Routine versus selective chest and abdominopelvic CT-scan in conscious blunt trauma patients: a randomized controlled study

CT scan in the evaluation of pediatric abdominal trauma

OBJECTIVE

to assess the need of computed tomography (CT) for the definition of management in pediatric abdominal trauma.

METHODS

observational retrospective study with patients under 18 years old victims of blunt or penetrating abdominal trauma that underwent CT of the abdomen and pelvis at admission. We evaluated CT scan findings, indications and management. We calculated the sensitivity, specificity, positive predictive value and negative predictive value of clinical variables and energy of trauma for findings on CT.

RESULTS

among the 236 patients included in our study, 72% (n=170) did not present abnormal findings on CT. It was performed surgical treatment in 15% (n=10), conservative treatment in 54,5% (n=36) and 27% (n=18) did not receive treatment for abdominal injuries. In the assessment of CT indications, 28,8% (n=68) presented no justifications. In this group, 91% (n=62) did not show any abnormal findings. Among the six patients with positive findings, half were selected for conservative treatment, while the rest did not need any treatment for abdominal injuries. The presence of abdominal pain, hemodynamic alterations and high energy blunt trauma had low positive predictive values when isolated, whereas the negative predictive values were higher.

CONCLUSION

although CT is necessary in some instances, there is a possible high number of exams that did not make any difference in the management of the pediatric population.

Splenic Heterogeneity in Focused Assessment With Sonography for Trauma (FAST) Scan Led to the Diagnosis of Grade 2 Splenic Injury in a Pediatric Blunt Abdominal Trauma

Splenic injuries are one of the most common injuries following blunt abdominal trauma. It occurs in 32% of blunt abdominal trauma, with motor vehicle accidents being the most common cause. The patient may present with generalized abdominal pain or left upper quadrant pain associated with left shoulder pain. Hemodynamic instability is one of the most reliable signs of splenic injuries. A focused assessment with sonography for trauma (FAST) scan is the initial imaging used to assess for solid organ injury in the abdomen, followed by computed tomography (CT) scans. Evidence of free fluid in the abdomen in the FAST scan indicates a solid organ injury. However, the absence of the before-mentioned finding does not rule out the presence of solid organ injury. Hereby a case of a 13-year-old Saudi male with left-sided abdominal pain after falling from a motorbike. A set of the investigation was done with insignificant results. However, FAST revealed a heterogenous appearance in the spleen. Thus, the patient subsequently underwent abdominal CT scans. The patient was managed conservatively and then discharged against medical advice (DAMA). Previously documented cases have mentioned the presence of free fluid in the abdomen in FAST scan in a stable patient leading to undergoing a CT scan and further managing trauma victim patients, which was absent in the present case.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

Tomografia computadorizada na avaliação do trauma abdominal pediátrico

RESUMO Introdução: avaliar a necessidade da tomografia computadorizada (TC) para definição de condutas em trauma abdominal pediátrico. Métodos: estudo observacional retrospectivo com pacientes menores de 18 anos vítimas de trauma abdominal contuso ou penetrante e que realizaram TC de abdome e pelve na admissão. Avaliou-se achados das tomografias, condutas e justificativas para indicação da TC. Foram calculados sensibilidade, especificidade, valor preditivo positivo e valor preditivo negativo de fatores clínicos e energia do trauma para alterações na TC. Resultados: dentre os 236 pacientes incluídos, 72% (n=170) não apresentaram alterações na TC. Foi realizado tratamento cirúrgico em 15% (n=10), tratamento conservador em 54,5% (n=36) e 27% (n=18) não receberam tratamento por lesões abdominais. Na avaliação das indicações de TC, 28,8% (n=68) não apresentavam nenhuma justificativa, sendo que nesse grupo 91% (n=62) resultaram em ausência de achados. Dentre os seis pacientes com achados positivos, metade recebeu tratamento conservador, enquanto o restante não necessitou de tratamento por lesões abdominais. A presença de dor abdominal, alteração hemodinâmica e trauma contuso de alta energia apresentaram baixos valores preditivos positivos de forma isolada, enquanto os valores preditivos negativos foram mais altos. Conclusão: apesar de a TC ser necessária e justificável em alguns casos, há um possível excesso de tomografias dispensáveis para definição de condutas em população pediátrica.

CT as a first-line modality in elderly patients with stable blunt chest trauma

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.

Implementation of an algorithm for chest imaging in blunt trauma decreases use of CT-scan: Resource management in a middle-income country

PURPOSE

Due to the low sensitivity of chest radiography, chest CT-scan is usually recommended for the evaluation of high-risk blunt trauma patients. Considering the radiation exposure and costs accompanying routine CT-scan, the aim of this study was to design and implement an evidence-based institutional algorithm for selective chest imaging in high energy blunt trauma patients and evaluate its effect on patient outcome and resource utilization.

METHODS

For this field trial, an institutional evidence-based algorithm for chest trauma imaging was designed according to existing data and expert panel. After final consent and ethic committee approval, the algorithm was integrated in the diagnostic flow sheet in the emergency department and patient data were collected from the pre- and post-implementation period.

RESULTS

One-hundred and sixty-five patients before algorithm implementation and 158 patients after that were included. Chest CT-scan was requested for 93% of patients in the pre-implementation group and for 73% in the post-implementation group (P<0.001). Length of stay in hospital was slightly shorter in the post-implementation group (p = 0.036), however, duration of stay in emergency room and ICU, pulmonary complications and mortality showed no significant difference.

CONCLUSION

Implementation of an algorithm for limiting chest CT-scan to a subgroup of patients with a higher risk of chest injuries can reduce radiation exposure and more useful distribution of resources without harming the patients. Each institution should use institutional guidelines and algorithms with respect to patient load, available resources and desired sensitivity for injury detection.

Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation

PURPOSE

To determine whether torso CT can be avoided in patients who experience high-energy blunt trauma but have normal vital signs.

METHODS

High-energy blunt trauma patients with normal vital signs were retrieved retrospectively from our registry. We reviewed 1317 patients (1027 men and 290 women) and 761 (57.8%) fulfilled the inclusion criteria. All patients were initially evaluated at the emergency room (ER), with a set of tests, part of a specific protocol. Patients with at least one altered exam at initial examination or after six-hour observation received a torso CECT. Sensitivity, specificity, accuracy, positive (PPV) and negative predictive values (NPV), and likelihood ratio (LH) of the protocol were evaluated.

RESULTS

Of 761 patients, 354 (46.5%) received torso CECT because of the positive ER test, with 330 being true positive and 24 being false positive. The remaining 407 patients were negative at ER tests and did not receive torso CECT, showing a significantly (P < 0.001) lower Injury Severity Score (ISS). The positive and negative LH of the protocol to detect torso injuries were respectively 16.5 and 0.01 (overall accuracy of 0.96).

CONCLUSIONS

Torso CT can be avoided without adverse clinical outcomes in patients who experience high-energy blunt trauma, are hemodynamically stable, and have normal initial laboratory and imaging tests.