Article

Whole Body Imaging in Blunt Multisystem Trauma Patients Without Obvious Signs of Injury: Results of a Prospective Study

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Abstract

The use of liberal whole body imaging (pan scan) in patients based on mechanism is warranted, even in evaluable patients with no obvious signs of chest or abdominal injury. Prospective observational study. Academic level I trauma center. All patients admitted following blunt multisystem trauma. Pan scan, including computed tomography (CT) of the head, cervical spine, chest, abdomen, and pelvis, with the following inclusion criteria: (1) no visible evidence of chest or abdominal injury, (2) hemodynamically stable, (3) normal abdominal examination results in a neurologically intact patient or unevaluable abdominal examination results secondary to a depressed level of consciousness, and (4) significant mechanisms of injury. Radiological findings and changes in treatment based on these findings were recorded. Any alteration in the normal treatment plan as a direct result of CT scan findings. These alterations include early hospital discharge, admission for observation, operative intervention, and additional diagnostic studies or interventions. One thousand patients underwent pan scan during the 18-month observation period, of which 592 were evaluable patients with no obvious signs of abdominal injury. Clinically significant abnormalities were found in 3.5% of head CT scans, 5.1% of cervical spine CT scans, 19.6% of chest CT scans, and 7.1% of abdominal CT scans. Overall treatment was changed in 18.9% of patients based on abnormal CT scan findings. The use of pan scan based on mechanism in awake, evaluable patients is warranted. Clinically significant abnormalities are not uncommon, resulting in a change in treatment in nearly 19% of patients.

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... SWBCT examination in potentially severely injured patients gives the trauma team a tool for fast decision making on intervention, identifies injuries not suspected and facilitates patient logistics [14,[30][31][32][33][34]. Accordingly, in our institution, the use of SWBCT has increased over the last fifteen years. ...
... Hare et al. [70] reviewed the literature to clarify whether such tools improve diagnostic accuracy of whole body CT, and concluded that the evidence to support this is limited. All identified studies were retrospective analyses of predictors for CT findings [32,34,65,71]. Davis et al. [65] recorded all findings from clinical examination, including superficial physical signs as bruising, tenderness and swelling. ...
... This indicates that the selective strategy practiced by our trauma teams is safe, despite not following a validated decision rule. This is in accordance with some previous studies [23,63], while other report risk for missing potentially important injuries with this approach [32,33]. The interpretation of our findings should, however, take into consideration that the use of SWBCT was relatively high (50.7%). ...
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Background: The International Commission on Radiological Protection's (ICRP) justification principles state that an examination is justified if the potential benefit outweighs the risk for radiation harm. Computer tomography (CT) contributes 50% of the radiation dose from medical imaging, and in trauma patients, the use of standardized whole body CT (SWBCT) increases. Guidelines are lacking, and reviews conclude conflictingly regarding the benefit. We aimed to study the degree of adherence to ICRP's level three justification, the individual dose limitation principle, in our institution. Methods: This is a retrospective clinical audit. We included all 144 patients admitted with trauma team activation to our regional Level 1 trauma centre in 2015. Injuries were categorized according to the Abbreviated Injury Scale (AIS) codes. Time variables, vital parameters and interventions were registered. We categorized patients into trauma admission SWBCT, selective CT or no CT examination strategy groups. We used descriptive statistics and regression analysis of predictors for CT examination strategy. Results: The 144 patients (114 (79.2%) males) had a median age of 31 (range 0-91) years. 105 (72.9%) had at least one AIS ≥ 2 injury, 26 (18.1%) in more than two body regions. During trauma admission, at least one vital parameter was abnormal in 46 (32.4%) patients, and 73 (50.7%) underwent SWBCT, 43 (29.9%) selective CT and 28 (19.4%) no CT examination. No or only minor injuries were identified in 17 (23.3%) in the SWBCT group. Two (4.6%) in the selective group were examined with a complement CT, with no new injuries identified. A significantly (p < 0.001) lower proportion of children (61.5%) than adults (89.8%) underwent CT examination despite similar injury grades and use of interventions. In adjusted regression analysis, patients with a high-energy trauma mechanism had significantly (p = 0.028) increased odds (odds ratio = 4.390, 95% confidence interval 1.174-16.413) for undergoing a SWBCT. Conclusion: The high proportion of patients with no or only minor injuries detected in the SWBCT group and the significantly lower use of CT among children, indicate that use of a selective CT examination strategy in a higher proportion of our patients would have approximated the ICRP's justification level three, the individual dose limitation principle, better.
... As these criteria mostly apply to older patients, mean age was therefore smaller. The proportion of male participants in the present study was 62%, which is comparable to other study populations (66-70%) [8,10,11,[18][19][20]. ...
... Considering our demographic data, the mechanisms of accidents in this study are comparable with the ones reported in previous studies [8,10,11,19], with the exception of Salim et al., who reported a slightly higher incidence of pedestrian struck-accidents (25.9%) [20]. ...
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Introductio: Although management of severely injured patients in the Trauma Resuscitation Unit (TRU) follows evidence-based guidelines, algorithms for treatment of the slightly injured are limited. Methods: All trauma patients in a period of eight months in a Level I trauma center were followed. Retrospective analysis was performed only in patients ≥18 years with primary TRU admission, Abbreviated Injury Scale (AIS) ≤ 1, Maximum Abbreviated Injury Scale (MAIS) ≤ 1 and Injury Severity Score (ISS) ≤3 after treatment completion and ≥24 h monitoring in the units. Cochran's Q-test was used for the statistical evaluation of AIS and ISS changes in units. Results: One hundred and twelve patients were enrolled in the study. Twenty-one patients (18.75%) reported new complaints after treatment completion in the TRU. AIS rose from the Intermediate Care Unit (IMC) to Normal Care Unit (NCU) 6.2% and ISS 6.9%. MAIS did not increase >2, and no intervention was necessary for any patient. No correlation was found between computed tomography (CT) diagnostics in TRU and AIS change. Conclusions: The data suggest that AIS, MAIS and ISS did not increase significantly in patients without a severe injury during inpatient treatment, regardless of the type of CT diagnostics performed in the TRU, suggesting that monitoring of these patients may be unnecessary.
... 6 Some studies do not believe that selective CT scan is capable of detecting all injuries caused by blunt trauma. 7,8 The Trauma Audit Research Network (TARN) data highlights that major trauma patients in the England and Wales are becoming more elderly, and that low level falls can be a leading cause of severe injury. 9 Two-thirds of female and one-third of male injuryrelated deaths occur in those over age 65 years. ...
... The potentially harmful effects of increased radiation exposure have to be weighed against the better diagnostic accuracy of the whole-body technique which is mandatory in critically injured patients. 8 Many studies showed the effectiveness of whole body CT over selective CT scan. 8, 30 Salim and colleagues 8 showed that wholebody CT resulted in a change of treatment in 19% of 1000 patients without obvious external signs of injuries. ...
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Purpose There are currently no clear guidelines for use of pan- or selective CT in elderly trauma patients and this subject matter remains controversial. The aim of this study is to compare the outcome of elderly trauma patients in a level 1 trauma centre who required a pan- or selective CT scan on admission. Methods The Trauma Audit Research Network database was reviewed to identify eligible patients (65 years old and older) over a one-year period, from January 2018 to January 2019. Patients’ demographics, mechanism of injury, injury severity score, length of hospital stay (LOS), mortality and type of CT scans done were recorded. Results There were 481 patients with the mean age of 80.8 years were evaluated (48.6% male). Among them 232 cases were multiple injuries while 249 were single system injuries. And 235 patients (48.8%) underwent pan-CT in whom 66.8% were multiple injuries; 246 (51.1%) did selective CT scan in whom 69.5% were single system injuries. In multiple injury patients, performing a pan-CT scan on presentation was associated with lower LOS compared to those who had a selective CT, in which 76.4% patients spent < 21 days in the pan-CT group compared to 16.0% for those investigated by selective CT scan (p < 0.001); and 2.5% spent > 60 days in pan-CT group compared to 64% in selective CT group (p < 0.0001). Performing pan-CT was also associated with lower need to repeat CT (p < 0.01). In patients with a single system injury, no differences were found in LOS or the need to repeat CT if either pan-CT or selective CT were requested. Conclusion We recommend doing pan-CT scan in all elderly patients with multiple system injuries as it decreases the LOS and the need for another CT during hospital stay. No difference in LOS or need to repeat another CT if pan-CT or selective CT were requested initially in single system injuries. Although age and injury severity score are poor predictors for the need to do pan-CT, the mechanism of injury may be helpful.
... C OMPUTED TOMOGRAPHY (CT) is an integral tool for the diagnosis of injuries in the trauma population. 1 The speed of image acquisition and resolution becomes better with each new generation of CT scanner. With this increasing availability and decreasing cost of CT scanners, Level I trauma centers are not the only institutions with access to these devices. ...
... Whether it is improved diagnosis for cervical spine injury, shorter time to the operating room, or identifying injuries that were not found on physical examination, the literature is replete with examples of the benefit of CT scan. 1,7,8 Thus, it is understandable why an institution-be it a community hospital or a Level I trauma center-uses a CT scan for accurate diagnosis of injuries. ...
Article
Our goal was to determine the characteristics of trauma transfer patients with repeat imaging. A retrospective trauma registry review was performed to evaluate trauma patients who were transferred from referring institutions between January 2005 and December 2009. Patients were divided into those who had a duplicate computed tomography (CT) scan versus those who did not. There were 2678 patients included of whom 559 (21%) had at least one repeat CT scan, whereas 2119 (79%) did not have any repeat CT scans. Those with repeat CT scans were older (42.3 ± 27.3 years vs 37.3 ± 25.6 years), had a higher Injury Severity Score (ISS) (13.7 ± 8.7 vs 11.9 ± 8.8), and more likely to have blunt trauma (odds ratio, 4.7; confidence interval, 2.3 to 9.6) (P for all < 0.0007). Those with CT scans done only at the referring facility were younger, had a lower ISS, and shorter lengths of stay (P for all < 0.0003). ISS and age were independent predictors for repeat CT scans. Transfer patients had imaging repeated one-fifth of the time. The younger, less injured patient went without repeat imaging suggesting that they may have been adequately cared for at the outside institution.
... As CT technology has improved, more injuries are detected in shorter periods of time [3,4]. This has led some centers to use CT scanning of the torso liberally [5][6][7][8][9]. Whereas others advocate for use in selected patients [10,11]. ...
... Although they are not randomized controlled trials, there are several studies supporting pan CT in trauma. Salim et al. reported findings in a prospective observational study that changed management in 19% of stable trauma patients that received pan CT [8]. Yeguiayan et al. showed a 30-day reduction in mortality from 22% to 16% by using pan CT, and Self et al. showed that 26% of patients receiving CT C/ A/P who were already receiving a head CT had unexpected findings that changed treatment [16,25]. ...
Article
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Background: High morbidity and mortality rates of trauma injuries make early detection and correct diagnosis crucial for increasing patient's survival and quality of life after an injury. Improvements in technology have facilitated the rapid detection of injuries, especially with the use of computed tomography (CT). However, the increased use of CT imaging is not universally advocated for. Some advocate for the use of selective CT imaging, especially in cases where the severity of the injury is low. The purpose of this study is to review the CT indications, findings, and complications in patients with low Injury Severity Scores (ISS) to determine the utility of torso CT in this patient cohort. Methods: A retrospective review of non-intubated, adult blunt trauma patients with an initial GCS of 14 or 15 evaluated in an ACS verified level 1 trauma center from July 2012 to June 2015 was performed. Data was obtained from the hospital's trauma registry and chart review, with the following data included: age, sex, injury type, ISS, physical exam findings, all injuries recorded, injuries detected by torso CT, missed injuries, and complications. The statistical tests conducted in the analysis of the collected data were chi-squared, Fischer exact test, and ANOVA analysis. Results: There were 2306 patients included in this study, with a mean ISS of 8. For patients with a normal chest exam that had a chest CT, 15% were found to have an occult chest injury. In patients with a negative chest exam and negative chest X-ray, 35% had occult injuries detected on chest CT. For patients with a negative abdominal exam and CT abdomen and pelvis, 16% were found to have an occult injury on CT. Lastly, 25% of patients with normal chest, abdomen, and pelvis exams with chest, abdomen, and pelvis CT scans demonstrated occult injuries. Asymptomatic patients with a negative CT had a length of stay 1 day less than patients without a corresponding CT. No incidents of contrast-induced complications were recorded. Conclusions: A negative physical exam combined with a normal chest X-ray does not rule out the presence of occult injuries and the need for torso imaging. In blunt trauma patients with normal sensorium, physical exam and chest X-ray, the practice of obtaining cross-sectional imaging appears beneficial by increasing the accuracy of total injury burden and decreasing the length of stay.
... The modern care of trauma patients relies on extensive use of whole-body computed tomography (CT) imaging for assessment of injuries. 2 Although CT imaging is invaluable in demonstrating the extent of injuries, unrelated incidental findings such as occult masses, lesions, and anatomic anomalies are often uncovered. 3 Incidental findings are quite common and range from an insignificant cyst in the kidney to a life-threatening nodule in the lung. ...
... Users are able to add incidental findings missed by the prototype (bolded in a) and also remove incorrectly highlighted findings (b). (2) The tool shows an overview of the patient case in a miniaturized view of all the records with highlights marking regions of interest (d). In the right sidebar, the tool allows the users to define search terms to be highlighted in pink. ...
Article
Background Despite advances in natural language processing (NLP), extracting information from clinical text is expensive. Interactive tools that are capable of easing the construction, review, and revision of NLP models can reduce this cost and improve the utility of clinical reports for clinical and secondary use. Objectives We present the design and implementation of an interactive NLP tool for identifying incidental findings in radiology reports, along with a user study evaluating the performance and usability of the tool. Methods Expert reviewers provided gold standard annotations for 130 patient encounters (694 reports) at sentence, section, and report levels. We performed a user study with 15 physicians to evaluate the accuracy and usability of our tool. Participants reviewed encounters split into intervention (with predictions) and control conditions (no predictions). We measured changes in model performance, the time spent, and the number of user actions needed. The System Usability Scale (SUS) and an open-ended questionnaire were used to assess usability. Results Starting from bootstrapped models trained on 6 patient encounters, we observed an average increase in F1 score from 0.31 to 0.75 for reports, from 0.32 to 0.68 for sections, and from 0.22 to 0.60 for sentences on a held-out test data set, over an hour-long study session. We found that tool helped significantly reduce the time spent in reviewing encounters (134.30 vs. 148.44 seconds in intervention and control, respectively), while maintaining overall quality of labels as measured against the gold standard. The tool was well received by the study participants with a very good overall SUS score of 78.67. Conclusion The user study demonstrated successful use of the tool by physicians for identifying incidental findings. These results support the viability of adopting interactive NLP tools in clinical care settings for a wider range of clinical applications.
... 5,15 Although WBCT demonstrates a benefit in rapid recognition and treatment, it has been shown that only one-fifth (~19%) of the patients' management was changed by the WBCT findings. 21 On the other hand, another study by Oosthuizen et al has reported 77% of WBCT influenced the course of management in their polytrauma cohort. 15 The main difference between the two studies was the policy of ordering WBCT. ...
... The study by Salim et al used a liberal WBCT scanning policy, compared to the study by Oosthuizen et al, which applied a strict protocol for the use of WBCT in their trauma patients to minimize unnecessary scans. 15,21 Our secondary observation showed that mechanism of injury, ISS score of more than 24, GCS ≤ 8, oxygen saturation <94% to be statistically significant with positive CT scans; however, a clinical judgment based on a combination of multiple data points including the severe mechanism of injury, compromised vital signs, physical examination, radiographic trauma series, and E-FAST scan is essential for the selection of patients who should be undergoing WBCT. 14 Likewise, the simultaneous use of other decision rules, including Canadian CT head rule, Canadian C-spine rule, and NEXUS chest CT, may aid in the decision-making process. 1 Equilibrium must be taken in the selection criteria to avoid underutilizing WBCT scans, leading to missing critical injuries. ...
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Background: Whole-body computed tomography (WBCT) has been a mainstay and an integral part of the evaluation of polytrauma patients in trauma centers and emergency departments (ED) for a comprehensive evaluation of the extent of injuries. However, routine use of WBCT remains controversial since it exposes patients to radiation and exponentially increases financial expense. The primary objective was to determine the rate of negative WBCT in polytrauma patients. Patients and Methods: A retrospective cohort study was conducted at an academic hospital in the Kingdom of Saudi Arabia, which is a dedicated trauma center with a mean of 237,392 ED visits and 10,714 trauma per year. The study included all adult (≥18 years) polytrauma patients who presented to our ED, requiring trauma team activation, and underwent WBCT as part of their evaluation from January 2016 to May 2017. We excluded pediatric patients, patients transferred from another facility, and pregnant patients. The primary endpoint was to measure the rate of negative WBCT in polytraumatized patients. Results: A total of 186 patients were included with a mean age of 28.8 ± 12.9 years. The rate of negative WBCT scans was 20.4%. The positive scans were subclassified based on the number of anatomical body regions that were affected radiologically. One body region was affected in 47 patients (31.8%), two body regions were affected in 50 patients (33.8%), and ≥3 body regions were affected in 51 patients (34.3%). In a subset analysis, we identified that oxygen saturation <94% and GCS ≤8 were associated with positive CT scans. Conclusion: Our study revealed a slightly higher rate of utilization of WBCT in the management of trauma patients compared to studies with similar practice. We believe that in the correct setting with incorporating high index of suspicion, a physical examination with attention to vital signs and mental status, performing E-FAST, and dedicated X-Rays is a way to potentially reduce the use of WBCT in polytrauma patients.
... Air transport of patients with severe injuries provides the opportunity to initiate advanced clinical procedures within 15 min, which considerably improves a patient's chances for survival. An assortment of "errors" that occur during the prehospital period that have an impact on PTDR are estimated to be ∼30%; those committed in the ED are 50%, and those related to failures in clinical treatment and hospital structure/organization are ∼40 to 50% (Kunihiro, 2005;Nast-Kolb et al., 2006;Pamerneckas et al., 2006;Salim et al., 2006;Sanddal et al., 2011;Park et al., 2017). ...
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This analysis is based on a review of 224 out of 323 cases of trauma deaths in Regional Specialist Hospital of Grudziądz during the period of 2003–2017. In this study, we have described and systematized the most common situations resulting in severe personal injury. We then evaluated whether the diagnostic procedures and treatments that were employed were correct. From the objective statistical parameters described, we evaluate the level of quality of emergency medicine and the effectiveness of the integrated medical rescue system. Ultimately, the most significant component is PTDR (preventable trauma death rate). Inspiration for our research came from direct observation of our daily experiences in the ED where we derived great satisfaction from treating patients successfully. More importantly, however, we suffered the severe disappointments of failure that always and inevitably raised the same question: Have we done everything humanely possible to save this patient? In the daily struggle of saving lives, the question always remains: What could we have done differently? Better? More effectively? To answer this question, we have to examine our emergency procedures and activities. Were they correct and effective? This documentation not only shows us a statistical picture of the injuries sustained by trauma victims, but also presents a dynamic reconstruction of events as well as the pathophysiology of dying. When we view all this material as a complete picture, we see that it provides the opportunity to assess the accuracy of judgment, especially during the critical moments of diagnosis and subsequent treatment of the casualties. Not only did we describe the anatomic results of injuries, including rankings to proper regions of the body, we also reconstructed the pathophysiology of dying such as airway obstruction—suffocation, bleeding—exsanguination, or severe complications such as acute respiratory distress syndrome, pulmonary emboli, thrombosis of intracranial vasculature, and fatal, irreversible organ damage. We checked operating procedures that had been done and those that should have been done to give the patient a chance for survival but were not due to wrong decisions. We have demonstrated that the element of time is critically important in diagnosing and implementing treatment of patients with major injuries; further, we have enumerated the potential complications, time errors, missed injury, and general mismanagement as professional risks for the emergency team: physicians, nurses, and paramedics. We have determined that almost half of all trauma deaths occur within the first 2 days following major injury, with most of those occurring within the first 6 h of hospitalization. The other deaths—“late deaths”—are the result of unsuccessful treatment or the development of complications in intensive care unit. In all hospital trauma deaths the leading causes are severity of brain injury (51%), exsanguination (31%), and asphyxiation (13%).
... Multitravma hastalarında, tüm vücut bilgisayarlı tomografi içinde de BBT'nin oldukça önemli bir yeri olduğunu gösteren çalışmalar vardır. 5,6 Ancak, mesai saatleri dışında aynı çekim hızımız olmasına rağmen, radyoloji uzmanlarının nöbet ekibinde yer almaması ve kanunen nöbete girmelerinin olası olmaması nedeniyle; tanı koymada bir çok sorun ile karşılaşmaktadır. Bu güçlükleri aşmak için birtakım çözümler geliştirilmiştir. ...
Article
INTRODUCTION: Head trauma is the most common cause of traumatic death between the ages 1 and 44 and especially among 15-24 year- old males. Most frequent causes of head trauma are car accidents, sports injuries, work accidents, assaults, and terrorism. When classification is based on Glasgow Coma Scale head injuries are divided into 3 groups as minimal-minor, mild and severe head traumas. The most important points in the early diagnosis, and treatment of the patient with head trauma are detailed anamnesis, physical, neurological, and radiological examination.Diagnostic evaluation of patients with head trauma has been a great problem for physicians for years. Introduction of brain CT into medical practice has created revolution in this field. Brain CT is a diagnostic tool for the evaluation of traumatic brain injuries, because it has a rapid acquisition time, it is universally available, easy to interpret, and reliable. METHODS: The cases brought to the Emergency Medicine Clinic due to head trauma and underwent brain CT in June 2015 were included in our study. The data of the patients were evaluated retrospectively. For this purpose, emergency service files, hospitalization files and records entered into the hospital automation system with ICD-10 codes were analyzed. RESULTS: A total of 353 patients with head trauma applied to our emergency department between the specified dates, and 177 of these patients had undergone brain CT. The female/male ratio of these patients was 40/64 and the most common application was in the 18-59 age group. According to the brain CT results, 89 patients did not have any pathological findings, while indicated number of patients had atrophy (n=8), intracranial hemorrhage (n=2), contusion (n=2), subdural hematoma (n=1), hydrocephalus (n=1) and chronic ischemia (n=1). DISCUSSION AND CONCLUSION: In this study, the benefit of using online technology in interpreting tomography of patients who admitted to emergency department with head trauma and underwent brain CT during off-hours was emphasized.
... A large prospective observational study of patients with blunt polytrauma but no clinical signs of injury-which found radiological evidence of abdominal injury in almost 10% of patients-and a recent consensus guideline suggest that the threshold for investigation of blunt abdominal trauma should be low. [3,4] Plain abdominal radiography has limited role in the assessment of blunt abdominal trauma, although some authorities continue to advocate its use. Plain abdominal radiography does not visualise abdominal viscera or detect free fluid, so it cannot provide direct evidence of organ injury or indirect evidence of haemorrhage. ...
Article
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Background: Unlike penetrating abdominal trauma, where management is largely determined clinically, the diagnosis of blunt abdominal injury by clinical examination is unreliable, particularly in patients with a decreased level of consciousness.Plain abdominal radiography has limited role in the assessment of blunt abdominal trauma, although some authorities continue to advocate its use. CT scan’s main advantage is the ability to detect arterial contrast extravasation, uncontained or as a pseudoaneurysm, which predicts the need for surgery or angioembolisation. The aim is to study computed tomography evaluation of blunt abdominal injury. Subjects and Methods: The present study was conducted in the Department of Radiology of the medical institution. For the study, we used abdomen CT scan reports of 100 patients with BAT, who were stable enough to undergo radiological investigation. The patients included 66 males and 34 females. All CT scans were obtained with a 16 slice MDCT Scanner (Siemens). All patients received intravenous bolus of iodinated contrast agents. Individual organ injuries were graded according to the American Association for the Surgery of Trauma (AAST - OIS) injury scoring scale. The overall imaging findings were analysed for their role in guiding the therapeutic options, whether conservative or surgical. Results: Total number of patients included in the study was 100. The mean age of patients was 41.97 years. Number of male patients was 66 and number of female patients was 34. For the mode of injury, other miscellaneous causes were most common in out study group followed by road traffic accidents. It was observed that OIS grade II patients were 19, OIS grade III patients were 29, OIS grade IV patients were 12 and OIS grade V patients were 10. The highest proportion of conservatively managed patients were seen in OIS grade II patients. Conclusion: Within the limitations of the present study, it can be concluded that CT scan for blunt abdominal injury is a reliable and accurate method for diagnosis. It has all the qualities to make it a gold standard for initial investigation of choice for blunt abdominal injury patients.
... 4,5 Here, we explored the benefit of additional scans ordered by trauma surgeons after consultation to ED cases. From the literature review, although the positive benefit of liberal imaging in the severely injured has been well studied, 8,9,15 there is little information on the benefit of additional scans after initial ED workup in the mild to moderately injured trauma patient. In the present study, it was found that approximately a third of patients, all with an arrival ISS of 15 or less, had new injuries discovered with additional CT scans (Fig. 3 a). ...
Article
Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.
... We found no other study investigating and demonstrating similar differences between the use of CI vs. WBCT per patient. To date, published data only show partial comparisons, such as the usefulness of routine WBCT in blunt head trauma, the comparison of solely CXR vs. WBCT or selective CT of the thorax or abdomen compared to CXR and FAST, et alia [25,26,35,36]. One might also argue that FAST anyway should only diagnose free abdominal liquid or pericardial tamponade. ...
Article
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Purpose: The indication of whole body computed tomography (WBCT) in the emergency treatment of trauma is still under debate. We were interested in the detailed information gain obtained from WBCT following standardized conventional imaging (CI). Methods: Prospective study including all emergency trauma centre patients examined by CI (focused assessment of sonography in trauma, chest and pelvic X-ray) followed by WBCT from 2011 to 2017. Radiology reports were compared per patient for defined body regions for number and severity of injuries (Abbreviated Injury Scale, AIS; Injury Severity Score, ISS), incidental findings and treatment consequences (Wilcoxon signed rank test, Spearman rho, Chi-square). Results: 1271 trauma patients (ISS 11.3) were included in this study. WBCT detected more injury findings than CI in the equivalent body regions (1.8 vs. 0.6; p < 0.001). In 44.4% of cases at least one finding was missed by CI alone. Compared to WBCT, injury severity of specified body regions was underestimated by CI on average by an AIS of 1.9 (p < 0.001). In 22.0% of cases injury severity increased by an AIS ≥ 2 following WBCT. In 16.8% of patients additional injury findings resulted in a change of treatment (number needed to profit, NNP = 6 patients): NNP decreased from 25 for patients with an ISS < 7 up to nearly 2 for patients with an ISS > 25 at final evaluation, thereby demonstrating a significant improvement in the NNP with increasing ISS (rho = 0.33, p < 0.001). Moreover, WBCT in 88.4% of patients identified ≥ 1 incidental finding (mean 3.4) vs. 28.9% by CI only (p < 0.001). Overall, WBCT had treatment consequences in 31.9% of cases (NNP = 3.1). Conclusions: The application of WBCT in addition to CI in the emergency treatment of trauma had therapy consequences for almost every third patient. On the other hand, WBCT appeared not to be indicated (ISS < 8) in at least 2/5 of patients.
... Although whole-body CT scanning is reported to not significantly affect overall effective radiation dose during hospital stay in patients with ISS ≥ 16 [14], radiation exposure may be a reason for its restrictive use in less severely injured patients. On the other hand, whole-body CTs are reported to result in a change of treatment in nearly 19% of trauma patients without obvious signs of injury [15]. Moreover, incidental findings unrelated to the trauma may be found in up to 45% of the patients examined [16]. ...
Article
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Purpose To evaluate the current practice regarding the prevalence and sequence of x-ray and CT scan in diagnostic algorithms for multiple injured patients. Methods All primarily treated patients with ISS ≥ 9 were selected from the TraumaRegister DGU® (years 2008–2015; n = 109,257). Four subgroups of diagnostic algorithm were defined: CT only (group C; n = 63,763), CT before x-ray (group CX; n = 3711), x-ray followed by CT (group XC; n = 33,590), and x-ray only (group X, n = 8193). We analysed the type and sequence of diagnostic procedures and their association with hospital mortality and length-of-stay in the emergency room (ER-LOS). Results Predominant strategies were CT only (58.4%) and x-ray followed by CT (30.7%). Overall mortality was between 10 and 12% in all subgroups involving CT, and 6.6% in the x-ray only group. Expected mortality was within the 95% confidence of observed mortality except for the CX group (observed 10.0%; CI95 8.9–11.0; expected 11.1%). Mean / median length of stay in the emergency room was shortest in the CT only subgroup: (60 / 50 min). Prior x-ray diagnostic resulted in additional 3 min (group XC). The use of additional x-ray diagnostic decreased from 51.6% (in 2008) to 35.4% (in 2015). Conclusions ER-LOS is significantly affected by diagnostic pathway. CT scan alone accelerates ER-LOS, which however was not associated with lower mortality rates. Performing completive x-ray examinations after an initial CT scan seems not to deteriorate mortality rates.
... 19 Deunk et al. 12 reviewed CXR and chest CT of 106 blunt chest trauma patients and demonstrated a change of treatment in 34% (95% CI: 23%e44%) of the patients. Salim et al. 20 in a prospective observational study of 592 awake and evaluable trauma patients found 19.6% clinically significant abnormalities on chest CT, resulted in change of treatment in 19% of patients. ...
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Purpose Blunt thoracic injuries are common among elderly patients and may be a common cause of morbidity and death from blunt trauma injuries. We aimed to examine the impact of chest CT on the diagnosis and change of management plan in elderly patients with stable blunt chest trauma. We hypothesized that chest CT may play an important role in providing optimal management to this subgroup of trauma patients. Methods A retrospective analysis was performed on all the admitted adult blunt trauma patients between January 2014 and December 2018. Stable blunt chest trauma patients with abbreviated injury severity (AIS) < 3 for extra-thoracic injuries confirmed with chest X-ray (CXR) and chest CT on admission or during hospitalization were included in the study. The AIS is an international scale for grading the severity of anatomic injury following blunt trauma. Primary outcome variables were occult injuries, change in management, need for surgical procedures, missed injuries, readmission rate, intensive care unit (ICU) and length of hospital stay. Results There are 473 patients with blunt chest trauma included in the study. The study patients were divided into two groups according to the age range: group 1: 289 patients were included and aged 18–64 years; group 2: 184 patients were included and aged 65–99 years . Elderly patients in group 2 more often required ICU admission (11.4% vs. 5.2%), had a longer length of ICU stay (days) (median 11 vs. 6, p = 0.01), and the length of hospital stay (days) (median 14 vs. 6, p = 0.04). Injuries identified on chest CT has led to a change of management in 4.4% of young patients in group 1 and in 10.9% of elderly patients in group 2 with initially normal CXR. Chest CT resulted in a change of management in 12.8% of young patients in group 1 and in 25.7% of elderly patients in group 2 with initially abnormal CXR. Conclusion Chest CT led to a change of management in a substantial proportion of elderly patients. Therefore, we recommend chest CT as a first-line imaging modality in patients aged over 65 years with isolated blunt chest trauma.
... Air transport of patients with severe injuries provides the opportunity to initiate advanced clinical procedures within 15 min, which considerably improves a patient's chances for survival. An assortment of "errors" that occur during the prehospital period that have an impact on PTDR are estimated to be ∼30%; those committed in the ED are 50%, and those related to failures in clinical treatment and hospital structure/organization are ∼40 to 50% (Kunihiro, 2005;Nast-Kolb et al., 2006;Pamerneckas et al., 2006;Salim et al., 2006;Sanddal et al., 2011;Park et al., 2017). ...
... This diagnostic imaging modality is particularly helpful in the unevaluable patient or in those sustaining high-impact mechanisms of injury with multi-system trauma. 1 While missed injuries cannot be overlooked in this vulnerable population, not all identified injuries require acute intervention. Therefore, efforts to develop CT protocols for pediatric trauma patients have been an area of ongoing interest. ...
Article
Background The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes. Methods We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality. Results Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts. Conclusion Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.
... Стремительное развитие технологии многосрезовой компьютерной томографии (МСКТ) кардинально изменило представления о показаниях к его проведению при травме [13,14]. ...
Article
Relevance . The variety of options for combining injuries and disorders occurring in the body with a combined injury, the need for rapid decision-making on treatment require rapid diagnosis of the entire volume of injuries and determining the severity of the injury, but there is still no single protocol for examining such victims. The aim of the work was to present a modern CT study protocol for patients with concomitant trauma. Materials and methods . The results of computed tomography of 30 patients with severe concomitant trauma were analyzed. All the victims were admitted in the first hours after the injury. Men were 30 (67 %), women – 10 (33 %), the average age was 41.3 ± 7.6 (22–79) years. Traditional multiphase full-body MSCT was performed in 20 patients, in 10 patients a special protocol was used for the study of the "whole body" by the method of divided bolus. The results of the study . Craniocerebral injuries were detected in 15 (50 %), spinal injuries – in 7 (23.3 %). Simultaneous injuries to the chest and abdomen were detected in 19 (63.3 %) of the victims. When subjectively evaluated, the quality of the images obtained using the full-body MSCT protocol with bolus separation and the standard multiphase protocol for the diagnosis of traumatic injuries was equivalent. The average radiation load per patient with traditional multiphase full-body MSCT is 66 % higher than with the split-bolus protocol. Conclusions . Full-body MSCT using a split bolus is a modern technique that fully meets the diagnostic conditions for severe combined trauma and, with a decrease in the radiation dose, allows you to determine all possible injuries in the victim in a single study.
... The use of CT scans in the evaluation of trauma patients has significantly increased. Compared to chest x-rays, CT thorax has a greater sensitivity for detecting a pneumothorax or haemothorax and also allows evaluation of the rib cage, the mediastinum, the lung parenchyma & the aorta [1,3,14]. The decision to obtain a CT thorax should be based on physical findings, mechanism of injury and clinical judgement. ...
Article
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Trauma is the leading cause of death worldwide of which two thirds of the patients have blunt chest trauma with varying severity from a simple rib fracture to flail chest. In this paper we are reviewing the existing literature and the management of blunt chest trauma, throwing light on the critical aspects such as evaluation and treatment. Recent advances of VATS in blunt chest trauma are de-scribed as well, majority of the BCT cases are managed non-operatively with only a handful of cases needing surgical intervention by thoracic surgeons. Younger patients have better prognosis as compared to geriatric patients with the same injuries. We also throw light on the admission criteria for BCT cases, indications of tube thoracostomy and indications of thoracotomy in BCT cases. This particular paper will throw light on the management of blunt chest trauma and its various therapeutic options in detail so as to understand this clinical entity and its implications.
... [15][16][17][18] Several observational studies reported the improvement of clinical outcomes by decreasing mortality rate and hospital length of stay among trauma patients who underwent CT PANSCAN. [19][20][21][22] However, the REACT-2 Study, 23 an international, multicenter, randomized controlled trial, debated no statistical difference in the mortality rate for those who received CT PANSCAN or conventional scanning. In addition, this diagnostic procedure also extends the time spent in the emergency department (ED), especially in settings in which the CT room is not located within or near the ED. ...
Article
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Objective: The treatment of severe trauma patients requires a fast and accurate method to diagnose life-threatening conditions. Computerized tomography (CT)-PANSCAN has been widely used for the last 20 years to diagnose many patients in critical condition. However, no research has been performed into the efficacy of CT-PANSCAN. This research aims to compare the mortality rate of trauma patients who underwent CT-PANSCAN versus conventional CT scan. Methods: This retrospective cohort study enrolled patients who were at triage ESI level 1-2 in the emergency department of Ramathibodi Hospital from January 2013 to December 2018 and analyzed the mortality rate between those who underwent CT-PANSCAN and conventional CT scan. Results: The study enrolled 123 trauma patients; 61 patients underwent CT-PANSCAN, whereas 62 patients underwent conventional CT scan. There were 1 and 7 patients who expired in the CT-PANSCAN and conventional CT scan groups, respectively. After multivariate regression analysis, the result revealed that patients who underwent CT-PANSCAN had a lower mortality rate (adjusted odds ratio = 0.023; p-value = 0.018; 95% CI 0.001-0.518). Conclusion: Undergoing a CT-PANSCAN can reduce the mortality rate in trauma patients, especially in ESI level 1, 2 traumatic patients, and CT-PANSCAN available facilities.
... So well recognized complications include perforation, bleeding, post-polypectomy syndrome and side effects related to sedation and analgesia. Base on some reports, there are also a number of rare complications reported in the literature including splenic trauma, infection, diverticulitis and appendicitis [17]. ...
... In this context, however, CT imaging of the chest may not necessarily be part of the workup of every patient with presumed isolated TBI. However, thoracic trauma is common in the elderly and minor injuries may be missed without CT, as they may present with normal clinical exam and chest x-ray findings [14,15]. Without the recognition of the harmful effects of concomitant minor chest trauma, risk stratification and appropriate patient disposition is not possible. ...
Article
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Background: Traumatic brain injury (TBI) is associated with high rates of long-term disability and mortality. Our aim was to investigate the effects of thoracic trauma on the in-hospital course and outcome of patients with TBI. Methods: We performed a matched pair analysis of the multicenter trauma database TraumaRegisterDGU® (TRDGU) in the 5-year period from 2012 to 2016. We included adult patients (≥18 years of age) with moderate to severe TBI (abbreviated injury scale (AIS)= 3–5). Patients with isolated TBI (group 1) were compared to patients with TBI and varying degrees of additional blunt thoracic trauma (AISThorax= 2–5) (group 2). Matching criteria were gender, age, severity of TBI, initial GCS and presence/absence of shock. The χ2-test was used for comparing categorical variables and the Mann-Whitney-U-test was chosen for continuous parameters. Statistical significance was defined by a p-value < 0.05. Results: A total of 5414 matched pairs (10,828 patients) were included. The presence of additional thoracic injuries in patients with TBI was associated with a longer duration of mechanical ventilation and a prolonged ICU and hospital length of stay. Additional thoracic trauma was also associated with higher mortality rates. These effects were most pronounced in thoracic AIS subgroups 4 and 5. Additional thoracic trauma, regardless of its severity (AISThorax ≥2) was associated with significantly decreased rates of good neurologic recovery (GOS = 5) after TBI. Conclusions: Chest trauma in general, regardless of its initial severity (AISThorax= 2–5), is associated with decreased chance of good neurologic recovery after TBI. Affected patients should be considered “at risk” and vigilance for the maintenance of optimal neuro-protective measures should be high. Keywords: Traumatic brain injury, Thoracic injury, Glasgow Outcome Scale, Critical care, Registry
... Salim et al. reported that in high-energy trauma (such as a motor vehicle crash at >35 mph; a falling incident >15 ft; an automobile hitting a pedestrian, with the pedestrian thrown >10 ft; and being assaulted, resulting to a decreased level of consciousness), when trauma pan-scan was performed in patients with no obvious signs of trauma on the initial physical examination, abnormal findings were found in 19% (3.5% head, 5.1% cervical, 19.6% thoracic, and 7.1% abdominal) of all patients, and the treatment plan was changed [11]. In this case, the patient was asymptomatic; however, owing to the injury mechanism of being pulled by a car, a CT scan was performed. ...
Article
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Introduction Celiac artery (CA) dissection due to blunt abdominal trauma is extremely rare and, as such, the clinical features of this potentially life-threatening injury have not been clearly defined, nor have treatment strategies been established. Presentation of case We describe the case of a 61-year-old man who presented to our emergency department after a motor vehicle accident. Although the patient did not report abdominal pain, enhanced computed tomography (CT) revealed CA dissection. The patient was treated conservatively using antiplatelet therapy and was discharged from the hospital on day 8, without complications. Discussion As abdominal pain is not a common presenting factor of CA dissection after blunt trauma, it should be suspected as a potential injury in all affected patients and comprehensively assessed, with CT being the most useful diagnostic modality. Conclusion In the absence of any signs of organ ischemia, changes in the CA aneurysm, and persistent, severe abdominal pain following blunt abdominal trauma, conservative treatment is indicated, with or without anticoagulation or antiplatelet therapy.
... Previous studies recommended checking whole body scan with CT of patients who sustained blunt trauma but were suspected to have major trauma. [40,41] Blunt injury, such as injury sustained in a car accident or falls, can occur to any individual. Consequently, we could investigate masseter and abdomen muscular images simultaneously. ...
Article
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Nutritional assessment is feasible with computed tomography anthropometry. The abdominal muscle at the L3 vertebra is a well-known nutritional biomarker for predicting the prognosis of various diseases, especially sarcopenia. However, studies on nutritional assessment of the brain using computed tomography are still scarce. This study aimed to investigate the applicability of the masseter muscle as a nutritional biomarker.Patients who underwent simultaneous brain and abdominopelvic computed tomography in the emergency department was retrospectively analyzed. We assessed their masseter muscle 2 cm below the zygomatic arch and abdominal muscle at L3 via computed tomography anthropometry. The skeletal muscle index, prognostic nutritional index, and other nutritional biomarkers were assessed for sarcopenia using the receiver operating characteristic curve analysis.A total of 314 patients (240 men and 72 women) were analyzed (mean age, 50.24 years; mean areas of the masseter and abdominal muscles, 1039.6 and 13478.3 mm, respectively). Masseter muscle areas significantly differed in sarcopenic, obese, and geriatric patients (P < .001). The areas under the curve of the masseter muscle in sarcopenic, geriatric, and obese patients were 0.663, 0.686, and 0.602, respectively. Multivariable linear regression analysis showed a correlation with the abdominal muscle area, weight, and age.The masseter muscle, analyzed via computed tomography anthropometry, showed a statistically significant association with systemic nutritional biomarkers, and its use as a nutritional biomarker would be feasible.
... Furthermore, decreased levels of consciousness could be considered an indication on itself since several clinical indicators for imaging are unreliable owing to the lack of subjective input from the patient when screening for injuries. Routine CT imaging for patients with unreliable physical examination is reported to reveal unsuspected findings in up to 38%, leading to treatment changes in 19-26% [16,17]. Our study found GCS ≤ 13 or abnormal pupillary reaction an independent predictor for severe injury and further supports a compromised GCS to be a valid indication for iTBCT after severe trauma. ...
Article
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Objectives Initial trauma care could potentially be improved when conventional imaging and selective CT scanning is omitted and replaced by immediate total-body CT (iTBCT) scanning. Because of the potentially increased radiation exposure by this diagnostic approach, proper selection of the severely injured patients is mandatory. Methods In the REACT-2 trial, severe trauma patients were randomized to iTBCT or conventional imaging and selective CT based on predefined criteria regarding compromised vital parameters, clinical suspicion of severe injuries, or high-risk trauma mechanisms in five trauma centers. By logistic regression analysis with backward selection on the 15 study inclusion criteria, a revised set of criteria was derived and subsequently tested for prediction of severe injury and shifts in radiation exposure. Results In total, 1083 patients were enrolled with median ISS of 20 (IQR 9–29) and median GCS of 13 (IQR 3–15). Backward logistic regression resulted in a revised set consisting of nine original and one adjusted criteria. Positive predictive value improved from 76% (95% CI 74–79%) to 82% (95% CI 80–85%). Sensitivity decreased by 9% (95% CI 7–11%). The area under the receiver operating characteristics curve remained equal and was 0.80 (95% CI 0.77–0.83), original set 0.80 (95% CI 0.77–0.83). The revised set retains 8.78 mSv (95% CI 6.01–11.56) for 36% of the non-severely injured patients. Conclusions Selection criteria for iTBCT can be reduced from 15 to 10 clinically criteria. This improves the positive predictive value for severe injury and reduces radiation exposure for less severely injured patients. Key Points • Selection criteria for iTBCT can be reduced to 10 clinically useful criteria. • This reduces radiation exposure in 36% of less severely injured patients. • Overall discriminative capacity for selection of severely injured patients remained equal.
... A pan-scan can also increase the trauma team's confidence in patient disposition to the trauma ward, ICU, or home. Salim et al. [16,17] reported that the treatment plan was altered according to the pan-scan results in nearly 19% of patients. In the present study, this rate was 64%. ...
Article
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Background Severe trauma can cause multi-organ injuries, and the mortality rate may increase if significant organ injuries are missed. This study was performed to determine whether whole-body computed tomography scan (pan-scan) can detect significant injury and leads to proper management, including alteration the priority of management. Methods This prospective study was conducted from January 2019 to March 2021 and involved trauma patients level 1, level 2, and dangerous mechanism of trauma. Additionally, the data of trauma patients who had selective computed tomography scan were retrospectively reviewed to compared the clinical benefits. Results Twenty-two patients were enrolled in the prospective study. The pan-scan detected significant organ injury in 86% of the patients. Prioritization of organ injury management changed after performance of the pan-scan in 64% (major change in 64.29% and minor change in 35.71%). Skull base fracture, small bowel injury, retroperitoneal injury, kidney and bladder injury, and occult pneumothorax were the majority of injuries which was not consider before underwent pan-scan (p < 0.05). The door-to-scan time tended to be shorter in the pan-scan group than in the selective scan group without a significant difference [mean (SD), 59.5 (34) and 72.0 (86) min, respectively; p = 0.13]. Pan-scan contribute 100% confidence for trauma surgeon in diagnosis of specific organ injuries in severe injured patients. Conclusions The pan-scan facilitates timely detection of significant unexpected organ injuries such as the skull base, occult pneumothorax, small bowel, and retroperitoneum. It also helps to prioritize management and increases the diagnostic confidence of trauma surgeons, leading to better outcomes without delay.
... Urgent laparotomy is mandatory for hemodynamic instability, gross peritoneal signs, and evisceration. [17,18] If PAT presents with evisceration, signs of peritonism or hemodynamic instability, it requires urgent surgery. In our study, six patients had evisceration of omentum/small intestine and underwent urgent surgery. ...
Article
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Background: Abdominal trauma is a frequent indication for surgical exploration of the combat causality. Rapid transportation to trauma center, early recognition of injuries, sound surgical judgment, and timely intervention are critical for reducing mortality and morbidity. Patients and Methods: All penetrating abdominal trauma (PAT) cases admitted to a combat zone hospital from January 2014 to December 2016 were studied. Results: Forty-eight patients with PAT were evaluated and managed. Majority (66.7%) were secondary to gunshot injuries. Forty-one required operative management. Out of these, 6 (12.5%) underwent diagnostic laparoscopy and 35 (72.9%) required laparotomy. The small intestine was the most commonly injured organ which was encountered in 21 (43.7%) cases. Two (4.2%) patients succumbed to their injuries. Early resuscitation in combat zone followed by prompt evacuation to the combat hospital improved the overall outcome. Conclusion: PAT is a common cause of morbidity and mortality in combat areas. Rapid transportation, sound clinical judgment, and early surgical intervention are critical for patient survival and better outcomes.
... The most important diagnostic tool to detect bleeding and its source during the secondary survey is whole-body CT (WBCT) [6,10,11]. Implementation of multi-slice CT in the treatment algorithm could significantly reduce the time in the trauma suite [5]. In comparison to conventional radiography, CT enables a faster and more consistent diagnosis [12]. ...
Article
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Purpose Early detection of bleeding is important for managing trauma cases in the emergency department (ED). Several trauma suites are equipped with computed tomography (CT) scanners to reduce the time to CT. In the last decade, sliding gantry CT has been implemented in trauma suites, highlighting conventional techniques' advantages. We investigated the change in the time to CT and the challenges faced during the implementation. Methods Trauma suite treatments with a conventional CT scanner between January and December 2016 formed the control group. From January to April 2017, trauma suites were modified, and treatment was outsourced to an interim trauma suite. By May 2017, trauma suites were equipped with a sliding gantry CT scanner. Treatments from May to July 2017 formed the transition group, and those from August to December 2017 formed the routine use group. We evaluated the time to CT in all groups and considered the reasons for the delays in the transition and routine use groups. Results On sliding gantry CT implementation, although time to CT remained unaffected in the transition group, it significantly reduced in the routine use group, independent of injury severity score. The incidence of cable management problems was significantly higher in the latter group. Conclusions We have demonstrated a decrease in the time to CT with the implementation of a sliding gantry CT. However, due to a higher number of cable management problems in the routine use group, we recommend regular refresher team training with routine use.
... Although there is a strong argument for decreasing CT usage, it is important to note that there are also benefits to current utilization patterns. A study conducted by Salim et al. at a level one trauma center in Los Angeles, USA, found that of patients without obvious external signs of injury who underwent a whole-body CT pan scan, 18.9% had a change in management based on abnormal CT findings which were not suspected clinically [24]. ...
Article
Introduction Computed tomography (CT) imaging forms an important component in the evaluation and management of patients with traumatic injuries. Many South African emergency departments (EDs) have a significant trauma-related workload, especially in the public sector, where there are limitations in resources relating to CT scanners. It is important to gauge the impact of traumatic injuries on CT utilization. The primary objectives were to quantify the number and type of CT imaging studies trauma patients received, as well as to determine the frequency of radiologically significant findings in a level one trauma center. The secondary objectives were to determine the CT utilization rate and describe the demographics of patients who received imaging. Methods This was a retrospective, quantitative, descriptive, cross-sectional study undertaken over two months at the level one trauma center of a tertiary, academic, public sector teaching hospital in Johannesburg, South Africa. The radiology department's picture archiving and communication system (PACS) was used to evaluate the reports of trauma patients who were referred for a CT scan. The trauma center register was used to calculate the CT utilization rate. Results There were 5,058 trauma patients seen in the two months. A total of 1,277 CT scans were performed on 843 patients. CT brain accounted for 52% of all scans performed. Radiologically significant findings were demonstrated in 407 scans (354 patients), i.e. 31.9% of scans and 42% of patients. CT chest and peripheral angiogram demonstrated radiologically significant findings in 60.5% and 50.9% of scans respectively. Assault accounted for 55.8% of the injuries sustained and road traffic accidents accounted for 33.2%. The overall CT utilization rate was 16.7% i.e. 843 out of the 5,058 trauma patients underwent a CT scan. Conclusions South Africa has a substantial trauma burden which commonly necessitates CT utilization. It is concerning that blunt and penetrating assault continues to dominate these traumatic presentations. Worldwide, there is a broad range of described CT utilization rates and the findings at this level one trauma center fall within that range. ED clinicians are encouraged to continue carefully using this scarce resource in the trauma setting.
... This has serious consequences both for patients, due to the potential consequences of exposure to a high dose of ionising radiation, and for the entire healthcare system, due to the high costs of WBCT scanning [8]. On the other hand, proponents of a less restrictive approach to the use of this test in trauma patients point to the key role of WBCT in imagining serious injuries in those patients whose clinical condition is initially good [9,10]. Without doubt, the significance of WBCT as a primary diagnostic tool in the early phase of managing trauma patients was also established by studies proving its positive impact on reducing mortality [11][12][13]. ...
Article
Purpose: Identification of the group of patients meeting the criteria of a severe multiple trauma (polytrauma) among those admitted to the regional trauma centre and subjected to whole-body computed tomography (WBCT) due to injuries. Identification the patients for whom WBCT was the optimal choice. Material and methods: Retrospective analysis of the data of 303 patients undergoing WBCT in the period 2015-2017 with assessment of the injury severity based on the abbreviated injury scale (AIS) and injury severity score (ISS). Results: Among 303 patients undergoing WBCT due to trauma, multiple injuries with ISS > 15 were found in 74 individuals (24.4%). After excluding patients whose limb fractures increased ISS above 15, the group decreased to 63 patients (20.8%). For these patients, the WBCT may be described as the optimal imaging method at an early stage of management. Conclusions: Trauma patients are too often qualified for WBCT. Exposure to a high dose of ionising radiation associated with this modality requires critical analysis of the scope of indications and rules of conduct for trauma teams.
Article
Current evidence-based screening algorithms for blunt cerebrovascular injury (BCVI) may miss more than 30% of carotid or vertebral artery injuries. We implemented universal screening for BCVI with CT angiography (CTA) of the neck at our level 1 trauma center, hypothesizing that only universal screening would identify all clinically relevant BCVIs. Methods: Adult blunt trauma activations from 7/2017 through 8/2019 underwent full-body CT scan including CTA neck with a 128-slice CT scanner. We calculated sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of common screening criteria. We determined independent risk factors for BCVI using multivariate analyses. Results: 4,659 patients fulfilled inclusion criteria, 2.7% (n = 126) of which had 158 BCVIs. For the criteria outlined in the ACS TQIP Best Practices Guidelines, sensitivity, specificity, PPV, NPV, and accuracy were 72.2%, 64.9%, 6.8%. 98.5%, and 65.2%, respectively; for the risk factors suggested in the more extensive "expanded Denver criteria", they were 82.5%, 50.4%, 5.3%, 98.9%, and 51.4%, respectively. 23% (n = 14) of patients with BCVI grade 3 or higher would not have been captured by any screening criteria. Cervical spine, facial, and skull base fractures were the strongest predictors of BCVI with odds ratios and 95% confidence intervals of 8.1 (5.4 - 12.1), 5.7 (2.2 - 15.1), and 2.7 (1.5 - 4.7), respectively. 83% (n = 105) of patients with BCVI received antiplatelet agents or therapeutic anticoagulation, with 4% (n = 5) experiencing a bleeding complication, 3% (n = 4) BCVI progression, and 8% (n = 10) a stroke. Conclusions: Almost 20% of patients with BCVI, including a quarter of those with BCVI grade 3 or higher, would have gone undiagnosed by even the most extensive and sensitive BCVI screening criteria. Implementation of universal screening should strongly be considered to ensure the detection of all clinically relevant BCVIs. Level of evidence: Diagnostic study, level III.
Article
In an attempt to minimize missed injury rates, potentially decrease mortality, and enhance rapid patient disposition, standard-dose whole-body computed tomographic (WBCT) imaging has become ubiquitous at trauma centers for the hemodynamically stable patient admitted with trauma.¹,2 The radiation dose from WBCT ranges from 10 to 20 mGy, which results in an approximately 0.08% estimated lifetime cancer mortality for 45-year-old persons.³ Risk of mortality due to missed injury is therefore higher than the risk of future radiation-induced cancer.
Article
Objective: It is unclear if additional computerized tomography (CT) imaging is warranted after injuries are identified on CT in blunt trauma patients. The objective of this study was to determine the incidence and significance of injuries identified on secondary CT imaging after identification of injuries on initial CTs in blunt trauma patients. Methods: This was a retrospective cohort study at an academic Level 1 trauma center with a two-tiered trauma system. Inclusion criteria: age ≥ 18, level 2 trauma activation, injury identified on initial CT, and secondary CTs ordered. Secondary injuries were categorized as resulting in: no changes, minor changes, or major changes in management. Results: 537 patients underwent 1179 initial CT scans which identified 744 injuries. There were 1094 secondary CTs which identified 143 additional injuries in 94 (18%) patients. 9 (1.7%) patients had at least one major management change and 64 (12%) had at least one minor management change. Rib fracture(s) was the most common injury on secondary scans [45/143 (32%)]. The major management changes were: tube thoracostomy for pneumothorax (4 patients), blood transfusion for hemoperitoneum (1 patient), surgery for acetabular fracture (1 patient), thoracolumbar brace for spine fracture (2 patients) and angiography for splenic injury (1 patient). Conclusion: While a significant proportion of patients (18%) had injuries on secondary CT, only 1.7% of patients had a resultant major management change. Future research is warranted to determine the need for additional CT imaging after an initial selective imaging strategy in blunt trauma patients.
Chapter
By providing rapid and broad surveys, radiologic imaging is an essential tool in modern medicine for the evaluation of trauma patients. Radiologic imaging may inform clinical diagnosis and the development of treatment strategies such as operation, angiointerventions, or conservative treatment.
Article
Background: The use of whole-body computed tomography (WBCT) in awake, clinically stable injured patients is controversial. It is associated with unnecessary radiation exposure and increased cost. We evaluate use of computed tomography (CT) imaging during the initial evaluation of injured patients at American College of Surgeons Levels I and II trauma centers (TCs) after blunt trauma. Methods: We identified adult blunt trauma patients after motor vehicle crash (MVC) from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2007 and 2016 at Level I or II TCs. We defined awake clinically stable patients as those with systolic blood pressure of 100 mm Hg or higher with a Glasgow Coma Scale score of 15. Computed tomography imaging had to have been performed within 2 hours of arrival. Whole-body computed tomography was defined as simultaneous CT of the head, chest and abdomen, and selective CT if only one to two aforementioned regions were imaged. Patients were stratified by Injury Severity Score (ISS). Results: There were 217,870 records for analysis; 131,434 (60.3%) had selective CT, and 86,436 (39.7%) had WBCT. Overall, there was an increasing trend in WBCT utilization over the study period (p < 0.001). In patients with ISS less than 10, WBCT was utilized more commonly at Level II versus Level I TCs in patients discharged from the emergency department (26.9% vs. 18.3%, p < 0.001), which had no surgical procedure(s) (81.4% vs. 80.3%, p < 0.001) and no injury of the head (53.7% vs. 52.4%, p = 0.008) or abdomen (83.8% vs. 82.1%, p = 0.001). The risk-adjusted odds of WBCT was two times higher at Level II TC vs. Level I (odds ratio, 1.88; 95% confidence interval 1.82-1.94; p < 0.001). Conclusion: Whole-body computed tomography utilization is increasing relative to selective CT. This increasing utilization is highest at Level II TCs in patients with low ISSs, and in patients without associated head or abdominal injury. The findings have implications for quality improvement and cost reduction. Level of evidence: Care management, Level IV.
Chapter
Trauma is still one of the leading causes of death among teenagers and a major cause of morbidity and mortality among the elderly (DeGrauw et al., J Safety Res 56:105–109, 2016). Advances in technology have allowed more affordable and easily accessible imaging modalities. Modern trauma centers rely heavily on imaging for assessment of suspected injuries (Andrawes et al., Trauma Surg Acute Care Open 2(1):e0001012, 2017). In addition to providing information on acute injuries, however, imaging modalities have also been shown to reveal chest pathologies not related to trauma called “incidental findings” which may or may not require further investigation (Salim et al., Arch Surg 141:468–473, 2006; Sampson et al., Clin Radiol 61:365–369, 2006; Seah et al., Injury 47:691–694, 2016). In the acute setting when a patient is too unstable for immediate imaging, there is potential for discovery of incidental findings intraoperatively. Lung nodules or masses can originate from many different etiologies. Very few of these need to be directly addressed in the acute care surgery setting. The acute care surgeon’s role is often to identify the incidental finding and set the patient up for the appropriate work up and specialty follow-up. The diagnosis and correct treatment of these incidental findings could have a major impact on the patient’s future health and survival. The list of potential incidental findings is extensive. In this chapter, we will briefly cover some common incidental findings as well as discuss recommended work-up and potential treatment.
Article
Occult abdominal injuries are common and can be associated with increased risk of morbidity and mortality. Patients with a delayed presentation to care or who are multiply injured are at increased risk of this type of injury, and a high index of suspicion must be maintained. A careful combination of history, physical examination, laboratory, and imaging can be quite helpful in mitigating the risk of a missed occult abdominal injury.
Chapter
Traditional ATLS teachings recommend an initial trauma imaging workup of a chest X-ray, FAST examination, selective radiographs, and CT scanning based on physical examination findings (American College of Surgeons, Advanced Trauma Life Support, 2018). As imaging technology has improved, “whole-body CT” scanning (WBCT), or “pan-scanning” has become a viable and often used alternative for imaging multisystem trauma patients upon initial evaluation. This type of imaging, which includes the head, chest, abdomen, pelvis, and the entire spine including the neck, has been primarily used in patients who have undergone blunt trauma.
Article
Background Computed tomography (CT) has emerged as the diagnostic modality of choice in trauma patients. Recent studies suggest its use in hemodynamically unstable patients is safe and potentially lifesaving; however, the incidence of adverse events (AE) during the trauma CT scanning process remains unknown. Study Design Over a 6-month period at a Level 1 trauma center, data on patients undergoing trauma CT (whole-body CT (WBCT) +/− additional CT studies) were prospectively collected. All patients requiring a trauma team activation (TTA) were included. Adverse events and specific time intervals were recorded from the time of TTA notification to the time of return to the resuscitation bay from the CT suite. Results Of the 94 consecutive patients included in the study, 47.9% experienced 1 or more AE. Median duration away from the resuscitation bay for all patients was 24 minutes. Patients with AE spent a significantly longer time away from the resuscitation bay and had longer scan times. Vasopressor support and ongoing transfusion requirement at the time of CT scanning were associated with AE. Conclusion Adverse events of varying clinical significance occur frequently in patients undergoing emergent trauma CT. A standard trauma CT protocol could improve the efficiency and safety of the scanning process.
Article
PurposeRisks and benefits of systematic use of whole-body CT (WBCT) in patients with major trauma when no injury is clinically suspected is still subject of controversy. WBCT allows early identification of potentially evolving lesions, but exposes patients to the risk of high radiation dose and iodine contrast agent. The study aimed to assess if WBCT could be avoided in trauma patients with negative clinical examination. Materials and methodsThis retrospective study included polytrauma patients admitted to the Emergency Department in a six-month period, who had undergone a WBCT scan for major dynamic criteria, with hemodynamic stability, absence of clinical and medical risk factors for major trauma. The patients (n = 233) were divided into two groups according to the absence (n = 152) or presence (n = 81) of clinical suspicion of organ injury. The WBCT results were classified as negative, positive for minor and positive for major lesions.ResultsThe average patient age was 44 years. CT scans were completely negative in 111 (47.6%) patients, whose 104 (93.7%) were in the negative clinic group. 122 (52.4%) CT scans were positive, 69 (56.6%) for minor lesions and 53 (43.4%) for major lesions. Among the 48 (39.3%) positive CT scans in patients with negative clinic, only 5 (10.4%) were positive for major lesions. We found a significant difference in the frequency of injuries between the clinically negative and clinically positive patient groups (p < 0.001).ConclusionA thorough clinical examination associated with a primary radiological evaluation may represent a valid diagnostic approach for trauma with only major dynamic criteria to limit the use of WBCT.
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Purpose: Fetal radiation exposure in pregnant women with trauma is a concern. The purpose of this study was to evaluate fetal radiation exposure with regard to the type of injury assessment performed. Methods: It is a multicentre observational study. The cohort study included all pregnant women suspected of severe traumatic injury in the participating centres of a national trauma research network. The primary outcome was the cumulative radiation dose (mGy) received by the fetus with respect to the type of injury assessment initiated by the physician in charge of the pregnant patient. Secondary outcomes were maternal and fetal morbi-mortality, the incidence of haemorrhagic shock and the physicians’ imaging assessment with consideration of their medical specialty. Results: Fifty-four pregnant women were admitted for potential major trauma between September 2011 and December 2019 in the 21 participating centres. The median gestational age was 22 weeks [12-30]. Seventy-eight percent of women (n=42) underwent WBCT. The remaining patients underwent radiographs, ultrasound or selective CT scans based on clinical examination. The median fetal radiation doses were 38 mGy [23-63] and 0 mGy [0-1]. Maternal mortality (5.6%) was lower than fetal mortality (16.7%). Two women (out of 3 maternal deaths) and 7 fetuses (out of 9 fetal deaths) died within the first 24 hours following trauma. Conclusion: Immediate WBCT for initial injury assessment in pregnant women with trauma was associated with a fetal radiation dose below the 100 mGy threshold. Among the selected population with either a stable status with a moderate and nonthreatening injury pattern or isolated penetrating trauma, a selective strategy seemed safe.
Article
AIM To examine the radiological images of children with musculoskeletal injuries and accompanying organ injuries caused by explosions to determine the differences and frequency of injury types and to emphasise the importance of radiology in war injuries. MATERIALS AND METHODS Seventy-four children with injuries caused by bomb explosions were included in the study. The paediatric trauma scores evaluated in the emergency department on the first admission were recorded. All radiographs and computed tomography (CT) images were evaluated for musculoskeletal injuries and accompanying organ injuries. RESULTS The highest incidence of fracture in the primary blast injury (PBI) group was skull fracture in 15 (62.5%) patients (p=0.01) and fractures in the other groups were most common in the lower extremities. Amputation was observed in nine (31%) patients in the PBI group (p=0.003); however, there were no patients with amputations in the secondary blast injury (SBI) group (p=0.002). The frequency of pneumothorax (79.3%) and pulmonary contusion (59.4%) was high in the PBI group (p<0.001 and p=0.004, respectively). Skull fractures were observed in 15 (88.2%) of 17 patients with brain injury (p<0.001), and skull fractures were the most common fracture site accompanying pulmonary trauma. The average paediatric trauma score of individuals exposed to shrapnel was found to be high (p<0.001). CONCLUSION Because paediatric musculoskeletal injuries vary with the type of blast injury and severe trauma can occur in children due to blast effects, radiologists who triage mass injuries should understand the effects of blast injury patterns and the spectrum of injury.
Article
Hollow viscous injury and mesenteric vascular injury after a blunt trauma abdomen although may be third most common injury , occurs only in 3 to 5 % of patients making it a rare entity. Significant mesentric injury includes disruption of mesenteric, active mesenteric bleeding, and mesenteric injury leading to gangrenous bowel.A 56 year old male was brought to the emergency room with history of road traffic accident with no external injuries.On presentation his vitals were stable , examination of abdomen revealed tense abdomen with guarding and rigidity. Given the hemodynamic stability of the patient CT scan of abdomen was done which revealed intraperitoneal free fluid , normal solid organs, abnormal bowel wall enhancement with extraluminal air pockets.Patient underwent emergency laparotomy to find out a massive hemoperitoneum with long segment gangrenous illeal bowel loop. Gangrenous bowel segment was resected and double barrel ileostomy was fashioned. The mechanism of injury involved is either direct compression forces or shearing and deceleration forces in Blunt trauma abdomen.Undiagnosed mesenteric injuries are associated with high morbidity and mortality rates due to life-threatening haemorrhage from disruption of mesenteric vessels, bowel infarction and peritonitis . This can be avoided by using imaging investigations af earliest and emergency surgical intervention.
Chapter
Abdominopelvic computed tomography (CT) following life-saving damage control surgery (DCS) for trauma is becoming more common in the modern trauma center. Multisystem internal injuries, as well as the postoperative appearance of the peritoneal cavity, organs, bowel, and soft tissues, create a very complex and confusing picture for the interpreting radiologist. Therefore, the knowledge of DCS maneuvers and the process of damage control resuscitation (DCR) in the setting of hypothermia, acidosis, and coagulopathy are important to allow for more accurate and meaningful interpretation. Unexpected injuries are commonly encountered on post-DCS CT, thus rapid diagnosis and communication of these are essential as they may necessitate urgent, unplanned re-intervention. In this chapter, damage control surgery will be described, with special attention to details which are important for the radiologist to know during interpretation. Expected postoperative findings on CT will be reviewed, and special emphasis will be made on frequently encountered unexpected findings on post-DCS CT.
Chapter
The Focused Assessment with Sonography in Trauma (FAST) exam is performed to identify the presence of pathological fluid in the chest, abdomen, or pelvis of the trauma patient with blunt or penetrating injury to the torso. The FAST exam can be performed by any member of a trauma team during prehospital or in-hospital assessment. Paramedics, doctors in training, nurses and specialists in emergency medicine, critical care, and anesthesia can perform the FAST exam. This chapter aims to impart the necessary knowledge and skills required for clinicians to optimally and safely perform a FAST exam. This chapter describes the principles and techniques of the FAST exam, the various views obtained, and interpretation the images obtained. It also discusses tips on troubleshooting commonly encountered problems while performing the FAST exam. The basics of the FAST exam have been explicitly described for the new learner, laying a strong foundation for continued learning and progression into an advanced practitioner.KeywordsFASTFocused assessment with sonography in traumaFree fluidRUQ viewLUQ viewPelvic viewSubcostal viewHemoperitoneumPericardial effusionPneumothoraxLung pointBarcode sign
Article
Background In high-energy femoral shaft fractures (FSFs), ipsilateral femoral neck fractures (FNFs) can be missed by conventional trauma computed topography (CT) imaging, resulting in increased treatment costs and patient complications. Preliminary evidence suggests that a rapid, limited-sequence pelvis and hip magnetic resonance imaging (MRI) protocol can identify these occult fractures and be feasibly implemented in the trauma setting. This study aims to establish the economic break-even point for implementing such an MRI protocol in all high-energy FSFs. Methods We used an adapted break-even economic tool to determine whether the costs of a targeted MRI protocol can be offset by cost-savings achieved through prevention of missed fractures (thus avoiding prolonged admission and re-operation). Sensitivity analyses were performed to demonstrate reliability of the economic modelling across a range of assumptions. Results Assuming a baseline of FNFs missed on CT of 12%, an MRI cost of £129 and cost of treating each missed FNF of £2457.5, the equation yielded a break-even rate of 7% and absolute risk reduction (ARR) of 5%, indicating that for every 100 FSFs, MRI would need to diagnose 5 of the 12 missed FNF to be economically viable (number needed to treat (NNT)=20). Economic viability was maintained even at double the cost of MRI, while increasing the cost of treating each complication served to reduce the ARR further, increasing cost-savings. Conclusion A rapid, limited-sequence MRI protocol to exclude occult ipsilateral FNFs in all high-energy FSFs appears to be economically justified measure. Further research exploring the feasibility of such a protocol, as well as the role of intra-operative fluoroscopy in this context, is required.
Article
Objectives: Previous studies demonstrate that higher volume pediatric trauma centers (PTCs) offer improved outcomes. This study evaluated pediatric trauma volume and outcomes at an existing level I (L-I) adult and level II (L-II) PTC after the addition of a new children's hospital L-II PTC within a 2-mile radius, hypothesizing no difference in mortality and complications. Methods: A retrospective review of patients aged 14 years or younger presenting to a single adult L-I and L-II PTC was performed. Patients from 2015-2016 (PRE) were compared with patients from 2018-2019 (POST) for mortality and complications using bivariate analyses. Results: Compared with the PRE cohort, there were less patients in the POST cohort (277 vs 373). Patients in the POST cohort had higher rates of insurance coverage (91.3% vs 78.8%, P < 0.001), self-transportation (7.2% vs 2.7%, P < 0.01), and hospital admission (72.6% and 46.1%, P < 0.001). There was no difference in all complications and mortality (all P > 0.05) between the 2 cohorts. Conclusions: After opening a second L-II PTC within a 2-mile radius, there was an increase in the rate of admissions and self-transportation to the preexisting L-II PTC. Despite a nearly 26% decrease in pediatric trauma volume, there was no difference in length of stay, hospital complications, or mortality.
Article
Objectives: Computed tomography (CT) utilization is widespread in contemporary Emergency Departments (EDs). CT overuse leads to radiation exposure, contrast toxicity, overdiagnosis, and incidental findings. This study explores the prevalence of clinically significant injuries in patients identified as low-risk trauma patients (LRTPs) using newly created criteria that account for the patient's age, trauma mechanism, assessability (which relies on level of consciousness, intoxication, and neurologic deficits), vital signs and other evidence of hypoperfusion, bleeding risk, and past medical history. Methods: This was a 6-month retrospective chart review of all LRTPs presenting to a level 1 trauma center in Queens, New York. Data abstraction was performed independently by two abstractors and discrepancies adjudicated by the senior author. Patients were identified using the hospital trauma registry and two reports, created by the researchers, identifying selected chief complaints and discharge diagnoses. Results: 750 patients were identified of which 352 (46.93%) received one or more CT scans. There were a total of 790 CT scans ordered, of which 731 (92.53%) were negative for acute injury. There were 13 clinically significant injuries of which only one (0.13%) required immediate intervention. There were no mortalities in this LRTP group. Conclusion: The prevalence of clinically significant injuries in this population is very low and injuries requiring immediate intervention are even lower. CT utilization in LRTPs should be guided by an explicit consideration of benefit and harm for each patient.
Article
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Concerns have been raised over alleged overuse of CT scanning and inappropriate selection of scanning methods, all of which expose patients to unnecessary radiation. Thus, it is important to identify clinical situations in which techniques with lower radiation dose such as plain radiography or no radiation such as MRI and occasionally ultrasonography can be chosen over CT scanning. This article proposes the arguments for radiation dose reduction in CT scanning of the chest and discusses recommended practices and studies that address means of reducing radiation exposure associated with CT scanning of the chest.
Article
OBJECTIVE. The purpose of this study was to evaluate the efficacy of sonography in our algorithm when differentiating patients with blunt abdominal trauma who need immediate surgery from patients who would benefit from further diagnostic workup or who need no treatment. SUBJECTS AND METHODS. We performed abdominal sonography as the primary screening tool in 1671 consecutive patients in our prospective study. Radiologists performed sonography in the trauma room within minutes of the arrival of each patient. Hemodynamic instability in conjunction with positive sonographic findings led to emergency laparotomy, Otherwise, positive sonographic findings warranted additional diagnostic tests. Observing free fluid or organ injury caused us to categorize sonographic findings as positive. RESULTS. Sonography correctly identified all patients requiring emergency laparotomy. No inconclusive laparotomies were performed in this group. The sensitivity of sonography for revealing intraabdominal injury was 88%, the specificity was 100%, and the accuracy was 99%. In 132 patients (8%), abdominal CT was performed. CT revealed relevant posttraumatic abnormalities in 61% of all patients. Four hundred seventy patients with negative sonographic findings were discharged approximately 12 hr after admission; two of these patients (0.4%) were mistakenly discharged. Trauma scores did not influence the efficacy of sonography. CONCLUSION. Our algorithm that uses sonography as the primary diagnostic tool provides accurate, fast, cost-effective, and noninvasive initial management of patients with blunt abdominal trauma. Our test characteristics were excellent indicators of the need for emergency laparotomy. Sonography also achieves high values in revealing relevant injury. Our algorithm produced medically satisfactory and economically prudent management of patients with blunt abdominal trauma.
The purpose of this study was to attempt to identify those blunt trauma patients in whom expensive diagnostic studies such as computed tomography and diagnostic peritoneal lavage are unnecessary to exclude intra-abdominal injury. The medical records of 1096 blunt trauma patients evaluated at an urban level I trauma center were reviewed. Because of the urgent need to exclude intra-abdominal hemorrhage in patients with hypotension (blood pressure < 90 mm Hg), and the difficulty in obtaining reliable information from abdominal examination in patients with Glasgow Coma Scale scores < 11 or spinal cord injury, 140 patients meeting these criteria were reviewed but excluded from statistical analysis. Six groups of major associated injuries felt to be potential risk factors for the prediction of intra-abdominal injury were analyzed in the 956 remaining patients. Only two of these potential risk factors, namely chest injury (p = 0.0001) and gross hematuria (p = 0.0003) attained statistical significance. All of the 44 significant intra-abdominal injuries occurred in the group of 253 patients that had either an abnormal abdominal examination, one of the statistically significant risk factors, or both, for a sensitivity of 100%. Of the 703 patients with a normal abdominal examination and no risk factors, none had a significant abdominal injury, for a negative predictive value of 100%. This study suggests that patients with either an abnormal abdominal examination or one of the two statistically derived risk factors require adjunctive diagnostic evaluation with diagnostic peritoneal lavage or computed tomography scan to exclude intra-abdominal injury. Conversely, the incidence of significant intra-abdominal injury in patients with both a normal abdominal examination and no risk factors is negligible and this group, which accounted for 65% of all blunt trauma patients, may not require adjunctive diagnostic tests.
Article
Hypothesis Controversy exists regarding the use of diagnostic peritoneal lavage (DPL) vs computed tomography (CT) in the evaluation of blunt abdominal trauma. It has been suggested that one role for DPL is to diagnose bowel injuries in hemodynamically stable patients with an unreliable abdominal examination result. Our hypothesis is that CT is specific and sensitive for diagnosing hollow viscus injuries and is therefore an appropriate diagnostic modality in the hemodynamically stable blunt trauma patient with an unreliable abdominal examination result due to a depressed level of consciousness. Design Retrospective consecutive case review. Setting An urban level II trauma center. Patients The medical records of 1388 consecutive patients admitted between January 1, 1991, and December 31, 2000, were reviewed. Inclusion criteria included blunt trauma patients who were hemodynamically stable (defined as a systolic blood pressure >90 mm Hg) with unreliable abdominal examination results secondary to a depressed level of consciousness (Glasgow Coma Scale score <11). Main Outcome Measures Hollow viscus injury diagnosed by CT and missed diagnosis of hollow viscus injury by CT. Results Of 1388 patients who met entry criteria, 87 had hollow viscus injuries; CT identified 85 of these injuries. Computed tomography diagnosed intestinal injury with a sensitivity of 97.7%, specificity of 98.5%, and an overall accuracy of 99.4%. Conclusion At our institution, CT is a reliable and accurate diagnostic modality when used to evaluate hollow viscus injuries in the hemodynamically stable blunt trauma patient with an unreliable abdominal examination result due to a depressed level of consciousness.
Article
Background The indications and method of evaluation of the mediastinum in blunt deceleration trauma are controversial and vary among centers. Most centers practice a policy of angiographic evaluation only in the presence of an abnormal mediastinum on chest radiography. Routine aortography in the absence of any mediastinal abnormality is not widely practiced. Helical computed tomographic (CT) scan has been successfully used in recent studies in the evaluation of the thoracic aorta.Objective To determine the role of routine helical CT scan evaluation of the mediastinum in patients involved in high-speed deceleration injuries, irrespective of chest radiographic findings.Design A prospective study over a 1-year period. Included in the study were patients with high-speed deceleration injuries who required CT evaluation of the head or abdomen. This group of patients underwent routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings.Setting Large, urban, academic level I trauma center.Results A total of 112 trauma patients fulfilled the criteria for study inclusion. Overall, there were 9 patients (8.0%) with aortic rupture. Four (44.4%) of these patients had a normal mediastinum on the initial chest x-ray film and the diagnosis was made by CT scan. The CT scan was diagnostic in 8 of the aortic ruptures (intimal tear or pseudoaneurysm) and was suggestive of aortic injury but not diagnostic in 1 patient with brachiocephalic artery injury. In 42 patients (37.5%), there was a widened mediastinum: an aortic rupture was diagnosed in 5 of them (11.9%) and a spinal fracture in 9 (21.4%). One patient had both aortic rupture and spinal injury.Conclusions The incidence of aortic injury in patients with high-speed deceleration injury is high. A significant proportion of patients with aortic injury have a normal mediastinum on the initial chest radiograph. There is a high incidence of spinal injuries in the presence of a widened mediastinum. We recommend that all trauma patients with high-risk deceleration injuries undergo routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings.
Objectives: Hospitalization for observation is the current standard of practice for patients who have sustained blunt abdominal trauma and who do not require emergent operation, despite having undergone diagnostic studies that exclude the presence of an intra-abdominal injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that hospitalization will allow for the prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. The focus of this study was to determine whether hospitalization for observation is necessary after a negative diagnostic evaluation after blunt abdominal trauma, to determine the negative predictive value of abdominal computed tomographic (CT) scanning in a prospective series of patients, and to identify which patients can be safely released from the emergency department without observation or hospitalization after blunt abdominal trauma. Methods: In a prospective, multi-institutional study over 22 months at four Level I trauma centers, all patients with blunt abdominal trauma suspected by either physical examination or mechanism of injury were evaluated using the following protocol: physical examination in the emergency department, followed by abdominal CT scanning, followed by hospitalization for observation. The standardized physical examination was repeated between 4 and 8 hours. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, the need for celiotomy, and mortality. Other data collected included demographics, mechanism of injury, and findings on physical examination and abdominal CT scanning. Results: Three thousand eight hundred twenty-two consecutive patients with suspected abdominal trauma presented to the four trauma centers. Two thousand seven hundred seventy-four of these met study eligibility criteria and were prospectively enrolled. Of these, 2299 fulfilled the entire study protocol. CT scan was negative in 1,809 patients, positive for organ injury or abdominal fluid in 389 patients, and nondiagnostic in 78 patients. Abdominal tenderness or bruising was present in 1,380 patients (61%), but only 22% had a positive CT scan. Nineteen percent of patients with a positive CT scan had no tenderness. Computed tomography detected 22 of the 25 blunt intestinal injuries in this series. Free intraperitoneal fluid without solid visceral injury was present in 90 patients, and but only 7 patients had intestinal injuries. There were nine celiotomies in patients whose CT scan was initially interpreted as negative: six were therapeutic (intestine in three, bladder in one, kidney in one, and diaphragm in one), two were nontherapeutic, and one was negative. The negative predictive power of an abdominal CT scan based on the preliminary reading and as defined by the subsequent need for a celiotomy in the population fully satisfying the protocol was 99.63% (lower 95 and 99% confidence bounds of 99.31 and 99.16%, respectively). Conclusion: These data indicate that abdominal tenderness is not predictive of an abdominal injury and that patients with a negative CT scan after suspected blunt abdominal trauma do not benefit from hospital admission and prolonged observation.
Article
Background: Early generation scanners have demonstrated poor sensitivity detecting blunt bowel/mesenteric injuries (BBMI). This study was aimed at determining the accuracy and role of helical scanners in BBMI. Methods: Retrospective chart review of patients with BBMI, or computed tomographic scans suspicious of BBMI, from August of 1995 to December of 1998. Results: One hundred of 8,112 scans (1.2%) were suspicious of BBMI, Of these suspicious scans, 53 patients had BBMI (true positive-TP) and 47 patients did not (false positive-FP). Seven patients with negative scans had BBMI (false negative-FN). Computed tomography contributed toward early surgery in 77% of patients who may have been delayed. Six patients developed intra-abdominal abscess. The abscess group had a significantly longer time interval from injury to surgery. Multiple findings were seen in 57% of true positive scans, whereas in 13% of false positive scans (p < 0.0001), An algorithm for management of BBMI is presented. Conclusion: Helical scanners have high accuracy in detecting BBMI, Single versus multiple findings are useful in managing these injuries.
Article
While most conscious patients with severe intraabdominal injuries (IAI) will usually present with either abdominal pain or tenderness, there is a small group of awake and alert patients in whom the physical examination will be falsely negative because of the presence of associated extraabdominal ("distracting") injuries. We sought to define the types of extraabdominal injuries that could lead to a false negative physical examination for potentially severe IAI in adult victims of blunt trauma. This study was prospectively performed on consecutive blunt trauma patients over a 14-month period in our level I trauma center. Inclusion criteria were as follows: (1) Glasgow Coma Scale score of 15; (2) age 18 years or older; and (3) computed tomography (CT) of the abdomen or diagnostic peritoneal lavage (DPL) performed regardless of initial physical examination findings. Patients were questioned specifically about the presence of abdominal pain and the initial abdominal examination was documented in addition to other extraabdominal injuries. Abdominal injuries were considered to be present based upon either abdominal CT findings or a positive DPL. Patients with and without abdominal pain or tenderness were compared for the presence of IAI. A total of 350 patients were enrolled. There were 142 patients with neither abdominal pain nor tenderness (group 1) and 208 patients with either or both (group 2). Ten of the 142 patients (7.0%) in group 1 had IAI compared with 44 of the 208 patients (21.2%) in group 2 (P = .0003). Presence of pain and/or tenderness had a sensitivity of 82%, a specificity of 45%, a positive predictive value of 21%, and negative predictive value of 93%. All 10 patients in group 1, and 36 of the 44 group 2 patients, had associated extraabdominal injuries. Although the presence of abdominal pain or tenderness was associated with a significantly higher incidence of IAI, the lack of these findings did not preclude IAI.
Article
Hospitalization for observation is the current standard of practice for patients who have sustained blunt abdominal trauma and who do not require emergent operation, despite having undergone diagnostic studies that exclude the presence of an intra-abdominal injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that hospitalization will allow for the prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. The focus of this study was to determine whether hospitalization for observation is necessary after a negative diagnostic evaluation after blunt abdominal trauma, to determine the negative predictive value of abdominal computed tomographic (CT) scanning in a prospective series of patients, and to identify which patients can be safely released from the emergency department without observation or hospitalization after blunt abdominal trauma. In a prospective, multi-institutional study over 22 months at four Level I trauma centers, all patients with blunt abdominal trauma suspected by either physical examination or mechanism of injury were evaluated using the following protocol: physical examination in the emergency department, followed by abdominal CT scanning, followed by hospitalization for observation. The standardized physical examination was repeated between 4 and 8 hours. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, the need for celiotomy, and mortality. Other data collected included demographics, mechanism of injury, and findings on physical examination and abdominal CT scanning. Three thousand eight hundred twenty-two consecutive patients with suspected abdominal trauma presented to the four trauma centers. Two thousand seven hundred seventy-four of these met study eligibility criteria and were prospectively enrolled. Of these, 2299 fulfilled the entire study protocol. CT scan was negative in 1,809 patients, positive for organ injury or abdominal fluid in 389 patients, and nondiagnostic in 78 patients. Abdominal tenderness or bruising was present in 1,380 patients (61%), but only 22% had a positive CT scan. Nineteen percent of patients with a positive CT scan had no tenderness. Computed tomography detected 22 of the 25 blunt intestinal injuries in this series. Free intraperitoneal fluid without solid visceral injury was present in 90 patients, and but only 7 patients had intestinal injuries. There were nine celiotomies in patients whose CT scan was initially interpreted as negative: six were therapeutic (intestine in three, bladder in one, kidney in one, and diaphragm in one), two were nontherapeutic, and one was negative. The negative predictive power of an abdominal CT scan based on the preliminary reading and as defined by the subsequent need for a celiotomy in the population fully satisfying the protocol was 99.63% (lower 95 and 99% confidence bounds of 99.31 and 99.16%, respectively). These data indicate that abdominal tenderness is not predictive of an abdominal injury and that patients with a negative CT scan after suspected blunt abdominal trauma do not benefit from hospital admission and prolonged observation.
Article
The accuracy of diagnostic peritoneal lavage is compared to that of initial clinical evaluation in 46 pediatric patients with blunt abdominal trauma. The peritoneal lavage accuracy was 97.8%; the clinical accuracy was 71%. The use of a specially prepared 14-gauge trocar has made this technique safe for even very small children. The reliability and safety of diagnostic peritoneal lavage in this as well as in other series suggests that nonoperative or expectant treatment of the patient with blunt abdominal trauma can be safely substituted when peritoneal lavage is negative.
Article
This study undertook to determine the yield of abdominal CT scans ordered only because the patient's sensorium was decreased or general anesthesia was planned. The abdominal CT scans and hospital charts of 191 consecutive patients examined following blunt trauma were reviewed with respect to clinical indications prompting the study. In 143, some clinical or laboratory justification was in evidence. In this group, 55 patients (38.5%) were found to have trauma-related pathology at CT scan. In 48 patients, no clinical or laboratory suggestion of abdominal pathology was evident. Instead, the primary indications for ordering the CT scan were decreased sensorium (28 cases), the planning of general anesthesia for orthopedic procedures (8 cases), and a variety of non-abdominal-trauma-related reasons. In this group, only a single positive finding was identified (small pneumothorax), and in no case was the clinical course altered by findings at abdominal CT scan. Performance of abdominal CT scans without clinical or laboratory evidence of trauma, merely because of decreased patient sensorium or prophylactically prior to general anesthesia for non-abdomen-related surgery, is an extremely low yield study and should be discouraged. In the current study, no significant abdominal pathology would have been overlooked by omission of such scans. Similar findings have been reported in children. To our knowledge, this is the first such report in a largely adult population.
Article
To determine the utility of serum glutamic oxaloacetic transaminase (SGOT) and serum glutamic pyruvic transaminase (SGPT) in predicting intra-abdominal injury in blunt trauma patients. Descriptive review of 309 blunt trauma admissions during study period. A 1,000-bed Level I trauma center in a major metropolitan area. Consecutive adult blunt trauma admissions to the trauma service. Serum levels of study enzymes were measured at initial evaluation and subsequent hospitalization. Results of all intra-abdominal evaluations were recorded. Significantly greater numbers of patients with SGOT and/or SGPT elevated to more than 130 IU/L had associated intra-abdominal injuries as compared with patients with enzyme elevations of less than 130 IU/L (52% versus 8%). All 18 patients with liver injuries had one or both enzymes elevated to more than 130 IU/L. Higher enzyme levels were more frequently associated with liver injury. Elevation of serum levels of the study enzymes is a marker for intra-abdominal injury. Levels in excess of 130 IU/L are relative indicators of abdominal computed tomography scan. Levels of less than 130 IU/L are unlikely to be associated with liver injury.
Article
• The initial physical examination is frequently unreliable in identifying patients with blunt trauma at high risk for having serious intra-abdominal injury. Intra-abdominal injury may be associated with specific injuries or risk factors, but the usefulness of such objective clinical criteria in predicting intra-abdominal injury has not previously been determined. The presence or absence of each of 11 clinical indicators and their association with serious intra-abdominal injury were analyzed in 3223 patients with blunt trauma. Linear and logistic regressions were used to determine which factors were significant predictors of an increased probability of intra-abdominal injury. Arterial base deficit less than −3 mEq/L, major chest injury, hypotension, and pelvic fractures were found to significantly increase the chance of intra-abdominal injury. Early diagnostic evaluation of the abdomen using diagnostic peritoneal lavage or computed tomography should be strongly considered in patients with blunt trauma who present with these associated factors. (Arch Surg. 1989;124:809-813)
Article
Physical examination may be unreliable in the evaluation of children with blunt abdominal trauma particularly in those with associated major head injuries. In the absence of obvious clinical signs or physical findings of intraabdominal injury, the usefulness of abdominal computed tomography in children is controversial. To test the efficacy of CT scans, a 12-month prospective study of computed tomography for the initial assessment of children with blunt abdominal trauma and major head injuries was carried out. Of 320 pediatric trauma admissions to our regional trauma center, 65 consecutive patients with Glasgow Coma Scores less than ten were managed with sequential head and abdominal computed tomography in the emergency room for (1) closed head injury and (2) suspected abdominal trauma. Fifteen patients (23%) were found to have significant intraabdominal injury. Only two required operative intervention. No patients died as a result of the abdominal injuries. In children with significant head trauma and suspected abdominal trauma, combined head and abdominal CT proved to be reliable.
Article
The accuracy of initial physical examination and peritoneal lavage in detecting intra-abdominal injury was assessed in 221 consecutive blunt trauma victims. Of the patients, 121 had negative peritoneal lavages, with one false result, and 100 had positive peritoneal lavages, including six false results and two injuries not requiring surgical correction. Hemoperitoneum occurred in 32 of 71 patients with a depressed sensorium and in 29 of 54 patients with thoracic injury. Twenty-eight of 120 patients with absent bowel tones and 20 of 100 patients with abdominal guarding or rigidity had negative peritoneal lavages. Among the 150 conscious, responsive patients there was a high incidence of false-positive and false-negative abdominal findings on physical examination. Hemoperitoneum was detected in four clinically negative patients. Significant error accompanies the initial abdominal examination and clinical assessment in the blunt trauma victim. In contract, open diagnostic peritoneal lavage is a sensitive and highly accurate test for blunt intraperitoneal injury. We believe peritoneal lavage is the single best test for intra-abdominal injury and should be performed in th majority of patients with such injuries.
Article
Radiographic evaluation of the upper cervical spine in patients who have suffered severe trauma is often problematic because of the difficulty of obtaining adequate open-mouth views of the odontoid in these critically ill patients. This study was undertaken to determine the frequency and clinical significance of upper cervical spine fractures detected by CT in this patient population. The study group consisted of 100 consecutive patients brought to the emergency department after severe trauma who had CT of the craniocervical junction done instead of an open-mouth view. Plain film evaluation consisted of a cross-table lateral view, an anteroposterior view, and, if necessary, a swimmer's view. The radiographic studies were reviewed retrospectively by a musculoskeletal radiologist and a neuroradiologist, respectively. Hospital records were reviewed to ascertain the patients' clinical signs and symptoms on admittance and to determine how identification of the fractures changed the treatment plan. Eight fractures in seven patients were identified with CT of the craniocervical junction. Three of the fractures were of the occipital condyle, and five were at the C1-C2 level. None of the fractures were seen directly on plain radiographs, although secondary signs of injury such as prevertebral soft-tissue swelling were seen in two of the seven cases. CT of the craniocervical junction revealed an 8% frequency of fractures of the occipital condyle and C1-C2 that were undetected on the cross-table lateral cervical spine radiographs. Fractures occurred in greater numbers than expected, and all surviving patients were stabilized with a halo. This experience shows that CT is an efficient method of evaluating patients in whom the standard open-mouth radiograph of the odontoid cannot be done.
Article
The use of computed tomography (CT) has helped revolutionize the process and accuracy of diagnosis of the trauma patient. We have noted a striking increase in the use of CT scanning early in the management of trauma patients at our trauma center and sought to assess our experience. All trauma patients admitted to our trauma center from February 1991 to February 1992 who received any CT scan within the first 12 hours after arrival were enrolled in the study. A positive (+) CT scan was defined as a scan that demonstrated a significant finding consistent with the injury and a negative (-) CT scan was one in which there were either no abnormalities or only incidental findings unrelated to the injury. Each patient was followed daily by one of the authors (A.G.R.). Patient records were reviewed and treating surgeons were interviewed to determine whether the CT scan improved the process of therapy. Morbidity incident to the performance of the CT scans was assessed. 1609 trauma patients underwent 2047 CT scans (1.3 CT scans per patient). Sixteen percent (n = 260) had scans of more than one part of the body. Thirty-eight percent (n = 770) of scans were positive but 29% (n = 225) of these were not helpful to the patient care process. Overall, 29% of scans, either because they were positive or negative, assisted in the clinical care of the patient. Six percent (n = 45) of CT scans were falsely positive. Sixty-five percent of scans were true negatives. Two patients died in the CT suite, 6 died shortly after completion of the scan, and 12 required emergency trips to the operating room from the CT suite. A large number of CT scans are being performed in our trauma patient population. Less than 30% contributed to patient management. Because of morbidity and cost, strict surgeon and radiologist oversight of CT for trauma is essential.
Article
It is now 21 years since the revolutionary imaging technique of computed tomography (CT) was introduced into clinical practice. In coming of age, CT has found increasing use in the diagnosis and assessment of cancer and other pathological conditions and has undoubtedly led to significant advances in patient care. As a measure of this success, perhaps, CT now represents a major source of exposure from diagnostic X-rays for the UK population. This importance was firmly established by a national survey relating to the 200 scanners in clinical use in 1989 (Shrimpton, 1992). Information on CT practice was provided by questionnaires completed by over 80% of National Health Service scanners (Shrimpton et al, 1991).
Article
Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrast-enhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with 'isolated' abdominal trauma (N = 23) or with fractures of lower ribs 7-12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected 'isolated' head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with 'isolated' head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7-12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with 'isolated' head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7-12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.
Article
A study was undertaken to determine the criteria for ordering abdominal computed tomography (CT) in the emergency department (ED) for stable patients who sustained blunt trauma and to identify a patient population at high risk for having intra-abdominal injury (IAI) utilizing physical examination, decrease in hematocrit, and hematuria. Patients in a university ED who had abdominal CT from April 1995 to October 1995 were evaluated prospectively. Before the scan, the examining physician completed an entry form that included physical findings, hematocrit, hematuria, Glasgow Coma Scale score, intoxication, distracting injuries, reasons for obtaining the scan, and planned disposition. Patients were followed until discharge. A total of 196 patients were evaluated. Abdominal tenderness was present in 120 patients. Twenty-two patients had IAI. Eight required surgical intervention, and all 8 had abdominal tenderness. A total of 40 potential trauma admissions were averted by obtaining CT within the ED. The combined abnormal abdomen examination and presence of hematuria had a sensitivity of 64%, specificity of 94%, positive predictive value of 56%, and negative predictive value of 95%. Decrease of > or = 5 in hematocrit was not statistically significant for detection of IAI. CT had no false negatives in this cohort. These results show that early CT scanning of stable patients who have sustained blunt trauma is an effective screen for IAI and may result in fewer total admissions, but has potential for overuse. Patients with abdominal pain and hematuria should be scanned. The benefit of a CT scan for patients without tenderness or with an isolated decrease in hematocrit is questionable.
Article
The indications and method of evaluation of the mediastinum in blunt deceleration trauma are controversial and vary among centers. Most centers practice a policy of angiographic evaluation only in the presence of an abnormal mediastinum on chest radiography. Routine aortography in the absence of any mediastinal abnormality is not widely practiced. Helical computed tomographic (CT) scan has been successfully used in recent studies in the evaluation of the thoracic aorta. To determine the role of routine helical CT scan evaluation of the mediastinum in patients involved in high-speed deceleration injuries, irrespective of chest radiographic findings. A prospective study over a 1-year period. Included in the study were patients with high-speed deceleration injuries who required CT evaluation of the head or abdomen. This group of patients underwent routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings. Large, urban, academic level I trauma center. A total of 112 trauma patients fulfilled the criteria for study inclusion. Overall, there were 9 patients (8.0%) with aortic rupture. Four (44.4%) of these patients had a normal mediastinum on the initial chest x-ray film and the diagnosis was made by CT scan. The CT scan was diagnostic in 8 of the aortic ruptures (intimal tear or pseudoaneurysm) and was suggestive of aortic injury but not diagnostic in 1 patient with brachiocephalic artery injury. In 42 patients (37.5%), there was a widened mediastinum: an aortic rupture was diagnosed in 5 of them (11.9%) and a spinal fracture in 9 (21.4%). One patient had both aortic rupture and spinal injury. The incidence of aortic injury in patients with high-speed deceleration injury is high. A significant proportion of patients with aortic injury have a normal mediastinum on the initial chest radiograph. There is a high incidence of spinal injuries in the presence of a widened mediastinum. We recommend that all trauma patients with high-risk deceleration injuries undergo routine helical CT evaluation of the mediastinum irrespective of chest radiographic findings.
Article
The purpose of this study was to evaluate the efficacy of sonography in our algorithm when differentiating patients with blunt abdominal trauma who need immediate surgery from patients who would benefit from further diagnostic workup or who need no treatment. We performed abdominal sonography as the primary screening tool in 1671 consecutive patients in our prospective study. Radiologists performed sonography in the trauma room within minutes of the arrival of each patient. Hemodynamic instability in conjunction with positive sonographic findings led to emergency laparotomy. Otherwise, positive sonographic findings warranted additional diagnostic tests. Observing free fluid or organ injury caused us to categorize sonographic findings as positive. Sonography correctly identified all patients requiring emergency laparotomy. No inconclusive laparotomies were performed in this group. The sensitivity of sonography for revealing intraabdominal injury was 88%, the specificity was 100%, and the accuracy was 99%. In 132 patients (8%), abdominal CT was performed. CT revealed relevant posttraumatic abnormalities in 61% of all patients. Four hundred seventy patients with negative sonographic findings were discharged approximately 12 hr after admission; two of these patients (0.4%) were mistakenly discharged. Trauma scores did not influence the efficacy of sonography. Our algorithm that uses sonography as the primary diagnostic tool provides accurate, fast, cost-effective, and noninvasive initial management of patients with blunt abdominal trauma. Our test characteristics were excellent indicators of the need for emergency laparotomy. Sonography also achieves high values in revealing relevant injury. Our algorithm produced medically satisfactory and economically prudent management of patients with blunt abdominal trauma.
Article
To determine the negative predictive value of cranial computed tomography (CT) scanning in a prospective series of patients and whether hospital admission for observation is mandatory after a negative diagnostic evaluation after minimal head injury (MHI). Hospital admission for observation is a current standard of practice for patients who have sustained MHI, despite having undergone diagnostic studies that exclude the presence of an intracranial injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that admission will allow prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. In a prospective, multiinstitutional study during a 22-month period at four level I trauma centers, all patients with MHI were evaluated using the following protocol: a standardized physical and neurologic examination in the emergency department, cranial CT scanning, and then admission for observation. MHI was defined as either a documented loss of consciousness or evidence of posttraumatic amnesia and an emergency department Glasgow Coma Scale score of 14 or 15. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, need for craniotomy, and death. Two thousand one hundred fifty-two consecutive patients fulfilled the study protocol. The CT was interpreted as negative for intracranial injury in 1,788, positive in 217, and equivocal in 119. Five patients with CT scans initially interpreted as negative required intervention. There was one craniotomy in a patient whose CT scan was initially interpreted as negative. This patient had facial fractures that required surgical intervention and elevation of depressed intracranial fracture fragments. The negative predictive power of a cranial CT scan based on the preliminary reading of the CT scan and defined by the subsequent need for neurosurgical intervention in the population fully satisfying the protocol was 99.70%. Patients with a cranial CT scan, obtained on a helical CT scanner, that shows no intracerebral injury and who do not have other body system injuries or a persistence of any neurologic finding can be safely discharged from the emergency department without a period of either inpatient or outpatient observation. Implementation of this practice could result in a potential decrease of more than 500,000 hospital admissions annually.
Article
Early generation scanners have demonstrated poor sensitivity detecting blunt bowel/mesenteric injuries (BBMI). This study was aimed at determining the accuracy and role of helical scanners in BBMI. Retrospective chart review of patients with BBMI, or computed tomographic scans suspicious of BBMI, from August of 1995 to December of 1998. One hundred of 8,112 scans (1.2%) were suspicious of BBMI. Of these suspicious scans, 53 patients had BBMI (true positive-TP) and 47 patients did not (false positive-FP). Seven patients with negative scans had BBMI (false negative-FN). Computed tomography contributed toward early surgery in 77% of patients who may have been delayed. Six patients developed intra-abdominal abscess. The abscess group had a significantly longer time interval from injury to surgery. Multiple findings were seen in 57% of true positive scans, whereas in 13% of false positive scans (p < 0.0001). An algorithm for management of BBMI is presented. Helical scanners have high accuracy in detecting BBMI. Single versus multiple findings are useful in managing these injuries.
Article
To evaluate the necessity of abdominal screening beyond physical examination in awake and alert blunt trauma patients who require emergent extra-abdominal trauma surgery. Data from an urban Level I trauma center was reviewed for all blunt trauma patients who underwent extra-abdominal emergency procedures during the period from January 1995 through August 1998. Awake and alert patients (Glasgow Coma Scale [GCS] score > or = 14) with negative abdominal physical examination results who underwent extra-abdominal emergent surgery were entered in the study. All patients entered were older than 14 years of age, hemodynamically stable, and underwent further abdominal evaluation with computed tomographic scan or diagnostic peritoneal lavage after the decision for extra-abdominal surgical intervention. Emergent surgery occurred within 8 hours of admission. Data was collected for results of diagnostic studies, hemodynamic status, mechanism of injury, indications for operative intervention, and admission blood ethanol (EtOH) levels. A total of 210 patients with an average age of 33 years (range, 14-92 years) were entered in the study. The most common mechanism of injury was motor vehicle crash (67%). Sixty-six (32%) patients presented with EtOH levels > 100 mg/dL; 181 (86%) patients presented with a GCS score of 15, and 29 (14%) presented with a GCS score of 14. The majority of surgical procedures were orthopedic (86%). Diagnostic peritoneal lavage was performed in 55 (26%) patients, and computed tomographic scans were obtained in 155 (74%) patients. Three (1.4%) intraperitoneal injuries were diagnosed in the study population. Two of the injuries were stable grade 1 liver injuries, and missed diaphragmatic injury was diagnosed on postadmission day 1. Before emergent extra-abdominal trauma surgery, abdominal evaluation with physical examination is sufficient to identify surgically significant abdominal injury in the awake and alert blunt trauma patient. Screening with additional studies does not impact patient outcome.
Article
A major cause of morbidity and mortality after blunt chest trauma remains undetected injuries. This study evaluates the role of routine computed tomographic (CT) scan. We studied 93 consecutive patients from January 1999 to July 2000: 73 (76.3%) after motor vehicle crash with crash speed > 10 mph, and 22 (23.7%) after fall from height > 5 ft. Simultaneous with initial clinical evaluation, anteroposterior chest radiograph and helical chest CT scan were obtained for all patients. Sixty-eight patients (73.1%) showed at least one pathologic sign on chest radiograph, and 25 patients (26.9%) had normal chest radiograph. In 13 (52.0%) of these 25 patients, the CT scan showed multiple injuries; among these were two aortic lacerations, three pleural effusions, and one pericardial effusion. Over 50% of patients with normal initial chest radiograph showed multiple injuries on the CT scan, among which were also two (8%) potentially fatal aortic lesions. We therefore recommend primary routine chest CT scan in all patients with major chest trauma.
Article
Computed tomography (CT) is used liberally in the evaluation of pediatric trauma, even of low or moderate severity, because clinical examination of pediatric patients is considered unreliable. Appropriate utilization of valuable resources is essential in a cost-conscious medical era. The objective of this study is to determine if children with mild to moderate trauma are evaluated by more CT scans than adults with injuries of similar severity. Altogether, 108 pediatric patients less than 7 years old were matched according to mechanism of injury, Injury Severity Score (ISS), and the six individual body-region Abbreviated Injury Scores with adult patients admitted over the same 2-year period. All these patients had mild or moderate injuries (mean ISS 3.3 +/- 3.4). Pediatric patients had significantly more CT scans than adults, mostly because of a more liberal use of abdominal CT. CT scans of multiple body areas on the same patient were used more frequently in children but failed to identify more injuries compared to adults. None of the pediatric patients required an operation for abnormalities identified by CT. No differences were observed in morbidity, mortality, length of hospital stay, or length of intensive care unit stay for the two groups. It was concluded that a liberal policy of CT scanning for pediatric patients with a low ISS leads to increased resource consumption with no obvious diagnostic or treatment benefit.
Article
Patients at risk for thoracolumbar junction (TLJ) and lumbar spine (LS) injury after blunt trauma are classically evaluated using conventional radiographs. Frequently, these patients also undergo abdominal and pelvic computed tomographic (CT) scanning to exclude the presence of associated intra-abdominal injuries. Standard abdominal and pelvic CT scan usually includes an anteroposterior (AP) scout film (scanogram) obtained before the cross-sectional imaging. The objective of this study was to determine whether a lateral CT scanogram and axial CT views would provide adequate imaging to allow for evaluation of the TLJ and LS and therefore eliminate the need for conventional screening computed lumbar spine radiographs (CLSRs). Patients who sustained blunt injury and required both CLSRs as well as abdominal and pelvic CT scans were prospectively identified. The study protocol (CT + S) added lateral CT scanograms to all helical abdominal and pelvic CT scan studies. The AP and lateral CT scanograms were included with the axial images, and these views were reviewed together during final radiographic interpretation and diagnosis. The results of CT + S were compared with readings of the CLSRs (AP and lateral) in a blinded fashion by a trauma radiologist. Lateral scanograms were generated for 71 patients. All scanograms were technically adequate, with image quality equal or superior to computed plain radiographs. Ten patients were found to have 20 fractures, 19 acute and 1 chronic. All abnormalities identified by plain radiographs were seen using CT + S (sensitivity, 100%; specificity, 100%). Eight transverse process and two spinous process fractures not seen on CLSRs were identified using CT + S. Our CT + S protocol (axial CT images plus AP and lateral scanograms) outperformed screening CLSRs in the detection of fractures of the lower spine (TLJ + LS) after blunt trauma. In addition, scanogram imaging is less dependent on body habitus and adds no additional cost or time to abdominal and pelvic CT scanning. Further study is required to determine whether CT + S can routinely replace conventional radiographs of the lower spine after blunt trauma.
Article
An anteroposterior pelvic radiograph (PXR) continues to be recommended by Advanced Trauma Life Support protocol as an early diagnostic adjunct in the resuscitation of blunt trauma patients. At the same time, computed tomographic (CT) scanning has become a practice standard for diagnosis of most abdominal and pelvic injury. The objective of this study was to determine the necessity of obtaining an early PXR in stable trauma patients who will undergo CT scanning during the initial resuscitation. A retrospective review of all blunt trauma patients undergoing immediate abdomen and pelvic CT scanning was performed from July 2000 until June 2001 at an urban Level I trauma center. These patients were divided into two groups depending on whether they also received a PXR (group I) or not (group II). At the time of the study, there was no formal protocol to determine which patients underwent pelvic radiography. Radiology reports of all PXRs and CT scans were reviewed. Patient demographics and Injury Severity Scores (ISSs) were abstracted from our trauma registry. The data were analyzed using Student's test. A total of 686 patients with blunt trauma underwent CT scanning of the abdomen and pelvis. Group I consisted of 311 (45%) patients with an average ISS of 12.3 +/- 0.7. In group I, 56 (10%) patients were found to have at least one pelvic fracture on CT scan, 38 of which were also identified on the PXR. Defining CT scanning as the definitive test, the sensitivity and specificity of the PXR in group I was 68% and 98%, respectively. The false-negative rate for pelvic radiography was 32%. In all patients with a positive PXR, the majority (55%) had either additional fractures or an increase in the Young and Burgess grade of fracture diagnosed on CT scan. Group II consisted of 375 patients, with 16 fractures noted in 13 (3%) patients, none of which required treatment. The mean ISS of group II was 8.0 +/- 0.5. The PXR has limited sensitivity for detecting pelvic fractures compared with CT scanning. Selected hemodynamically stable patients who undergo CT scanning during their immediate resuscitation do not need a routine PXR. The PXR may continue to be beneficial in unstable patients, those with positive physical findings, or those who cannot undergo CT scanning because of other clinical priorities.
Article
Blunt SBI is infrequent and its diagnosis may be difficult, especially in the face of confounding variables. The purpose of this study was to evaluate methods for making the diagnosis of blunt SBI. Patients with blunt small bowel injury (SBI) were identified from the registries of 95 trauma centers for a 2-year period (1998-1999). Patients with SBI (cases) were matched by age and Injury Severity Score with a blunt trauma patient receiving an abdominal workup who did not have SBI (controls). Logistic regression models were unable to differentiate SBI with perforation from SBI without perforation. Thirteen percent of patients with documented perforating SBI had normal abdominal computed tomographic scans preoperatively. Alone or in combination, current diagnostic approaches lack sensitivity in the diagnosis of perforated SBI. Improvements in diagnostic methods and approaches are needed to ensure the prompt diagnosis of this uncommon but potentially devastating injury.