Evaluation of PERSH Criteria to Avoid Unnecessary Chest X-ray in Patients with Blunt Chest Trauma: A Qualitative Study

Document Type: Original Article


1 Assistant Professor of Emergency Medicine, Endocrinology and Metabolism Research Center, Institute of Basic and Clinical Physiology Sciences, Kerman University of Medical Sciences, Kerman, Iran

2 Assistant Professor of Emergency Medicine, Clinical Research Unit, Shahid Bahonar Academic Center, Kerman University of Medical Sciences, Kerman, Iran


Background: Chest X-rays (CXRs) are traditionally performed to determine intra-thoracic injuries in all blunt chest trauma patients in Shahid Bahonar hospital in Kerman. As there are some disadvantages upon CXR and radiation exposure, therefore, this study aimed to evaluate the role of CXR in the diagnosis of intra-thoracic injuries caused by any blunt chest trauma.
Methods: This prospective qualitative study was conducted on all patients over 16 years old with blunt chest trauma. Unstable patients with GCS<13/15, RTS<12, dyspnea, intratracheal intubation, pregnancy, intoxication, an accident time longer than 24 hours, patients referred from other centers, and patients who did not agree to participate were excluded. All patients underwent routine CXR and followed up by telephone call 48 hours after admission. Data were analyzed through SPSS version 16.
Results: Of 2850 patients, 1320 cases were encountered and screened using screening tools. Mean age of patients was 31.6±15.6 years. From all, 1022 (67.4%) patients were male. Motor vehicle accident [439 (28.9%)] and motorcycle crash [437 (28.8%)] were the most frequent causes of trauma. The mean accident-visit time was 181.2±72.7 min. There was no trauma-related pathogenic finding in CXRs. None of the patients needed any further emergency treatment.
Conclusion:Some parameters may be used to rule out intra-thoracic injuries, and accordingly, decrease CXR performance. Four areas including physical examination (PE), Revised Trauma Score (R), oxygen saturation (S), and history taking (H), were explained and presented as PERSH criteria. Therefore, there is no need to perform CXR as a standard process of care in stable multiple trauma patients who have negative PERSH criteria.


  1. Calderon G, Perez D, Fortman J, Kea B, Rodriguez RM. Provider perceptions concerning use of chest x-ray studies in adult blunt trauma assessments. J Emerg Med 2012; 43(4):568-74.
  2. Rodriguez RM, Hendey GW, Marek G, Dery RA, Bjoring A. A pilot study to derive clinical variables for selective chest radiography in blunt trauma patients. Ann Emerg Med 2006; 47(5):415-8.
  3. Rodriguez RM, Hendey GW, Mower W, Kea B, Fortman J, Merchant G, et al. Derivation of a decision instrument for selective chest radiography in blunt trauma. J Trauma 2011; 71(3):549-53.
  4. Paydar S, Johari HG, Ghaffarpasand F, Shahidian D, Dehbozorgi A, Ziaeian B, et al. The role of routine chest radiography in initial evaluation of stable blunt trauma patients. Am J Emerg Med 2012; 30(1):1-4.
  5. Forouzanfar MM, Safari S, Niazazari M, Baratloo A, Hashemi B, Hatamabadi HR, et al. Clinical decision rule to prevent unnecessary chest X‐ray in patients with blunt multiple traumas. Emerg Med Australas 2014; 26(6):561-6.
  6. Myint KS, French S, Williams-Johnson J, Williams E, Johnson P, Reid MO, et al. Role of routine chest radiographs in the evaluation of patients with stable blunt chest trauma: a prospective analysis. West Indian Med J 2012; 61(1):64-72.
  7. Sears BW, Luchette FA, Esposito TJ, Dickson EL, Grant M, Santaniello JM et al. Old fashion clinical judgment in the era of protocols: is mandatory chest X-ray necessary in injured patients? J Trauma 2005; 59(2):324-32.
  8. Yamamoto L, Schroeder C, Morley D, Beliveau C. Thoracic trauma: the deadly dozen. Crit Care Nurs Q 2005; 28(1):22-40.
  9. Lindsell DR, Wilson AG, Maxwell JD. Fractures on the chest radiograph in detection of alcoholic liver disease. Br Med J (Clin Res Ed) 1982; 285(6342):597-9.
  10. Petersen WG, Zimmerman R. Limited utility of chest radiograph after thoracentesis. Chest 2000; 117(4):1038-42.
  11. Richardson DB, Mountain D. Myths versus facts in emergency department overcrowding and hospital access block. Med J Aust 2009; 190(7):369-74.
  12. Kolb EM, Peck J Schoening S, Lee T. Reducing emergency department overcrowding: five patient buffer concepts in comparison. [Dec 2008] Available from: https://www.researchgate.net/publication/221529204_Reducing_Emergency_Department_overcrowding_five_patient_buffer_concepts_in_comparison.
  13. Winchell RJ, Sanddal N, Ball J, Michaels H, Kaufmann CR, Gupta R, et al. A reassessment of the impact of trauma systems consultation on regional trauma system development. J Trauma Acute Care Surg 201; 78(6):1102-10.
  14. Tintinalli JE, Stephan Stapczynski J, John Ma O, Cline D, Yealy DM, Meckler GD. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 9th ed. USA: McGraw-Hill Education; 2019.
  15. Rodriguez RM, Anglin D, Langdorf MI, Baumann BM, Hendey GW, Bradley RN et al. NEXUS chest: validation of a decision instrument for selective chest imaging in blunt trauma. JAMA Surg 2013; 148(10):940-6.
  16. Chaudhry B, Wang J, Wu S, Maglione M, Mojica W, Roth E, et al. Systematic review: impact of health information technology on quality, efficiency, and costs of medical care. Ann Intern Med 2006; 144(10):742-52.
  17. Pinette W, Barrios C, Pham J, Kong A, Dolich M, Lekawa M. A comparison of thoracic CT and abdominal CT for the identification of thoracic blunt trauma. Am J Surg 2012; 204(6):927-32.
  18. Ungar TC, Wolf SJ, Haukoos JS, Dyer DS, Moore EE. Derivation of a clinical decision rule to exclude thoracic aortic imaging in patients with blunt chest trauma after motor vehicle collisions. J Trauma 2006; 61(5):1150-5.