The use of chest computed tomography versus chest X-ray in patients with major blunt trauma

Clinical Utility of Chest Computed Tomography in Patients with Rib Fractures CT Chest and Rib Fractures

Background

Chest CT is more sensitive than a chest X-ray (CXR) in diagnosing rib fractures; however, the clinical significance of these fractures remains unclear.

Objectives

The purpose of this study was to determine the added diagnostic use of chest CT performed after CXR in patients with either known or suspected rib fractures secondary to blunt trauma.

Methods

Retrospective cohort study of blunt trauma patients with rib fractures at a level I trauma center that had both a CXR and a CT chest. The CT finding of ≥ 3 additional fractures in patients with ≤ 3 rib fractures on CXR was considered clinically meaningful. Student’s t-test and chi-square analysis were used for comparison.

Results

We identified 499 patients with rib fractures: 93 (18.6%) had CXR only, 7 (1.4%) had chest CT only, and 399 (79.9%) had both CXR and chest CT. Among these 399 patients, a total of 1,969 rib fractures were identified: 1,467 (74.5%) were missed by CXR. The median number of additional fractures identified by CT was 3 (range, 4 - 15). Of 212 (53.1%) patients with a clinically meaningful increase in the number of fractures, 68 patients underwent one or more clinical interventions: 36 SICU admissions, 20 pain catheter placements, 23 epidural placements, and 3 SSRF. Additionally, 70 patients had a chest tube placed for retained hemothorax or occult pneumothorax. Overall, 138 patients (34.5%) had a change in clinical management based upon CT chest.

Conclusions

The chest X-ray missed ~75% of rib fractures seen on chest CT. Although patients with a clinical meaningful increase in the number of rib fractures were more likely to be admitted to the intensive care unit, there was no associated improvement in pulmonary outcomes.

Pulmonary contusion in the pan-scan era

BACKGROUND

Although pulmonary contusion (PC) is traditionally considered a major injury requiring intensive monitoring, more frequent detection by chest CT in blunt trauma evaluation may diagnose clinically irrelevant PC.

OBJECTIVES

We sought to determine (1) the frequency of PC diagnosis by chest CT versus chest X-ray (CXR), (2) the frequency of PC-associated thoracic injuries, and (3) PC patient clinical outcomes (mortality, length of stay [LOS], and need for mechanical ventilation), considering patients with PC seen on chest CT only (SOCTO) and isolated PC (PC without other thoracic injury).

METHODS

Focusing primarily on patients who had both CXR and chest CT, we conducted a pre-planned analysis of two prospectively enrolled cohorts with the following inclusion criteria: age >14 years, blunt trauma within 24h of emergency department presentation, and receiving CXR or chest CT during trauma evaluation. We defined PC and other thoracic injuries according to CT reports and followed patients through their hospital course to determine clinical outcomes.

RESULTS

Of 21,382 enrolled subjects, 8661 (40.5%) had both CXR and chest CT and 1012 (11.7%) of these had PC, making it the second most common injury after rib fracture. PC was SOCTO in 739 (73.0%). Most (73.5%) PC patients had other thoracic injury. PC patients had higher admission rates (91.9% versus 61.7%; mean difference 30.2%; 95% confidence interval [CI] 28.1-32.1%) and mortality (4.7% versus 2.0%: mean difference 2.8%; 95% CI 1.6-4.3%) than non-PC patients, but mortality was restricted to patients with other injuries (injury severity scores>10). Patients with PC SOCTO had low rates of associated mechanical ventilation (4.6%) and patients with isolated PC SOCTO had low mortality (2.6%), comparable to that of patients without PC.

CONCLUSIONS

PC is commonly diagnosed under current blunt trauma imaging protocols and most PC are SOCTO with other thoracic injury. Given that they are associated with low mortality and uncommon need for mechanical ventilation, isolated PC and PC SOCTO may be of limited clinical significance.

Chest X-rays in detecting injuries caused by blunt trauma

BACKGROUND

The appropriate sequence of different imagings and indications of thoracic computed tomography (TCT) in evaluating chest trauma have not yet been clarified at present. The current study was undertaken to determine the value of chest X-ray (CXR) in detecting chest injuries in patients with blunt trauma.

METHODS

A total of 447 patients with blunt thoracic trauma who had been admitted to the emergency department (ED) in the period of 2009-2013 were retrospectively reviewed. The patients met inclusion criteria (age>8 years, blunt injury to the chest, hemodynamically stable, and neurologically intact) and underwent both TCT and upright CXR in the ED. Radiological imagings were re-interpreted after they were collected from the hospital database by two skilled radiologists.

RESULTS

Of the 447 patients, 309 (69.1%) were male. The mean age of the 447 patients was 39.5±19.2 (range 9 and 87 years). 158 (35.3%) patients were injured in motor vehicle accidents (MVA). CXR showed the highest sensitivity in detecting clavicle fractures [95%CI 78.3 (63.6-89)] but the lowest in pneuomediastinum [95%CI 11.8 (1.5-36.4)]. The specificity of CXR was close to 100% in detecting a wide array of entities.

CONCLUSION

CXR remains to be the first choice in hemodynamically unstable patients with blunt chest trauma. Moreover, stable patients with normal CXR are candidates who should undergo TCT if significant injury has not been ruled out.

A decision tool for whole-body CT in major trauma that safely reduces unnecessary scanning and associated radiation risks: An initial exploratory analysis

BACKGROUND

Whole-body CT (WBCT) has become routine practice in the assessment of major trauma patients. Whilst this may be associated with increased survival, several studies report high rates of negative scans. As no national guideline exists, selection criteria for WBCT vary widely. This study aims to (1) produce a scoring system that improves patient selection for WBCT (2) quantify patient radiation doses and their concomitant risk of malignancy.

METHODS

Clinical notes were reviewed for all patients undergoing a WBCT for trauma over a 21-month period at a UK major trauma centre. Clinical and radiological findings were categorised according to body region. Univariate analysis was performed using Chi-squared testing, followed by multivariable logistic regression. Secondary regression analysis of patients with significant injuries that the model did not identify was performed. The model was optimised and used to develop a scoring system. Sensitivity and specificity were calculated using the same dataset as was used to derive the models. Radiation exposure was determined and the excess lifetime risk of malignancy calculated.

RESULTS

255 patients were included, with a mean age of 45 years. 16% of scans were positive for polytrauma, 42% demonstrated some injury and 42% showed no injury. The regression model identified independent predictors of polytrauma to be (1) clinical signs in more than one body region, (2) reduced Glasgow Coma Score, (3) haemodynamic abnormality, (4) respiratory abnormality, (5) mechanism of injury. The final model had a sensitivity of 95% (95% CI 86-99%) and specificity of 59% (95% CI 52-66%) for significant CT findings. Mean radiation exposure was 31.8 mSv, conferring a median excess malignancy risk of 1 in 474.

CONCLUSION

After including neurological deficit, our scoring system had a sensitivity of 97% (95% CI 88-99%) and specificity of 56% (95% CI 49-64%) for significant injury. We propose this is used to stratify the use of trauma radiographs, focused CT and WBCT for major trauma patients. Although not intended to replace clinical judgement, our scoring system adds an objective component to decision-making. We believe this will safely reduce the number of unnecessary CT scans performed on a relatively young cohort of patients.

[Importance of multidetector CT imaging in multiple trauma]

CLINICAL/METHODICAL ISSUE

Diagnostic imaging of complex multiple trauma remains a challenge for any department providing modern emergency radiology (ER) service. An early and comprehensive approach for ER imaging is crucial for a priority-oriented and timely therapy concept with the aim of identifying potentially life-threatening injuries early and initiating appropriate treatment.

STANDARD RADIOLOGICAL METHODS

The basic diagnostic approach still consists of focused ultrasound using focused assessment with sonography for trauma (FAST) and conventional radiography (CR), usually limited to a single supine chest x-ray for triaging patients undergoing immediate operations.

METHODICAL INNOVATIONS

Multidetector computed tomography (MDCT) has become established as early whole body CT (WBCT) as the undisputable diagnostic method. The detection rate of injuries by WBCT is outstanding and it improves the probability of survival by 20-25% compared with all other previous methods. At the same time, the spatial and temporal resolution of MDCT was improved resulting in considerably shortened examination times but WBCT is still associated with a significant radiation exposure, even in the acute single use setting. Using modern scanner and dose reduction technology, including iterative reconstruction, a dose reduction of up to 40% could be achieved. The substantial number of images in WBCT is another challenge; images must be processed priority-oriented, read and transferred to the picture archiving and communications system (PACS). For rapid diagnosis, volume image reading (VIR) offers additional options to keep the diagnostic process on time.

ACHIEVEMENTS/PRACTICAL RECOMMENDATIONS

Modern WBCT after multiple trauma is performed early, comprehensively and personalized so that WBCT improves the probability of survival by 20-25%.

Derivation and validation of two decision instruments for selective chest CT in blunt trauma: a multicenter prospective observational study (NEXUS Chest CT)

BACKGROUND

Unnecessary diagnostic imaging leads to higher costs, longer emergency department stays, and increased patient exposure to ionizing radiation. We sought to prospectively derive and validate two decision instruments (DIs) for selective chest computed tomography (CT) in adult blunt trauma patients.

METHODS AND FINDINGS

From September 2011 to May 2014, we prospectively enrolled blunt trauma patients over 14 y of age presenting to eight US, urban level 1 trauma centers in this observational study. During the derivation phase, physicians recorded the presence or absence of 14 clinical criteria before viewing chest imaging results. We determined injury outcomes by CT radiology readings and categorized injuries as major or minor according to an expert-panel-derived clinical classification scheme. We then employed recursive partitioning to derive two DIs: Chest CT-All maximized sensitivity for all injuries, and Chest CT-Major maximized sensitivity for only major thoracic injuries (while increasing specificity). In the validation phase, we employed similar methodology to prospectively test the performance of both DIs. We enrolled 11,477 patients-6,002 patients in the derivation phase and 5,475 patients in the validation phase. The derived Chest CT-All DI consisted of (1) abnormal chest X-ray, (2) rapid deceleration mechanism, (3) distracting injury, (4) chest wall tenderness, (5) sternal tenderness, (6) thoracic spine tenderness, and (7) scapular tenderness. The Chest CT-Major DI had the same criteria without rapid deceleration mechanism. In the validation phase, Chest CT-All had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 20.8% (95% CI 19.2%-22.4%), and a negative predictive value (NPV) of 99.8% (95% CI 98.9%-100%) for major injury, and a sensitivity of 95.4% (95% CI 93.6%-96.9%), a specificity of 25.5% (95% CI 23.5%-27.5%), and a NPV of 93.9% (95% CI 91.5%-95.8%) for either major or minor injury. Chest CT-Major had a sensitivity of 99.2% (95% CI 95.4%-100%), a specificity of 31.7% (95% CI 29.9%-33.5%), and a NPV of 99.9% (95% CI 99.3%-100%) for major injury and a sensitivity of 90.7% (95% CI 88.3%-92.8%), a specificity of 37.9% (95% CI 35.8%-40.1%), and a NPV of 91.8% (95% CI 89.7%-93.6%) for either major or minor injury. Regarding the limitations of our work, some clinicians may disagree with our injury classification and sensitivity thresholds for injury detection.

CONCLUSIONS

We prospectively derived and validated two DIs (Chest CT-All and Chest CT-Major) that identify blunt trauma patients with clinically significant thoracic injuries with high sensitivity, allowing for a safe reduction of approximately 25%-37% of unnecessary chest CTs. Trauma evaluation protocols that incorporate these DIs may decrease unnecessary costs and radiation exposure in the disproportionately young trauma population.

Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study

STUDY OBJECTIVE

Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention.

METHODS

Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury.

RESULTS

Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury).

CONCLUSION

In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries.

Sternal fracture in the age of pan-scan

STUDY OBJECTIVE

Widespread chest CT use in trauma evaluation may increase the diagnosis of minor sternal fracture (SF), making former teaching about SF obsolete. We sought to determine: (1) the frequency with which SF patients are diagnosed by CXR versus chest CT under current imaging protocols, (2) the frequency of surgical procedures related to SF diagnosis, (3) SF patient mortality and hospital length of stay comparing patients with isolated sternal fracture (ISF) and sternal fracture with other thoracic injury (SFOTI), and (4) the frequency and yield of cardiac contusion (CC) workups in SF patients.

METHODS

We analyzed charts and data of all SF patients enrolled from January 2009 to May 2013 in the NEXUS Chest and NEXUS Chest CT studies, two multi-centre observational cohorts of blunt trauma patients who received chest imaging for trauma evaluation.

RESULTS

Of the 14,553 patients in the NEXUS Chest and Chest CT cohorts, 292 (2.0%) were diagnosed with SF, and 94% of SF were visible on chest CT only. Only one patient (0.4%) had a surgical procedure related to SF diagnosis. Cardiac contusion was diagnosed in 7 (2.4%) of SF patients. SF patient mortality was low (3.8%) and not significantly different than the mortality of patients without SF (3.1%) [mean difference 0.7%; 95% confidence interval (CI) -1.0 to 3.5%]. Only 2 SF patient deaths (0.7%) were attributed to a cardiac cause. SFOTI patients had longer hospital stays but similar mortality to patients with ISF (mean difference 0.8%; 95% CI -4.7% to 12.0).

CONCLUSIONS

Most SF are seen on CT only and the vast majority are clinically insignificant with no change in treatment and low associated mortality. Workup for CC in SF patients is a low-yield practice. SF diagnostic and management guidelines should be updated to reflect modern CT-driven trauma evaluation protocols.

Routine Chest Computed Tomography and Patient Outcome in Blunt Trauma

Background:

Computerized Tomography (CT) scan is gaining more importance in the initial evaluation of patients with multiple trauma, but its effect on the outcome is still unclear. Until now, no prospective randomized trial has been performed to define the role of routine chest CT in patients with blunt trauma.

Objectives:

In view of the considerable radiation exposure and the high costs of CT scan, the aim of this study was to assess the effects of performing the routine chest CT on the outcome as well as complications in patients with blunt trauma.

Patients and Methods:

After approval by the ethics board committee, 100 hemodynamically stable patients with high-energy blunt trauma were randomly divided into two groups. For group one (control group), only chest X-ray was requested and further diagnostic work-up was performed by the decision of the trauma team. For group two, a chest X-ray was ordered followed by a chest CT, even if the chest X-ray was normal. Injury severity, total hospitalization time, Intensive Care Unit (ICU) admission time, duration of mechanical ventilation and complications were recorded. Data were evaluated using t-test, Man-Whitney and chi-squared test.

Results:

No significant differences were found regarding the demographic data such as age, injury severity and Glasgow Coma Scale (GCS). Thirty-eight percent additional findings were seen in chest CT in 26% of the patients of the group undergoing routine chest CT, leading to 8% change in management. The mean of in-hospital stay showed no significant difference in both groups with a P value of 0.098. In addition, the mean ICU stay and ventilation time revealed no significant differences (P values = 0.102 and 0.576, respectively). Mortality rate and complications were similar in both groups.

Conclusions:

Performing the routine chest CT in high-energy blunt trauma patients (with a mean injury severity of 9), although leading to the diagnosis of some occult injuries, has no impact on the outcome and does not decrease the in-hospital stay and ICU admission time. It seems that performing the routine chest CT in these patients may lead to overtreatment of nonsignificant injuries. The decision about performing routine CT scan in a trauma center should be made cautiously, considering the detriments and benefits.

The SCRAP rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma

Objective:

To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans.

Methods:

Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score > 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score ≤ 8, paralysis, or age < 16 years were excluded.

Results:

There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4–100], specificity 46.9% [95% CI 44.2–46.9], and negative likelihood ratio 0.00 [95% CI 0.00–0.04]). The five variables were oxygensaturation (< 95% on room air or < 98% on any supplemental oxygen),chest radiograph, respiratoryrate ≥ 25, chestauscultation, and thoracicpalpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2–100%), a specificity of 44.7% (95% CI 39.5–44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00–0.10).

Conclusions:

In major blunt trauma with a GCS score > 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting.

The significance of routine thoracic computed tomography in patients with blunt chest trauma

PURPOSE

The purpose of this study is to investigate whether the use of thoracic computed tomography (TCT) as part of nonselective computed tomography (CT) guidelines is superior to selective CT during the diagnosis of blunt chest trauma.

SUBJECTS AND METHODS

This study was planned as a prospective cohort study, and it was conducted at the emergency department between 2013 and 2014. A total of 260 adult patients who did not meet the exclusion criteria were enrolled in the study. All patients were evaluated by an emergency physician, and their primary surveys were completed based on the Advanced Trauma Life Support (ATLS) principles. Based on the initial findings and ATLS recommendations, patients in whom thoracic CT was indicated were determined (selective CT group). Routine CTs were then performed on all patients.

RESULTS

Thoracic injuries were found in 97 (37.3%) patients following routine TCT. In 53 (20%) patients, thoracic injuries were found by selective CT. Routine TCT was able to detect chest injury in 44 (16%) patients for whom selective TCT would not otherwise be ordered based on the EP evaluation (nonselective TCT group). Five (2%) patients in this nonselective TCT group required tube thoracostomy, while there was no additional treatment provided for thoracic injuries in the remaining 39 (15%).

CONCLUSION

In conclusion, we found that the nonselective TCT method was superior to the selective TCT method in detecting thoracic injuries in patients with blunt trauma. Furthermore, we were able to demonstrate that the nonselective TCT method can change the course of patient management albeit at low rates.

The ribs unfolded - a CT visualization algorithm for fast detection of rib fractures: effect on sensitivity and specificity in trauma patients

OBJECTIVE

To assess a radiologist's detection rate of rib fractures in trauma CT when reading curved planar reformats (CPRs) of the ribs compared to reading standard MPRs.

METHODS

Two hundred and twenty trauma CTs (146 males, 74 females) were retrospectively subjected to a software algorithm to generate CPRs of the ribs. Patients were split into two equal groups. Sixteen patients were excluded due to insufficient segmentation, leaving 107 patients in group A and 97 patients in group B. Two radiologists independently evaluated group A using CPRs and group B using standard MPRs. Two different radiologists reviewed both groups with the inverse methods setting. Results were compared to a standard of reference created by two senior radiologists.

RESULTS

The reference standard identified 361 rib fractures in 61 patients. Reading CPRs showed a significantly higher overall sensitivity (P < 0.001) for fracture detection than reading standard MPRs, with 80.9% (584/722) and 71.5% (516/722), respectively. Mean reading time was significantly shorter for CPRs (31.3 s) compared to standard MPRs (60.7 s; P < 0.001).

CONCLUSION

Using CPRs for the detection of rib fractures accelerates the reading of trauma patient chest CTs, while offering an increased overall sensitivity compared to conventional standard MPRs.

KEY POINTS

• In major blunt trauma, rib fractures are diagnosed with Computed Tomography. • Image processing can unfold all ribs into a single plane. • Unfolded ribs can be read twice as fast as axial images. • Unfolding the ribs allows a more accurate diagnosis of rib fractures.

Multidetector computer tomography: evaluation of blunt chest trauma in adults

Imaging plays an essential part of chest trauma care. By definition, the employed imaging technique in the emergency setting should reach the correct diagnosis as fast as possible. In severe chest blunt trauma, multidetector computer tomography (MDCT) has become part of the initial workup, mainly due to its high sensitivity and diagnostic accuracy of the technique for the detection and characterization of thoracic injuries and also due to its wide availability in tertiary care centers. The aim of this paper is to review and illustrate a spectrum of characteristic MDCT findings of blunt traumatic injuries of the chest including the lungs, mediastinum, pleural space, and chest wall.

Predictors of poor outcomes after significant chest trauma in multiply injured patients: a retrospective analysis from the German Trauma Registry (Trauma Register DGU®)

Background

Blunt thoracic trauma is one of the critical injury mechanisms in multiply injured trauma victims. Although these patients present a plethora of potential structural damages to vital organs, it remains debated which injuries actually influence outcome and thereby should be addressed initially. Hence, the aim of this study was to identify the influence of critical structural damages on mortality.

Methods

All patients in the database of the TraumaRegister DGU® (TR-DGU) from 2002–2011 with AIS Chest ≥ 2, blunt trauma, age of 16 or older and an ISS ≥ 16 were analyzed.

Outcome parameters were in-hospital mortality as well as ventilation time in patients surviving the initial 14 days after trauma.

Results

22613 Patients were included (mean ISS 30.5 ± 12.6; 74.7% male; Mean Age 46.1 ± 197 years; mortality 17.5%; mean duration of ventilation 7.3 ± 11.5; mean ICU stay 11.7 ± 14.1 days).

Only a limited number of specific injuries had a significant impact on survival. Major thoracic vessel injuries (AIS ≥5), bilateral lung contusion, bilateral flail chest, structural heart injury (AIS ≥3) significantly influence mortality in study patients. Several extrathoracic factors (age, blood transfusion, systolic blood pressure and extrathoracic severe injuries) were also predictive of increased mortality.

Most injuries of the thoracic wall had no or only a moderate effect on the duration of ventilation. Injuries to the lung (laceration, contusion or pneumothoraces) had a moderate prolonging effect. Cardiac injuries and severe injuries to the thoracic vessels induced a substantially prolonged ventilation interval.

Conclusions

We demonstrate quantitatively the influence of specific structural damages of the chest on critical outcome parameters. While most injuries of the chest wall have no or only limited impact in the study collective, injuries to the lung overall show adverse outcome. Injuries to the heart or thoracic vessels have a devastating prognosis following blunt chest trauma.

Hemothorax after the intravenous administration of tissue plasminogen activator in a patient with acute ischemic stroke and rib fractures

A 79-year-old man experienced sudden-onset left hemiparesis and disturbance of consciousness. Diffusion-weighted magnetic resonance imaging showed an acute ischemic stroke in the territory of the right middle cerebral artery. He underwent systemic thrombolysis via the intravenous administration of tissue plasminogen activator (t-PA). Chest radiography and computed tomography performed the following day showed severe hemothorax with atelectasis of the left lung and multiple rib fractures; the initial chest radiogram had revealed rib fractures but we did not recognize them at the time. Conservative treatment with the placement of chest tubes was successful, and the patient recovered without further deterioration. Although systemic thrombolysis with t-PA is an accepted treatment for acute cerebral ischemic stroke, posttreatment intracranial hemorrhage has a negative effect on prognosis. Extracranial bleeding is a rare complication, and our search of the literature found no reports of hemothorax after treatment with t-PA in patients with cerebral ischemic stroke. We have reported a rare case of severe hemothorax after systemic thrombolysis with t-PA. This important complication indicates the need to rule out thoracic trauma with radiography and computed tomography of the chest.

Evidence-based practice: best imaging practice in musculoskeletal disorders

As musculoskeletal disorders are a common cause of emergency department visits in the United States, it is vital for nurses and nurse practitioners to understand the decision rules for ordering imaging tests when triaging patients with musculoskeletal complaints. Proper knowledge and command of selecting the most appropriate imaging for these frequent emergency department presentations will help reduce costs, decrease ionizing radiation exposure, and increase patient throughput. This article reviews the current evidence-based literature for musculoskeletal imaging in the emergency department and discusses the epidemiology, etiology, management, and prevention of the most common musculoskeletal disorders.

What is the clinical significance of chest CT when the chest x-ray result is normal in patients with blunt trauma?

BACKGROUND

Computed tomography (CT) has been shown to detect more injuries than plain radiography in patients with blunt trauma, but it is unclear whether these injuries are clinically significant.

STUDY OBJECTIVES

This study aimed to determine the proportion of patients with normal chest x-ray (CXR) result and injury seen on CT and abnormal initial CXR result and no injury on CT and to characterize the clinical significance of injuries seen on CT as determined by a trauma expert panel.

METHODS

Patients with blunt trauma older than 14 years who received emergency department chest imaging as part of their evaluation at 2 urban level I trauma centers were enrolled. An expert trauma panel a priori classified thoracic injuries and subsequent interventions as major, minor, or no clinical significance.

RESULTS

Of 3639 participants, 2848 (78.3%) had CXR alone and 791 (21.7%) had CXR and chest CT. Of 589 patients who had chest CT after a normal CXR result, 483 (82.0% [95% confidence interval [CI], 78.7-84.9%]) had normal CT results, and 106 (18.0% [95% CI, 15.1%-21.3%]) had CTs diagnosing injuries-primarily rib fractures, pulmonary contusion, and incidental pneumothorax. Twelve patients had injuries classified as clinically major (2.0% [95% CI, 1.2%-3.5%]), 78 were clinically minor (13.2% [95% CI, 10.7%-16.2%]), and 16 were clinically insignificant (2.7% (95% CI, 1.7%-4.4%]). Of 202 patients with CXRs suggesting injury, 177 (87.6% [95% CI, 82.4%-91.5%]) had chest CTs confirming injury and 25 (12.4% [95% CI, 8.5%-17.6%]) had no injury on CT.

CONCLUSION

Chest CT after a normal CXR result in patients with blunt trauma detects injuries, but most do not lead to changes in patient management.

Incidence of delayed and missed diagnoses in whole-body multidetector CT in patients with multiple injuries after trauma

BACKGROUND

Whole-body CT (WBCT) is the imaging modality of choice during the initial diagnostic work-up of multiple injured patients in order to identify serious injuries and initiate adequate treatment immediately. However, delayed diagnosed or even missed injuries have been reported frequently ranging from 1.3% to 47%.

PURPOSE

To highlight commonly missed lesions in WBCT of patients with multiple injuries.

MATERIAL AND METHODS

A total of 375 patients (age 42.8 ± 17.9 years, ISS 26.6 ± 17.0) with a WBCT (head to symphysis) were included. The final CT report was compared with clinical and operation reports. Discrepant findings were recorded and grouped as relevant and non-relevant to further treatment. In both groups, an experienced trauma radiologist read the CT images retrospectively, whether these lesions were missed or truly not detectable.

RESULTS

In 336 patients (89.6%), all injuries in the regions examined were diagnosed correctly in the final reports of the initial CT. Forty-eight patients (12.8%) had injuries in regions of the body that were not included in the CT. Fourteen patients (3.7%) had injuries that did not require further treatment. Twenty-five patients (6.7%) had injuries that required further treatment. With secondary interpretation, 85.4% of all missed lesions could be diagnosed in retrospect from the primary CT data-set. Small pancreatic and bowel contusions were identified as truly non-detectable.

CONCLUSION

In multiple traumas, only a few missed injuries in initial WBCT reading are clinically relevant. However, as the vast majority of these injuries are detectable, the radiologist has to be alert for commonly missed findings to avoid a delayed diagnosis.

Advanced accident research system based on a medical and engineering data in the metropolitan area of Florence

BACKGROUND

In the metropolitan area of Florence, 62% of major traumas involve powered two wheeler rider and pillion passengers, 10% cyclists, and 7% pedestrians. The urban and extra-urban areas are the most dangerous for the vulnerable road user. In-depth investigations are needed for assessing detailed information on road accidents. This type of study has been very limited in time frame in Italy, and completely absent in the Tuscan region.Consequently a study called "In-depth Study of road Accident in FlorencE" (In-SAFE) has been initiated.

METHODS

A network between the Department of Mechanics and Industrial Technologies (University of Florence) and the Intensive Care Unit of the Emergency Department (Careggi Teaching Hospital, Florence) was created with the aim of collecting information about the road accidents. The data collected includes: on-scene data, data coming from examination of the vehicles, kinematics and dynamic crash data, injuries, treatment, and injury mechanisms. Each injury is codified thorough the AIS score, localized by a three-dimensional human body model based on computer tomography slices, and the main scores are calculated. We then associate each injury with its cause and crash technical parameters. Finally, all the information is collected in the In-SAFE database.

RESULTS

Patient mean age at the time of the accident was 34.6 years, and 80% were males. The ISS mean is 24.2 (SD 8.7) and the NISS mean is 33.6 (SD 10.5). The main road accident configurations are the "car-to-PTW" (25%) and "pedestrian run over" (17,9%). For the former, the main collision configuration is "head-on crash" (57%). Cyclists and PTW riders-and-pillions-passengers suffer serious injuries (AIS3+) mainly to the head and the thorax. The head (56.4%) and the lower extremities (12.7%) are the most frequently injured pedestrian body regions.

CONCLUSIONS

The aim of the project is to create an in-depth road accident study with special focus on the correlation between technical parameters and injuries. An in-depth investigation team was setup and is currently active in the metropolitan area of Florence.Twenty-eight serious road accidents involving twenty-nine ICU patients are studied. PTW users, cyclist and pedestrians are the most frequently involved in metropolitan accidents.

Epidural analgesia for blunt thoracic injury--which patients benefit most?

INTRODUCTION

Epidural analgesia for blunt thoracic injury has been demonstrated to be beneficial for pulmonary function, analgesia, and subjective pain; however the optimal patient selection and timing of thoracic epidural placement have not been well studied. We hypothesised that early (<48h) epidural analgesia (EA) as compared with usual care involving oral and intravenous narcotics delivered by patient-controlled analgesia (PCA) in patients with blunt thoracic trauma (>3 ribs fractured) is associated with fewer pulmonary complications and lower resource utilisation as measured by ICU and hospital length of stay.

METHODS

This is a retrospective review of all non-intubated patients suffering from blunt thoracic injury with 3 or more rib fractures requiring hospital admission for >24h over a recent 5-year period. Pulmonary complications were defined as pneumonia, empyema, hypoxia, and need for delayed intubation. Logistic regression was utilised to analyse patient and injury characteristics associated with pulmonary complications.

RESULTS

187 patients were included in the analysis; early thoracic epidural was utilised in 18% (n=34). There was no difference in age, ISS, ICU length of stay (LOS), or pulmonary complications between patients who received an epidural (EPI) compared with those who did not (NO EPI). A significantly increased incidence of pulmonary complications was noted in patients who required tube thoracostomy (p=0.017).

CONCLUSION

In our experience, insertion of a thoracic epidural catheter early post-injury failed to reduce the incidence of pulmonary complications, ICU and hospital LOS. However, since pulmonary complications are more frequent in patients requiring tube thoracostomy, the cost-effectiveness of epidural analgesia in these patients warrants further investigation.

Blunt thoracic injury in older adults: application of Haddon's phase-factor matrix model

Blunt thoracic injury (BTI) in older adults can lead to grave illness, permanent disability, and even death. Using Haddon's phase-factor matrix model, this article examines the phenomenon of BTI in older adults. Preventive, diagnostic, and treatment interventions are discussed from the perspective of the pre-event, event, and post-event phases. Relevant physiological and pathophysiological changes regarding senescence and injury are reviewed, as are the common mechanisms of blunt trauma and anatomic injury patterns seen in older adults. Considerations for clinical interventions and future research are also presented.

Deaths at a Level 1 Trauma Unit: a clinical finding and post-mortem correlation study

BACKGROUND

Missed injuries continue to cause deaths amongst trauma patients. Regardless of the definition of missed injuries, it is important to identify all injuries at any stage in the care of trauma patients in order to improve patient outcome. This study was performed to evaluate to what extent missed injuries contribute to a fatal outcome at a new Level 1 Trauma Unit.

METHODS

The medical records and autopsy reports of all trauma patients who died at the IALCH trauma unit from March 2007 through August 2009 were reviewed. The mortality rate and incidence of missed injuries were determined. A missed injury was defined as one that was found at autopsy but was not mentioned in the medical records or in any ante mortem radiological report. This excluded minor injuries such as superficial contusions and minor lacerations, which are sometimes not included in the case notes during resuscitation. Deaths due to trauma are considered unnatural and legal provisions require that all unnatural deaths undergo medico-legal postmortem examination. The study was approved by the UKZN Biomedical Research Ethics Committee.

RESULTS

Five hundred and forty-seven patients were admitted to the trauma unit of which 135 (24.7%) demised. Three patients were excluded, due to inability to retrieve their autopsy reports, leaving a study group of 132 patients in which there were 100 males and 32 females. The mean age was 33.2 years, mean ISS was 34.0. A total of 26 missed injuries were found in 14 patients, giving a total incidence of 10.6%. Three percent had missed injuries that were variously deemed to be possibly related, probably related, or related to the fatal outcome, whether the deaths were deemed preventable or not. Severe physiological derangement which precluded any imaging before death may have caused the injury to be overlooked. The thorax was the anatomical region where most injuries were missed.

CONCLUSIONS

A number of injuries remain undetected in trauma care and are found only at autopsy, emphasizing that the autopsy remains an important tool in evaluating trauma care. However, in only a few patients did the missed injuries have a detrimental effect on outcome.

Association between a single-pass whole-body computed tomography policy and survival after blunt major trauma: a retrospective cohort study

INTRODUCTION

Single-pass, whole-body computed tomography (pan-scan) remains a controversial intervention in the early assessment of patients with major trauma. We hypothesized that a liberal pan-scan policy is mainly an indicator of enhanced process quality of emergency care that may lead to improved survival regardless of the actual use of the method.

METHODS

This retrospective cohort study included consecutive patients with blunt trauma referred to a trauma center prior to (2000 to 2002) and after (2002 to 2007) the introduction of a liberal single-pass pan-scan policy. The overall mortality between the two periods was compared and stratified according to the availability and actual use of the pan-scan. Logistic regression analysis was employed to adjust mortality estimates for demographic and injury-related independent variables.

RESULTS

The study comprised 313 patients during the pre-pan-scan period, 223 patients after the introduction of the pan-scan policy but not undergoing a pan-scan and 608 patients undergoing a pan-scan. The overall mortality was 23.3, 14.8 and 7.9% (P < 0.001), respectively. By univariable logistic regression analysis, both the availability (odds ratio (OR) 0.57, 95% confidence interval (CI): 0.36 to 0.90) and the actual use of the pan-scan (OR 0.28, 95% CI: 0.19 to 0.42) were associated with a lower mortality. The final model contained the Injury Severity Score, the Glasgow Coma Scale, age, emergency department time and the use of the pan-scan. 2.7% of the explained variance in mortality was attributable to the use of the pan-scan. This contribution increased to 7.1% in the highest injury severity quartile.

CONCLUSIONS

In this study, a liberal pan-scan policy was associated with lower trauma mortality. The causal role of the pan-scan itself must be interpreted in the context of improved structural and process quality, is apparently moderate and needs further investigation with regard to the diagnostic yield and changes in management decisions. (The Pan-Scan for Trauma Resuscitation [PATRES] Study Group, ISRCTN35424832 and ISRCTN41462125).

"Buckle" rib fracture: an artifact following cardio-pulmonary resuscitation detected on postmortem CT

Buckle rib fractures are incomplete fractures involving the inner cortex alone, and are rarely detected on routine chest X-ray or at autopsy. The characteristics of these fractures have not been well evaluated in situ although they are commonly observed on postmortem CT images especially following CPR. The postmortem CT findings in 42 cases showing buckle rib fractures caused by CPR were reviewed. The cause of death in all cases was non-traumatic. The shape, number, location, and distribution of these buckle rib fractures and their relationship to other types of rib fractures were evaluated using a novel oblique axial multiplanar reconstruction technique. Almost all incomplete rib fractures associated with CPR are buckle rib fractures (90.5%). All rib fractures were distributed from the second to ninth ribs with over 95% being within the second to seventh ribs. Buckle rib fractures are dominant in the seventh to ninth ribs and the proportion of buckle rib fractures located in the vicinity of the costochondral junctions increases with the lower ribs. Over 97% of all CPR associated rib fractures are located in the anterior one third of the ribs based on a new measurement method utilizing oblique axial multiplanar reconstruction of the CT data. When recognition of incomplete or buckle rib fractures on postmortem CT is taken into account, detection of symmetry and continuity of rib fractures typically associated with CPR is improved compared with the detection of complete fractures alone. Recognition of buckle rib fractures and their characteristics on postmortem CT is of benefit to the forensic pathologist in evaluating the possibility of CPR and the differentiation of resuscitative artifact from forensically significant visceral injury observed at autopsy.

Association of dynamic changes in serum cytokine levels with the severity of injury in patients suffering from closed chest traumas complicated with pulmonary contusions

This study aimed to examine the dynamic changes in the serum levels of tumor necrosis factor (TNF)-α, interleukin (IL)-6 and IL-10 in patients suffering from closed chest injuries and concomitant pulmonary contusions and their correlation with the Thoracic Trauma Severity Score (TTS) and Injury Severity Score (ISS). Patients with multiple traumas with an ISS ≥16 (n=41) were evaluated in the study. Patients included 21 individuals with trauma complicated by pulmonary contusion and 20 patients with trauma without contusion. Venous blood samples were collected from the patients on days 1, 2, 3, 5 and 7 following trauma to assess serum levels of TNF-α, IL-6 and IL-10, whose correlation with TTS and ISS was analyzed. Levels of TNF-α, IL-6 and IL-10 remained significantly higher in the patients with trauma complicated by contusion compared to the patients with trauma without contusion (P<0.01). These three cytokines were positively correlated with TTS and ISS in the patients with trauma complicated by contusion. Serum TNF-α, IL-6 and IL-10 levels increased significantly in the patients with trauma complicated by pulmonary contusion. In conclusion, both cytokine assays and TTS facilitate the accurate assessment of the severity of chest injury.

Advanced trauma life support radiographic trauma series: part 2--the chest radiograph

The chest radiograph is used as a screening test to exclude significant thoracic injuries in cases of major trauma. A systematic approach to reviewing chest radiographs is necessary for accurate interpretation. Radiographic findings should be considered together with clinical assessment.

Criteria for the selective use of chest computed tomography in blunt trauma patients

PURPOSE

The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury.

METHODS

This observational study prospectively included consecutive patients (>or=16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre.

RESULTS

We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age >or=55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <-3 mmol/l and haemoglobin <6 mmol/l). Of 855 patients with >or=1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant.

CONCLUSION

Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.

Occult pneumomediastinum in blunt chest trauma: clinical significance

INTRODUCTION

Thoracic injuries are potentially responsible for 25% of all trauma deaths. Chest X-ray is commonly used to screen patients with chest injury. However, the use of computed tomography (CT) scan for primary screening is increasing, particularly for blunt trauma. CT scans are more sensitive than chest X-ray in detecting intra-thoracic abnormalities such as pneumothoraces and pneumomediastinums. Pneumomediastinum detected by chest X-ray or "overt pneumomediastinum", raises the concern of possible aerodigestive tract injuries. In contrast, there is scarce information on the clinical significance of pneumomediastinum diagnosed by CT scan only or "occult pneumomediastinum". Therefore we investigated the clinical consequences of occult pneumomediastinum in our blunt trauma population.

METHODS

A 2-year retrospective chart review of all blunt chest trauma patients with initial chest CT scan admitted to a level I trauma centre. Data extracted from the medical records include; demographics, occult, overt, or no pneumomediastinum, the presence of intra-thoracic aerodigestive tract injuries (trachea, bronchus, and/or esophagus), mechanism and severity of injury, endotracheal intubation, chest thoracostomy, operations and radiological reports by an attending radiologist. All patients with intra-thoracic aerodigestive tract injuries from 1994 to 2004 were also investigated.

RESULTS

Of 897 patients who met the inclusion criteria 839 (93.5%) had no pneumomediastinum. Five patients (0.6%) had overt pneumomediastinum and 53 patients (5.9%) had occult pneumomediastinum. Patients with occult pneumomediastinum had significantly higher ISS and AIS chest (p<0.0001) than patients with no pneumomediastinum. A chest thoracostomy tube was more common (p<0.0001) in patients with occult pneumomediastinum (47.2%) than patients with no pneumomediastinum (10.4%), as well as occult pneumothorax. None of the patients with occult pneumomediastinum had aerodigestive tract injuries (95%CI 0-0.06). Follow up CT scan of patients with occult pneumomediastinum showed complete resolution in all cases, in average 3 h after the initial exam.

CONCLUSION

Occult pneumomediastinum occurred in approximately 6% of all trauma patients with blunt chest injuries in our institution. Patients who had occult pneumomediastinum were more severely injured than those who without. However, none of the patients with occult pneumomediastinum had aerodigestive tract injuries and follow up chest CT scans demonstrated their complete and spontaneous resolution.

Role of lung contusions on posttraumatic inflammatory response and organ dysfunction in traumatized patients

BACKGROUND

Multiple trauma is often accompanied by lung contusion leading to secondary pulmonary inflammation and organ dysfunction. The particular role of lung contusions on the systemic inflammatory response remains unclear. Therefore, the aim of the present study was to compare the degree of lung contusion with markers of inflammation and multiple organ failure (MOF) in trauma patients.

METHODS

According to the Injury Severity Score (ISS), 45 patients were assigned to a low (< 25 points) and a high ISS group (> 25 points), respectively. Both groups were subdivided into minor and major lung injury groups as defined by computed tomography (CT) scan. Plasma levels of interleukin 6 (IL-6), interleukin 8 (IL-8), tumor necrosis factor (TNF) receptors, C-reactive protein (CRP), and polymorphonuclear (PMN) elastase were assessed, as well as the Murray lung score (MLS) and the MOF score.

RESULTS

Patients with low ISS present moderate activation of inflammation which is not influenced by the degree of lung contusion. In contrast, patients with a high ISS develop significant posttraumatic inflammation and MOF. Patients with high ISS and severe lung contusions present significantly higher MLS and MOF scores. Interestingly, patients of the high ISS group without severe lung contusions develop a similar degree of MLS and MOF only after 5 days following the traumatic insult. However, the initial plasma levels of IL-6 and IL-8 differ significantly in this group.

CONCLUSION

Our data show that severe lung contusions contributes to an immediate onset of posttraumatic inflammation in severely traumatized patients, resulting in MOF, while in severely injured patients without lung contusion, this development requires up to 5 days.

[Imaging of trauma with multi-detector computed tomography]

Diagnosis of trauma-related injuries is a key task in modern radiology. Early, thorough and accurate detection of potentially life-threatening injuries is crucial for fast and targeted initiation of treatment. Conventional radiography (CR) and ultrasound (US) are well-established and still represent the basic diagnostic tools for trauma imaging. However, a number of studies have shown a lower detection rate of injuries for radiography and ultrasound compared with computed tomography (CT). Multi-detector CT (MDCT) with its shorter scan time and increased accuracy has become the gold standard for many indications in trauma imaging. As MDCT has a higher radiation dose, its use should be restricted and carefully indicated especially when dealing with a younger patient population. Careful optimization of imaging parameters has to be performed to minimize exposure and maximize diagnostic safety. Modern MDCT examinations produce a large number of images, which have to be limited to a reasonable number for interpretation. This review article focuses on optimization of examination protocols and on how to handle the flood of images for viewing and archiving.

Management of the pediatric organ donor to optimize lung donation

Lung transplantation in childhood is a highly specialized clinical practice confined to a few centers around the world. Organ availability remains an important limiting factor in extending the application of this procedure to more infants, children and adolescents. The lungs are the organ most vulnerable to injury, infection and dysfunction among transplantable organs in the brain dead deceased donor. In this manuscript, we review the pathophysiology of the most common and important disease states that affect the lungs in potential donors. Furthermore, we herein provide recommendations for optimal management of the pediatric organ donor with an emphasis on strategies to improve the opportunity for the lungs to be placed in candidates on the transplant list.

Skeletal imaging of child abuse (non-accidental injury)

In recent years there has been a worldwide increased awareness that children are physically abused by their carers. Radiologists play a vital role in the detection of inflicted injuries. This article reviews the skeletal imaging findings seen in child abuse.