[Priority-oriented shock trauma room management with the integration of multiple-view spiral computed tomography]

CT scan and conventional x-ray in multiple injured patient care: diagnostic strategies and outcomes analysed from the TraumaRegister DGU®

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.

Deep learning algorithm in detecting intracranial hemorrhages on emergency computed tomographies

BACKGROUND

Highly accurate detection of intracranial hemorrhages (ICH) on head computed tomography (HCT) scans can prove challenging at high-volume centers. This study aimed to determine the number of additional ICHs detected by an artificial intelligence (AI) algorithm and to evaluate reasons for erroneous results at a level I trauma center with teleradiology services.

METHODS

In a retrospective multi-center cohort study, consecutive emergency non-contrast HCT scans were analyzed by a commercially available ICH detection software (AIDOC, Tel Aviv, Israel). Discrepancies between AI analysis and initial radiology report (RR) were reviewed by a blinded neuroradiologist to determine the number of additional ICHs detected and evaluate reasons leading to errors.

RESULTS

4946 HCT (05/2020-09/2020) from 18 hospitals were included in the analysis. 205 reports (4.1%) were classified as hemorrhages by both radiology report and AI. Out of a total of 162 (3.3%) discrepant reports, 62 were confirmed as hemorrhages by the reference neuroradiologist. 33 ICHs were identified exclusively via RRs. The AI algorithm detected an additional 29 instances of ICH, missed 12.4% of ICH and overcalled 1.9%; RRs missed 10.9% of ICHs and overcalled 0.2%. Many of the ICHs missed by the AI algorithm were located in the subarachnoid space (42.4%) and under the calvaria (48.5%). 85% of ICHs missed by RRs occurred outside of regular working-hours. Calcifications (39.3%), beam-hardening artifacts (18%), tumors (15.7%), and blood vessels (7.9%) were the most common reasons for AI overcalls. ICH size, image quality, and primary examiner experience were not found to be significantly associated with likelihood of incorrect AI results.

CONCLUSION

Complementing human expertise with AI resulted in a 12.2% increase in ICH detection. The AI algorithm overcalled 1.9% HCT.

TRIAL REGISTRATION

German Clinical Trials Register (DRKS-ID: DRKS00023593).

Trauma Computed Tomography in the Modern Era: Not Always Quick and Safe

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.

Is There a Need for Abdominal CT Scan in Trauma Patients With a Low-Risk Mechanism of Injury and Normal Vital Signs?

Background Clinically significant injuries are often missed in trauma patients with low-risk mechanisms of injury and lack of "red flags," such as abnormal vital signs. The purpose of this retrospective analysis was to evaluate the efficacy of computed axial tomography (CT) for identifying occult injuries in a high-volume trauma center. Methods Records from our institutional trauma registry were retrospectively extracted, examining encounters from January 2015 to October 2019. Those patients between the ages of 18 and 65 who were referred to the trauma team with a CT scan of the abdomen and had low-risk mechanisms of injury, a Glasgow Coma Scale (GCS) score of 15, and normal vital signs at presentation were included. Patients in the lowest trauma categorization (Level Three, Consult) met the study definition for the low-risk mechanism of injury. Demographic and clinical data were abstracted for all patients. For this analysis, patients were divided into two groups based on age (18 - 40 years or 40 - 65 years). Injuries found on CT, their clinical significance, and the likelihood of being missed without CT were determined. Results Of 2,103 blunt trauma patients that received a CT scan of the abdomen from January 2015 to October 2019, 134/2,103 (6.4%) met the inclusion criteria (mean age: 44.6 years; 72.3% male). Patients between the ages of 40 and 65 years comprised 61.2% (82/134) of the study population. Of the included patients, 17.2% (23/134) had at least one acute traumatic injury identified after CT imaging of the torso. Occult injuries found on CT included rib fracture with associated lung injuries (10/23, 43.5%), splenic laceration (4/23, 17.4%), liver laceration (3/23, 13.0%), gluteal hematoma with active bleeding (1/23, 4.3%), sternal fractures (3/23, 13.0%), and thoracic or lumbar spine fractures (2/23, 8.7%). An independent review of the medical records determined that 9.0% (12/134) of these patients had traumatic injuries that would have been missed based on clinical examination without CT. Conclusions Based on our experience, utilizing CT imaging of at least the abdomen as a routine screening measure for all trauma consults - even low-risk patients with normal vital signs - can rapidly and accurately identify clinically significant injuries that would have been otherwise missed in a notable portion of the population.

Evidence of Prolonged Monitoring of Trauma Patients Admitted via Trauma Resuscitation Unit without Primary Proof of Severe Injuries

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.

Time to computed tomography: does this affect trauma patient outcomes? A retrospective analysis at an Australian major trauma centre

BACKGROUND

Computed tomography (CT) is an essential diagnostic tool for severe multi-trauma patients. International guidelines recommend an optimal time of 1 h from arrival. The aim of this study was to determine the time interval from arrival at the emergency department to CT for all trauma patients and the effects on in-hospital mortality and hospital length of stay.

METHODS

Retrospective study of all patients who triggered a trauma call and underwent CT scanning at the Gold Coast University Hospital from January 2016 to December 2017. Exclusion criteria were scans performed at peripheral hospitals or performed more than 5 h after arrival to emergency department.

RESULTS

One thousand six hundred and nineteen eligible trauma patients were admitted over the study period and underwent CT scanning. Median time to CT was found to be 43 min. CTs done within 1 h compared to those done after 1 h from emergency department arrival were found to have a higher mean injury severity score (11 ± 10 versus 9 ± 9, P = 0.003), a longer mean hospital length of stay (9 ± 21 versus 7 ± 13 days, P = 0.012) and no difference in mortality rates (2.2% versus 2.1%, P = 1.000). Age, injury severity score and intubation status were identified as independent predictors for longer hospital length of stay and higher mortality while time to CT did not. Injury severity score was shown to be an independent predictor of time to CT.

CONCLUSION

Our time to CT scanning is well within the timeframe recommended by international guidelines. Early CT scanning may also improve outcomes in severely injured trauma patients.

[Optimized resource mobilization and quality of treatment of severely injured patients through a structured trauma room alarm system]

BACKGROUND

The treatment of severely injured patients in the trauma resuscitation unit (TRU) requires an interdisciplinary and highly professional trauma team approach. The complete team needs to be waiting for the patient in the TRU on arrival. Treating severely injured patients in the TRU, the trauma team connects the initial preclinical emergency stabilization with the subsequent sophisticated treatment. Thus, the trauma team depends on concise information from the emergency personnel at the scene to provide its leader with further information as well as an accurate alarm including all departments necessary to stabilize the patient in the TRU.

METHOD

Aiming at an accurate and most efficient trauma team alarm, this study was designed to provide and analyze an alarm system which mobilizes the trauma team in a stepwise fashion depending on the pattern of injuries and the threat to life. The trauma team alarm system was analyzed in a prospective data acquisition at a level I trauma center over a period of 12 months. Evaluation followed the acquisition phase and provided comparison to the status prior to the establishment of the alarm system. All items underwent statistical testing using t‑tests (p < 0.05).

RESULTS

The data of 775 TRU patients showed a significant reduction of false information on the patients status prior to arrival. It also showed an increase in punctual arrival in the TRU of the emergency teams. False alarms were significantly reduced (from 11.9% to 2.7%, p > 0.01). The duration from arrival of the patient in the TRU to the initial multislice computed tomography (CT) scan was reduced by 6 min while the total period of treatment in the TRU was reduced by 17 min. After the alarm system to gradually mobilize the trauma team was put into action, team members left the TRU if unneeded prior to finishing the initial treatment in only 4% of the cases. The patient fatality rate was 8.8% (injury severity score, ISS = 23 points) after establishment of the alarm system compared to 12.9% (ISS = 25 points) before.

CONCLUSION

The implementation of an accurate and patient status-based alarm system to mobilize the trauma team can improve the quality of treatment while the duration of treatment of the severely injured patients in the TRU can be decreased. It also provides a most efficient mobilization of personnel resources while sustaining patient safety.

Whole-body computed tomography in severely injured patients

PURPOSE OF REVIEW

To provide an update on the relevant and recent studies on whole-body computed tomography (WBCT) imaging of severely injured patients.

RECENT FINDINGS

The advantages of WBCT in time saving, diagnostic accuracy and even in survival have been proven in numerous studies. WBCT can also be beneficial in haemodynamically unstable major trauma patients. The CT scanner should be located close to the emergency department or even in the trauma room. The issue of radiation is still quite important, however, iterative as well as split-bolus protocols can nowadays reduce radiation significantly. The question: which trauma patient should receive WBCT and which not is not yet solved sufficiently. Postmortem WBCT has a promising potential to promptly define the definitive cause of death of trauma victims comparably to traditional autopsy.

SUMMARY

On account of the recent advances, whole-body CT has become a crucial part of the initial in-hospital assessment of severely injured patients. It is recommended as the standard radiological tool for the emergency diagnostic work-up in major trauma patients.

Changes in trauma management following the implementation of the whole-body computed tomography: a retrospective multi-centre study based on the trauma registry of the German Trauma Society (TraumaRegister DGU®)

OBJECTIVES

Whole-body computed tomography (WBCT) plays an increasingly important role in the diagnostic assessment of trauma room patients. It is still unclear whether its use has led to changes of trauma room procedures and patient outcomes.

METHODS

In a retrospective multi-centric study based on the trauma registry of the German Trauma Society (TraumaRegister DGU^®), we analysed patients with an ISS ≥ 9 between 2002 and 2013. Two periods of time, i.e. up to 3 years preceding (pre-WBCT) and up to 3 years following the introduction of the WBCT (WBCT-group), were assessed separately for every hospital (TR-DGU Project ID 2014-020).

RESULTS

19,838 patients underwent treatment in 77 hospitals. Of these, 5621 were assigned to the pre-WBCT group and 11,307 to the WBCT group. Basic data did not differ relevantly. The time spent in the trauma room decreased from 77.9 min (pre-WBCT) to 63.3 min (WBCT). Following the introduction of the trauma scan, the number of diagnoses per patient increased from 4.6 to 5.1. The percentage of patients who underwent surgery immediately after the completion of trauma room procedures decreased from 44.5 to 39.1%. There was an increase in mortality from 15.7 to 15.9%.

CONCLUSIONS

Routine use of WBCT is not superior to a combination of conventional radiography, ultrasound and focused CT in terms of mortality. The entire process involving the introduction of the trauma scan and the further development of algorithms has caused changes that can be observed in the trauma room setting.

Early computed tomography or focused assessment with sonography in abdominal trauma: what are the leading opinions?

PURPOSE

The initial assessment of severely injured patients in the resuscitation room requires a systematic and quickly performed survey. Whereas the Advanced Trauma Life Support (ATLS^®)-based algorithm recommends focused assessment with sonography in trauma (FAST) among others, recent studies report a survival advantage of early whole-body computed tomography (WBCT) in haemodynamically stable as well as unstable patients. This study assessed the opinions of trauma surgeons about the early use of WBCT in severely injured patients with abdominal trauma, and abdominal CT in patients with isolated abdominal trauma, during resuscitation room treatment.

METHODS

An online cross-sectional survey was performed over 8 months. Members of the Swiss Society for Surgery and the Austrian and German associations for trauma surgery were invited to answer nine online questions.

RESULTS

Overall, 175 trauma surgeons from 155 departments participated. For haemodynamically stable patients, most considered FAST (77.6%) and early CT (82.3%) to be the ideal diagnostic tools. For haemodynamically unstable patients, 93.4% considered FAST to be mandatory. For CT imaging in unstable patients, 47.5% agreed with the use of CT, whereas 52.5% rated early CT as not essential. For unstable patients with pathological FAST and clinical signs, 86.8% agreed to proceed with immediate laparotomy.

CONCLUSIONS

Most surgeons rely on early CT for haemodynamically stable patients with abdominal trauma, whereas FAST is performed with similar frequency and is prioritized in unstable patients. It seems that the results of recent studies supporting early WBCT have not yet found broad acceptance in the surgical community.

Whole body CT versus selective radiological imaging strategy in trauma: an evidence-based clinical review

BACKGROUND

Trauma patients often present with injuries requiring resuscitation and further evaluation. Many providers advocate for whole body computed tomography (WBCT) for rapid and comprehensive diagnosis of life-threatening injuries.

OBJECTIVE

Evaluate the literature concerning mortality effect, emergency department (ED) length of stay, radiation, and incidental findings associated with WBCT.

DISCUSSION

Physicians have historically relied upon history and physical examination to diagnose life-threatening injuries in trauma. Diagnostic imaging modalities including radiographs, ultrasound, and computed tomography have demonstrated utility in injury detection. Many centers routinely utilize WBCT based on the premise this test will improve mortality. However, WBCT may increase radiation and incidental findings when used without considering pre-test probability of actionable traumatic injuries. Studies supporting WBCT are predominantly retrospective and incorporate trauma scoring systems, which have significant design weaknesses. The recent REACT-2 trial randomized trauma patients with high index of suspicion for actionable injuries to WBCT versus selective imaging and found no mortality difference. Additional prospective trials evaluating WBCT in specific trauma subgroups (e.g. polytrauma) are needed to evaluate benefit. In the interim, the available data suggests clinicians should adopt a selective imaging strategy driven by history and physical examination.

CONCLUSIONS

While observational data suggests an association between WBCT and a benefit in mortality and ED length of stay, randomized controlled data suggests no mortality benefit to this diagnostic tool. The literature would benefit from confirmatory studies of the use of WBCT in trauma sub-groups to clarify its impact on mortality for patients with specific injury patterns.

Evaluation of a new imaging tool for use with major trauma cases in the emergency department

BACKGROUND

The aim of this study was to evaluate potential benefits of a new diagnostic software prototype (Trauma Viewer, TV) automatically reformatting computed tomography (CT) data on diagnostic speed and quality, compared to CT-image data evaluation using a conventional CT console.

METHODS

Multiple trauma CT data sets were analysed by one expert radiology and one expert traumatology fellow independently twice, once using the TV and once using the secondary conventional CT console placed in the CT control room. Actual analysis time and precision of diagnoses assessment were evaluated. The TV and CT-console results were compared respectively, but also a comparison to the initial multiple trauma CT reports assessed by emergency radiology fellows considered as the gold standard was performed. Finally, design and function of the Trauma Viewer were evaluated in a descriptive manner.

RESULTS

CT data sets of 30 multiple trauma patients were enrolled. Mean time needed for analysis of one CT dataset was 2.43 min using the CT console and 3.58 min using the TV respectively. Thus, secondary conventional CT console analysis was on average 1.15 min shorter compared to the TV analysis. Both readers missed a total of 11 diagnoses using the secondary conventional CT console compared to 12 missed diagnoses using the TV. However, none of these overlooked diagnoses resulted in an Abbreviated Injury Scale (AIS) > 2 corresponding to life threatening injuries.

CONCLUSIONS

Even though it took the two expert fellows a little longer to analyse the CT scans on the prototype TV compared to the CT console, which can be explained by the new user interface of the TV, our preliminary results demonstrate that, after further development, the TV might serve as a new diagnostic feature in the trauma room management. Its high potential to improve time and quality of CT-based diagnoses might help in fast decision making regarding treatment of severely injured patients.

The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma: A retrospective cohort study

We aimed to evaluate the benefit of whole-body computed tomography (WBCT) scanning for unconscious adult patients suffering from high-energy multiple trauma compared with the conventional stepwise approach of organ-selective CT.Totally, 144 unconscious patients with high-energy multiple trauma from single level I trauma center in North Taiwan were enrolled from January 2009 to December 2013. All patients were managed by a well-trained trauma team and were suitable for CT examination. The enrolled patients are all transferred directly from the scene of an accident, not from other medical institutions with a definitive diagnosis. The scanning regions of WBCT include head, neck, chest, abdomen, and pelvis. We analyzed differences between non-WBCT and WBCT groups, including gender, age, hospital stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, time in emergency department (ED), medical cost, and survival outcome.Fifty-five patients received the conventional approach for treating trauma, and 89 patients received immediate WBCT scanning after an initial examination. Patients' time in ED was significantly shorter in the WBCT group in comparison with the non-WBCT group (158.62 ± 80.13 vs 216.56 ± 168.32 min, P = 0.02). After adjusting for all possible confounding factors, we also found that survival outcome of the WBCT group was better than that of the non-WBCT group (odds ratio: 0.21, 95% confidence interval: 0.06-0.75, P = 0.016).Early performing WBCT during initial trauma management is a better approach for treating unconscious patients with high-energy multiple trauma.

Dose reduction in 64-row whole-body CT in multiple trauma: an optimized CT protocol with iterative image reconstruction on a gemstone-based scintillator

OBJECTIVE

Evaluation of potential dose savings by implementing adaptive statistical iterative reconstruction (ASiR) on a gemstone-based scintillator in a clinical 64-row whole-body CT (WBCT) protocol after multiple trauma.

METHODS

Dose reports of 152 WBCT scans were analysed for two 64-row multidetector CT scanners (Scanners A and B); the main scanning parameters were kept constant. ASiR and a gemstone-based scintillator were used in Scanner B, and the noise index was adjusted (head: 5.2 vs 6.0; thorax/abdomen: 29.0 vs 46.0). The scan length, CT dose index (CTDI) and dose-length product (DLP) were analysed. The estimated mean effective dose was calculated using normalized conversion factors. Student's t-test was used for statistics.

RESULTS

Both the mean CTDI (mGy) (Scanner A: 53.8 ± 2.0, 10.3 ± 2.5, 14.4 ± 3.7; Scanner B: 48.7 ± 2.2, 7.1 ± 2.3, 9.1 ± 3.6; p < 0.001, respectively) and the mean DLP (mGy cm) (Scanner A: 1318.9 ± 167.8, 509.3 ± 134.7, 848.8 ± 254.0; Scanner B: 1190.6 ± 172.6, 354.6 ± 128.3, 561.0 ± 246.7; p < 0.001, respectively) for the head, thorax and abdomen were significantly reduced with Scanner B. There was no relevant difference in scan length. The total mean effective dose (mSv) was significantly decreased with Scanner B (24.4 ± 6.0, 17.2 ± 5.8; p < 0.001).

CONCLUSION

The implementation of ASiR and a gemstone-based scintillator allows for significant dose savings in a clinical WBCT protocol.

ADVANCES IN KNOWLEDGE

Recent technical developments can significantly reduce radiation dose of WBCT in multiple trauma. Dose reductions of 10-34% can be achieved.

Multidisciplinary sliding-gantry CT: from concept to reality

Sliding-gantry computed tomography offers an interesting variety of treatment options for emergency radiology and clinical routine. The Frankfurt 2-room installation provides an interdisciplinary, multifunctional, and cost-effective concept. It is based on a magnetically sealed rail system for the permanent movement of the gantry between 2 adjacent rooms with fixed-mounted tables. In case of emergency or intensive care patients, routine scanning can be performed in room 1 until computed tomography diagnosis is required in room 2 and can then be continued in room 1 again. Moreover, this concept allows the simultaneous handling of 2 emergency patients.

Effect of the localisation of the CT scanner during trauma resuscitation on survival -- a retrospective, multicentre study

INTRODUCTION

Whole-body computed tomography (WBCT) is increasingly becoming the standard diagnostic technique during the resuscitation of severely injured patients. However, little is known about the ideal localisation of the CT scanner within the emergency setting. We intended to analyse the potential effect of the localisation of the CT scanner on outcome.

PATIENTS AND METHODS

In a retrospective multicentre cohort study involving 8004 adult blunt major trauma patients out of 312 hospitals, we analysed the effect of the distance of the trauma room to the CT scanner on the outcome. Three groups were built: 1. CT in the trauma room 2. CT equal or less than 50 m away and 3. CT more than 50 m away. Using data derived from the 2007-2011 version of TraumaRegister DGU(®) and the structure data bank of the TraumaNetzwerk DGU(®) (trauma network, TNW; German Trauma Society, DGU) we determined the observed and predicted mortality and calculated the standardised mortality ratio (SMR) as well as logistic regressions.

RESULTS

n=8004 patients fulfilled the inclusion criteria: their mean age was 46.4 ± 21.0 years. 72.8% of them were male and the mean injury severity score (ISS) was 28.6 ± 11.8. The overall mortality rate was 16.0%. The mean time from hospital admission to whole-body CT was 17.1 ± 12.3 min for group 1, 22.7 ± 15.5 min for group 2 and 27.7 ± 17.1 min for group 3, p<0.001. Risk adjusted SMR was 0.74 (CI 95% 0.67-0.81) in group 1, 0.81 (CI 95% 0.76-0.87) in group 2, and 0.88 (CI 95% 0.79-0.98) in group 3. SMR group 1 vs. SMR group 2: p=0.130. SMR group 2 vs. SMR group 3: p=0.170. SMR group 1 vs. SMR group 3: p=0.016. SMR groups 1+2 vs. SMR group 3: p=0.046. Comparable data were found for the subgroup analysis of Level-I trauma centres only. Logistic regression confirmed the positive effect of a close localisation of the CT to the trauma room. The odds ratio (OR) was lowest for the localisation of the CT in the trauma room (OR 0.68, CI 95% 0.54-0.86, p<0.001).

CONCLUSIONS

It was proven for the first time that a close distance of the CT scanner to the trauma room has a significant positive effect on the probability of survival of severely injured patients. The closer the CT is located to the trauma room, the better the probability of survival. Distances of more than 50 m had a significant negative effect on the outcome. If new emergency departments are planned or rebuilt, the CT scanner should be placed less than 50 m away from or preferably in the trauma room.

[Emergency room management of multiple trauma : ATLS® and S3 guidelines]

Trauma management in the emergency room is an important part of the treatment chain of the severely injured. Important decisions with respect to diagnostics and treatment must be made under time pressure. Successful trauma management in the emergency room requires a hospital tailored treatment protocol. This written protocol needs consent from all participating disciplines and must be known by all members of the resuscitation team. The ATLS® and the recently published clinical practice guidelines on multiple trauma can be of help in order to establish or update such protocols. In order to continuously evaluate and improve performance in the emergency room local quality circles are needed that truly follow that aim. Important factors are reliability of agreement between the different disciplines and continuous communication of results to the team members. In order to be successful such quality circles need people that care.

Use of multidetector computed tomography to guide management of pneumothorax

PURPOSE OF REVIEW

Pneumothorax, a potentially life-threatening condition, is present in about one-third of chest trauma patients. Traditionally, pneumothorax has been diagnosed and managed by use of chest radiography, which has been found inaccurate and inconsistent. With the ubiquitous application of multidetector computed tomography (MDCT) in emergency care, MDCT quantification of pneumothoraces becomes an emerging technique for accurate determination of the size of pneumothoraces. The use of MDCT quantification provides a promising means to improve pneumothorax management.

RECENT FINDINGS

Recent studies have demonstrated that MDCT is the gold standard for detecting pneumothorax and MDCT provides an effective imaging modality for the accurate measurement of the volume of pneumothoraces. The use of MDCT volumetric quantification of pneumothoraces has been evidenced in the improvement of performance in pneumothorax management for clinically stable chest trauma patients.

SUMMARY

The MDCT volumetric quantification of pneumothoraces is a new concept in the care of chest trauma patients and has the potential to improve pneumothorax management. Further clinical studies are needed to establish a MDCT-based clinical guideline for pneumothorax management.

Dose reduction in whole-body computed tomography of multiple injuries (DoReMI): protocol for a prospective cohort study

BACKGROUND

Single-pass, contrast-enhanced whole body multidetector computed tomography (MDCT) emerged as the diagnostic standard for evaluating patients with major trauma. Modern iterative image algorithms showed high image quality at a much lower radiation dose in the non-trauma setting. This study aims at investigating whether the radiation dose can safely be reduced in trauma patients without compromising the diagnostic accuracy and image quality.

METHODS/DESIGN

Prospective observational study with two consecutive cohorts of patients.

SETTING

A high-volume, academic, supra-regional trauma centre in Germany.

STUDY POPULATION

Consecutive male and female patients who 1. had been exposed to a high-velocity trauma mechanism, 2. present with clinical evidence or high suspicion of multiple trauma (predicted Injury Severity Score [ISS] ≥16) and 3. are scheduled for primary MDCT based on the decision of the trauma leader on call.Imaging protocols: In a before/after design, a consecutive series of 500 patients will undergo single-pass, whole-body 128-row multi-detector computed tomography (MDCT) with a standard, as low as possible radiation dose. This will be followed by a consecutive series of 500 patients undergoing an approved ultra-low dose MDCT protocol using an image processing algorithm.

DATA

Routine administrative data and electronic patient records, as well as digital images stored in a picture archiving and communications system will serve as the primary data source. The protocol was approved by the institutional review board.

MAIN OUTCOMES

(1) incidence of delayed diagnoses, (2) diagnostic accuracy, as correlated to the reference standard of a synopsis of all subsequent clinical, imaging, surgical and autopsy findings, (3) patients' safety, (4) radiation exposure (e.g. effective dose), (5) subjective image quality (assessed independently radiologists and trauma surgeons on a 100-mm visual analogue scale), (6) objective image quality (e.g., contrast-to-noise ratio).

ANALYSIS

Multivariate regression will be employed to adjust and correct the findings for time and cohort effects. An exploratory interim analysis halfway after introduction of low-dose MDCT will be conducted to assess whether this protocol is clearly inferior or superior to the current standard.

DISCUSSION

Although non-experimental, this study will generate first large-scale data on the utility of imaging-enhancing algorithms in whole-body MDCT for major blunt trauma.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN74557102.

Dose effects and image quality: is there any influence by bearing devices in whole-body computed tomography in trauma patients?

BACKGROUND

Stable bearing devices are often utilized by prehospital first responders in modern management of severely injured patients. It is not known whether these devices influence radiation exposure or image quality in whole-body computed tomography (WBCT). Additionally, manufacturers currently provide no specifications concerning these criteria. This investigation analyzed the influence of nine different bearing devices on these specified criteria.

METHODS

The influence of nine different bearing devices on radiation exposure and image quality in WBCT was investigated. The dose-length-product (DLP100) was obtained through use of a CT-ionisation chamber placed in the centre of a 32 cm CT-phantom and compared with a reference value. Moreover, the results were calculated as effective dose data E (mSv). The image quality was assessed by three expert radiologists using the following scoring scale (0=no artefacts; 1=minor artefacts; 2=clearly artefacts; 3=massive artefacts).

RESULTS

Out of nine bearing devices examined, four showed significantly higher (2.5-4.5%, p<0.05) DLP100 and five showed no significant difference between DLP100 and the reference value. The image quality was classified in the categories "0", "1", "2" and "3" in 4, 3, 1 and 1 case, respectively.

CONCLUSIONS

In diagnostic producers using WBCT, bearing devices may be associated with relevant increases in radiation dose and can affect the image assessability. Some bearing devices are associated with no significant influence on radiation dose and reduction of image quality. Considering all results to get the best balance between image quality and radiation dose, aluminium and metal-free devices should be preferred.

Whole-body CT in haemodynamically unstable severely injured patients--a retrospective, multicentre study

BACKGROUND

The current common and dogmatic opinion is that whole-body computed tomography (WBCT) should not be performed in major trauma patients in shock. We aimed to assess whether WBCT during trauma-room treatment has any effect on the mortality of severely injured patients in shock.

METHODS

In a retrospective multicenter cohort study involving 16719 adult blunt major trauma patients we compared the survival of patients who were in moderate, severe or no shock (systolic blood pressure 90-110,<90 or >110 mmHg) at hospital admission and who received WBCT during resuscitation to those who did not. Using data derived from the 2002-2009 version of TraumaRegister®, we determined the observed and predicted mortality and calculated the standardized mortality ratio (SMR) as well as logistic regressions.

FINDINGS

9233 (55.2%) of the 16719 patients received WBCT. The mean injury severity score was 28.8±12.1. The overall mortality rate was 17.4% (SMR  = 0.85, 95%CI 0.81-0.89) for patients with WBCT and 21.4% (SMR = 0.98, 95%CI 0.94-1.02) for those without WBCT (p<0.001). 4280 (25.6%) patients were in moderate shock and 1821 (10.9%) in severe shock. The mortality rate for patients in moderate shock with WBCT was 18.1% (SMR 0.85, CI95% 0.78-0.93) compared to 22.6% (SMR 1.03, CI95% 0.94-1.12) to those without WBCT (p<0.001, p = 0.002 for the SMRs). The mortality rate for patients in severe shock with WBCT was 42.1% (SMR 0.99, CI95% 0.92-1.06) compared to 54.9% (SMR 1.10, CI95% 1.02-1.16) to those without WBCT (p<0.001, p = 0.049 for the SMRs). Adjusted logistic regression analyses showed that WBCT is an independent predictor for survival that significantly increases the chance of survival in patients in moderate shock (OR = 0.73; 95%CI 0.60-0.90, p = 0.002) as well as in severe shock (OR = 0.67; 95%CI 0.52-0.88, p = 0.004). The number needed to scan related to survival was 35 for all patients, 26 for those in moderate shock and 20 for those in severe shock.

CONCLUSIONS

WBCT during trauma resuscitation significantly increased the survival in haemodynamically stable as well as in haemodynamically unstable major trauma patients. Thus, the application of WBCT in haemodynamically unstable severely injured patients seems to be safe, feasible and justified if performed quickly within a well-structured environment and by a well-organized trauma team.

Blunt polytrauma: evaluation with 64-section whole-body CT angiography

Blunt polytrauma remains a leading cause of death and disability worldwide. With the major advances in computed tomography (CT) technology over the past decade, whole-body CT is increasingly recognized as the emerging standard for providing rapid and accurate diagnoses within the narrow therapeutic window afforded to trauma victims with multiple severe injuries. With a single continuous acquisition, whole-body CT angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis. As its use becomes more widespread, the large volume of information inherent to whole-body CT poses new challenges to radiologists in providing efficient and timely interpretation. An awareness of trauma scoring systems and injury mechanisms is essential to maintain an appropriate level of suspicion in the search for multiple injuries, and the use of multiplanar reformation and three-dimensional postprocessing techniques is important to maximize efficiency in the search. Knowledge of the key injuries that require urgent surgical or percutaneous intervention, including major vascular injuries and active hemorrhage, diaphragmatic rupture, unstable spinal fractures, pancreatic injuries with ductal involvement, and injuries to the mesentery and hollow viscera, is also necessary.

Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients

BACKGROUND

The aim of this review was to assess the value of immediate total-body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT.

METHODS

A systematic search of the literature was performed in MEDLINE, Embase, Web of Science and Cochrane Library databases. Reports were eligible if they contained original data comparing immediate total-body CT with conventional imaging supplemented with selective CT in injured patients. The main outcomes of interest were overall mortality and time in the emergency room (ER).

RESULTS

Four studies were included describing a total of 5470 patients; one study provided 4621 patients (84.5 per cent). All four studies were non-randomized cohort studies with retrospective data collection. Mortality was reported in three studies. Absolute mortality rates differed substantially between studies, but within studies mortality rates were comparable between immediate total-body CT and conventional imaging strategies (pooled odds ratio 0.91, 95 per cent confidence interval 0.79 to 1.05). Time in the ER was described in three studies, and in two was significantly shorter in patients who underwent immediate total-body CT: 70 versus 104 min (P = 0.025) and 47 versus 82 min (P < 0.001) respectively.

CONCLUSION

This review showed differences in time in the ER in favour of immediate total-body CT during the primary trauma survey compared with conventional radiographic imaging supplemented with selective CT. There were no differences in mortality. The substantial reduction in time in the ER is a promising feature of immediate total-body CT but well designed and larger randomized studies are needed to see how this will translate into clinical outcomes.

MDCT quantification is the dominant parameter in decision-making regarding chest tube drainage for stable patients with traumatic pneumothorax

It is commonly believed that the size of a pneumothorax is an important determinant of treatment decision, in particular regarding whether chest tube drainage (CTD) is required. However, the volumetric quantification of pneumothoraces has not routinely been performed in clinics. In this paper, we introduced an automated computer-aided volumetry (CAV) scheme for quantification of volume of pneumothoraces in chest multi-detect CT (MDCT) images. Moreover, we investigated the impact of accurate volume of pneumothoraces in the improvement of the performance in decision-making regarding CTD in the management of traumatic pneumothoraces. For this purpose, an occurrence frequency map was calculated for quantitative analysis of the importance of each clinical parameter in the decision-making regarding CTD by a computer simulation of decision-making using a genetic algorithm (GA) and a support vector machine (SVM). A total of 14 clinical parameters, including volume of pneumothorax calculated by our CAV scheme, was collected as parameters available for decision-making. The results showed that volume was the dominant parameter in decision-making regarding CTD, with an occurrence frequency value of 1.00. The results also indicated that the inclusion of volume provided the best performance that was statistically significant compared to the other tests in which volume was excluded from the clinical parameters. This study provides the scientific evidence for the application of CAV scheme in MDCT volumetric quantification of pneumothoraces in the management of clinically stable chest trauma patients with traumatic pneumothorax.

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2)

BACKGROUND

Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients.

METHODS/DESIGN

The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness.

DISCUSSION

The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group.

TRIAL REGISTRATION

ClinicalTrials.gov: (NCT01523626).

The role of early multislice computed tomography in major trauma

Whole-body multislice spiral computed tomography (MSCT) has become a very important dignostic tool in the management of patients with multiple injuries. Many reports exist which demonstrate the feasibility and the benefit when using whole-body MSCT in the early phase of in-hospital management of trauma patients. Even in hemodynamically instable patients (except cardiac arrest), whole-body MSCT can be used and is a safe diagnostic procedure. While the diagnostic superiority of multislice computed tomography is proven for different organ regions (e.g. head/brain, chest, abdomen, pelvis and spine), its use as a single whole-body scan is still part of an ongoing discussion. Especially concerns about radiation exposure are the reason for uncertainty about when using whole-body trauma scan. Predefined scan protocols and individual positioning of patients may help to keep radiation dose as minimal as possible. To justify higher radiation dose, the indication must be chosen appropriately. Therefore, the use of a sensitive and specific triage scheme seems to be reasonable. Overscanning patients with minor trauma needs to be avoided, while the benefit for patients with severe multiple injuries is obvious.

Radiation exposure in whole-body computed tomography of multiple trauma patients: bearing devices and patient positioning

BACKGROUND

Whole-body computed tomography (WBCT) plays an important role in the management of severely injured patients. We evaluated the radiation exposure of WBCT scans using different positioning boards and arm positions.

METHODS

In this retrospective study, the radiation exposure of WBCT using a 16-slice multislice computed tomography scanner was evaluated. Individual effective doses (E, mSV) was calculated. Patients were assigned to two groups according to placement on a plastic transfer mat (PTM, group 1) or on the Trauma Transfer™-Board (TTB, group 2). Data were collected for each group with arm placement on the abdomen (a) or in raising position (b), respectively. The maximum ventro-dorsal diameter [VDD] at the trunk was measured.

RESULTS

100 patients with potentially life-threatening injuries were analysed. Patient demographics and VDD did not differ in the two groups. Radiation exposure in term of E did not reveal any significant differences between the two positioning boards using same arm position [group 1a (n=26) vs. 2a (n=24) (mSV): 16.7±4.7 vs. 17.1±4.4, group 1b (n=26) vs. 2b (n=24) (mSV): 13.1±3.9 vs. 14.3±1.5]. The arm raising positioning showed a significant reduction in E in comparison to the placement on abdomen position [group 1b vs. 1a (mSV): 13.1±3.9 vs. 16.7±4.7, p<0.05, group 2b vs. 2a (mSV): 14.3±1.5 vs. 17.1±4.4, p<0.05].

CONCLUSIONS

Patient arm positioning for WBCT has an important influence on radiation exposure. Effective dose was 16-22% lower when arms were raised. An individual placement algorithm may lead to a relevant reduction of radiation exposure of severely injured patients.

64-MDCT in mass casualty incidents: volume image reading boosts radiological workflow

OBJECTIVE

The purpose of this study was to evaluate the impact of the use of 64-MDCT and volume image reading on the radiologic workflow during a mass casualty incident simulation.

MATERIALS AND METHODS

For this simulation, casualties were taken to our level I trauma center, and triage was done with whole-body 64-MDCT. The complete raw dataset of thin-section images was sent to a dedicated 3D workstation for further interpretation and simultaneous reformations. This new reading method is called volume image reading. Several time frames were documented to evaluate the workflow: examination time, time needed for image processing, and mean image transfer rates. The results were compared with those of a previous study using a 4-MDCT with axial images only and transfer of data to a PACS.

RESULTS

The time for complete image processing (acquisition, reconstruction, and transfer) for 64-MDCT was 4.1 minutes (range, 3.9-4.3 minutes) compared with 9.0 minutes (range, 6.4-10.2 minutes) for 4-MDCT (p ≤ 0.001). The image processing capacity was 14.8 examinations/h for 64-MDCT compared with 6.7 examinations/h for 4-MDCT. The mean number of images was 953 for 64-MDCT compared with 202 for 4-MDCT (p ≤ 0.001). There were no significant differences between 64- and 4-MDCT for the time needed to prepare patients.

CONCLUSION

The use of 64-MDCT with volume image reading led to evident advantages in the radiologic trauma workflow compared with 4-MDCT. Reading of the full image set including reformations can be initiated earlier with volume image reading.

Pediatric Polytrauma Management

Caring for pediatric trauma patients requires an understanding of the distinct anatomy and pathophysiology of the pediatric population compared to adult trauma patients. Initial evaluation, management, and resuscitation are performed as a multidisciplinary approach including pediatric physicians, trauma surgeons, and pediatric intensive care physicians. Head injury severity is the principle determinant of outcome and mortality in polytraumatized children. Abdominal injuries rarely require surgery in contrast to adults, but need to be detected. Spine and pelvic injuries as well as injuries of the extremities require age-adapted surgical procedures. However, the degree of recovery in polytraumatized children is often remarkable, even after apparently devastating injuries. Maximal care should, therefore, be rendered under the assumption that a complete recovery will be made.

[Different case fatality rates at German trauma centres : Critical analysis]

OBJECTIVE

The level of trauma care in Germany belongs to one of the best worldwide. Nevertheless, previous studies have shown significant differences in the case fatality rates of multiple trauma patients in German trauma centres. The objective of this study was to indentify the reasons for the different outcomes based on data of the trauma registry of the German Society of Orthopaedic Surgery and Traumatology.

METHODS

Due to the inadequacy of comparing only the case fataltiy rates in the different trauma centres, the data recorded in the trauma registry were analyzed in a retrospective, multicentre study to calculate the probability of survival, revised injury severity classification (RISC) and, additionally, the standardized mortality ratio (SMR) for ranking of the participating trauma centres. As a criterion for inclusion in the study, a minimum of 100 trauma patients admitted directly from the scene within a 4 year period was set. The ranking was carried out using the SMR (observed mortality divided by probability of survival). With the help of data from the trauma registry an attempt was made to find the differences in trauma management between the top 10 centres (lowest SMR), the 10 middle and the last 10 centres (highest SMR) in the ranking.

RESULTS

The data of 6,522 patients were included in the study. There were significant differences in the pre-hospital time, the time spent in the emergency room (ER) and time until a CT scan had been performed. Pre-hospital time was longer in patients admitted to the top centres, whereas time in the ER was longer in the last centres of the ranking. Comparing the sum of pre-hospital time and time in the ER, there were no differences between the top and the last centres. At the scene of accident overall intubation rate and intubation rate in patients with traumatic brain injury were higher in patients admitted to the top centres. Regarding the transport modality, significantly more patients were transported by helicopter in the group of the top centres. In top centres CT scans, in particular whole-body CTs, were initiated sooner and used much more frequently so that the rate of missed injuries was much lower. The amount of fluid given at the scene of accident did not differ between the centres but the amount of fluid given in ER and the operating room until admission to the intensive care unit was significantly higher in the top centres.

CONCLUSION

There are significant differences in the pre-hospital and clinical care of patients admitted to German trauma centres. Under clinical conditions a tight time management, an immediate and complete diagnostic approach, particularly by means of whole-body CT and a liberal fluid resuscitation seem to be favorable factors.

Trauma management incorporating focused assessment with computed tomography in trauma (FACTT) - potential effect on survival

Background

Immediate recognition of life-threatening conditions and injuries is the key to trauma management. To date, the impact of focused assessment with computed tomography in trauma (FACTT) has not been formally assessed. We aimed to find out whether the concept of using FACTT during primary trauma survey has a negative or positive effect on survival.

Methods

In a retrospective, multicentre study, we compared our time management and probability of survival (Ps) in major trauma patients who received FACTT during trauma resuscitation with the trauma registry of the German Trauma Society (DGU). FACTT is defined as whole-body computed tomography (WBCT) during primary trauma survey. We determined the probability of survival according to the Trauma and Injury Severity Score (TRISS), the Revised Injury Severity Classification score (RISC) and the standardized mortality ratio (SMR).

Results

We analysed 4.817 patients from the DGU database from 2002 until 2004, 160 (3.3%) were from our trauma centre at the Ludwig-Maximilians-University (LMU) and 4.657 (96.7%) from the DGU group. 73.2% were male with a mean age of 42.5 years, a mean ISS of 29.8. 96.2% had suffered from blunt trauma. Time from admission to FAST (focused assessment with sonography for trauma)(4.3 vs. 8.7 min), chest x-ray (8.1 vs. 16.0 min) and whole-body CT (20.7 vs. 36.6 min) was shorter at the LMU compared to the other trauma centres (p < 0.001). SMR calculated by TRISS was 0.74 (CI95% 0.40-1.08) for the LMU (p = 0.24) and 0.92 (CI95% 0.84-1.01) for the DGU group (p = 0.10). RISC methodology revealed a SMR of 0.69 (95%CI 0.47-0.92) for the LMU (p = 0.043) and 1.00 (95%CI 0.94-1.06) for the DGU group (p = 0.88).

Conclusion

Trauma management incorporating FACTT enhances a rapid response to life-threatening problems and enables a comprehensive assessment of the severity of each relevant injury. Due to its speed and accuracy, FACTT during primary trauma survey supports rapid decision-making and may increase survival.

[Multiple trauma in pediatric patients]

Important prerequisites to adequately treat pediatric patients with multiple trauma are a profound knowledge of the underlying mechanisms of injury, common injury patterns and the associated mortality. The younger the child the more injury patterns as well as organ-specific injury severity differ in comparison to adult trauma patients. Traumatic brain and thorax injuries are the key to the prognosis of the injured child. Abdominal injuries rarely require surgery in contrast to adults. Spine and pelvic injuries as well as injuries of the extremities make age-adapted surgical procedures mandatory. The present article describes the established primary diagnostic evaluation after admittance to the emergency room as well as specific treatment options for particular organ systems with respect to age-specific anatomical characteristics and pitfalls in children.

[Time intervals during and after emergency room treatment. An analysis using the trauma register of the German Society for Trauma Surgery]

BACKGROUND

The prognosis of severely injured patients depends on a rapid diagnosis and early initiation of therapeutic procedures.

MATERIAL AND METHODS

To that end a total of 6,927 prospectively documented severely injured patients with an Injury Severity Score (ISS) > or =16 from the Trauma Registry of the German Trauma Society (DGU, 2002-2007) were analyzed with respect to time intervals during emergency trauma treatment.

RESULTS

In cases of indicated emergency surgery the average +/-time in the emergency department was 42+/-34 min, in cases of early surgery 75+/-41 min and in cases of transfer to the intensive care unit (ICU) 83+/-43 min, respectively. The time from the last diagnostic procedure until the end of emergency treatment was 12 min (emergency surgery), 26 min (early surgery) and 32 min (ICU), respectively. Level I (78 min) and level II (72 min) trauma centres showed similar mean times in the emergency department while level III trauma centres had a mean time of 86 min. According to this analysis no general correlation between shorter duration of emergency trauma care and reduced mortality could be observed.

CONCLUSION

The duration of time intervals depends on injury severity, treatment after completion of emergency trauma care and the level of the trauma centre. Time management in emergency trauma care can potentially be optimized after completion of the last diagnostic procedure in the emergency room.

[Emergency room management of severely injured patients]

BACKGROUND

In cases involving major trauma life-threatening situations should be immediately diagnosed and treated. Clinical algorithms can potentially decrease the rate of complications and errors. The purpose of this study was to investigate the incidence of deviations from a multislice computed tomography based trauma room algorithm.

MATERIALS AND METHODS

During a primary trauma survey an independent study monitor observed the on site treatment sequence step by step. Time intervals between admission and start of each procedure were recorded. Deviations from the algorithm and delays were analyzed.

RESULTS

In 57 trauma patients a total of 49 deviations were documented. Median time between admission and transfer to the adjacent MSCT room was 9 min. Of the patients 11 were bypassed to the MSCT suite without a primary survey (19.3%). In 2 cases an absence of non-invasive blood pressure monitoring was recorded (3.5%) and 3 patients with potential cervical spine trauma were not immobilized at the scene or during primary survey (5.3%). In 8 cases focused assessment with sonography for trauma (FAST) was not performed (14%). Contrary to the algorithm 10 patients received an arterial or central venous line during initial treatment (18%) resulting in a median delay of 8 min. The deviations from the algorithm resulted in no adverse effects on complications or mortality.

CONCLUSION

Self-critical analysis of trauma resuscitation can increase the quality of treatment by revealing constantly recurring faults.

[Herniation of the middle lobe of the right lung due to a coarsely dislocated sternum fracture]

In cases of multiple trauma in patients with an injury severity score (ISS) > or =16 chest injuries, abbreviated injury scale (AIS) > or =3, are also sustained in 57.2% of all patients. Life-threatening complications may occur with lung contusions and rib fractures also in combination with hemothorax/pneumothorax being the most common diagnoses. In addition the lungs can also be functionally impaired by ruptures of the great thoracic vessels or in isolated cases by herniation of lung tissue following tears in the wall of the thorax. A case of multiple trauma in a 44-year-old male (ISS 29) with blunt thoracic trauma resulting in herniation of the middle lobe of the right lung into the subcutaneous tissue due to a coarsely dislocated fracture of the sternum is reported. This still ventilated lung tissue was surgically resituated 4 weeks after the event and the sternum fracture was simultaneously stabilized by plate osteosynthesis. Clinical examination and awareness of the possibility of other injuries (high level of suspicion) are essential. Therefore, standard diagnostic procedures combined with multislice computed tomography during the first examination and reassessment should be included to avoid missed injuries.

Changes in transfusion practice in multiple injury between 1993 and 2006: a retrospective analysis on 5389 patients from the German Trauma Registry

To evaluate transfusion practices in multiple injured patients and to demonstrate changes in the pattern of packed red blood cell (pRBC) transfusions over the last one-and-half decade (1993-2006). A retrospective analysis using the German Trauma Registry database (DGU-Traumaregister) including 29 353 multiple injured patients was conducted. The study population included primary admissions presenting to the emergency room (ER) with clinical and laboratory signs of active haemorrhage [haemoglobin < 9 g x dL(-1), platelets < 90000 xmicroL(-1) and prothrombin time (Quick-value) < 60%]. The pattern of pRBC transfusions was followed from ER to intensive care unit (ICU) admission. A total of 5389 patients with complete data sets were divided into the following three groups according to the year of treatment and analysed: (a) group 1: 1993-1998 (n = 870), (b) group 2: 1999-2002 (n = 2044) and (c) group 3: 2003-2006 (n = 2475). Patients had a mean age of 40.5 (+/-20) years and were predominantly male (67.2%). All patients were substantially injured (mean injury severity score = 32 +/- 15.5) and in 93% the mechanism of injury was blunt. The percentage of patients who received pRBC transfusions between ER and ICU dropped from 72% in 1993-1998 to 54% in 2003-2006 (P < 0.005). Similarly, the percentage of patients receiving mass transfusions (> 10 pRBC units) dropped from 51.3 to 17.1%. This decline was accompanied by lower incidence rates for septic complications, ventilator days, ICU length-of-stay and mortality. pRBC transfusion practices in acute trauma care have changed substantially over the last one-and-half decade and were associated with better outcome.

[Polytrauma management in a period of change: time analysis of new strategies for emergency room treatment]

BACKGROUND

Quality management and the early implementation of whole-body multi-slice spiral computed tomography (whole-body MSCT) are becoming increasingly important in the management of patients with multiple trauma. The aim of this study was to evaluate both components with respect to the time factor for treatment.

METHODS

The investigation involved a retrospective data analysis of the time needed in the emergency room for the initial stabilization (phase A), completing the diagnosis (phase B) and the emergency room treatment (phase C). The investigation included three groups: trauma patients imaged in the emergency room with conventional imaging procedures (group I), with whole-body MSCT alone (group II) and those who were imaged with whole-body MSCT after the introduction of a quality management system with standard operating procedures (group III).

RESULTS

The times for resuscitation (phase A), for diagnostic evaluation (phase B) and for total treatment (phase C) were analyzed. The times for phase A were for group I (n=79) 10 min (interquartile range, IQR 8-12 min), group II (n=82) 13 min (IQR 10-17 min) and group III (n=79) 10 min (IQR 8-15 min; p<0.001). The times for phase B were 70 min (IQR 56-85 min) for group I, 23 min (IQR 17-33 min) for group II and 17 min (IQR 13-21 min; p<0.001) for group III. For phase C the times were 82 min (IQR 66-110 min) for group I, 47 min (IQR 37-59 min) for group II and 42 min (IQR 34-52 min; p<0.05) for group III.

CONCLUSION

Quality management and the early implementation of whole-body MSCT can accelerate the treatment work flow. A rapid initial diagnosis represents an important component in the high quality of treatment of polytrauma patients.

[Primary care hospital for a mass disaster MANV IV. Experience from a mock disaster exercise]

BACKGROUND

In Hannover and in nationwide contingency plans there are clear instructions for the medical care of mass casualties which are designed to cope with 50 to a maximum of 200 patients. Disaster simulations and practical exercises in Hannover regarding EXPO 2000 and the FIFA World Cup 2006 showed a very good and effective prehospital treatment and management up to a number of about 200 patients. Due to infrastructural settings a scenario with up to 1,000 (MANV IV) patients in the region of Hannover was beyond the capacity of existing concepts for the management of mass casualties, which comprised initial medical care at the on-site treatment area and subsequent transport to local or regional hospitals for definitive management. A new practicable and well trained model was necessary to improve the hospital admission and primary treatment capacity (Erstversorgungsklinik--EVK). In the case of MANV IV it was proposed that the tasks of on-site treatment area should be concentrated on triage and the stabilization of severely injured victims with immediate transport to special primary care hospitals. The main task of these hospitals was further stabilization of patients for inhospital care or further transport to other special facilities.

METHODS

The main aim of the study was, after the initial trauma scenario, to provide the logistical and personal background for the fastest possible advanced life support and the further treatment of more than 60 severely injured patients at a city hospital with trauma centre level I experience. The timescale from the first alarm until the hospital was ready for action was approximately 60 min. To gain knowledge about the regional implementation of the whole logistic scenario in the case of MANV IV and to practice detailed questioning, a major casualty training was needed. This resulted in a large targeted disaster medical training with a realistic situation simulation on the 25.03.2006 including the Diakoniekrankenhaus Friederikenstift under the aspect of a special primary care hospital (EVK) working at full capacity.

RESULTS

The AWD arena in Hannover was the site of a simulated major casualty event resulting in 620 patients with various penetrating or blunt trauma injuries. Within 60 min of the first alarm call the admission and casualty treatment capacity at the Diakoniekrankenhaus Friederikenstift was increased up to approximately 60 patients including 30 ventilated patients. After initial inspection of 78 patients according to the ATLS criteria advanced life support was performed (airway management, volume resuscitation, basic diagnostic and surgical techniques) by flexible treatment teams (including physicians of all other faculties) in 3 treatment corridors within 135 min. Of the patients 69 were admitted to the wards and intensive care units, 5 were discharged after ambulant treatment and 3 patients were transferred to an eye and ENT hospital. Of the patients 10 had already been intubated on arrival, another 6 patients were intubated in the treatment corridors. Simulations of 4 urgent laparatomies, 2 trepanations, 1 artery seam, osteosynthesis of 3 perforating fractures was performed in the operating theatre. A total of 6 extremity fractures were immobilized by a fixateur externe, 7 chest tubes were placed and 43 surgical wound dressings were performed in the treatment corridors. There was no significant shortage of logistical or personal resources.

CONCLUSION

In a major disaster with more than 200 seriously injured patients the EVK model is a practicable and regional well tried solution that could increase the capacity of hospital admissions and advanced trauma life support, regardless of the type of casualty, season or weather conditions. It is possible to reduce the interval to advanced trauma life support, temporary fracture stabilization (damage control) and definitive surgical care by means of rapid and targeted utilization of resources and manpower. Physicians involved in the initial treatment play a key role and have to be highly trained (ATLS). The EVK model is variable and can easily be established and adapted to regional conditions at basic regional hospitals as well as at level I trauma centers.

[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.

Patterns of mortality and causes of death in polytrauma patients--has anything changed?

INTRODUCTION

Numerous articles have examined the pattern of traumatic deaths. Most of these studies have aimed to improve trauma care and raise awareness of avoidable complications. The aim of the present review is to evaluate whether the distribution of complications and mortality has changed.

MATERIALS AND METHODS

A review of the published literature to identify studies examining patterns and causes of death following trauma treated in level 1 hospitals published between 1980 and 2008. PubMed was searched using the following terms: Trauma Epidemiology, Injury Pattern, Trauma Deaths, and Causes of Death. Three time periods were differentiated: (n=6, 1980-1989), (n=6, 1990-1999), and (n=10, 2000-2008). The results were limited to the English and/or German language. Manuscripts were analysed to identify the age, injury severity score (ISS), patterns and causes of death mentioned in studies.

RESULTS

Twenty-two publications fulfilled the inclusion criteria for the review. A decrease of haemorrhage-induced deaths (25-15%) has occurred within the last decade. No considerable changes in the incidence and pattern of death were found. The predominant cause of death after trauma continues to be central nervous system (CNS) injury (21.6-71.5%), followed by exsanguination (12.5-26.6%), while sepsis (3.1-17%) and multi-organ failure (MOF) (1.6-9%) continue to be predominant causes of late death.

DISCUSSION

Comparing manuscripts from the last three decades revealed a reduction in the mortality rate from exsanguination. Rates of the other causes of death appear to be unchanged. These improvements might be explained by developments in the availability of multislice CT, implementation of ATLS concepts and logistics of emergency rescue.

Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study

BACKGROUND

The number of trauma centres using whole-body CT for early assessment of primary trauma is increasing. There is no evidence to suggest that use of whole-body CT has any effect on the outcome of patients with major trauma. We therefore compared the probability of survival in patients with blunt trauma who had whole-body CT during resuscitation with those who had not.

METHODS

In a retrospective, multicentre study, we used the data recorded in the trauma registry of the German Trauma Society to calculate the probability of survival according to the trauma and injury severity score (TRISS), revised injury severity classification (RISC) score, and standardised mortality ratio (SMR, ratio of recorded to expected mortality) for 4621 patients with blunt trauma given whole-body or non-whole-body CT.

FINDINGS

1494 (32%) of 4621 patients were given whole-body CT. Mean age was 42.6 years (SD 20.7), 3364 (73%) were men, and mean injury-severity score was 29.7 (13.0). SMR based on TRISS was 0.745 (95% CI 0.633-0.859) for patients given whole-body CT versus 1.023 (0.909-1.137) for those given non-whole-body CT (p<0.001). SMR based on the RISC score was 0.865 (0.774-0.956) for patients given whole-body CT versus 1.034 (0.959-1.109) for those given non-whole-body CT (p=0.017). The relative reduction in mortality based on TRISS was 25% (14-37) versus 13% (4-23) based on RISC score. Multivariate adjustment for hospital level, year of trauma, and potential centre effects confirmed that whole-body CT is an independent predictor for survival (p </= 0.002). The number needed to scan was 17 based on TRISS and 32 based on RISC calculation.

INTERPRETATION

Integration of whole-body CT into early trauma care significantly increased the probability of survival in patients with polytrauma. Whole-body CT is recommended as a standard diagnostic method during the early resuscitation phase for patients with polytrauma.

FUNDING

None.