Multislice-Spiral-CT zur Diagnostik beim Polytrauma

A silver bullet? The role of radiology information system data mining in defining gunshot injury trends at a South African tertiary-level hospital

Background

South Africa (SA) has no national injury surveillance system, and hence, non-fatal gunshot injuries are not routinely recorded. Most firearm-related injuries require multi-detector computer tomography (MDCT) assessment at a tertiary-level facility. MDCT scanning for victims with gunshot injuries thus provide an indication of the societal burden of firearm trauma. The potential of the modern radiology information system (RIS) to serve as a robust research tool in such settings is not fully appreciated.

Objective

The aim of this study was to evaluate the use of institutional RIS data in defining MDCT scanning trends for gunshot victims presenting to a tertiary-level SA hospital.

Method

A single-institution, retrospective, comparative study was conducted at the Tygerberg Hospital (TBH) Trauma Unit for the years 2013 and 2018. Using data-mining software, customised RIS searches for information on all gunshot-related emergency computed tomography scans in the respective years were performed. Demographic, temporal, anatomical and scan-protocol trends were analysed by cross tabulation, Chi-squared and Fisher’s exact tests.

Results

Gunshot-related emergency MDCT scans increased by 62% (546 vs. 887) from 2013 to 2018. Lower-limb CT angiography was the commonest investigation in both periods. A higher proportion of victims in 2018 sustained thoracic injuries (12.5% vs. 19.8%; p < 0.01) and required imaging of more than two body parts (13.1% vs. 19.2%; p < 0.01).

Conclusion

By using RIS data to demonstrate the increasing gunshot-related MDCT workload in the review period, as well as a pattern of more complex and potentially life-threatening injury, this study highlights the burden of firearm trauma in the society and the potential role of the modern RIS as a robust research tool.

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.

[Costs and proceeds from patients admitted via the emergency room with mild craniocerebral trauma]

The introduction of the diagnosis-related groups (DRG) in 2003 radically changed the billing of the treatment costs. From the very beginning, trauma surgeons questioned whether the introduction of the DRG could have a negative impact on the care of the severely injured. "Trauma centers in need" was the big catchword warning against shortfalls at trauma centers due to the billing via DRG. This situation was confirmed in the first publications after introduction of the DRG, showing a clearly deficient level of care of polytrauma cases. Over the years, adjustments have led to an improvement in the remuneration for polytraumatized patients. In the emergency room, polytrauma is not always the final diagnosis. A considerable proportion of patients are only slightly injured, but must be admitted via the emergency room due to the circumstances of the accident or suspected diagnosis at the scene of the accident to exclude life-threatening injuries. In this study, patients with the billing diagnosis of mild craniocerebral trauma were selected as an example. The proportion of these patients was 22% during the period of observation in 2017. For these patients, the proportional costs during treatment were calculated. It could be shown that 60.36% of the costs during a 2‑day treatment of these patients were incurred in the emergency room. Costs for material and personnel could not be considered. Despite not including these expenses, the costs were never covered for any of these patients. For patients with slight injuries after trauma management in the emergency room, the present adjustments to the DRG system by increasing the basic case value seem to be insufficient. Additional remuneration for these patients seems absolutely justified to further ensure adequate quality of care.

The Role of the Integrated Digital Radiology System in Assessing the Impact of Patient Load on Emergency Computed Tomography (CT) Efficiency

Time-critical management is of particular significance in the trauma and emergency setting, where intervals from patient arrival to diagnostic imaging and from imaging to radiology report are key determinants of outcome. This study, based in the Trauma and Emergency Unit of a large, tertiary-level African hospital with a fully digital radiology department, assessed the impact of increased workload on computerised tomography (CT) efficiency. Sequential, customised searches of the institutional radiology information system (RIS) were conducted to define two weekends in 2016 with the lowest and highest emergency CT workloads, respectively. The electronic RIS timestamps defining the intervals between key steps in the CT workflow were extracted and analysed for each weekend. With the exception of radiologist reporting time, workflow steps were significantly prolonged by increased workload. This study highlights the potential role of the integrated digital radiology system in enabling a detailed analysis of imaging workflow, thereby facilitating the identification and appropriate management of bottlenecks.

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.

Indications for total-body computed tomography in blunt trauma patients: a systematic review

PURPOSE

Total-body CT scanning (TBCT) could improve the initial in-hospital evaluation of severe trauma patients. Indications for TBCT, however, differ between trauma centers, so more insight in how to select patients that could benefit from TBCT is required. The aim of this review was to give an overview of currently used indications for total-body CT in trauma patients and to describe mortality and Injury Severity Scores of patient groups selected for TBCT.

METHODS

A systematic review was performed by searching MEDLINE and Embase databases. Studies evaluating or describing criteria for selection of patients with potentially severe injuries for TBCT during initial trauma care were included. Also, studies comparing total-body CT during the initial assessment of injured patients with conventional imaging and selective CT in specific patient groups were included.

RESULTS

Thirty eligible studies were identified. Three studies evaluated indications for TBCT in trauma with divergent methods. Combinations of compromised vital parameters, severe trauma mechanisms and clinical suspicion on severe injuries are often used indications; however, clinical judgement is used as well. Studies describing TBCT indications selected patients in different ways and were difficult to compare regarding mortality and injury severity.

CONCLUSIONS

Indications for TBCT in trauma show a wide variety in structure and cut-off values for vital parameters and trauma mechanism dimensions. Consensus on indications for TBCT in trauma is lacking.

Split bolus technique in polytrauma: a prospective study on scan protocols for trauma analysis

BACKGROUND

For the evaluation of severely injured trauma patients a variety of total body computed tomography (CT) scanning protocols exist. Frequently multiple pass protocols are used. A split bolus contrast protocol can reduce the number of passes through the body, and thereby radiation exposure, in this relatively young and vitally threatened population.

PURPOSE

To evaluate three protocols for single pass total body scanning in 64-slice multidetector CT (MDCT) on optimal image quality.

MATERIAL AND METHODS

Three total body CT protocols were prospectively evaluated in three series of 10 consecutive trauma patients. In Group A unenhanced brain and cervical spine CT was followed by chest-abdomen-pelvis CT in portovenous phase after repositioning of the arms. Group B underwent brain CT followed without arm repositioning by a one-volume contrast CT from skull base to the pubic symphysis. Group C was identical to Group A, but the torso was scanned with a split bolus technique. Three radiologists independently evaluated protocol quality scores (5-point Likert scale), parenchymal and vascular enhancement and artifacts.

RESULTS

Overall image quality was good (4.10) in Group A, more than satisfactory (3.38) in Group B, and nearly excellent (4.75) in Group C (P < 0.001). Interfering artifacts were mostly reported in Group B in the liver and spleen.

CONCLUSION

In single pass total body CT scanning a split bolus technique reached the highest overall image quality compared to conventional total body CT and one-volume contrast CT.

Outcomes of polytrauma patients with diabetes mellitus

BACKGROUND

The impact of diabetes mellitus in patients with multiple system injuries remains obscure. This study was designed to increase knowledge of outcomes of polytrauma in patients who have diabetes mellitus.

METHODS

Data from the Trauma Audit and Research Network was used to identify patients who had suffered polytrauma during 2003 to 2011. These patients were filtered to those with known outcomes, then separated into those with diabetes, those known to have other co-morbidities but not diabetes and those known not to have any co-morbidities or diabetes. The data were analyzed to establish if patients with diabetes had differing outcomes associated with their diabetes versus the other groups.

RESULTS

In total, 222 patients had diabetes, 2,558 had no past medical co-morbidities (PMC), 2,709 had PMC but no diabetes. The diabetic group of patients was found to be older than the other groups (P <0.05). A higher mortality rate was found in the diabetic group compared to the non-PMC group (32.4% versus 12.9%), P <0.05). Rates of many complications including renal failure, myocardial infarction, acute respiratory distress syndrome, pulmonary embolism and deep vein thrombosis were all found to be higher in the diabetic group.

CONCLUSIONS

Close monitoring of diabetic patients may result in improved outcomes. Tighter glycemic control and earlier intervention for complications may reduce mortality and morbidity.

[The TraumaRegister DGU® as the basis of medical quality management. Ten years experience of a national trauma centre exemplified by emergency room treatment]

BACKGROUND

The trauma register of the German Society of Trauma Surgery (TraumaRegister DGU®/TR-DGU) has been proven to be a valuable tool for external assessment of quality in the treatment of patients with major trauma. This publication shows for the first time how the quality of trauma treatment in a level I trauma centre could be improved over a period of almost ten years with the help of continuous quality management, i.e. recognizing a problem, developing a solution and evaluating its effect.

MATERIALS AND METHODS

Tracer parameters and indicators of quality are presented in four periods over a total study period from 1st January 1989 to 31st March 2007. The division into four periods is due to major changes in the trauma treatment algorithms or structural changes in the trauma room. The results are displayed for all patients treated in the trauma room and for those patients with an injury severity score (ISS)≥16.

RESULTS

Over all four periods a total number of n=2,239 patients were admitted to the trauma room. Based on the results of the trauma register a number of changes were made, not only structural changes, such as the introduction of point-of-care diagnostics, initially conventional X-ray, then digital X-ray and finally multislice computed tomography (CT) scanning in the trauma room but also changes in the way personnel participating in the trauma treatment are trained. Advanced trauma life support (ATLS®) has become the standard training for doctors and prehospital trauma life support (PHTLS®) for nurses. Time efficient treatment algorithms were introduced. All measures led to changes in several parameters which are chosen as indicators for good treatment quality. It was for instance possible to reduce the average total trauma treatment time for patients with an ISS≥16 from initially 90.9±48.6 min to 37.4±18.  min in the final study period.

CONCLUSIONS

The external quality management performed by the TR-DGU has proved to be a constant source of inspiration. The effects of the changes made can be scientifically proven. It is to be discussed to what extent a sole external quality management can be useful.

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.

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).

[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.

Three-dimensional scanning with dual-source computed tomography in patients with acute skeletal trauma

OBJECTIVE

The aim of this study was to compare the efficiency of multiplanar reformatted images and three-dimensional images created after multidetector computed tomography examination in detecting acute posttraumatic osseous pathology of the skeletal system.

METHOD

Between October 2006 and December 2008, 105 patients with a history of acute trauma were referred to our service. Patients were evaluated with multidetector computed tomography using multiplanary reconstructed images initially (R-I), and six months after this initial evaluation, three-dimensional images were assessed of each patient (R-II). Axial images were used for guiding as a reference Data obtained was recorded and graded according to importance levels of the pathologies.

RESULTS

The R-II score was higher in the non-articular and highest in periartricular fractures of the extremities, and thoracic and pelvic cage injuries. For the spinal column, while R-I data was more significant In patients referred with polytrauma, R-II data, was more statistically significant, for short processing and adaptation time to acquiring immediate critical information. For all cases it was seen that three dimensional scans were more efficient in providing the orientation, within a short time.

CONCLUSION

By dual source multidedector tomography systems trauma patients may be evaluated by multiplanary and three dimensionally reconstructed images. When used correctly, three dimensional imaging is advantageous and can help determine the exact nature and extension and also importance of osseous injuries.

MDCT evaluation of injuries after tram accidents in pedestrians

Multidetector computed tomography (MDCT) is especially suited for emergency diagnostics in multiple trauma patients. The objectives of this study were to investigate the types and frequencies of injuries associated with tram accidents in pedestrians. Eighteen consecutive pedestrian patients with multiple traumas after tram accidents were evaluated with MDCT in our Level I Trauma Center. The mean age in our patient cohort was 36.9 years with a range from 14-92 years. There was a trend for accident events occurring more commonly during the winter months in middle-aged men, often under the influence of alcohol. Patients were divided into two groups with unilateral or complex injury patterns. In both groups, leading diagnoses were head (83.3%) and thorax injuries (66.6%). Abdominal injuries (44.4%) were less common and mainly found in the complex injuries group. The most serious injuries occurred in the complex injuries group when the victim was caught under or between tramcars. A wide range of injuries is associated with tram accidents in pedestrians, which can be classified into two main injury patterns, unilateral and complex. The life-limiting injuries in this setting involved the head with a mortality rate of 22.2% (four patients) in our cohort.

[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.

Five years experience of trauma care in a German urban level I university trauma center

BACKGROUND

A regionalized approach to trauma care with the implementation of designated level I trauma centers has been shown to improve survival after multiple injuries. Our study aimed to describe the current reality in an urban German level I university trauma center concerning the primary admission of patients into the emergency room.

MATERIALS AND METHODS

We performed a retrospective analysis of all multiple trauma patients that were prospectively documented in our documentation system TraumaWatch(®) from 2003 to 2007. Documentation included physiological findings as well as diagnostic and therapeutic procedures structured as: (A) preclinical phase; (B) emergency room treatment; (C) intensive care unit; and (D) final outcome according to the German Trauma Registry.

RESULTS

In total, 1,848 patients were completely documented and, thus, analyzed. The mean ± standard deviation (SD) Injury Severity Score (ISS) was 16.5 ± 14.1 points and the mean ± SD age was 38.7 ± 21.9 years. An increasing number of patients received whole-body computed tomography (48.8% in 2003 vs. 83.3%in 2007, p < 0.001) and, on average, the ISS increased over the years (14.4 points in 2003 vs. 17.9 points in 2007). The overall hospital mortality was 7.1%, without significant change over time. The completionofimagingdiagnostics became significantly faster for all of the documented procedures (X-ray pelvis, X-ray chest, whole-body CT, abdominal ultrasound) (p < 0.001).

DISCUSSION

Descriptive data on the current reality in urban level I trauma care can be derived from our study. Additionally, we achieved improved time intervals for emergency diagnostics and treatment, while hospital mortality remained constant, despite a higher injury severity. This is due to a standardized protocol which is applied during the 24-h in-house attending coverage.

CONCLUSION

Regionalized trauma care with designated level I trauma centers is justified by the improvement of time intervals and outcome, but adequate resources are required.

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.

Whole-body multislice computed tomography as the first line diagnostic tool in patients with multiple injuries: the focus on time

OBJECTIVE

Whole-body multislice helical computed tomography (MSCT) becomes increasingly important as a diagnostic tool in patients with multiple injuries. We describe time requirement of two different diagnostic approaches to multiple injuries one with whole-body-MSCT (MSCT Trauma-Protocol) as the sole radiologic procedure and one with conventional use of radiography, combined with abdominal ultrasound and organ focused CT (Conventional-Trauma-Protocol).

METHODS

Observational study with retrospective analysis of time requirements for resuscitation, diagnostic workup and transfer to definitive treatment after changing from conventional to MSCT Trauma-Protocol. Group I: data from trauma patients imaged with whole-body MSCT. Group II: data of trauma patients investigated with conventional trauma protocol before the introduction of MSCT-Trauma-Protocol.

RESULTS

The complete diagnostic workup in group I (n = 82) was finished after 23 minutes (17-33 minutes) [median; interquartile range (IQR)] and after 70 minutes (IQR, 56-85) in group II (n = 79). The definitive management plan based on a completed diagnostic workup was devised after 47 minutes (IQR, 37-59) in group I and after 82 minutes (IQR, 66-110) in group II.

CONCLUSION

A whole-body MSCT-based diagnostic approach to multiple injuries might shorten the time interval from arrival in the trauma emergency room until obtaining a final diagnosis and management plan in patients with multiple injuries and might, therefore, contribute to improvements in patient care.

Initial clinical experience with a 64-MDCT whole-body scanner in an emergency department: better time management and diagnostic quality?

BACKGROUND

The objective of this study was to assess time management and diagnostic quality when using a 64-multidetector-row computed tomography (MDCT) whole-body scanner to evaluate polytraumatized patients in an emergency department.

METHODS

Eighty-eight consecutive polytraumatized patients with injury severity score (ISS) > or = 18 (mean ISS = 29) were included in this study. Documented and evaluated data were crash history, trauma mechanism, number and pattern of injuries, injury severity, diagnostics, time flow, and missed diagnoses. Data were stored in our hospital information system. Seven time intervals were evaluated. In particular, attention was paid to the "acquisition interval," the "reformatting and evaluation time" as well as the "CT time" (time from CT start to preliminary diagnosis). A standardized whole-body CT was performed. The acquired CT data together with automatically generated multiplanar reformatted images ("direct MPR") were transferred to a 3D rendering workstation. Diagnostic quality was determined on the basis of missed diagnoses. Head-to-toe scout images were possible because volume coverage was up to 2 m. Experienced radiologists at an affiliated workstation performed radiologic evaluation of the acquired datasets immediately after acquisition.

RESULTS

The "acquisition interval" was 12 minutes +/- 4.9 minutes, the "reformatting and evaluation interval" 7.0 minutes +/- 2.1 minutes, and the "CT time" 19 minutes +/- 6.1 minutes. Altogether, 7 of 486 lesions were recognized but not communicated in the "reformatting and evaluation interval", and 10 injuries were initially missed and detected during follow-up.

CONCLUSION

This study indicates that 64-MDCT saves time, especially in the "reformatting and evaluation interval." Diagnostic quality is high, as reflected by the small number of missed diagnoses.

[Management of ipsilateral femoral neck and shaft fractures]

PURPOSE

The combination of ipsilateral femoral neck and shaft fractures remains a treatment challenge in orthopedic surgery because both fracture types constitute separate entities and require specific treatment concepts.

MATERIAL AND METHODS

In a case control study, incidence, treatment strategies, and outcomes of this injury were analyzed. All patients with femoral fractures treated between 1 January 2001 and 31 July 2007 at a level I trauma center were included in the study.

RESULTS

Twenty-one out of 1,935 patients (1.1%) sustained 22 combined fractures of the femoral neck and shaft. Also considering the combination of femoral shaft fractures with fractures of the acetabulum and the distal femur (knee), the proportion of chain injuries of the femur was 3.1%. The rate of multiply injured patients in the group of patients with ipsilateral femoral neck and shaft fractures was 64%. The majority of the patients could be treated with a single implant for both fracture components. The leading fracture component was the femoral neck fracture in eight cases. All fractures consolidated after 4.7 months on average; one pseudarthrosis of the femoral neck was observed. All fractures were discovered in the course of primary diagnostic measures; in 73% of the patients, a computed tomography (CT) body scan was done. Fifty-nine percent of the patients with ipsilateral femoral neck and shaft fractures received primary definitive operative care. Complications included two torsional failures that needed correction and one case of postoperative infection that was easily treated.

CONCLUSION

Treatment of ipsilateral femoral neck and shaft fractures is still demanding, but diagnosis has improved with regular use of CT body scans in the management of multiply injured patients. Furthermore, possibilities for operative treatment have been advanced by the introduction of the long proximal femoral nail and the antegrade femoral nail, two implants supporting stabilization of these fracture entities.

The use of intraoperative three-dimensional imaging (ISO-C-3D) in fixation of intraarticular fractures

INTRODUCTION

The purpose of this study was to analyse the applicability and advantages of the intraoperative use of a mobile isocentric C-arm with three-dimensional imaging (Siremobil ISO-C-3D) in fixation of intraarticular fractures.

METHODS

After the fixation was judged to be satisfactory relying on the images provided by routine fluoroscopy, intraoperative CT visualisation with ISO-C-3D was performed to evaluate the fracture reduction and implant position. Intraoperative revision was performed based on the additional information ISO-C-3D provided beyond routine fluoroscopy. ISO-C-3D was used on a series of 72 closed-intraarticular fractures in 70 patients. Fracture distribution was: calcaneus (25), tibial plateau (17), tibial plafond (12), acetabulum (11), distal radius (3), ankle Weber-C (3) and femoral head (l). The primary outcome measure was revision rate after final ISO-C-3D data acquisition and prior to wound closure. Secondary objectives were to measure the additional time required for ISO-C-3D use and to determine the rate of further re-do surgeries.

RESULTS

Eight out of 72 (11%) fracture fixations were judged by the surgeon to require intraoperative revision following ISO-C-3D imaging. Prior to leaving the operating room, the surgeon was satisfied with fracture alignment in all the procedures. The mean additional operative time using ISO-C-3D was 7.5 min (8.2% of the mean total operative time). No patient required re-do surgery.

CONCLUSION

: Intraoperative three-dimensional visualisation of intraarticular fractures enables the surgeon to identify inadvertent malreductions or implant malpositions which may be overlooked by routine C-arm fluoroscopy and hence may eliminate the need for re-do procedures. ISO-C-3D adds little operative time and may preclude the need for pre-operative and post-operative CT-scans in selected cases.

[Emergency treatment of thoracic trauma]

Thoracic trauma, most often associated with other serious injuries, is the main cause of death in the first 45 years of life. The percentage of chest injuries in multiple trauma, mainly from blunt impact, has remained relatively constant at 80% during the last 30 years. Isolated thoracic injuries comprise only 25% of all trauma cases, 90% of chest injuries are due to blunt impact, while penetrating injuries make up 5-10%. Since 25% of deaths from trauma are attributable to chest injuries, they determine the survival rate in multiple trauma to a significant extent. The pattern of chest injuries is variable, frequently in different combinations comprising rib cage and diaphragm, lung parenchyma, airway and mediastinal organs. This article details the immediate simultaneous diagnostic and therapeutic procedures in the prehospital phase, management in the emergency room, the relative importance of computed tomography, ultrasound examination and endoscopy in the primary diagnostic evaluation and the principles of anaesthetic management of thoracic trauma.