The PXR in trauma.

Here is a primary survey X-ray done on a patient in their early teens.  Request form states; “pedestrian vs car.” 

What do you think?

It’s traditionally been done as part of the primary survey series (this one is normal by the way) – designed to identify life-threatening injuries that need action.  This predates the easy availability of CT.  In someone with a binder on who is stable, what would the PXR add?  In specific circumstances it’s really useful:  if you have a really sick patient (probably in need of theatre immediately) and you want to know whether pelvis or abdomen is the most likely culprit, do a PXR and a FAST scan.  Hence in our Traumatic Cardiac Arrest algorithm (see below) the PXR has clear value.

If the patient is having a CT anyway and has a binder on, it probably adds no useful information as the sensitivity of PXR for fractures is variably reported but low-ish in adults (78%) – and even when it picks them up, it underestimates their severity in 50%.  It could safely be omitted in many cases.

If you have a well patient who you don’t feel needs CT, but after the primary survey you still wish to exclude pelvic fracture, a PXR is reasonable (combined with a functional clinical examination).

Certainly it has a less role now as a blanket trauma primary survey X-ray.  If you are worried, but they are stable, get a CT and don’t increase their dose with a PXR as well.  If you are not worried, don’t image. 

There is new guidance about imaging in children which raises important points that we should be aware of in terms of the impact of IR on kids, and the different injury patterns vs adults which we should bear in mind as part of your decision making.

Traumatic cardiac arrest SOP.pdf
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