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Three Part Question

In [adults presenting with acute confusion] is [chest x-ray] and appropriate screening exam in [diagnosing acute confusion]

Clinical Scenario

A 45 year old male presents at the emergency department with apparent acute confusion. He has no obvious signs of respiratory distress and the routine bloods have not come back yet. You wonder whether to order a chest x-ray next as you know some chest pathologies can cause delirium.

Search Strategy

MEDLINE 1950 to June week 4 2010, EMBASE 1980 to 2010 week 26 and the COCHRANE LIBRARY
(exp confusion/ OR exp delirium/)AND (exp Radiography, thoracic/ OR chest x-ray.mp.) limit to human and English language

Search Outcome

6 papers were found on medline, 1 of which was relevant. 218 papers were found on Embase, none of which were relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Krista L Birkemeier, Michael L Nipper, Jonathan M Williams. June 2008 Texas, USA	100 consecutive patients that under went chest x-ray for altered mental status at the emergency department.	Randomised Trial.	number of patients whose results of the chest x-ray altered care given	17%	Not blinded. Selection bias as performed at a hospital serving mainly an elderly and nursing home population.
			number of patients who had obvious signs on examination that would indicate getting a chest x-ray	15%

Comment(s)

Out of the 100 patients, only 17 had findings on the chest x-ray that altered patient care. Only 2 of these did not have obvious clinical signs, however did have elevated leukocyte count on laboratory analysis which would have then lead to a chest x-ray. Therefore from the findings in the one paper found, it shows routine chest x-ray screening is not necessary as a first line unless clinically indicated or no other cause is found. The current protocols recommend chest x-ray screening as standard in those presenting with acute confusion. Although this paper contradicts these current guidelines, this is not enough evidence to change clinical practice and further research must be done.

Clinical Bottom Line

Although there is some evidence to indicate running routine chest x-ray screening on those with acute confusion is not necessary, more research must be done before we change clincal practice. Refer to local guidlines.

References

1. Krista L Birkemeier, Michael L Nipper, Jonathan M Williams. Is the chest x-ray an appropriate screening exam for ER patients with AMS? The American society of emergency radiology 2008; 421-425