Background: Traumatic pneumothorax is a potentially life-threatening condition requiring timely diagnosis and management, particularly in the prehospital setting where diagnostic tools are limited. This study aimed to evaluate the diagnostic performance of clinical signs used by emergency physicians in the field to identify traumatic pneumothorax requiring early thoracic decompression.
Methods: We conducted a retrospective observational study in a French level I trauma center from January 2015 to August 2022. All patients with CT-confirmed pneumothorax managed by prehospital emergency physicians were included. The primary endpoint was the diagnostic performance of prehospital clinical assessment to identify pneumothorax requiring early decompression (prehospital or within four hours of admission). Statistical analysis was focused on predictive performance of three clinical signs (asymmetric lung auscultation, thoracic expansion asymmetry, and subcutaneous emphysema) in identifying cases requiring early decompression, using univariable analyses and the construction of a composite predictive score by logistic regression.
Results: Among 280 included patients, 115 (41%) required early thoracic decompression. Clinical suspicion of pneumothorax was present in 63% (95% CI: 54‒71) of these cases. Asymmetric lung auscultation showed the highest sensitivity (74%; 95% CI: 62‒86), while subcutaneous emphysema demonstrated the highest specificity (79%; 95% CI: 68‒89). The overall clinical suspicion rate across the cohort was 46% (95% CI: 41‒52). A composite predictive score using the three clinical signs demonstrated better diagnostic performance (AUC 0.63 (95% CI 0.57‒0.69); score = 1 OR 2.0 [95% CI 1.1‒3.6], score = 2 OR 3.0 [95% CI 1.6‒5.7]; score = 3 OR 11.0 [95% CI 1.3‒96.8]).
Conclusion: Prehospital clinical assessment alone had limited diagnostic performance for detecting blunt traumatic pneumothorax requiring early decompression. A simple clinical composite score offers higher specificity but remains insufficiently sensitive to be used as a standalone diagnostic tool; it may support field decision-making as a risk-stratification aid, but prehospital clinical signs alone are not sufficient to rule out a pneumothorax requiring early decompression.
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