Influence of medical speciality and experience on interpretation of helicoidal thoracic computed tomography in blunt chest trauma

Introduction of a treatment algorithm can improve the early management of emergency patients in the resuscitation room

INTRODUCTION

Successful management of emergency patients with multiple trauma in the hospital resuscitation room depends on the immediate diagnosis and rapid treatment of the most life-threatening injuries. In order to reduce the time spent in the resuscitation room, an in-hospital algorithm was developed in an interdisciplinary team approach with respect to local structures. The aim of the study was to analyse whether this algorithm affects the interval between hospital admission and the completion of diagnostic procedures and the start of life-saving interventions. Moreover, in-hospital mortality was investigated before and after the algorithm was introduced.

MATERIAL AND METHODS

In this prospective study, all consecutive trauma patients in the resuscitation room were investigated before (group I, 01/04-10/04) and after (group II, 01/05-11/05) introduction of the algorithm. The times between hospital admission and the end of the diagnostic procedures (ultrasound [sono], chest X-ray [CF], and cranial computed tomography [CCT]), and between hospital admission and the start of life-saving interventions were registered and in-hospital mortality analysed.

RESULTS

In the study period, 170 patients in group I and 199 patients in group II were investigated. Injury severity score (ISS) were comparable between the two groups. The intervals between admission and completion of diagnostic procedures were significantly lower after the algorithm was introduced (mean+/-S.D.): sono (11 +/- 10 min versus 7 +/- 6 min, p < 0.05), CF (21 +/- 12 min versus 12 +/- 9 min, p < 0.01), and CCT (55 +/- 27 min versus 32 +/- 14 min, p < 0.01). Moreover, the interval to the start of life-saving interventions was significantly shorter (126 +/- 90 min versus 51 +/- 20 min, p < 0.01). After introducing the algorithm, in-hospital mortality was reduced significantly from 33.3% to 16.7% (p < 0.05) in the most severely injured patients (ISS>or=25).

CONCLUSION

The introduction of an algorithm for early management of emergency patients significantly reduced the time spent in the resuscitation room. The periods to completion of sono, CF, and CCT, respectively, and the start of life-saving interventions were significantly shorter after introduction of the algorithm. Moreover, introduction of the algorithm reduced mortality in the most severely injured patients. Although further investigations are needed to evaluate the effects of the Heidelberg treatment algorithm in terms of outcome and mortality, the time reduction in the resuscitation room seems to be beneficial.

The Quality of Surgical Resident Interpretation of After-Hour CT Scans of the Head and Abdomen in Trauma

Computed tomography (CT) is an important diagnostic tool in the evaluation of trauma patients. Accurate interpretation of CT scans remains critical in decision-making and the resultant quality of care. In our study, the records of a consecutive cohort of trauma patients who underwent after-hour CT scans of the head and abdomen between January 23 and June 30, 2004, at Kern Medical Center were reviewed. Three hundred thirty-five CT studies were collected in 211 patients. The accuracy of resident interpretation was 92.8 per cent for abdominal and 97.5 per cent for head CT. Resident readings were 93.2 per cent sensitive and 95.4 per cent specific with a positive predictive value of 85.2 per cent and a negative predictive value of 98.0 per cent. There were 16 (4.8%) instances of interpretation discrepancy between the surgical resident and attending radiologist. Most differences occurred in the evaluation of abdominal CT. In no instance was management or outcome for these patients affected. This data demonstrates a low error rate in resident interpretation of after-hour CT scans of the head and abdomen in trauma, but there remains a need for the continued review of the quality of surgical resident radiologic interpretation in situations when an attending radiologist is not immediately available.

[Personnel and structural requirements for the shock trauma room management of multiple trauma. A systematic review of the literature]

The aim of the study was the description of personal and structural preconditions essential for adequate diagnostic requirements and treatment in severely injured patients. Herein we give detailed information regarding both the composition and qualification of the trauma team and the activation criteria as well as instructions for the design of the emergency room and technical requirements. Clinical trials were systematically collected (MEDLINE, Cochrane, and hand searches) and classified into evidence levels (1 to 5 according to the Oxford system). The trauma team should consist of (trauma) surgeons, anesthesiologists, radiologists, and one to two nursing staff members of each department. The attending physician should be present within 20 min. Trauma team activation criteria are among others: high energy/velocity trauma, penetrating injuries, GCS < or =14, and intubation. The emergency room should be integrated in the emergency department with all technical equipment being permanently available for optimal diagnostic and therapeutic management. A CT scanner should be positioned nearby.Adequate management of severely injured patients requires optimal personal and structural conditions. High costs and additional personnel are justified by improved quality of treatment.