Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Older adults frequently present to the emergency department (ED) with low-energy blunt chest trauma, and clinically important intrathoracic injuries may be under-detected during the initial evaluation. We aimed to evaluate whether bedside findings—particularly focal chest tenderness patterns (including anterior chest wall tenderness [ACWT] and lateral compression tenderness)—were associated with computed tomography (CT)-confirmed intrathoracic injury in older adults with low-energy blunt chest trauma, while also examining chest pain and early warning scores (EWS) as adjunct clinical variables.

Methods: A single-center prospective study included 136 patients 65 years or older presenting within 24 hours of low-energy blunt trauma that did not meet prespecified high-energy criteria. The primary outcome was any intrathoracic pathology on chest CT during the index ED visit. Secondary analyses examined associations between CT-confirmed injury and bedside findings (including chest pain, ACWT, lateral compression tenderness, thoracic spine tenderness, visible chest skin trauma, and auscultatory abnormalities), routine clinical variables, and laboratory measures; rib fracture and disposition were treated as prespecified exploratory analyses. The National Early Warning Score and Modified Early Warning Score were evaluated as exploratory physiologic comparators. Routine laboratory testing at presentation included arterial blood gas analysis. Chest CT performed during the index ED visit served as the imaging reference standard, with intravenous contrast use determined by clinical indication. The National Emergency X-Radiography Utilization Study (NEXUS) chest criteria informed routine imaging selection. Logistic regression identified independent associations, and diagnostic performance metrics were calculated for key bedside tenderness findings.

Results: For 136 studied patients, mean age was 78.9 (9.2) years, and 60.3% of patients were female. Ground-level falls accounted for 72.8% of injuries. Chest pain was reported in 19.9% of patients. Lateral compression tenderness (21.3%) and ACWT (25.0%) were the most common examination findings. On univariable analysis, chest pain and lateral compression tenderness were associated with intrathoracic pathology; in multivariable analysis, ACWT was the only independent bedside predictor of the primary outcome (adjusted odds ratio [OR] 4.18, 95% CI, 1.85–9.44; P < .001). For rib fracture, ACWT, chest pain, and lateral compression tenderness remained independently associated. For intrathoracic injury, ACWT had a sensitivity of 47.6% (95% CI, 32.0–63.6), specificity of 85.1% (95% CI, 76.3–91.6), positive predictive value of 58.8% (95% CI, 44.5–71.8), negative predictive value of 78.4% (95% CI, 72.9–83.1), a positive likelihood ratio of 3.2 (95% CI, 1.79–5.70), and a negative likelihood ratio of 0.62 (95% CI, 0.46–0.83), supporting its role as a rule-in bedside cue. Lateral compression tenderness was also associated with intrathoracic injury (OR 3.81, 95% CI, 1.62–8.94; P = .002).

Conclusion: In older adults with low-energy blunt chest trauma, focal chest tenderness findings—especially anterior chest wall tenderness, lateral compression tenderness, and chest pain—were associated with higher odds of CT-confirmed thoracic injury; however, ACWT was the only independent bedside predictor of the primary outcome. These findings function as rule-in rather than rule-out cues. Early warning scores showed limited utility for anatomic injury detection in this cohort and should not be interpreted as trauma-specific imaging decision tools.