Frühes klinisches Management nach Polytrauma mit 1- und 4-Schicht-Spiral-CT

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.

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.

[Polytrauma with pelvic fractures and severe thoracic trauma: does the timing of definitive pelvic fracture stabilization affect the clinical course?]

BACKGROUND

The aim of this study was to investigate the influence of the surgical timing in patients with pelvic fractures and severe chest trauma on the clinical course, especially on postoperative lung function.

METHODS

A total of 47 patients were included in a prospective dual observational study. The study investigated the clinical course depending on the time of operation based on the functional lung parameters, SAPS II, SOFA and total hospital stay.

RESULTS

The average ISS was 32±6, PTS was 34±11 and TTSS was 9±3 points. The pelvic fractures were stabilized definitively after an average of 7±2 days. The early stabilization correlated significantly with a lower TTSS and SAPS II on admission (p<0.05), shorter time of ventilation (p<0.05) and stay in the intensive care unit (p<0.01) as well as the decreased need for packed red blood cells (p<0.01).

CONCLUSIONS

In this study patients with pelvic fractures and thoracic trauma benefited positively from an earlier definitive pelvic fracture stabilization with respect to a shorter time of ventilation and stay in the intensive care unit due to a lower need for red cell concentrates.

[German trauma centers: level-dependent differences in polytrauma care regarding resources and diagnostic concepts]

BACKGROUND

The aim was to survey the radiological diagnostics and type of primary radiological examination of polytraumatized patients treated in German hospitals at various levels in the three-tiered system.

MATERIAL AND METHODS

A questionnaire was sent in October 2007 to every traumatology department registered in the DGU (German Society for Trauma Surgery) databank and forms returned by January 2008 were included in this study.

RESULTS

A total of 273 (54.71 %) of forms were returned and were applicable to statistical analysis. In the three-tiered hospital system 35.9 % of returned questionnaires came from third-tier hospitals, 41.02 % from second-tier and 23.08 % from highest tier (maximum care) hospitals. With a higher hospital level of inpatient care more computed tomography (CT) scans were examined by a radiologist during 24 h daily (p = 0.0014) and CT scanners were located closer to the resuscitation room (p < 0.0001). We found significant differences in the ratios of primary whole-body CTs (WBCT) performed depending on the hospital level: third-tier hospitals 44 %, second tier hospitals 67 % and maximum care hospitals 84 % (p < 0.05).

CONCLUSIONS

Standardized structures regarding radiological diagnostics of polytraumatized patients do not exist at either the same level of the three-tiered hospital system or between levels of care of German hospitals..

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.

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.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Computed tomography imaging strategies and perspectives in orbital fractures

Objective:

The objective of this study was to demonstrate the sensitivity and specificity of multislice computed tomography (CT) for diagnosis of orbital fractures following different protocols, using an independent workstation.

Materials and methods:

CT images of 36 patients with maxillofacial fractures (symptomatic to orbit region) who were submitted to multislice CT scanning were analyzed, retrospectively. The images were interpreted based on 5 protocols, using an independent workstation: 1) axial (original images); 2) multiplanar reconstruction (MPR); 3) 3D images; 4) association of axial/MPR/3D images and 5) coronal images. The evaluated anatomical sites were divided according to the orbital walls: lateral (with or without zygomatic frontal process fracture); medial; superior (roof) and inferior (anterior, medial). The collected data were analyzed statistically using a validity test (Youden's J index; p<0.05). The clinical and/or surgical findings (medical records) were considered as the gold standard to corroborate the diagnosis of the anatomical localization of the orbital fracture.

Results:

3D-CT scanning presented sensitivity of 78.9%, which was not superior to that of MPR (84.0%), axial/MPR/3D (90.5%) and coronal images (86.1%). On the other hand, the diagnostic value of axial images was considered limited for orbital fractures region, with sensitivity of 44.2%.

Conclusions:

Except for the axial images, which presented a low sensitivity, all methods evaluated in this study showed high specificity and sensitivity for the diagnosis of orbital fractures according to the proposed methodology. This protocol can add valuable information to the diagnosis of fractures using the association of axial/MPR/3D with multislice CT.

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.

[Modern imaging techniques for liver trauma]

Involvement of the liver is one of the most common injuries in addition to those of the pancreas following blunt force abdominal trauma. Due to the even now high mortality radiological imaging must provide a rapid, definitive and exact assessment of the extent of the damage. Despite conflicting study results ultrasound has become established as a rapid and relatively simple method in emergency room treatment and is irreplaceable for initial orientation diagnostics. The use of contrast medium-assisted examinations promises to be an advantage for diagnostics in the secondary phase. Due to the high sensitivity and specificity modern multidetector computed tomography is the most effective examination modality for the detection of liver damage and hepatobiliary complications and plays a central role in non-operative management following abdominal trauma. Shorter and shorter scan times even allow the examination of metastable patients and a rapid assessment even of large body volumes.

[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.

Distribution of Spinal and Associated Injuries in Multiple Trauma Patients

Injury to the spinal column and cord are often part of life-threatening multiple trauma. Epidemiological data could help to establish an evidence-based assessment and therapy of these patients. We present a retrospective chart analysis of 590 multiple traumatized patients admitted within a 4-year-period. Patients suffering from injuries of the spinal column were analysed regarding mechanism and distribution of their injuries to all body regions. Thirty-one percent (n = 183) of polytraumatized patients displayed a spine injury. Distribution analysis showed peaks in the cervical spine and the thoraco-lumbar junction. The risk of relevant associated injuries is mainly influenced from anatomical vicinity to the injured spinal segment. Injuries to the spinal column are frequent in the multiple trauma patients population. Diagnosed injuries to distinct body regions should make the trauma team suspicious of injury to the nearby spinal column. Appropriate treatment includes thorough assessment of all injuries to clarify the damage and carry on special protection of these spinal regions preventing from deterioration.

New aspects in the emergency room management of critically injured patients: a multi-slice CT-oriented care algorithm

BACKGROUND

Time-critical care of seriously injured patients is gaining more and more significance. The availability of the multi-slice CT allows a complete diagnostic assessment of injured patients in 90-240 s, but is presently carried out only at the conclusion of basic diagnostics. We investigated the effects of a clinical algorithm using multi-slice CT scanning ahead of other measures in the clinical care of seriously injured patients.

METHODS

Availability of a trauma admitting room with integrated multi-slice CT scanner enabled a new algorithm for patient care. We prospectively examined the time taken to reach established benchmarks in clinical care (completion of diagnosis, completion of resuscitation, exit from the trauma room) under this new approach. Data were collected for consecutive patients with serious injury (estimated injury severity score >15), and compared to historical data from the previous 2 years.

RESULTS

The new algorithm was employed in 139 patients with a mean ISS of 26.93. CT scanning was initiated 8 min (S.D. 5.7) after patient arrival, and concluded 13 min (S.D. 8.4) after patient arrival. Stabilising measures (initial resuscitation) were completed an average of 36 min from patient arrival. The length of stay in the trauma room was reduced to an average of 38 min (S.D. 19.1). Four patients required life-saving interventions after admission to the trauma room but before CT scanning began.

CONCLUSIONS

A new algorithm for trauma patient care that integrates high resolution CT scanning into the early diagnostic protocol reduces the length of stay in the trauma room markedly, and will facilitate rapid therapeutic intervention in patients with unstable haemorrhagic shock or neurosurgical emergencies.

Whole body 16-row multislice CT in emergency room: effects of different protocols on scanning time, image quality and radiation exposure

The objective of this study was to compare two different scanning protocols in patients suspected to have multiple trauma using multidetector 16-row computed tomography (CT) to better define scanning time, imaging quality and radiation exposure. Forty-six patients, between March 2004 and March 2005, with suspected multiple trauma (cerebral, spine, chest, abdominal and pelvis) were evaluated with two different protocols: Protocol "A" 26 patients; Protocol "B" 20 patients. Protocol A consists of a single-pass continuous whole-body acquisition (from vertex to pubic symphysis), whereas Protocol B of conventional segmented acquisition with scanning of body segments individually. Both protocols were performed using a multidetector 16-rows CT (Light-Speed 16, General Electric Medical System, Milwaukee, WI, USA) with the same technical factors. Radiation dose was evaluated in two ways: computer tomography dose index (CTDI) = dose measured in central and peripheral region of the subjects as a direct result of a CT section acquisition of T millimeters thick (independent from the two protocols) and dose length product (DLP) = total dose deposited over the length of the acquisition (dependent from the two protocols). Image quality was rated according to the following scores: 1, excellent; 2, good; 3, satisfactory; 4, moderate and 5, poor. The results were compared using Wilcoxon's test to identify significant difference in terms of image quality, scanning time, radiation exposure and presence of artifacts, assuming significance at a p value of <0.05. In the single-pass scanning, DLP was 2.671 mGy x cm and a total scan time of 35 s. In whole-body protocols, we have seen artifacts due to arm adduction in thorax and less image quality in brain. In the conventional segmented study, DLP was 3.217 mGy x cm and a total scan time of 65 s; this protocol offered less extraction capabilities of off-axial on focused images of the entire spine, aorta, facial bones or hip without rescanning. Protocol A revealed a significant decrease in scan time (35 vs 65 min, p < 0.05), time in the CT examination room (21.7 vs 31.6 min.; p < 0.05), and final image analysis (83.7 vs 102.9 min; p < 0.05) and radiation dose compared to protocol B (p < 0.05). No significant difference was found for patient transport time, image reconstruction time and imaging quality. Reconstruction and isotropic reformation of axial image acquired by whole-body, single-pass protocols due to entire spine evaluation, aortic and splanchnic CT angiography eliminate additional studies. The whole-body, single-pass protocols, compared with segmented acquisitions protocols, resulted in a reduced total radiation dose without relevant loss of diagnostic image information.

[Management of seriously injured patients without conventional radiography? Does a whole body MSCT scanner replace the conventional X-ray unit in the emergency room?]

BACKGROUND

[corrected] In the Wuerzburg University level one trauma centre, mobile whole-body multislice computed tomography (MSCT) is used as the primary diagnostic tool in multiple trauma patients. A conventional X-ray unit is not available directly in the resuscitation room of the trauma suite. Three cases are reported to discuss whether state-of-the-art trauma management can be done without conventional radiography.

METHODS

In each of the three cases reported here, an emergency situation has occurred in which the emergency diagnosis of the chest with the CT-scan was found to be difficult or impossible. These specific situations are described and discussed for each case and a conclusion is given at the end of this paper.

RESULTS

Three scenarios were identified in which conventional radiological diagnostics seemed to be necessary in the emergency room despite the availability of the MSCT. One is the patient undergoing cardiopulmonary resuscitation, the second is the patient that deteriorates after CT-diagnostic is completed and the third is technical problems with the CT-scanner.

CONCLUSION

Whole-body MSCT is not sufficient as the sole diagnostic tool in hemodynamically instable trauma patients requiring resuscitation and needs to be complemented by a conventional x-ray unit for emergency diagnosis of the chest.

Multislice-Spiral-CT zur Diagnostik beim Polytrauma

BACKGROUND

In severely injured patients, diagnostic procedures should be as brief as possible. With the use of spiral CT technology, the time required for diagnosis is minimized.

QUESTION

Do severely injured patients benefit when primary diagnostic examinations are completed in less than 30 min? How much time is required for primary emergency department (ED) care and how much in the CT scanner?

MATERIAL AND METHODS

Between 31 July 2001 and 31 December 2003, severely injured patients with ISS scores over 16 underwent total body spiral CT scans (Siemens Somatom Volume Zoom Multislice CT) after initial ultrasonography. One hundred patients (M:F=25:75) with an average age of 42 years (range: 3-81 years) were evaluated retrospectively. The average ISS score was 32.8+/-12 points (range: 17-75 points).

RESULTS

The average time in the ED, prior to CT, was 33+/-14 min. The CT scans lasted 16+/-5 min and the total diagnostic time was 48+/-14 min. Fifty percent of patients were taken immediately to the operating room. The mortality rate in hospital was 13%. The average hospital stay was 30 days, with an average ICU stay of 10 days.

CONCLUSION

The shorter the time spent in the ED, the shorter the stays in ICU and in total hospitalization were, regardless of injury severity. With structured management and shortening of diagnostic time with spiral CT, the time in the ED was decreased from 85 to 48 min.

Development of an accelerated MSCT protocol (Triage MSCT) for mass casualty incidents: comparison to MSCT for single-trauma patients

During multiple casualty incidents (MCI) emergency radiology departments have to deal with a large number of patients with suspected severe trauma within a short period of time. The aim of this study was to develop a suitable accelerated multislice computed tomography (MSCT) protocol to increase patient throughput for this kind of emergency situation. We presumed a scenario of 15 patients being admitted to the trauma service with suspicion of severe injuries after a MCI over a period of 2 h. An accelerated Triage MSCT protocol was developed and evaluated for MSCT scanner productivity (patients per hour) and time (minutes) needed for a total MSCT body workup using an anthropomorphic phantom. In addition, time (minutes) for transfer and preparation was measured. These timeframes were compared to a control group consisting of 144 single patients with multiple trauma undergoing standard MSCT according to our trauma room protocol. All MSCT studies were conducted using a 4-detector row scanner. (1) For the study group (Triage MSCT), average time for patient transfer and preparation was 2.9 min (2.5-4.3 min), mean CT examination time was 2.1 min (1.7-2.4 min); image reconstruction took 4.0 min (3.3-4.3 min). Total time in scanner room was 8.9 min (7.7-11.3 min), resulting in a maximal productivity of 6.7 patients per hour. Image transfer to the digital picture archive and communication system archive was completed after an average 9.5 min (8.9-10.8 min). (2) For the control group (single casualty MSCT), the mean time for patient transfer and preparation was 20.4 min (9.0-39.2 min), mean examination time was 6.0 min (3.1-11.3 min). Times for image reconstructions were not recorded in the patient series. Mean total time in scanner room was 25.3 min (11.0-72.4 min), resulting in a patient throughput of 2.4 patients per hour. MSCT has potential to serve as a powerful tool in triage of multiple casualty patients. The introduction of a Triage MSCT scanning protocol resulted in an increase of patient throughput per hour by a factor of almost 3.

Traumatic arterial injuries of the extremities: initial evaluation with MDCT angiography

OBJECTIVE

The purpose of this study was to retrospectively assess the accuracy of MDCT angiography as the initial diagnostic technique to depict arterial injury in patients with extremity trauma.

MATERIALS AND METHODS

Over 36 months, 87 patients (16 females and 71 males; age range, 16-87 years) with clinically suspected arterial injury after extremity trauma underwent 4-MDCT angiography and 67 ultimately underwent surgery. Eighty patients had blunt injuries, and seven had penetrating injuries. The presence of arterial involvement was investigated prospectively by the radiologist in charge and retrospectively by two independent radiologists. Each detected arterial lesion was then characterized as a spasm, stenosis, occlusion, or rupture. The standard of reference was surgery in 67 patients, angiography in two patients, and clinical and radiologic follow-up findings in 18 patients. MDCT angiography was assessed by means of receiver operating characteristic (ROC) curve analysis for lesion detection and Spearman's rank correlation test for lesion characterization. Image quality, lesion depiction, and artifacts were subjectively assessed.

RESULTS

Sixty-two traumatic arterial lesions were confirmed at surgery in 55 patients. MDCT angiography yielded high accuracy in detection (area under the ROC curve [Az] = 0.96; p < 0.001) and characterization (r = 0.94; p < 0.001) of traumatic arterial injuries and in recognizing an underlying dissection (Az= 0.82; p < 0.001). Prospective sensitivity and specificity were 95% and 87%, respectively, and retrospective sensitivity and specificity were 99% and 87%, respectively. MDCT angiography was considered to be sufficient for a reliable diagnosis in 83 patients (p < 0.001). Image quality and lesion depiction on MDCT angiograms were considered to be good and artifacts were considered mild with substantial interobserver agreement (kappa, 0.62-0.69).

CONCLUSION

MDCT angiography provides significant and reproducible technique for the detection and characterization of arterial injuries to the extremities with high image quality and vascular delineation.

[Management of spine injuries in polytraumatized patients]

The management of spine injuries in polytraumatized patients remains a great challenge for the diagnostic procedures and institution of appropriate treatment by integrating spinal trauma treatment into the whole treatment concept as well as following the treatment steps for the injured spine itself. The established concept of "damage control" and criteria regarding the optimal time and manner for operative treatment of the injured spine in the polytrauma setting is presented and discussed.

Multidetector computed tomography in acute joint fractures

Conventional radiography plays an essential diagnostic role in the primary evaluation of acute joint trauma. In complex fractures, however, computed tomography (CT) is an imaging modality often used second to radiography. As a result of technical breakthroughs in the field, multidetector CT (MDCT) allows faster imaging and better temporal, spatial, and contrast resolution compared with conventional single-slice spiral CT. MDCT with multiplanar reformation is helpful in disclosing fracture patterns, particularly in complex joint fractures, where they reveal occult fractures and show the exact number of fracture components and their degree of displacement.

Der Würzburger Schockraumalgorithmus

BACKGROUND

The purpose of this study was to show the practicability of a new algorithm in the management of polytraumatized patients based on Advanced Trauma Live Support (ATLS) and using mobile whole body multislice CT (MMDCT) as the primary imaging system.

PATIENTS AND METHODS

A series of 120 trauma patients referred to the Würzburg University Hospital Trauma Emergency Room were categorized into suspected polytrauma and suspected non-polytrauma groups. The polytraumatized patients were investigated using the Würzburg polytrauma-algorithm including whole body multislice CT with a 16-row-scanner. The algorithm is described. The time for the diagnostic procedure was measured and compared with data from the Trauma Registry of the German Society of Trauma Surgery.

RESULTS

From 120 patients 78 (66%) underwent whole body CT. The diagnostic procedure was quick with significant advantages especially for cranial and trunk diagnostics.

CONCLUSION

The Würzburg polytrauma algorithm worked well. There was excellent cooperation within the interdisciplinary leading team consisting of anaesthesiologists, surgeons, and radiologists. The principles of ATLS could be respected. Mobile whole body multislice CT was an effective tool in the diagnostic evaluation of polytrauma patients.

Evaluation of a 16-MDCT Scanner in an Emergency Department: Initial Clinical Experience and Workflow Analysis

OBJECTIVE

MDCT is especially suited for emergency purposes because it allows rapid high-resolution scans of large areas, fast high-quality reformatting in every orientation, and 3D illustration of the data set. In a prospective study, we evaluated the reliability and workflow of a dedicated emergency department 16-MDCT scanner in the management of patients presenting to the emergency department.

SUBJECTS AND METHODS

The use of a 16-MDCT scanner for 503 patients in the emergency department of a university clinic was evaluated. For reasons of workflow analysis, seven precise time intervals were recorded during the emergency examinations. A new setting for repositioning multiple-trauma patients after imaging of the head and neck from the head-first position to the feet-first position was introduced.

RESULTS

Six (1.2%) of the 503 patients were excluded because of technical malfunction or patient noncompliance. Image quality in the remaining 497 cases, including CT angiography and CT of multiple-trauma patients, was outstanding. Positioning of the patients took from 3 to 13 min depending on the body region examined, representing 33-67% of the mean room time, which ranged from 8 to 21 min. In multiple-trauma patients, the initial positioning took a mean of 6 min and repositioning took 8 min, representing 19% and 26% of total room time, respectively.

CONCLUSION

The use of a dedicated 16-MDCT scanner in the emergency department resulted in short examination times even for examinations of multiple body regions under emergency conditions. The introduced setting-repositioning of multiple-trauma patients-allowed high image quality to be maintained. The trade-off in multiple-trauma patients was prolonged room time because of patient repositioning.

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

In major trauma it is essential to immediately recognize and treat life-threatening problems and conditions. Most trauma protocols reserve the use of computed tomography for the secondary survey, as patients cannot be attended to during the examination and must be transferred from the emergency room to the CT suite. The relevant reduction in the scanning time of multidetector computed tomography (MDCT) or multislice computed tomography (MSCT) justifies its use as the major diagnostic adjunct for primary trauma survey and initial resuscitation. According to our ATLS((R))-based trauma algorithm, the multidetector scanner situated in the emergency department is utilized immediately after the correction of respiratory problems to detect causes of bleeding or intracranial hematomas. In a prospective series a total of 125 consecutive major trauma patients were evaluated. After focused sonography in trauma (FAST) and plain chest films in intubated patients, whole body MDCT was performed. By retrieving data from our trauma registry and a picture archiving and communication system (PACS), time from trauma room admission to the end of head CT scan for the entire MDCT study and calculation of multiplanar reconstruction (MPR) was analyzed. Additionally, relevant complications such as untreated tension pneumothorax or circulatory arrest during MDCT examination were recorded. The time from admission to the trauma room until completion of head CT scan without contrast was 21:12 min (median, IQR 18:13-27:52). The entire contrast-enhanced MDCT study, including pilot scan and contrast application, required 6:08 min (median, IQR 4:33-8:14) with a total scanning time of 0:59 min (median, IQR 0:55-1:03). MPR calculation of the spine and bony pelvis was performed in 11:37 min (median, IQR 8:03-16:41). A relevant life-threatening complication due to CT scanning during primary trauma survey was not observed in the 125 cases (0/125 CI 95% 0%-3%). Complete diagnostic imaging can be performed within 30 min after trauma room admission by using MDCT. During the primary survey, treatment of the patient is interrupted just for the few minutes of the CT scan and contrast application. An adequate survey of injuries can be achieved earlier and a targeted therapy can be initiated ahead of time. Integration of MDCT scanners in the primary trauma survey provides a high standard of imaging in a very short time without endangering the patient. When dealing with multiple casualties, MDCT could be used also as an accurate and time-efficient means of hospital triage to diagnose and prioritize patients and to plan further surgical interventions and intensive care.

Alveolar recruitment in combination with sufficient positive end-expiratory pressure increases oxygenation and lung aeration in patients with severe chest trauma

OBJECTIVE

Investigation of oxygenation and lung aeration during mechanical ventilation according to the open lung concept in patients with acute lung injury or acute respiratory distress syndrome.

DESIGN

Retrospective analysis.

SETTING

Surgical intensive care unit of a university hospital.

PATIENTS

We retrospectively identified 17 patients with acute lung injury/acute respiratory distress syndrome due to pulmonary contusion who had thoracic helical computed tomography scans before and after ventilation with the open lung concept.

INTERVENTIONS

Baseline ventilation consisted of low tidal volumes (< or =6 mL/kg) and positive end-expiratory pressure (PEEP; 5-17 cm H2O). We briefly applied high inspiratory pressures for opening up collapsed alveoli. External PEEP and intrinsic PEEP were combined to keep recruited lung units open. We generated intrinsic PEEP by pressure-cycled high-frequency inverse ratio ventilation (80 min, inspiratory/expiratory ratio 2:1) and maintained our ventilatory strategy for 24 hrs. Then, after reducing total PEEP by decreasing respiratory rate, Pao2/Fio2 ratio was reevaluated. If it remained >300 mm Hg, weaning was started. If not, previous ventilator settings were resumed for another 24 hrs after recruiting the lungs once again.

MEASUREMENTS AND MAIN RESULTS

Physiologic variables and ventilator settings were obtained from routine charts. Data from computed tomography before and after the open lung concept were analyzed for volumetric quantification of lung aeration and collapse. All results are presented as median and range. During baseline ventilation, PEEP was 10 (range, 5-17) cm H2O and after recruitment 21 (range, 18-26) cm H2O. Opening pressures were 65 (range, 50-80) cm H2O. After recruitment, Pao2/Fio2 ratio was higher in all patients. Total lung volume increased from 2915 (range, 1952-4941) to 4247 (range, 2285-6355) mL and normally aerated volume from 1742 (range, 774-2941) to 2971 (range, 1270-5232) mL. Atelectasis decreased significantly from 604 (range, 147-1538) to 106 (range, 0-736) mL. Hyperinflation increased significantly from 5 (range, 0-188) to 62 (range, 1-424) mL, whereas poor aeration did not change substantially from 649 (range, 302-1292) to 757 (range, 350-1613) mL. No hemodynamic problems occurred.

CONCLUSIONS

Lung recruitment increased arterial oxygenation, normally aerated lung volume, and total lung volume while decreasing the amount of collapsed tissue. These results indicate that the open lung concept is a reasonable mode of ventilation for patients with severe chest trauma.

Value of Multiplanar Reformations (MPR) in Multidetector CT (MDCT) of Acute Vertebral Fractures

OBJECTIVE

To determine the value of multiplanar reformations (MPRs) in multidetector computed tomography (MDCT) diagnosis of acute vertebral fractures and to assess the necessity to read the whole set of transverse images.

METHODS

Retrospectively, 56 MDCT of 55 patients with acute vertebral fractures were included. The images were analyzed by two radiologists in a consensus procedure. First, the diagnosis was made exclusively from sagittal and coronal MPRs; secondly, the transverse images were analyzed with knowledge of the MPRs. Diagnostic accuracy is given as percentage. Image amounts were compared using the Wilcoxon test.

RESULTS

In 244 vertebral bodies, all 70 fractured vertebrae were diagnosed on reviewing MPRs only. There were no false positive cases. In 2/70 fractures, the anatomically exact diagnosis was complemented by reading the transverse images. Forty-two of 43 unstable fractures were diagnosed correctly on MPRs only. With preference of MPR reading, the total number of images to be analyzed could be reduced significantly (P < 0.01).

CONCLUSION

Reading of MPRs alone is a feasible approach for correct assessment of vertebral fractures and classifying them into stable/unstable, if MPRs are done properly. Transverse images must be analyzed in complex fractures or uncertain findings.

First experiences with multidetector CT in traumatized children

INTRODUCTION

The aim of this study was to describe and discuss first experiences with multidetector CT (MDCT) in the assessment of traumatized children.

MATERIAL AND METHODS

Since the implementation of a MDCT scanner in April 2002, 85 children (31 girls, 54 boys with a mean age of 9.2 years) consecutively underwent MDCT (Siemens, Erlangen, Germany) with different protocols depending on age, weight, trauma mechanism and clinical presentation. In all patients in whom pathology was suspected, multiplanar reformations (MPR) in coronal and or sagittal orientation was performed. Examinations were evaluated by two radiologists retrospectively and in consensus.

RESULTS

In 55 (65%) children, a MDCT solely of the head was performed, in 46 there was no pathology found. In six (7%), head and facial bones were scanned. Head and abdomen was examined in two (2%), in two (2%) the abdomen only and in one (1%) the pelvis solely. Scans of the spine were obtained in seven (8%) children. A thorax and abdomen examination only was obtained in one (1%) child each. In 11 (13%) children, a polytrauma protocol was performed. In all patients, the time of examination did not exceed 17 min, including setup time. All children survived at the writing of this report.

CONCLUSION

MDCT was promising in the management of traumatized children and seems to shorten the necessary time to reach diagnosis and to initiate life-saving treatment.

Radiological emergency room management with emphasis on multidetector-row CT

Trauma is the fifth leading cause of death after disease of the cardiovascular system, malignomas and disease of the respiratory and digestive system. The management of severely injured patients, including radiological imaging, is a matter of ongoing development. In particular, as for the imaging modalities, multidetector-row CT represents a substantial refinement in the diagnostic work-up of multitrauma patients. Sufficient therapy within the first hour after trauma increases the patient's chances for survival significantly. Thus, therapeutic procedures and diagnostic evaluation have to be concomitant events, performed by a multidisciplinary team, namely trauma surgeon, anesthesiologist and, last but not least, radiologist. The increased performance of multidetector-row CT leads to increased spatial resolution, which is a prerequisite for sophisticated two- and three-dimensional postprocessing. The increased volume coverage speed allows for comprehensive whole-body CT at still high levels of spatial resolution, resulting in significant spare of time which influences patient's survival. Using this technique conventional imaging such as plane film or angiography may be omitted.

Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole-body helical computed tomography

The estimated prevalence of liver injury in patients with blunt multiple trauma ranges from 1% to 8%. The objective of this study was to investigate the profile of accompanying liver injury in a cohort of polytraumatized patients who had regularly undergone contrast-enhanced, whole-body helical computed tomography (CT). We enrolled consecutive patients admitted between September 1997 and January 2001 to a level I trauma center. Clinical baseline data were compiled as part of a nationwide trauma registry. Morphologic features were evaluated descriptively, whereas prognostic variables were assessed by logistic regression analysis. We identified 218 patients [149 men, mean age 35 +/- 18 years, mean injury severity score (ISS) 35 +/- 10], 55 of whom had sustained blunt liver trauma [25.2%, 95% confidence interval (CI) 19.6-31.5%]. The prevalence of Moore III to V lesions was 10.1%. There were 99 parenchymal contusions, 15 capsular tears, and 2 liver fractures. Surgery was required in 15 patients and was best predicted by the classification of the American Association for the Surgery of Trauma [odds ratio (OR) 3.91, 95% CI 1.59-9.61]. The mortality rate was 0.0035/person/day. Patients requiring surgical repair had fourfold increased relative odds of case fatality (OR 4.50, 95% CI 1.01-19.96). Sevenfold increased relative odds were observed if liver laceration was considered the leading injury (OR 7.17, 95% CI 1.17-43.97). The prevalence of liver lacerations among multiple-trauma patients is likely to be underestimated and must be determined by the independent application of reference standards, such as helical CT. High-grade hepatic injuries and the need for surgical repair are associated with poorer survival prognosis.

Three-dimensional volume rendering of multidetector-row CT data: applicable for emergency radiology

Multidetector-row computed tomography (MD-CT) not only creates new opportunities but also challenges for medical imaging. Isotropic imaging allows in-depth views into anatomy and disease but the concomitant dramatic increase of image data requires new approaches to visualize, analyze and store CT data. The common diagnostic reviewing process slice by slice becomes more and more time consuming as the number of slice increases, while on the other hand CT volume data sets could be used for three-dimensional visualization. These techniques allow for comprehensive interpretation of extent of fracture, amount of dislocation and fragmentation in a three-dimensional highly detailed setting. Further more, using minimal invasive techniques like CT angiography, new opportunities for fast emergency room patient's work up arise. But the most common application is still trauma of the musculoskeletal system as well as face and head. The following is a brief review of recent literature on volume rendering technique and some exemplary applications for the emergency room.