A Case-matched Series of Immediate Total-body CT Scanning Versus the Standard Radiological Work-up in Trauma Patients

Emergency Radiology in the First 24 h of Two Major Earthquakes on the Same Day and Radiologic Evaluation of Trauma Cases

BACKGROUND

On 6 February 2023, two major earthquakes occurred in Turkey on the same day. More than 50,000 people died, and more than 100,000 people were injured in these earthquakes. The aim of this study is to contribute to disaster management plans by evaluating the functioning of a radiology department and the imaging examinations performed after this disaster.

METHODS

The functioning of the radiology clinic at Malatya Training and Research Hospital in the first 24 h after the earthquake was evaluated. The images of 596 patients who were admitted to Malatya Training and Research Hospital for earthquake-related trauma between 6 February 2023, at 4:17 a.m. and 7 February 2023, at 4:17 a.m., and who underwent radiography and computed tomography (CT) were retrospectively reviewed.

RESULTS

The mean age of the patients was 37.3 ± 20.1 years. A total of 313 (52.5%) patients were male. The most frequently performed imaging test was a CT scan. In total, 437 (73.3%) of 596 patients underwent a CT scan. At least one body part was affected in 160 patients (26.8%). The most commonly affected regions were the thorax, vertebrae, and extremities. Thoracic findings were observed in 52 patients (32.5%), vertebral findings in 52 patients (32.5%), and extremity findings in 46 patients (28.7%). Fractures were the most common finding in our study. Of the 160 patients with pathologic findings, 139 (86.9%) had evidence of fractures.

CONCLUSIONS

The role of radiology in disasters is important. When disaster preparedness plans are made, radiology departments should be actively involved in these plans. This will ensure the quick and efficient functioning of radiology departments.

Diagnostic utility of whole-body computed tomography/pan-scan in trauma: a systematic review and meta-analysis study

Trauma is a significant cause of mortality and morbidity. It is crucial to diagnose trauma patients quickly to provide effective treatment interventions in such conditions. Whole-body computed tomography (WBCT)/pan-scan is an imaging technique that enables a faster and more efficient diagnosis for polytrauma patients. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of WBCT in diagnosing injuries in polytrauma patients. We will also assess its impact on the mortality rate and length of hospital stay among trauma centers between patients who underwent WBCT and those who did not (non-WBCT). Twenty-seven studies meeting our inclusion criteria were selected among PubMed, Scopus, Web of Science, and Google Scholar. The criteria were centered on the significance of WBCT/pan-scan application in trauma patients. Stata version 15 was used to perform statistical analysis on the data. The authors have also used I2 statistics to evaluate heterogeneity. Egger and Begg's tests were performed to rule out any publication bias. Total of twenty-seven studies including 68,838 trauma patients with a mean age of 45.0 ± 24.7 years were selected. Motor vehicle collisions were the most common cause of blunt injuries (80.0%). Head, neck, and face injuries were diagnosed in 44% (95% CI, 0.28-0.60; I2 = 99.8%), 6% (95% CI, 0.02-0.09; I2 = 97.2%), and 9% (95% CI, 0.05-0.13; I2 = 97.1%), respectively. Chest injuries were diagnosed by WBCT in 39% (95% CI, 0.28-0.51; I2 = 99.8%), abdominal injuries in 23% (95% CI, 0.03-0.43; I2 = 99.9%) of cases, spinal injuries 19% (95% CI, 0.11-0.27; I2 = 99.4%), extremity injuries 33% (95% CI, 0.23-0.43; I2 = 99.2%), and pelvic injuries 11% (95% CI, 0.04-0.18; I2 = 97.4%). A mortality odd ratio of 0.94 (95% CI, 0.83-1.06; I2 = 40.1%) was calculated while comparing WBCT and non-WBCT groups. This systematic review and meta-analysis provide insight into the possible safety, efficacy, and efficiency of WBCT/pan-scan as a diagnostic tool for trauma patients with serious injuries, regardless of their hemodynamic status. In patients with serious injuries from trauma, whether or not there are indicators of hemodynamic instability, our recommended approach is to, wherever possible, perform a WBCT without stopping the hemostatic resuscitation. By using this technology, the optimal surgical strategy for these patients can be decided upon without causing any delays in their final care or greatly raising their radiation dose.

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

PURPOSE

To evaluate the current practice regarding the prevalence and sequence of x-ray and CT scan in diagnostic algorithms for multiple injured patients.

METHODS

All primarily treated patients with ISS ≥ 9 were selected from the TraumaRegister DGU® (years 2008-2015; n = 109,257). Four subgroups of diagnostic algorithm were defined: CT only (group C; n = 63,763), CT before x-ray (group CX; n = 3711), x-ray followed by CT (group XC; n = 33,590), and x-ray only (group X, n = 8193). We analysed the type and sequence of diagnostic procedures and their association with hospital mortality and length-of-stay in the emergency room (ER-LOS).

RESULTS

Predominant strategies were CT only (58.4%) and x-ray followed by CT (30.7%). Overall mortality was between 10 and 12% in all subgroups involving CT, and 6.6% in the x-ray only group. Expected mortality was within the 95% confidence of observed mortality except for the CX group (observed 10.0%; CI95 8.9-11.0; expected 11.1%). Mean / median length of stay in the emergency room was shortest in the CT only subgroup: (60 / 50 min). Prior x-ray diagnostic resulted in additional 3 min (group XC). The use of additional x-ray diagnostic decreased from 51.6% (in 2008) to 35.4% (in 2015).

CONCLUSIONS

ER-LOS is significantly affected by diagnostic pathway. CT scan alone accelerates ER-LOS, which however was not associated with lower mortality rates. Performing completive x-ray examinations after an initial CT scan seems not to deteriorate mortality rates.

Illuminating the Use of Trauma Whole-Body CT Scan During the Global Contrast Shortage

BACKGROUND

Use of whole-body CT scan (WBCT) is widespread in the evaluation of traumatically injured patients and may be associated with improved survival. WBCT protocols include the use of IV contrast unless there is a contraindication. This study tests the hypothesis that using plain WBCT scan during the global contrast shortage would result in greater need for repeat contrast-enhanced CT, but would not impact mortality, missed injuries, or rates of acute kidney injury (AKI).

STUDY DESIGN

All trauma encounters at an academic level-I trauma center between March 1, 2022 and June 24, 2022, excluding burns and prehospital cardiac arrests, were reviewed. Imaging practices and outcomes before and during contrast shortage (beginning May 3, 2022) were compared.

RESULTS

The study population included 1,109 consecutive patients (72% male), with 890 (80%) blunt and 219 (20%) penetrating traumas. Overall, 53% of patients underwent WBCT and contrast was administered to 73%. The overall rate of AKI was 6% and the rate of renal replacement therapy (RRT) was 1%. Contrast usage in WBCT was 99% before and 40% during the shortage (p < 0.001). There was no difference in the rate of repeat CT scans, missed injuries, AKI, RRT, or mortality.

CONCLUSIONS

Trauma imaging practices at our center changed during the global contrast shortage; the use of contrast decreased despite the frequency of trauma WBCT scans remaining the same. The rates of AKI and RRT did not change, suggesting that WBCT with contrast is insufficient to cause AKI. The missed injury rate was equivalent. Our data suggest similar outcomes can be achieved with selective IV contrast use during WBCT.

Diagnostic accuracy, yield, and comparative effectiveness of whole-body computed tomography in blunt trauma: A protocol for systematic review and meta-analysis

OBJECTIVES

Controversies emerge over routine performances of whole-body computed tomography (WBCT) in patients with blunt polytrauma. The existing randomized and non-randomized evidence is inconclusive, and during observations of non-trauma, incidental findings, detected by WBCT, have left uncertainty regarding their consequences and optimal management. Additionally, previous meta-analyses have failed to address the limitations of primary studies and issues associated with incidental findings. Therefore, we planned a new systematic review to address these points.

METHODS

We will search the PubMed, EMBASE, and Cochrane Central databases from inception to December 31, 2020, with no language restriction and perform full-text evaluation of potentially relevant articles. We will include prospective and retrospective studies with a single-gate design that assessed diagnostic accuracy and/or yield of WBCT to detect traumatic injuries, and studies that assessed incidental findings detected by WBCT. Additionally, we will include randomized controlled trials and non-randomized comparative studies that assessed the effectiveness of WBCT against conventional care, including selective computed tomography (CT). Studies of patients of all ages with blunt traumatic injuries, assessed at an emergency department, will be included. Two reviewers will extract data and rate the study validity via standard quality assessment tools. The primary outcome of interest will be reduction in mortality. Our secondary outcomes will include diagnostic accuracy and yield, detection of incidental findings and clinical outcomes associated with these detections, and improvement in other non-mortality clinical outcomes. We will qualitatively assess study, patient, and intervention characteristics and clinical outcomes. If appropriate, we will perform random-effects model meta-analyses to obtain summary estimates. Finally, we will assess the certainty of evidence by the grading the quality of evidence and strength of recommendations.

ETHICS AND DISSEMINATION

Ethics approval is not applicable, as this is a secondary analysis of publicly available data. The review results will be submitted for publication in peer-reviewed journals.

PROSPERO REGISTRATION

CRD42020187852.

Negative Whole-Body Computed Tomography Scans in Polytrauma Patients: A Retrospective Cohort Study

Background

Whole-body computed tomography (WBCT) has been a mainstay and an integral part of the evaluation of polytrauma patients in trauma centers and emergency departments (ED) for a comprehensive evaluation of the extent of injuries. However, routine use of WBCT remains controversial since it exposes patients to radiation and exponentially increases financial expense. The primary objective was to determine the rate of negative WBCT in polytrauma patients.

Patients and Methods

A retrospective cohort study was conducted at an academic hospital in the Kingdom of Saudi Arabia, which is a dedicated trauma center with a mean of 237,392 ED visits and 10,714 trauma per year. The study included all adult (≥18 years) polytrauma patients who presented to our ED, requiring trauma team activation, and underwent WBCT as part of their evaluation from January 2016 to May 2017. We excluded pediatric patients, patients transferred from another facility, and pregnant patients. The primary endpoint was to measure the rate of negative WBCT in polytraumatized patients.

Results

A total of 186 patients were included with a mean age of 28.8 ± 12.9 years. The rate of negative WBCT scans was 20.4%. The positive scans were subclassified based on the number of anatomical body regions that were affected radiologically. One body region was affected in 47 patients (31.8%), two body regions were affected in 50 patients (33.8%), and ≥3 body regions were affected in 51 patients (34.3%). In a subset analysis, we identified that oxygen saturation <94% and GCS ≤8 were associated with positive CT scans.

Conclusion

Our study revealed a slightly higher rate of utilization of WBCT in the management of trauma patients compared to studies with similar practice. We believe that in the correct setting with incorporating high index of suspicion, a physical examination with attention to vital signs and mental status, performing E-FAST, and dedicated X-Rays is a way to potentially reduce the use of WBCT in polytrauma patients.

Systematic review and meta-analysis of whole-body computed tomography compared to conventional radiological procedures of trauma patients

PURPOSE

The superior diagnostic accuracy of CT makes it an attractive tool for initial trauma imaging. This meta-analysis aimed to assess the evidence regarding the value of whole-body CT (WBCT) as part of the primary survey, in comparison to conventional radiological procedures.

METHODS

A comprehensive systematic search of the literature was conducted using keywords applied in Scopus, Cochrane and PubMed databases. Articles were eligible if they contained original data comparing the use of WBCT in the primary survey, with conventional radiological procedures. Outcomes included overall and 24 -h mortality, emergency department (ED) time, intensive care unit (ICU) and hospital length of stay (LOS), and multiple organ dysfunction syndrome/failure (MODS/MOF) incidence. Radiation dose, mechanical ventilation duration and cost were evaluated qualitatively. Analysis was performed with Covidence, MedCalc Version 19.1.3. and Meta-Essentials.

RESULTS

Fourteen studies were included. Statistical pooling demonstrated comparable rates between conventional procedures and WBCT (OR = 0.854, CI = 0.715-1.021, p = 0.083) in 63,529 patients across 11 studies. A significant finding favouring WBCT was discovered for ED time (SMD = -0.709, CI -1.198 to -0.220, p = 0.004). Patients experienced similar 24 -h mortality rates (p = 0.450), MODS/MOF incidence (p = 0.274), and hospital (p = 0.541) and ICU LOS (p = 0.457). WBCT is associated with increased radiation dose and mechanical ventilation duration.

CONCLUSION

This review demonstrates that WBCT markedly reduces time spent in ED. No significant differences in mortality rate are suggested. WBCT currently entails greater radiation dose and mechanical ventilation time. Further research is necessitated to address limitations of predominately retrospective observational data available.

Mass casualty incidents-are you ready? A major incident planning template for diagnostic radiology

Mass casualty incidents (MCIs) create a large number of casualties in a short period of time. Diagnostic radiology plays an important role in major incident responses but is often underrepresented during major incident planning (MIP) and simulation. Surveys suggest radiologists are unfamiliar with their role during an MCI. We aimed to identify key topics for radiology MIP, familiarize radiologists with their role during an MCI and identify areas for future research. The terms "radiology" and "mass casualty incident" were entered into the advanced search builder on PubMed. Abstracts from this primary search were reviewed and papers selected for inclusion. Additional studies of interest were identified upon review of reference sections of relevant articles and from the related article tab on PubMed. MCI and trauma guidelines were reviewed. Key factors that caused issues during prior MCIs were identified including staff alert mechanisms, patient identification strategies, patient tracking, scan ordering and result communication. Limitations of local imaging resources and capacity should be identified and inform plans for the utilization of diagnostic radiology in the MCI setting. Simulation can help identify areas for improvement and familiarize staff with their roles. Further development of reliable MCI alert technology and patient identification strategies are needed as well as prospective validation of trauma CT selection criteria to identify patients who will benefit most from CT. Radiology should take part in MIP to address key issues encountered during prior MCIs and in MCI simulation to optimize major incident response.

Is a "Pan-Scan" Indicated in the Older Patient with a Ground Level Fall?

Routine full-body CT "pan-scan" use in older patients after ground level falls (GLFs) is of questionable benefit. Retrospective review of new diagnosis & changes in management in patients >55 years with Glasgow Coma Scale of 15 after a GLF who received a pan-scan (routine head, cervical spine/neck, chest abdomen, and pelvis CT). Head CT results were considered separately; results described in the following paragraph pertains to cervical spine/neck, chest, abdomen, and pelvis CT. One hundred and fifty-two patients received pan-scans; 96 (63%) had new findings. Thirty-five (23%) resulted in a minor change and three (2%) in a major change in management, defined as a procedural intervention. This included tube thoracostomy in one patient and cervical spine surgery in two. A further eight patients required the use of a cervical collar. In all patients requiring intervention, there were clinical signs present that should have led to directed CT scan of area of concern. Routine pan-scans in stable, alert older patients after a GLF result in new findings in most patients, with primarily nonprocedural interventions for these additional findings.

A meta-analysis of the efficacy of whole-body computed tomography imaging in the management of trauma and injury

BACKGROUND

Traumatic injury is the third leading cause of death overall. To optimize the outcomes in these patients, hospitals employ whole-body computed tomography (WBCT) imaging due to the high diagnostic yield and potential to identify missed injuries. However, this delays time-critical interventions. Currently, there is an absence of any high-level evidence to support or refute either view. We present a meta-analysis of the available literature to elucidate the efficacy of WBCT in improving the outcomes of trauma, specifically the mortality rate.

METHODS

A systematic review of studies comparing WBCT and selective CT imaging in secondary survey was conducted, using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. The articles were evaluated for intervention using WBCT to reduce mortality rate, followed by subgroup analysis for other secondary measures, using Review Manager 5.3 software.

RESULTS

Eleven studies of 32,207 patients were included. There were lower overall (OR=0.79; 95% CI 0.74,0.83, p<0.05) and 24h mortality rates (OR=0.72, 95% CI 0.66,0.79, p<0.05) in the WBCT cohort. Additionally, patients in the WBCT arm spent less time in the emergency room (MD=-14.81; 95% CI -17.02, -12.60, p<0.00001) and needing ventilation (MD=-2.01; 95% CI -2.41, -1.62, p<0.05) despite a higher baseline injury severity score.

CONCLUSION

The analysis shows that WBCT is associated with better outcomes, including a lower overall and 24h mortality rate, however the included studies are mostly observational and show considerable heterogeneity. Further work is required to make definitive clinical recommendations for a tailored algorithm in managing trauma patients.

Computed tomography during initial management and mortality among hemodynamically unstable blunt trauma patients: a nationwide retrospective cohort study

Background

Although many hemodynamically unstable trauma patients undergo computed tomography (CT) to identify a source of bleeding, this practice is currently only recommended by a few guidelines. To clarify whether CT has harmful effects among these patients, we examined the association between CT during initial management and mortality among unstable blunt trauma patients.

Methods

This was a retrospective cohort study based on Japan Trauma Data Bank 2004–2014 registry data. Study population was adult blunt trauma patients with hypotension on arrival. The primary outcome was the in-hospital mortality. Two types of analyses were performed to adjust for confounding factors including propensity score inverse probability of treatment weighted (IPTW) and instrumental variable (IV) analysis.

Results

Among 5,809 patients who met inclusion criteria, 5,352 (92.1%) underwent CT. The No CT group was more likely to have severe physiological conditions and lower probability of survival than those of the CT group. In IPTW analysis adjusting for measured confounders, we found a significant protective effect of undergoing CT on in-hospital mortality (excess deaths: −20.6 per 100 patients, 95% CI −26.2 to −14.9). In IV analysis adjusting both for measured and unmeasured confounders, the association between CT and mortality was not statistically significant (excess deaths: −4.1 per 100 patients, 95% CI −23.1 to 14.8).

Discussion

We did not find clinically meaningful harmful effect of CT on survival for unstable blunt trauma patients even after adjusting both for measured and unmeasured confounders.

Conclusions

Our results did not support the recommendation of current guideline. We suggest physicians should consider CT as one of the diagnostic options even when patients are unstable.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-017-0396-7) contains supplementary material, which is available to authorized users.

Radiological findings and radiation exposure during trauma workup in a cohort of 1124 level 1 trauma patients

BACKGROUND

During the initial assessment of patients with potential severe injuries, radiological examinations are performed in order to rapidly diagnose clinically relevant injuries. Previous studies have shown that performing these examinations routinely is not always necessary and that trauma patients are exposed to substantial radiation doses. The aim of this study was to assess the amount and findings of radiological examinations during the initial assessment of trauma patients and to determine the radiation doses to which these patients are exposed to.

METHODS

We analyzed the 1124 patients included in a randomized trial. All radiological examinations during the initial assessment (i.e., primary and secondary survey) were assessed. The examination results were categorized as positive findings (i.e., (suspicion for) traumatic injury) and normal findings. The effective radiation doses for the examinations were calculated separately for each patient.

RESULTS

Eight hundred and three patients were male (71 %), median age was 38 years, and 1079 patients sustained blunt trauma (96 %). During initial assessment, almost 3900 X-rays were performed, of which 25.4 % showed positive findings. FAST of the abdomen was performed in 989 patients (88 %), with positive findings in 10.6 %. Additional CT scanning of specific body regions was performed 1890 times in 813 patients (72.1 %), of which approximately 43.4 % revealed positive findings. Hemodynamically stable patients showed more normal findings on the radiographic studies than unstable patients. The mean radiation doses for the total population was 8.46 mSv (±7.7) and for polytraumatized patients (ISS ≥ 16) 14.3 mSv (±9.5).

CONCLUSION

Radiological diagnostics during initial assessment of trauma patients show a high rate of normal findings in our trauma system. The radiation doses to which trauma patients are exposed are considerable. Considering that the majority of the injured patients are hemodynamically stable, we suggest more selective use of X-ray and CT scanning.

Can clinical prediction tools predict the need for computed tomography in blunt abdominal? A systematic review

INTRODUCTION

Blunt abdominal trauma is a common reason for admission to the Emergency Department. Early detection of injuries is an important goal but is often not straightforward as physical examination alone is not a good predictor of serious injury. Computed tomography (CT) has become the primary method for assessing the stable trauma patient. It has high sensitivity and specificity but there remains concern regarding the long term consequences of high doses of radiation. Therefore an accurate and reliable method of assessing which patients are at higher risk of injury and hence require a CT would be clinically useful. We perform a systematic review to investigate the use of clinical prediction tools (CPTs) for the identification of abdominal injuries in patients suffering blunt trauma.

MATERIALS AND METHODS

A literature search was performed using Medline, Embase, The Cochrane Library and NHS Evidence up to August 2014. English language, prospective and retrospective studies were included if they derived, validated or assessed a CPT, aimed at identifying intra-abdominal injuries or the need for intervention to treat an intra-abdominal after blunt trauma. Methodological quality was assessed using a 14 point scale. Performance was assessed predominantly by sensitivity.

RESULTS

Seven relevant studies were identified. All studies were derivative studies and no CPT was validated in a separate study. There were large differences in the study design, composition of the CPTs, the outcomes analysed and the methodological quality of the included studies. Sensitivities ranged from 86 to 100%. The highest performing CPT had a lower limit of the 95% CI of 95.8% and was of high methodological quality (11 of 14). Had this rule been applied to the population then 25.1% of patients would have avoided a CT scan.

CONCLUSIONS

Seven CPTs were identified of varying designs and methodological quality. All demonstrate relatively high sensitivity with some achieving very high sensitivity whilst still managing to reduce the number of CTs performed by a significant amount. Further studies are required to validate the results obtained by the highest performing CPTs before any firm recommendation can be used regarding their use in routine clinical practice.

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.

Radiological mass casualty incident (MCI) workflow analysis: single-centre data of a mid-scale exercise

OBJECTIVE

The aim of the study was to analyse and interpret radiological mass casualty incident workflow data.

METHODS

In a mid-scale mass casualty incident exercise, the on-site triage assigned 12 cases to the investigated institution (11 included in the study). Two out of five institutional multislice-CT-scanners were used and the whole CT workflow and radiological service process chain were simulated as close to realistic as possible. The respective time intervals for reaching defined milestones were measured.

RESULTS

The average CT in-room time, i.e. from entering to leaving the CT room was 9.43 min [(standard deviation) SD: 2.27 min; 95% (confidence interval) CI: 7.90-10.95 min]. Time spent on CT table was 6.75 min (SD: 1.67; CI: 5.63-7.87), and the pure scan time was 4.22 min (SD: 0.64; CI: 3.79-4.65). The first images after entering the CT room were available at a dedicated CT workstation after 5.85 min (SD: 2.20; CI: 4.37-7.32) and institution wide via picture archiving system (PACS) after 7.85 min (SD: 1.27; CI: 7.00-8.71). However, the PACS archiving process, that is, transfer of standard reconstruction set of CT images into the PACS was finished after 20.85 min (SD: 2.97; CI: 18.85-22.84).

CONCLUSION

Up to six patients may be served per hour and per CT scanner by using a standard whole body CT polytrauma protocol. Dedicated CT triage protocols may even increase this number. The time portion until images were available at end points was relatively long. A solution has to be developed in order to avoid scenarios of patients being faster at end points than their images.

Implications of an Incidental Pulmonary Arteriovenous Malformation

Introduction. Pulmonary arteriovenous malformations (PAVMs) have been associated with life-threatening complications, such as stroke and massive hemoptysis, thus posing significant morbidity if left untreated. We report a case of an incidental finding of a PAVM in a trauma patient newly recognized to have suspected hereditary hemorrhagic telangiectasia (HHT). Case Description. A 34-year-old man with a history of recurrent epistaxis presented with a sudden fall associated with seizure-like activity. Trauma imaging showed a large subdural hematoma and, incidentally, a serpiginous focus within the right upper lobe with a prominent feeding artery consistent with a PAVM. The patient was diagnosed with a simple PAVM related to possible or suspected HHT, an autosomal dominant trait with age-related penetrance. He underwent a pulmonary arteriography of the right upper and lower lobe with the use of a microcatheter system; however, the PAVM could not be visualized. Thus, he was managed medically. The patient was educated on the need for prophylactic antibiotics prior to dental procedures and surveillance imaging. Discussion. Our case highlights the importance of obtaining a complete past medical and family history in young patients with a history of recurrent epistaxis to elicit features of HHT. The diagnosis can be made clinically and directly affects family members, who would otherwise not receive appropriate screening.

A decision tool for whole-body CT in major trauma that safely reduces unnecessary scanning and associated radiation risks: An initial exploratory analysis

BACKGROUND

Whole-body CT (WBCT) has become routine practice in the assessment of major trauma patients. Whilst this may be associated with increased survival, several studies report high rates of negative scans. As no national guideline exists, selection criteria for WBCT vary widely. This study aims to (1) produce a scoring system that improves patient selection for WBCT (2) quantify patient radiation doses and their concomitant risk of malignancy.

METHODS

Clinical notes were reviewed for all patients undergoing a WBCT for trauma over a 21-month period at a UK major trauma centre. Clinical and radiological findings were categorised according to body region. Univariate analysis was performed using Chi-squared testing, followed by multivariable logistic regression. Secondary regression analysis of patients with significant injuries that the model did not identify was performed. The model was optimised and used to develop a scoring system. Sensitivity and specificity were calculated using the same dataset as was used to derive the models. Radiation exposure was determined and the excess lifetime risk of malignancy calculated.

RESULTS

255 patients were included, with a mean age of 45 years. 16% of scans were positive for polytrauma, 42% demonstrated some injury and 42% showed no injury. The regression model identified independent predictors of polytrauma to be (1) clinical signs in more than one body region, (2) reduced Glasgow Coma Score, (3) haemodynamic abnormality, (4) respiratory abnormality, (5) mechanism of injury. The final model had a sensitivity of 95% (95% CI 86-99%) and specificity of 59% (95% CI 52-66%) for significant CT findings. Mean radiation exposure was 31.8 mSv, conferring a median excess malignancy risk of 1 in 474.

CONCLUSION

After including neurological deficit, our scoring system had a sensitivity of 97% (95% CI 88-99%) and specificity of 56% (95% CI 49-64%) for significant injury. We propose this is used to stratify the use of trauma radiographs, focused CT and WBCT for major trauma patients. Although not intended to replace clinical judgement, our scoring system adds an objective component to decision-making. We believe this will safely reduce the number of unnecessary CT scans performed on a relatively young cohort of patients.

Improving Outcomes in the Patient with Polytrauma: A Review of the Role of Whole-Body Computed Tomography

Whole-body computed tomography (WBCT) is used for the workup of the patient with blunt polytrauma. WBCT is associated with improved patient survival and reduces the emergency department length of stay. However, randomized studies are needed to determine whether early WBCT improves survival, to clarify which patients benefit the most, and to model the costs of this technique compared with traditional workup. Advancements in modern multidetector computed tomography technology and an improved understanding of optimal protocols have enabled one to scan the entire body and achieve adequate image quality for a comprehensive trauma assessment in a short period.

[Interdisciplinary management of trauma patients : Update 3 years after implementation of the S3 guidelines on treatment of patients with severe and multiple injuries]

BACKGROUND

The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries.

AIM

This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies.

MATERIAL AND METHODS

In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations.

RESULTS

The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole-body computed tomography on treatment time and outcome; however, clear indications for the use of whole-body computed tomography are lacking. Further investigations supported the positive effects of air rescue on the treatment outcome of trauma patients.

CONCLUSION

The recommendations on interdisciplinary trauma management contained in the S3 guidelines on the treatment of patients with severe and multiple injuries should be implemented into the clinical routine. Additionally, the knowledge gained from more recent scientific studies is necessary for anesthetists and emergency physicians to be able to adequately implement the core statements of the S3 guidelines for the treatment of patients with severe and multiple injuries.

Routine Chest Computed Tomography and Patient Outcome in Blunt Trauma

Background:

Computerized Tomography (CT) scan is gaining more importance in the initial evaluation of patients with multiple trauma, but its effect on the outcome is still unclear. Until now, no prospective randomized trial has been performed to define the role of routine chest CT in patients with blunt trauma.

Objectives:

In view of the considerable radiation exposure and the high costs of CT scan, the aim of this study was to assess the effects of performing the routine chest CT on the outcome as well as complications in patients with blunt trauma.

Patients and Methods:

After approval by the ethics board committee, 100 hemodynamically stable patients with high-energy blunt trauma were randomly divided into two groups. For group one (control group), only chest X-ray was requested and further diagnostic work-up was performed by the decision of the trauma team. For group two, a chest X-ray was ordered followed by a chest CT, even if the chest X-ray was normal. Injury severity, total hospitalization time, Intensive Care Unit (ICU) admission time, duration of mechanical ventilation and complications were recorded. Data were evaluated using t-test, Man-Whitney and chi-squared test.

Results:

No significant differences were found regarding the demographic data such as age, injury severity and Glasgow Coma Scale (GCS). Thirty-eight percent additional findings were seen in chest CT in 26% of the patients of the group undergoing routine chest CT, leading to 8% change in management. The mean of in-hospital stay showed no significant difference in both groups with a P value of 0.098. In addition, the mean ICU stay and ventilation time revealed no significant differences (P values = 0.102 and 0.576, respectively). Mortality rate and complications were similar in both groups.

Conclusions:

Performing the routine chest CT in high-energy blunt trauma patients (with a mean injury severity of 9), although leading to the diagnosis of some occult injuries, has no impact on the outcome and does not decrease the in-hospital stay and ICU admission time. It seems that performing the routine chest CT in these patients may lead to overtreatment of nonsignificant injuries. The decision about performing routine CT scan in a trauma center should be made cautiously, considering the detriments and benefits.

Does repeat Hb measurement within 2 hours after a normal initial Hb in stable trauma patients add value to trauma evaluation?

Background

In our level I trauma center, it is considered common practice to repeat blood haemoglobin measurements in patients within 2 h after admission. However, the rationale behind this procedure is elusive and can be considered labour-intensive, especially in patients in whom haemorrhaging is not to be expected. The aim of this study was to assess the value of the repeated Hb measurement (r-Hb) within 2 h in adult trauma patients without evidence of haemodynamic instability.

Methods

The local trauma registry was used to identify all trauma patients without evidence of haemodynamic instability from January 2009 to December 2010. Patients in whom no initial blood Hb measurement (i-Hb) was done on admission, referrals, and patients without risk for traumatic injuries or haemorrhage based upon mechanism of injury (e.g. inhalation or drowning injury) were excluded.

Results

A total of 1,537 patients were included in the study, 1,246 of which did not present with signs of haemodynamic instability. Median Injury Severity Score (ISS) was 5 (interquartile range (IQR) 1 to 13), 22% of the patients were multitrauma patients (ISS > 15). A normal i-Hb was found in 914 patients (73%). Of the 914 patients with a normal i-Hb, 639 (70%) had a normal r-Hb, while in 127 patients (14%), an abnormal r-Hb was found. In none of these patients, the abnormal r-Hb led to new diagnoses. In 148 patients (16%), no repeated Hb measurement was done without clinical consequences.

Conclusion

We conclude that repeated blood Hb measurement within 2 h after admission in stable, adult trauma patients with a normal initial Hb concentration does not add value to a trauma patient's evaluation.

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.

Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis

Introduction

The purpose of this meta-analysis was to explore the value of whole-body computed tomography (WBCT) in major trauma patients (MTPs).

Methods

A comprehensive search for articles from Jan 1, 1980 to Dec 31, 2013 was conducted through PubMed, Cochrane Library database, China biology medical literature database, Web of knowledge, ProQuest, EBSCO, OvidSP, and ClinicalTrials.gov. Studies which compared whole-body CT with conventional imaging protocol (X-ray of the pelvis and chest, trans-abdominal sonography, and/or selective CT) in MTPs were eligible. The primary endpoint was all-cause mortality. The second endpoints included: time spent in the emergency department (ED), the duration of mechanical ventilation, ICU and hospital length of stay (LOS), the incidence of Multiple Organ Dysfunction Syndrome (MODS) /Multiple Organ Failure (MOF). Analysis was performed with Review Manager 5.2.10 and Stata 12.0.

Results

Eleven trials enrolling 26371 patients were analyzed. In MTPs, the application of WBCT was associated with lower mortality rate (pooled OR: 0.66, 95% CI: 0.52 to 0.85) and a shorter stay in the ED (weighted mean difference (WMD), −27.58 min; 95% CI, −43.04 to −12.12]. There was no effect of WBCT on the length of ICU stay (WMD, 0.95 days; 95% CI: −0.08 to 1.98) and the length of hospital stay (WMD, 0.56 days; 95% CI: −0.03 to 1.15). Patients in the WBCT group had a longer duration of mechanical ventilation (WMD, 0.96 days, 95% CI: 0.32 to 1.61) and higher incidence of MODS/MOF (OR, 1.44, 95% CI: 1.35-1.54; P = 0.00001).

Conclusions

The present meta-analysis suggests that the application of whole-body CT significantly reduces the mortality rate of MTPs and markedly reduces the time spent in the emergency department.

Clinical and economic effects of selective radiological evaluation of high-energy trauma patients: a prospective experience of a level 1 busy trauma centre

INTRODUCTION

Cervical spine, thoracic and pelvic fractures are the main causes of devastation in patients who have suffered blunt trauma. Radiographic imaging plays an important role in diagnosing such injuries. Nevertheless, the present dominant approach, the routine use of X-ray studies, seems to have no cost-benefit justification for healthcare systems.

METHODS

This prospective cross-sectional study was performed over a 3-month period. During the determined time frame, all haemodynamically stable, high-energy blunt trauma patients were included. Based on the predefined criteria, selective radiographic images of the neck, chest and pelvis were obtained. Patients were followed during their hospital stay and for a 2-week period after discharge.

RESULTS

1002 cases were included in the final survey. 247/1002 (24.6%) cervical radiographic images, 500/1002 (49.9%) CXRs and 171/1002 (17%) pelvic radiographic images of the patients were taken on the first day of hospital admission. New X-ray images required during the patients' hospital stay resulted in 5/1002 (0.4%) cervical, 4/1002 (0.3%) chest and 8/1002 (0.7%) pelvic radiographies. In the 2-week period after discharge, 4/1002 cases (0.3%) needed to repeat neck radiography. Overall, 697.44 mSv X-ray radiation was potentially prevented and US$426,450 were potentially saved.

CONCLUSIONS

Selective radiographic imaging of the neck, chest and pelvis together with a precise history-taking and physical examination in cases of high-energy blunt trauma could eliminate unnecessary costs to patients and healthcare systems, and significantly save resources.