 2
Chest X-ray is necessary to identify pneumothorax, hemothorax, or need for tube thoracostomy in hemodynamically unstable patients 1, 2
Pelvic X-ray is necessary to detect unstable pelvic fractures requiring urgent intervention in hemodynamically unstable patients 1, 2
The combination of chest X-ray, pelvic X-ray, and E-FAST enables 98% appropriate urgent intervention decisions, such as tube thoracostomy, emergency thoracotomy, pelvic angiography/embolization, and emergency laparotomy 1
When chest X-ray and E-FAST rule out extra-pelvic bleeding sources, the American College of Radiology recommends proceeding directly to pelvic angiography 2, 3

In hemodynamically stable patients, the American College of Radiology recommends proceeding directly to CT scan with intravenous contrast, as CT identifies 35.6% more pelvic fractures than pelvic X-ray and has a 93.9% positive predictive value and 87.5% negative predictive value for detecting active bleeding compared to angiography 1, 5
The European Society of Radiology recommends performing E-FAST first to rapidly detect free fluid, followed by thoraco-abdomino-pelvic CT scan with IV contrast, as CT provides complete injury inventory including hepatic, splenic, renal, and pelvic injuries 1, 5, 6
CT scanning should not be delayed to obtain pelvic X-rays in stable patients, as this adds no clinical value, according to the American College of Emergency Physicians 1, 5

E-FAST has a 97% positive predictive value for intra-abdominal bleeding and 97% negative predictive value in shock patients, according to the American College of Surgeons 1, 7
The Society of Critical Care Medicine recommends watching for E-FAST false positives, including hemoretroperitoneum suffusion and intraperitoneal bladder rupture 3, 7
High-risk mechanisms requiring imaging include motor vehicle crashes, falls from height, motorcycle collisions, and pedestrian accidents, which are associated with a high risk of pelvic fractures and massive hemorrhage, according to the National Highway Traffic Safety Administration 6
Unstable pelvic fractures correlate with massive hemorrhage and associated thoracic, abdominal, and head injuries, according to the American Association for the Surgery of Trauma 6