A critical look at the value of clinical examination in polytraumatized patients

Background and question: The Advanced Trauma Life Support (ATLS) offers a concept for the treatment of severely injured patients. In the so-called "primary survey", the patients are first examined clinically by "A-E". Subsequently, a CT scan will be performed to make accurate diagnosis. But what benefit do the clinical examinations have if a CT is performed immediately afterwards? Are the examinations just a waste of time or do they provide important information? Method: Systematic mesh-term research on pubmed.com with 62 studies to compare the latest literature on the value of clinical examinations with ATLS recommendations. Results: Relevant airway problems can directly threaten the patient and should be quickly diagnosed and fixed. Clinical examination of the cervical spine has poor sensitivity and should be avoided. The examination for hemato-/pneumothorax after blunt and penetration trauma shows a middle sensitivity but a good negative and positive predictive value. If a serious thoracic injury is suspected, a thoracic puncture or a chest tube should be done. Internal bleeding is difficult to diagnose clinically and often cannot be treated without surgical or radiological intervention. The CT scan should be done promptly and time delays by numerous clinical examinations should be avoided. Unstable pelvic fractures can be well diagnosed, depending on the technique used. If the pelvis is unstable a pelvic sling should be applied to avoid a “C-problem”. Intracranial and spinal injuries cannot be diagnosed clinically. If suspected, a CT scan should be performed. During a prolonged examination of the undressed patient, the body temperature can decrease, which may be accompanied by deterioration in blood coagulation. Conclusion: The extent of the physical examination in the shock room, immediately before the CT scan, should be taken individually. With exception of airway and breathing problems, most diagnoses can only be reliably detected and treated after the CT scan..


Background
The "Advanced Trauma Life Support" (ATLS) is a systematic approach of early care for polytraumatized patients invented by the American College of Surgeons nearly 30 years ago. This concept should enable one physician (male/female) and one nurse (male/female) to examine and treat a multiple-injured patient without missing significant findings. The focus is on the examination and treatment of the most bleak accident consequences. According to the motto "treat first what kills first" the pathologies, which endanger the patient directly should be treated first.
This systematic methodology for assessment and initial stabilization of the polytraumatized patients consists of five categories from AE: A = Airway; includes airway management and the immobilization of the cervical spine via Stiffneck B = Breathing; includes thoracic injuries and gas exchange disorders like pneumothorax and hematothorax C = Circulation; includes circulatory stabilization and the treatment of critical bleeding D = Disabilities; includes neurological and neurosurgical consequences of the accident E = Exposure; includes the undressing of the patient, body temperature, and fracture/wound management Question How good and valuable is the clinical examination of the patient in the emergency department (ED), if only a short time later a CT scan with contrast agent will be performed? Are these findings so valuable that they justify delaying CT by several minutes? How reliable are the clinical symptoms for diagnosis?

Method
In order to answer the question of the value of clinical symptoms in the early care of multiple-injured patients, the ATLS recommendations for the points A -E were compared with the current literature. For this purpose, a systematic search on pubmed.com under the following mesh terms was performed: "Thoracic Injuries/diagnosis", Abdominal Trauma/Injury", Head Trauma/Injury", Neck Trauma/Injury", "Pelvic Trauma/Injury", Temperature Trauma", Extremity Trauma", Spinal cord/ column Injury" and "Physical Examination". A total of 62 publications were evaluated from September 2000 to September 2018.

Airway and immobilization of the cervical spine
In a polytraumatized patient, a relevant A-problem may arise from aspirated or penetrating foreign objects like fractured teeth or knifes etc. [1][2][3]. Clinical symptoms include acute respiratory failure, dyspnoea, wheezing or coughing during spontaneous breathing or an increased ventilation pressure in the intubated patient [4]. A jigging over the obstructed lung field can be found at the auscultation.
In addition to airway obstructions by foreign objects a midface fracture or a dislocated vertebra can pose a threat to the airway [5]. Patients with midface fracture may also need a secured airway. These patients often have an initial loss of consciousness, a Glasgow coma scale (GCS) of ≤ 8 or positive physical examination findings [6]. Harrington et al. (2018) evaluated the Wisconsin´s Clinical Criteria for maxillofacial fractures. The sensitivity for ≥ 1 of the 5 clinical criteria (bony step off or instability, periorbital ecchymosis, malocclusion, tooth absence, and GCS) was 81%. The absence of all 5 criteria showed a negative predictive value of 60% [7]. Diagnosis of maxilla fracture could easily be missed in children because of their limited cooperation with clinical examination [8]. Goode et al. (2014) investigated the value of the clinical examination of the cervical spine for fractures and figured out that the sensitivity for patients over 65 years is only 66% and for patients under 65 years 84% [9].
Libermann et al. (2014) reported an overall sensitivity and specificity for the ability of the initial clinical examination of the cervical spine to predict radiological abnormality of 60.9% and 71.3%, respectively NPV = 82.9% in alcoholised patients. In alcoholised patients with GCS ≥13, sensitivity, specificity, and NPV for CS tenderness and radiological abnormality were 71.9%, 67.7% and 87.8% [10].
By using the 18 items of NEXUS and Canadian c-spine criteria the sensitivity of the clinical examination can be raised up to 100% but poor specificity (0.62%). By using only the seven most associated criteria with fracture (midline tenderness, GCS less than 15, age ≥ 65 years, paraesthesia, rollover motor vehicle collision, ejected, never in sitting position in ED) the sensitivity is 99.07%, positive predictive value (PPV) 6.95%, specificity 11.57%, and the negative predictive value (NPV) 99,47% [11].

Breathing
Thoracic injuries occur especially in high energy trauma like vehicle accidents or fall from greater altitude [12][13][14]. The most common injuries after thoracic trauma are rib fractures, pneumo-and/ or hematothorax, and pulmonary contusions. In polytrauma patients the abdominal visceral injury is the most associated injury with rip fracture [14]. Lavingia et al. (2015) investigated the need for thoracic CT scan for patients who fall from standing. All patients with findings in CT scan showed symptoms at the physical examination. Patients without clinical symptoms never had a positive radiographic finding for significant thoracic injury like fractures or pneumothorax (NPV 100%) [15].
But the physical findings like subcutaneous emphysema only have low sensitivity (12 -25 %) [16]. For thoracic pain after blunt trauma the sensitivity for pneumo-or hematothorax is 57.1% [17] (Figure 1 and 2). Only the auscultation seems to be a reliable clinical parameter for   a pneumo-or hematothorax. The sensitivity for auscultation within blunt thoracic trauma is up to 100%. The NPV for auscultation, pain, and tachypnea within blunt and penetrating thoracic trauma is 99% and over 90% [17]. Kong et al. (2015) described a sensitivity of physical examination for significant pathology findings of 68%, specificity 86%, the PPV 94%, and NPV 47% in penetrating thoracic trauma. Sensitivity and specificity of physical examination for pneumothorax was 59% and 96%, for hematothorax 79% and 96%. Physical examination was overall clinical status, respiratory rate, oxygen saturation, tracheal deviation, chest expansion, percussion note and auscultation findings [18].  (Table 1).
With the help of a CT scan, a reliable statement can be made about injury to internal organs in penetrating thoracic injuries. The sensitivity, specificity and accuracy of the CT scan for internal injuries are 91% [20].

Circulation
Chest: In addition to hematothorax, cardiovascular disorders that are relevant to the circulatory system may occur in blunt chest trauma. These cardiovascular disorders appear as arrhythmias, mainly tachycardia, cardiac murmurs or hypotension, can be alarm signals for cardiac trauma, but are non-specific [21]. Heavy chest trauma often shows Type II (blunt cardiac injury with heart block or ischemic changes without cardiac failure) or Type IV (Blunt or penetrating cardiac injury with septal rupture, pulmonary or tricuspid valvular incompetence, papillary muscle dysfunction, or distal coronary arterial occlusion producing cardiac failure) injuries of the Organ Injury Scale. Atrial-or ventricular arrhythmias occur in 34.0% respectively 38.3% and are also unspecific and hard to find within physical examination [22]. At the moment there is no gold standard for the evaluation of cardiac disorders in the context of chest trauma [23].
Patients with aortic injuries following blunt trauma are often inconspicuous in clinical examination [24]. In physical examination of patients with blunt chest trauma and aortic injury, only 10% shows crepitation and 16.7% shows subcutaneous emphysema as an unspecific consequence of accompanying injuries. The most common concomitant and clinically recoverable injuries are rib fractures (93.4%), pneumothorax (66.7%), and hematothorax (43.4%) [25].

Abdomen
Patients with blunt abdominal trauma, categorized as low-risk patients for intraabdominal injury, have a very low risk of intraabdominal injury. Of 237 patients who have all met low-risk criteria (no intoxication, no hypotension or tachycardia, no abdominal pain or tenderness, no hematuria, and no distracting injury), no patient has shown an intra-abdominal injury or has died [26].  [27]. But a negative CT scan finding in asymptomatic patients with blunt abdominal trauma can safely rule out an intraabdominal injury [28].
In a study from Firetto et al. (2018), 34 of 831 patients who had a blunt abdominal trauma and had unspecific clinical symptoms showed a blunt bowel and/or mesenteric injury in CT scan. Sensitivity and specificity for abdominal pain and guarding is 57.18% / 53.85% and 38.1% / 100.0% [29]. Lavingia et al. (2015) described a NPV of 100% for abdominal symptoms for patients with abdominal injury, intraabdominal hematoma, and hollow viscus injury, aortic or urologic injury [15]. Bladder perforation is often difficult to differentiate from other reasons of abdominal pain [30].

Pelvic
The second leading traumatic cause of death is the pelvic injury. The mortality in patients with pelvic injury and shock symptoms is 30-50% [31]. The sensitivity of the clinical signs of a pelvic injury is 39.75%, while specificity is 100%. The PPV and NPV are 100% and 10% [32]. Clinical symptoms of a pelvic fracture can be pelvic pain/ tenderness, sacrum-/coccyxpain or tenderness, the straight leg raising test or missing of other distracting pain. The most meaningful criterion is the lack of pelvic pain (sensitivity 91.8% and specificity 94.2%) [32]. The study of Bolt et al. (2018) confirms the importance of the straight leg raise and the pelvis pain. Patients with blunt pelvic trauma, GCS 15, and pelvic fracture always showed a positive straight leg raise test and pelvic pain (sensitivity and NPV = 100%) [33].
A study from Pehle et al. (2003) reported that the clinical stability tests for pelvic fractures with distraction, compression, and traction only shows a sensitivity of 44.1%. 22 Patients with stabile pelvic in clinical examination had an unstable pelvic fracture (AO type B or C) in CT scan. However, if the results of the pelvic stability tests are positive, the PPV is about 96% [34]. In another study, the sensitivity of the clinical examination for unstable pelvic fractures is only 26% [35] ( Table 2).
Polytraumatized children should undergo CT scans to rule out a pelvic fracture. In a study with 1433 patients aged ≤ 17 years with pelvic fracture only 84.6% got a CT scan [36].
From the outside, the morphology of the pelvic fracture as well as possible sources of bleeding cannot be evaluated. An uncertain sign of concomitant vascular injury in pelvic fractures is hypotension. Patients with external iliac artery branch injuries were significantly associated with hemodynamic instability, when compared to those without external iliac artery branch injuries [37]. In a study from Solai et al. (2018) the researchers reported on 28 patients with basilar skull fracture to check the value of early and late (within 48h) clinical symptoms of these fracture. Clinical symptoms were raccoon eyes, Battle´s sign, otorrhea and rhinorrhea (Figure 3  Only 23 -41% of patients with traumatic brain injuries also have severe external head injuries However, these patients have higher mortality and morbidity than patients with brain injuries without external head injuries. Extracranial injuries are therefore a prognostic factor for patients with intracranial injuries [39].
Even minor head injuries in combination with oral anticoagulants can have a negative outcome. In a systematic review with 346 patients the rate of adverse outcome after mild head injury in combination with oral anticoagulants ranged from 0.0 -8.3% [40].
Thoracolumbar spine: The clinical examination of patients with thoracolumbar spine injuries alone does not seem to be sufficiently certain. In a study of 666 patients examined, with a total of 56 thoracolumbar spine fractures, no pathological findings were found in the clinical examination in 29 patients (52%). The sensitivity and specificity of the clinical examination for fractures in the thoracolumbar spine is thus 48.2% and 84.9% [41].
For sternum fractures, special attention must be paid to fractures of the thoracic spine. If a sternal fracture occurs in combination with thoracic spine fracture, the chance for an unstable AO type A or B fracture is up to 62.5%. And even the chance of an unstable AO type C fracture is increased if the sternum and the thoracic spine fracture are at the same height [42].

Exposure
Body temperature: In trauma patients, body temperature control is crucial for the optimal function of blood clotting. In patients with cardiac arrest, hypothermia of 33 °C has no negative influence on blood clotting, frequency of adverse bleeding or thrombotic events [43]. Significant changes in blood clotting could be observed when body temperature of healthy volunteers is ≤ 32°C or ≥ 37°C [44].
But in trauma patients a loss of body temperature should be avoided and treated as well as acidema or mass infusion [45]. Time to clot formation increased and fibrin cross-linking decreased in polytraumatized patients as body temperature decreased. Polytraumatized patients are more hypercoagulable than healthy subjects at decreased body temperature [46]. Also, a hypercoagulability could be observed in healthy volunteers with an elevated body temperature of 1.3°C -1.5°C [47]. Therefore, the body temperature should be maintained in a range between 33°C and 37 °C.

Fracture and wound management
Exact examination and treatment of soft tissue trauma and fractures is often part of the secondary survey. While these injuries may look dramatic, they rarely pose an immediate threat to the patient's life [48]. An open long bone fracture with uncontrollable bleeding or unstable   pelvic fractures with hemodynamic instability are indications for immediate intervention [49]. The care of smaller fractures can be done as part of the secondary survey and is usually not time critical.

Conclusion
In the treatment of a seriously injured patient in the shock room, depending on the condition of the patient, hurry is required. The ATLS guidelines provide good recommendations for a thorough examination and treatment of a polytraumatized patient. Initially, a primary survey is recommended during the first ten minutes, during which the patient is examined from "A-E" and relevant findings are treated immediately. Subsequently, a polytrauma CT should be performed.
The current literature contains numerous studies describing the value of clinical investigations of traumatized patients in the ER. These studies investigated different types of injury's and clinical examinations and often describe sensitivity, specificity and PV of these methods. Sometimes, depending on the location and type of injury, a clinical examination immediately before the CT scan seems to be not useful. For the item "Airway and immobilization of the cervical spine" applies that problems in the airway management can be easily examined and have to be fixed immediately [2][3][4]. The separate investigation of the cervical spine, however, does not seem to provide sufficiently reliable findings and therefore appears not useful. This is also true for thoracolumbar spine [41][42]. Prophylactic immobilization of the cervical spine appears sufficient until CT scan [9][10][11].
Clinical findings for "Breathing" like subcutaneous emphysema or auscultatory findings and even the sonography only have middle sensitivity [16][17][18]. However, as a B-problem can quickly become life-threatening, an exploratory-clinically examination by means of auscultation and palpation should be done. The guidelines therefore recommend the use of a pleural puncture and / or the installation of a chest tube if there is a suitable accident mechanism and clinical suspicion of hemato-/pneumothorax [50]. CT scan is still the gold standard for the diagnosis of hemato-/pneumothorax.
Traumatic injuries of the heart, aorta or abdominal organs are poorly detectable be clinical examination [22,24,27]. Only CT brings a safe diagnosis that forms the basis for causal surgical or interventional therapy [28][29]. Depending on the examination method, a pelvic fracture can be clinically diagnosed and a possible bleeding can be provisionally treated by using a pelvic sling. For unstable patients with a "C problem", a CT scan should be performed as soon as possible [32].
Acute "D problems" may include anisocoria, vomiting, neurological deficits, or decreased GCS, and therefore the suspicion of an intracranial injury can often be asked. Clinical signs like raccoon eyes, Battle´s sign, otorrhea and rhinorrhea are hints for a skull fracture but have a middle sensitivity and specificity and low positive predictive value [38]. External head injuries often do not correlate with the intracranial findings and the symptoms often appear only in temporal interval.
To avoid an "E-problem" that can arise due to the undressing of the patient and can result in a hyper-or hypocoagulability, the body temperature should be kept constant between 33-37 °C [45][46]. X-ray diagnosis of smaller fractures can be performed after the primary survey and is often not time-critical. Critical bleeding in the unstable patient, which can be treated externally without additional diagnostics, should be treated. Otherwise, the CT is groundbreaking for the diagnosis of (internal) bleeding [48][49].
The decision on how much clinical diagnostics will be performed before running the CT scan in the emergency department depends on the patient's injury pattern and condition and should be individually assessed. With exception of airway and breathing problems, most diagnoses can only be reliably detected and treated after the CT scan.