Advanced Trauma Life Support. ABCDE from a radiological point of view

Paediatric Spinal Cord Injury: A Review of Current Management

Spinal cord injury (SCI) in the paediatric population is considered a separate entity from the same injury in adults due to the unique anatomical, physiological, and biomechanical properties of the pediatric spine. No comprehensive, standardized, international guidelines currently exist for physicians to follow regarding the management of paediatric spinal cord injuries. Therefore, a narrative literature review approach was employed to explore the management of paediatric spinal cord injuries. The review adhered to the methodological frameworks that entailed identifying a curated selection of pertinent articles on the topic, rather than an exhaustive comprehensive search that is utilised in systematic reviews, this was followed by a reflective interpretation of their content. Using the electronic databases, PubMed and Google Scholar, a search of peer-reviewed studies conducted only in the English language was included. Only studies in which the full article was available were included. Paediatric populations are defined as individuals aged between 0 and 18 years. In total, 26 studies were included in our review. We conclude that it is necessary to factor in specific paediatric considerations, such as disproportionate head size, increased ligament laxity, increased prevalence of upper cervical injury, and future development of scoliosis, in the prehospital, medical, and surgical management of paediatric spinal cord injuries. Clinicians should be made aware of these considerations, as they can improve the outcomes in the paediatric population who suffer from this devastating injury. There is a lack of high-quality studies and data concerning the paediatric population who have sustained SCIs. This literature review highlights the available data and calls for more studies to be conducted in this field.

Association of red blood cell distribution width with mortality among multiple trauma patients

Background

Identifying the severity of trauma to provide timely and adequate treatment and predict the prognosis are some of the significant challenges in trauma management. Increased red blood cell distribution width (RDW) is associated with several pathologies and associated mortality. This study aims to evaluate the RDW in predicting 24 h and 30-day mortality among multiple trauma patients.

Methods

In this retrospective study, multiple trauma patients with ISS ≤16 were included. Blood samples of the patients were collected at 1 h and 24 h of the referral to determine RDW. Demographic data, 24 h and 30-day mortality, injury severity score (ISS), and RDW outcomes were evaluated for all the patients.

Results

Of the 300 patients included in the study, 52 patients died in the first 24 h, and 85 patients within 30 days. One hour and 24 h RDW were not significantly different in 30-day mortality patients, P=0.104 and P=0.156, respectively. RDW in 30-day mortality patients was not significantly different at 1 h and 24 h, P-value=0.875. The means ISS in 24 h, 30-day mortality and survivors was significantly different, P<0.001.

Conclusion

Our study does not report a significant increase in RDW among 24 h and 30-day mortality and survivor patients. ISS was significantly different among the two groups.

Traumatic Injuries and Radiographic Study Utilization Among Children With Drowning Presenting to U.S. Pediatric Hospitals

OBJECTIVE

The role of traumatic injuries in fatal and nonfatal drownings is poorly described. We sought to characterize the incidence of traumatic injuries and diagnostic imaging performed among children who received pediatric hospital care for drowning.

METHODS

We conducted a retrospective study of children (≤18 years) with drowning encounters at 45 pediatric hospitals, October 2015 through December 2020. We described the presence of clinically important traumatic injuries to the following body regions: brain, spinal cord, thoracic and intra-abdominal organs, axial skeleton, pelvis, and long bones, and major vessels. We described patient characteristics and radiographic testing. We compared patients with and without traumatic injuries using the Fisher's exact and Wilcoxon signed rank tests.

RESULTS

We identified 10,397 children with a drowning encounter. Most (83.4%) were treated in the emergency department and 52.8% were admitted. There were 238 (2.3%) encounters with clinically important traumatic injuries. Intracranial injury was the most common (1.0%) with other traumatic injuries occurring in ≤0.5%. Less than 2% of children had a moderate or severe injury severity score and approximately half of these children had a clinically important traumatic injury. Among children with traumatic injuries, a higher proportion were 10 to 14 or 15 to 18 years old and from ZIP codes with lower median household income. Computerized tomography imaging was performed in the following proportions: brain (11.4%), cervical spine (3.7%), abdomen/pelvis (1.2%), chest (0.5%) and face/orbits (0.2%).

CONCLUSIONS

Clinically important traumatic injuries in children with drowning are rare. Further studies are needed to guide the optimal utilization of radiographic studies in this population.

February 6th, Kahramanmaraş earthquakes and the disaster management algorithm of adult emergency medicine in Turkey: An experience review

This compilation covers emergency medical management lessons from the February 6th Kahramanmaraş earthquakes. The objective is to review relevant literature on emergency services patient management, focusing on Koenig's 1996 Simple Triage and Rapid Treatment (START) and Secondary Assessment of Victim Endpoint (SAVE) frameworks. Establishing a comprehensive seismic and mass casualty incident (MCI) protocol chain is the goal. The prehospital phase of seismic MCIs treats hypovolemia and gets patients to the nearest hospital. START-A plans to expedite emergency patient triage and pain management. The SAVE algorithm is crucial for the emergency patient secondary assessment. It advises using Glasgow Coma Scale, Mangled Extremity Severity Score, Burn Triage Score, and Safe Quake Score for admission, surgery, transfer, discharge, and outcomes. This compilation emphasizes the importance of using diagnostic tools like bedside blood gas analyzers and ultrasound devices during the assessment process, drawing from 6 February earthquake research. The findings create a solid framework for improving emergency medical response strategies, making them applicable in similar situations.

Abdominal trauma

Traumatic injuries are the leading cause of death in people aged<45 years, and abdominal trauma is a source of significant morbidity and mortality and high economic costs. Imaging has a fundamental role in abdominal trauma, where CT is a fundamental tool for rapid, accurate diagnosis that will be key for patients' clinical outcomes.

Bilateral Traumatic Anterior Hip Dislocation - A Case Report

Introduction

Traumatic anterior hip dislocation is less common than posterior dislocation and bilateral anterior hip dislocation is a very rare presentation. Early diagnosis and treatment are of paramount importance to prevent complications. Here, we report a case of traumatic bilateral anterior hip dislocation following a high-velocity motor vehicle accident.

Case Report

A 26-year-old man was brought to the emergency department following high-energy trauma due to a motor vehicular accident. He was in considerable pain with both hips in flexion, abduction, and external rotation. There was a restriction to the range of movement at bilateral hip joints. Clinical and radiological examination revealed bilateral anterior hip dislocation.

Conclusion

Isolated anterior, obturator type of dislocation involving both hip joints with no other associated bony injury is quite unusual. The diagnosis and treatment have to be prompt. The chances of complications are high.

Current updates in acute traumatic aortic injury: radiologic diagnosis and management

Acute traumatic aortic injuries, which have substantial lethal outcomes at the time of admission, are fatal in 80% to 90% of cases. These injuries are relatively rare and have nonspecific clinical presentations. Radiologists and emergency physicians need to identify the radiological signs of acute traumatic aortic injury and differentiate them from common imaging errors to ensure accurate diagnosis and determine appropriate management protocols. In combination with image-guided interventions, advances in cross-sectional imaging have enabled nonsurgical management of acute traumatic aortic injuries. Timely and precise diagnoses of these injuries following prompt treatment are essential as up to 90% of patients presenting at the hospital can undergo early repair.

Post-traumatic bilateral posterior hip dislocations with femoral head fracture on one side and acetabular fracture on the other side: a very rare presentation

Hip dislocations are common orthopaedic emergencies which need early intervention to have a better outcome. They usually occur as a result of high energy trauma with motor vehicle accidents being the most common cause followed by fall from height. Posterior hip dislocation is more common than anterior. However, bilateral hip dislocations are rare compared with unilateral. Here we report our case with bilateral posterior hip dislocation with one side having head of femur fracture and contralateral side acetabulum fracture. Both hips were reduced under general anaesthesia on the same day of the trauma. Staged definitive treatment was carried out. The patient had an early recovery with no complications. This case represents an unusual, type of injury resulting from a high speed motor vehicle accident. Early diagnosis, immediate resuscitation and reduction of the hip joints followed by a careful and planned definitive treatment is necessary to have a better outcome.

Rapid Brain MRI Use in a Pediatric Emergency Department

Investigators from the University of Pittsburgh (Department of Emergency Medicine and Division of Pediatric Radiology) and Feinberg School of Medicine (Division of Emergency Medicine) studied the rates of neuroimaging (rapid brain MRI [rMRI], head CT [HCT], and full MRI) before and after implementation of four rapid MRI protocols in their ED.

The Use of Chest Computed Tomographic Angiography in Blunt Trauma Pediatric Population

INTRODUCTION

Blunt chest trauma in children is common. Although rare, associated major thoracic vascular injuries (TVIs) are lethal potential sequelae of these mechanisms. The preferred study for definitive diagnosis of TVI in stable patients is computed tomographic angiography imaging of the chest. This imaging modality is, however, associated with high doses of ionizing radiation that represent significant carcinogenic risk for pediatric patients. The aim of the present investigation was to define the incidence of TVI among blunt pediatric trauma patients in an effort to better elucidate the usefulness of computed tomographic angiography use in this population.

METHODS

A retrospective cohort study was conducted including all blunt pediatric (age < 14 y) trauma victims registered in Israeli National Trauma Registry maintained by Gertner Institute for Epidemiology and Health Policy Research between the years 1997 and 2015. Data collected included age, sex, mechanism of injury, Glasgow Coma Scale, Injury Severity Score, and incidence of chest named vessel injuries. Statistical analysis was performed using SAS statistical software version 9.2 (SAS Institute Inc, Cary, NC).

RESULTS

Among 433,325 blunt trauma victims, 119,821patients were younger than 14 years. Twelve (0.0001%, 12/119821) of these children were diagnosed with TVI. The most common mechanism in this group was pedestrian hit by a car. Mortality was 41.7% (5/12).

CONCLUSIONS

Thoracic vascular injury is exceptionally rare among pediatric blunt trauma victims but does contribute to the high morbidity and mortality seen with blunt chest trauma. Computed tomographic angiography, with its associated radiation exposure risk, should not be used as a standard tool after trauma in injured children. Clinical protocols are needed in this population to minimize radiation risk while allowing prompt identification of life-threatening injuries.

[Resuscitation room diagnostics]

CLINICAL PROBLEM

The indication for resuscitation room care is an acute (potentially) life-threatening patient condition. Typical causes for this are polytrauma, acute neurological symptoms, acute chest and abdominal pain or the cause remains unclear at first. The care is always provided in a suitably composed interdisciplinary team. This requires cause-specific standards tailored to the care facility and requires a mutual understanding of the partners involved with regard to specialist interests and care processes.

STANDARD RADIOLOGICAL METHODS

Whole-body CT is established for polytrauma imaging and usually each institution has already defined an institutional standard. For the other causes, first imaging with CT is just as common, but the protocols and procedures to be used are often not as clear as in the case of polytrauma.

METHODICAL INNOVATION AND EVALUATION

For polytrauma service, ATLS and procedures according to ABCDE already serve as a largely standardized framework in the resuscitation room. For every other group of causes, comparable concepts should be developed and institutionally strive for objectification of continuous improvement. This refers not only to the resuscitation room stay but also to the interfaces before and after resuscitation room service.

PRACTICAL RECOMMENDATIONS

After the patient has arrived, it has to be determined whether the assessment of a vital risk is retained. If so, institutionally defined care standards must be followed for the various causes. This concerns the interface logistics, the definition of a team leader including associated tasks, the supply processes including the CT examination protocols as well as the close communication.

[Update polytrauma and computed tomography in ongoing resuscitation : ABCDE and "diagnose first what kills first"]

CLINICAL ISSUE

The mean number of trauma room admissions and applied CT dose increase as the severity of injuries decreases. Therefore, appropriateness of established procedures should be re-evaluated.

STANDARD RADIOLOGICAL METHODS

Considering severely injured patients with an Injury Severity Score (ISS) ≥16, whole body CT (WB-CT) compared to selective CT decreased mortality by about 25%. Thus, the ISS is a good indicator for the severity of injuries. However, since ISS can only be determined after diagnosis, it does not help with the primary assessment.

METHODOLOGICAL INNOVATION AND EVALUATION

In addition to the currently used very fast WB-CT protocol with the highest diagnostic precision, a second protocol should be established applying a substantially lower dose. Under ongoing resuscitation, WB-CT often makes a substantial contribution towards targeted therapy or to justifying the discontinuation of resuscitation measures. The WB-CT findings should be performed several times and, at least in the acute emergency situation, it should follow the ABCDE scheme as close as possible.

PRACTICAL RECOMMENDATIONS

In the trauma room it should be initially decided whether the classification as polytrauma is to be maintained. If yes, every institution should provide a dose-reduced WB-CT protocol in addition to the maximum variant used so far. Dose-reduced WB-CT seems to be appropriate for stable and oriented patients, who receive a CT primarily because of the trauma mechanism. Even under resuscitation conditions, WB-CT is easy to perform and medically as well as ethically of high value. The reporting and communication should be structured according to "diagnose first what kills first".

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.

Rapid brain MRI protocols reduce head computerized tomography use in the pediatric emergency department

BACKGROUND

Rapid magnetic resonance imaging (MRI) protocols may be effective in the emergency department (ED) to evaluate nontraumatic neurologic complaints. We evaluate neuroimaging (rapid MRI [rMRI]), head computerized tomography [HCT], and full MRI) use following widespread implementation of rMRI protocols in a pediatric emergency department (ED).

METHODS

We conducted a retrospective study in a tertiary care pediatric ED of encounters with neuroimaging during two 9-month periods: one prior to (control period) and one after generalized availability of 4 rMRI protocols (rMRI period). The primary outcome was differences in neuroimaging rates between the two periods. Secondary outcomes included ED process measures, unsuccessful imaging, and undetected pathology, with full MRI within 14 days as the reference standard.

RESULTS

There were 1052 encounters with neuroimaging during the control and 1308 during the rMRI periods. Differences in neuroimaging between periods were 27.7% for rMRI (95% CI, 24.4, 31.0), - 21.5% for HCT (95% CI, - 25.5, - 17.5), and - 6.2% for full MRI (95% CI, - 9.3, - 3.1%.) Time to imaging (182 [IQR 138-255] versus 86 [IQR 52-137] minutes) as well as ED length of stay (396 [IQR 304-484] versus 257 [IQR 196-334] minutes) was longer for rMRI versus HCT (p < 0.01). Between the control and rMRI periods, there were differences in types of neuroimaging performed for patients with altered mental status, headache, seizure, shunt dysfunction, stroke, syncope, trauma, vomiting, infection, and other neurologic complaints (p < 0.05). rMRI studies were unsuccessful in 3.6% of studies versus 0.0% of HCTs (p < 0.01). The 22 unsuccessful rMRI studies were unsuccessful due to artifacts from dental hardware (n = 2) and patient motion (n = 20). None of the rMRI studies with full MRI follow-up imaging had undetected pathology; the false negative rate for the HCT exams was as high as 25%.

CONCLUSIONS

After routine ED use of 4 rMRI protocols, there was a more than 20% decrease in HCT use without missed diagnoses. Time to neuroimaging and length of stay were longer for rMRI than HCT, with higher rates of unsuccessful imaging. Despite these limitations, rMRI may be an alternative to HCT for nontraumatic complaints in the ED.

A Delayed Diagnosis of Hemorrhagic Shock in a Patient with Alcoholic Cirrhosis and Ascites on Bedside Ultrasound

Undifferentiated shock is a common and challenging problem in critical care. We present a case of hemorrhagic shock due to splenic and hepatic lacerations diagnosed by bedside paracentesis, initially misclassified as septic shock due to suspected spontaneous bacterial peritonitis (SBP). Case. A 47-year old man with a history of reported alcoholic cirrhosis and ongoing heavy alcohol use was brought to the emergency room after a syncopal event. He was found to be anemic (hemoglobin 9.9 g/dl) and hypotensive with a blood pressure of 64/34. Despite crystalloid infusion he remained hypotensive and required vasopressor support with norepinephrine. Bedside ultrasound revealed moderate ascites and as there was no evidence of active bleeding, his shock was attributed to sepsis due to SBP. A bedside paracentesis was performed which revealed gross blood. A repeat hemoglobin returned at 4.4 g/dl. Massive transfusion protocol was initiated and interventional radiology was emergently consulted due to concerns for intraabdominal hemorrhage; general surgery deemed the patient too unstable for surgical intervention. Angiogram revealed a splenic laceration and possible hepatic laceration, both embolized successfully. Internal medicine practitioners should keep the differential of hemorrhagic shock due to intraabdominal organ injury in mind for patients with undifferentiated shock.

[Blunt and penetrating thoracic trauma]

In most cases blunt chest trauma leads to fractures of the bony thorax, i. e. ribs. In the case of accompanying hemothorax or pneumothorax initial management consists of chest tube drainage by mini-thoracotomy. Subsequently patients with blunt chest trauma have to be transferred to the intensive care unit as these patients are at risk of pulmonary insufficiency or persistent blood loss via the chest tube. Injury to the great vessels or heart requires trauma care in specialized centers. Penetrating trauma is always surgically treated and the foreign body is removed in the operating room (OR). Life-threatening conditions, such as tension pneumothorax have to be treated by thorax drainage prior to hospital admission.

Usefulness of Pelvic Radiographs in the Initial Trauma Evaluation with Concurrent CT: Is Additional Radiation Exposure Necessary?

Trauma patients in a Level I Pediatric Trauma Center may undergo CT of the abdomen and pelvis with concurrent radiograph during initial evaluation in an attempt to diagnose injury. To determine if plain digital radiograph of the pelvis adds additional information in the initial trauma evaluation when CT of the abdomen and pelvis is also performed, trauma patients who presented to an urban Level I Pediatric Trauma Center between 1 January 2010 and 7 February 2017 in whom pelvic radiograph and CT of the abdomen and pelvis were performed within 24 hours of each other were analyzed. A total of 172 trauma patients had pelvic radiograph and CT exams performed within 24 hours of each other. There were 12 cases in which the radiograph missed pelvic fractures seen on CT and 2 cases in which the radiograph suspected a fracture that was not present on subsequent CT. Furthermore, fractures in the pelvis were missed on pelvic radiographs in 12 of 35 cases identified on CT. Sensitivity of pelvic radiograph in detecting fractures seen on CT was 65.7% with a 95% confidence interval of 47.79-80.87%. Results suggest that there is no added diagnostic information gained from a pelvic radiograph when concurrent CT is also obtained, a practice which exposes the pediatric trauma patient to unnecessary radiation.

Traumatic Airway Injuries: Role of Imaging

Airway Injuries are rare but often immediately life threatening. Incidence ranges from 0.5-2 % in blunt and 1-6 % in penetrating trauma. Upper airway injuries (UAI) are often clinically apparent and get shunted during the primary survey in the emergency department. Few UAI and majority of lower airway injuries (LAI) are occult on primary survey and need a high suspicion index. Clinically, the diagnosis of tracheobronchial injury is delayed in many patients because the airway column is maintained by the peribronchial tissue. Imaging in the form of MDCT, in conjunction with endoscopy, plays a role in delineating the exact site and extent of injury and ruling out associated vascular and esophageal injuries for definitive management of UAI. Chest radiographs and ultrasonography help raise suspicion of LAI by detection of pneumomediastinum, persistent pneumothorax and/or subcutaneous emphysema and should be followed up with multidetector computed tomography (MDCT) which is the mainstay of diagnosis. However, it requires careful evaluation of the airway tract and a thorough knowledge about the mechanism of trauma for detection of subtle injuries. Reconstructions in multiple planes and use of various post-processing techniques including minimum intensity projection (MinIP) images enhance the detection rate. The specific signs of LAI on CT include discontinuity in the tracheobronchial tree, focal intimal flap projecting in the lumen, focal soft tissue attached to the tracheal/bronchial wall, complete cut off of the bronchus/trachea and the fallen lung sign. We, hereby, illustrate the imaging spectrum of traumatic airway injuries in detail and discuss their management implications.

Asymmetric bilateral traumatic hip dislocation: A case report

INTRODUCTION

Traumatic hip dislocation is a severe injury with the potential for significant morbidity and mortality. Bilateral hip dislocation is rare representing 1.25% of all hip dislocations.

PRESENTATION OF THE CASE

A 19-year-old male had a high-speed motor vehicle accident. After stabilizing the patient, it was noticed that the position of the right lower limb was in adduction and internal rotation while the left was in external rotation and abduction. Pelvis x-ray showed right superior posterior and left anterior inferior hip dislocations. Closed reduction was performed within 3 hours from the trauma for both sides. The post reduction CT scan showed adequate reduction of both hips with no associated fractures. During his three-year follow-up, he never had any complaints and the clinical examination and radiographs did not reveal any abnormalities.

DISCUSSION

Early reduction of hip dislocations minimizes the risk of osteonecrosis of the femoral head. The current recommendations state that a hip dislocation must be reduced within 6 hours.

CONCLUSION

This is a rare case of bilateral asymmetric hip dislocations with no concomitant fractures. It is important to reduce hip dislocation within 6 hours from the time of injury to prevent osteonecrosis of the femoral head.

Thoracic injury rule out criteria and NEXUS chest in predicting the risk of traumatic intra-thoracic injuries: A diagnostic accuracy study

INTRODUCTION

This study aimed to compare the diagnostic accuracy of NEXUS chest and Thoracic Injury Rule out criteria (TIRC) models in predicting the risk of intra-thoracic injuries following blunt multiple trauma.

METHODS

In this diagnostic accuracy study, using the 2 mentioned models, blunt multiple trauma patients over the age of 15 years presenting to emergency department were screened regarding the presence of intra-thoracic injuries that are detectable via chest x-ray and screening performance characteristics of the models were compared.

RESULTS

In this study, 3118 patients with the mean (SD) age of 37.4 (16.9) years were studied (57.4% male). Based on TIRC and NEXUS chest, respectively, 1340 (43%) and 1417 (45.4%) patients were deemed in need of radiography performance. Sensitivity, specificity, and positive and negative predictive values of TIRC were 98.95%, 62.70%, 21.19% and 99.83%. These values were 98.61%, 59.94%, 19.97% and 99.76%, for NEXUS chest, respectively. Accuracy of TIRC and NEXUS chest models were 66.04 (95% CI: 64.34-67.70) and 63.50 (95% CI: 61.78-65.19), respectively.

CONCLUSION

TIRC and NEXUS chest models have proper and similar sensitivity in prediction of blunt traumatic intra-thoracic injuries that are detectable via chest x-ray. However, TIRC had a significantly higher specificity in this regard.

Duodenal Perforation following Blunt Abdominal Trauma Presenting as Normal in Abdominal Computed Tomography

Most emergency department (ED) physicians implement the Advanced Trauma Life Support (ATLS) approach, including primary and secondary survey, for the assessment of blunt abdominal trauma (BAT) patients. This report emphasizes the need for repeat Focused Assessment with Sonography for Trauma (FAST) and abdominal computed tomography (CT) if a BAT patient's condition persists or worsens. After initial negative FAST and abdominal CT findings, it is recommended that BAT patients with suspected intraabdominal injury should receive repeat examination in an optimal time. We report a patient who sustained duodenal perforation following BAT diagnosed by repeat ultrasound examination and abdominal CT scan. (Hong Kong j.emerg.med. 2014;21:396-399)

Anatomy of the sacroiliac joints in children and adolescents by computed tomography

BACKGROUND

Diagnosing sacroiliitis by magnetic resonance imaging (MRI) in children/adolescents can be difficult due to the growth-related changes. This study analyzed the normal osseous anatomy of the sacroiliac joints (SIJ) in a juvenile population using computed tomography (CT).

METHODS

The anatomy of the SIJ was retrospectively analyzed in 124 trauma patients aged 9 months - <18 years by CT, based on 2 mm slices in axial, semi-axial and semi-coronal planes. The following anatomical features were recorded: intersegmental fusion of the sacral vertebral segments 1-3 (S1-S3), ossified nuclei (antero-superior at S1, lateral to the intervertebral spaces and lateral to S1 and S2) and joint facet defects larger than 3 mm.

RESULTS

Fusion of S1/S2 started at the age of 6 years and was complete after the age of 13 years in most girls and after the age of 14 years in most boys. Fusion of S2/S3 started at the age of 9 years, but could remain incomplete up to 18 years in both genders. Ossified nuclei antero-lateral at S1 and/or in the joint space were observed until the age of 18 years and occurred in 77% of individuals ≥13 years with intraarticular localization in 64% of girls and 60% of boys. Joint facet defects >3 mm occurred in 21 children/adolescents (17%) located to both the iliac and sacral joint facets.

CONCLUSIONS

Normal osseous SIJ structures in children and adolescents vary considerably. Attention to these normal anatomical structures during growth may help to avoid false positive findings by MRI.

Correlating abdominal pain and intra-abdominal injury in patients with blunt abdominal trauma

Background

A thorough history and physical examination in patients with blunt abdominal trauma (BAT) is important to safely exclude clinically significant intra-abdominal injury (IAI). We seek to evaluate a correlation between self-reported abdominal pain, abdominal tenderness on examination and IAI discovered on CT or during exploratory laparotomy.

Methods

This retrospective analysis assessed patients with BAT ≥13 years old who arrived to the emergency department following BAT during the 23-month study period. Upon arrival, the trauma team examined all patients. Only those who underwent an abdominal and pelvic CT scan were included. Patients were excluded if they were unable to communicate or lacked documentation, had obvious evidence of extra-abdominal distracting injuries, had a positive drug or alcohol screen, had a Glasgow Coma Scale ≤13, or had a positive pregnancy screening. The primary objective was to assess the agreement between self-reported abdominal pain and abdominal tenderness on examination and IAI noted on CT or during exploratory laparotomy.

Results

Among the 594 patients included in the final analysis, 73.1% (n=434) had no self-reported abdominal pain, 64.0% (n=384) had no abdominal tenderness on examination, and 22.2% (n=132) had positive CT findings suggestive of IAI. Among the 352 patients who had no self-reported abdominal pain and no abdominal tenderness on examination, a significant number of positive CT scan results (14%, n=50) were still recorded. Furthermore, a small but clinically significant portion of these 50 patients underwent exploratory laparotomy (1.1%, n=4). All four of these patients ultimately underwent a splenectomy and all were completed on hospital day one.

Conclusion

Lack of abdominal pain and tenderness in patients with BAT with non-distracting injuries was associated with a small portion of patients who underwent a splenectomy. Patients with BAT without abdominal pain or tenderness may need a period of observation or CT scan to rule out IAI prior to discharge home.

Level of evidence

Level III, therapeutic/care management.

Roentgenographic and computerized tomography based morphometric analysis of cervical spinal canal diameters to establish normative measurements in an Indian population

Compressive cervical myelopathy secondary to degenerative changes in the cervical spine is a common cause of neurologic morbidity in the elderly. Identification of canal stenosis and addressing it surgically in addition to the obvious compressive lesions is essential to obtain satisfactory results. We attempt to define the saggital and transverse diameters in a normal adult population presenting at our centre with head injuries. We found that the values were lower than those reported in comparable studies for a western population, and also that the dimensions in women are significantly lower than in men.

Predictors of Intrathoracic Injury after Blunt Torso Trauma in Children Presenting to an Emergency Department as Trauma Activations

BACKGROUND

Thoracic injuries are a major cause of death associated with blunt trauma in children. Screening for injury with chest x-ray study, compared with chest computed tomography (CT) scan, has been controversial, weighing the benefits of specificity with the detriment of radiation exposure.

OBJECTIVE

To identify predictors of thoracic injury in children presenting as trauma activations to a Level I trauma center after blunt torso trauma, and to compare these predictors with those previously reported in the literature.

METHODS

We performed a retrospective chart review of pediatric patients (<18 years of age) who presented to the Emergency Department of a Level I trauma center between June 2010 and June 2013 as a trauma activation after sustaining a blunt torso trauma and who received diagnostic imaging of the chest as part of their initial evaluation.

RESULTS

Data analysis was performed on 166 patients. There were 33 patients (20%) with 45 abnormalities detected on diagnostic imaging of the chest, with the most common abnormalities being lung contusion (36%), pneumothorax (22%), and rib fracture (13%). Statistically significant predictors of abnormal diagnostic imaging of the chest included Glasgow Coma Scale score (GCS) < 15 (27% with abnormality vs. 13% without abnormality), hypoxia (22% vs. 5%), syncope/loss of consciousness (55% vs. 35%), cervical spine tenderness (12% vs. 3%), thoraco-lumbar-sacral spine tenderness (41% vs. 17%), and abdominal/pelvic tenderness (12% vs. 3%).

CONCLUSIONS

Based on our data, predictors of thoracic injury in children after blunt torso trauma include GCS < 15, hypoxia, syncope/dizziness, cervical spine tenderness, thoraco-lumbar-sacral spine tenderness, and abdominal/pelvic tenderness.

Simulation of Trauma Incidents : Modelling the Evolution of Patients and Resources

Mathematical modeling and simulation with medical applications has gained much interest in the last few years, mainly due to the widespread availability of low-cost technology and computational power. This paper presents an integrated platform for the in-silico simulation of trauma incidents, based on a suite of interacting mathematical models. The models cover the generation of a scenario for an incident, a model of physiological evolution of the affected individuals, including the possible effect of the treatment, and a model of evolution in time of the required medical resources. The problem of optimal resource allocation is also investigated. Model parameters have been identified according to the expertise of medical doctors and by reviewing some related literature. The models have been implemented and exposed as web services, while some software clients have been built for the purpose of testing. Due to its extendability, our integrated platform highlights the potential of model-based simulation in different health-related fields, such as emergency medicine and personal health systems. Modifications of the models are already being used in the context of two funded projects, aiming at evaluating the response of health systems to major incidents with and without model-based decision support.

Preliminary study on the automated skull fracture detection in CT images using black-hat transform

Linear skull fracture, following head trauma, may reach major blood vessels, such as the middle meningeal artery or sinus venosus, and may cause epidural hematoma. However, hematoma is likely to be missed in the initial interpretation because it spreads only gradually. In addition, the fracture lines that run along the scan slice plane are often missed during initial interpretation. In this study, we develop a novel method for automated detection of the linear skull fracture using head computed tomography (CT) images and conduct a basic evaluation using digital phantom and head phantom that enclose genuine human bones. In the proposed method, the bone region is first extracted using morphological processing of the head CT images. Then, the cranial vault is determined from the CT scout view image. The skull has low-density cancellous bone between the hard two-layer high-density compact bones. Because the fracture lines of compact bones are more clearly recognized as compared to cancellous bones, the bone surface is then extracted by performing three-dimensional (3D) Laplacian filtering. Finally, linear structures are extracted by applying the black-hat transform to the bone surface image. In the experiments, we evaluated the proposed method using digital phantom and CT images of the head phantom. From the experiments using digital phantom, we were able to detect a crack line with a width of 0.35 mm. In the experiments using head phantom, we were able to clearly detect the crack lines in the phantom. These results indicate that our proposed method will be useful for the automated detection of skull fracture in CT images.

Validation of thoracic injury rule out criteria as a decision instrument for screening of chest radiography in blunt thoracic trauma

BACKGROUND

Thoracic injury rule out criteria (TIRC) were first introduced as a decision instrument for selective chest radiography in blunt thoracic trauma in 2014. However, the validity of this model has not been assessed in other studies. In this regard, the present survey evaluates the validity of TIRC model in a multi-center setting.

METHODS

In this cross-sectional study, clinical presentations and chest radiograms of multiple trauma patients referring to 6 educational hospitals in Iran were evaluated. Data were gathered prospectively during 2015. In each center, data collection and interpretation of radiograms were conducted by two different emergency medicine specialists. Measures were then taken for assessment of discriminatory power and calibration of the model.

RESULTS

Data from 2905 patients were gathered (73.17% were male; the mean age was 33.53 ± 15.42 years). Area under the receiver operating characteristics curve of the TIRC model for detection of thoracic traumatic injuries was 0.93 (95%CI: 0.93-0.94). Sensitivity and specificity of the model were 100 (98.91-100) and 67.65 (65.76-69.45), respectively. The intercept of TIRC calibration plot was 0.08 (95%CI: 0.07-0.09), and its slope was 1.19 (95%CI: 1.15-1.24), which are indicative of the model being perfect in detecting presence or absence of lesions in chest radiograms.

CONCLUSION

The findings are corroborative of external validation, good discrimination, and proper calibration of TIRC model in screening of multiple trauma patients for obtaining chest radiograms.

Objective Structured Clinical Examination (OSCE)-based Assessment of the Advanced Trauma Life Support (ATLS) Course in Iran

OBJECTIVE

To evaluate the effect of advance trauma life support (ATLS®) training on general surgery residents clinical reasoning skills using the national boards-style objective structured clinical examination (OSCE).

METHODS

This cross-sectional single-center study was conducted in Shiraz University of Medical Sciences including 51 surgery residents that participated in a mandatory national board style OSCE between May 2014 and May 2015. OSCE scores of two groups of general surgery residents including 23 ATLS® trained and 28 non-ATLS® trained were compared using Mann-Whitney U test. The exam was graded out of 20 points and the passing score was ≥14 including 40% trauma cases.

RESULTS

There were 8(15.7%) women and 43(84.3%) men among the participants with mean age of 31.12 ± 2.69 and 33.67 ± 4.39 years in women and men respectively. Overall 7 (87.5%) women and 34 (79.07%) men passed the OSCE. The trauma section OSCE score was significantly higher in the ATLS® trained participants when compared to non-ATLS®(7.79 ± 0.81vs.6.90 ± 1.00; p=0.001). In addition, the total score was also significantly higher in ATLS® trained residents (16.07 ± 1.41 vs. 14.60 ± 1.40; p=0.001). There was no association between gender and ATLS® score (p=0.245) or passing the OSCE (p=0.503).

CONCLUSION

ATLS® training is associated with improved overall OSCE scores of general surgery residents completing the board examinations suggesting a positive transfer of ATLS learned skills to management of simulated surgical patients including trauma cases.

Traumatic atlantooccipital dislocation: comprehensive assessment of mortality, neurologic improvement, and patient-reported outcomes at a Level 1 trauma center over 15 years

BACKGROUND CONTEXT

Only Level 3 evidence exists for the diagnosis and treatment of atlantooccipital dislocation (AOD) with few studies examining mortality, neurologic improvement, and patient-reported outcomes (PROs).

PURPOSE

First, the aim was to determine: the incidence of AOD, 90-day surgical morbidity and mortality after AOD, patient factors that may be associated with delayed or missed diagnosis, and factors that were associated with mortality and neurologic improvement after AOD. Secondly, the aim was to quantify the pain, disability, and quality of life experienced by patients surviving AOD.

STUDY DESIGN/SETTING

This was a retrospective cohort study.

PATIENT SAMPLE

A total of 5,337 consecutive spine computed tomography traumagrams from 1997 to 2012 were included.

OUTCOME MEASURES

Mortality, neurologic improvement, complications, EuroQol five dimensions (EQ-5D), Neck Disability Index (NDI), Numeric Rating Scale (NRS)-neck, NRS-arm, and return-to-work were the outcome measures.

METHODS

Patients were considered to have AOD if they met one of the following radiographic criteria: basion-dens interval greater than 10 mm; basion-axial interval: anterior displacement greater than 12 mm or posterior displacement greater than 4 mm between the basion and posterior C2 line; and condyle to C1 interval greater than 1.4 mm. Linear regression analysis was performed to identify factors associated with 90-day mortality, neurologic improvement, and missed diagnosis. Patient-reported outcomes were assessed via phone interview.

RESULTS

Thirty-one patients met radiographic criteria for AOD; an incidence of 0.6% over 15 years. Twenty-one (68%) patients were treated with occipital cervical fusion. At 90 days postoperatively, there were no new neurologic deficits or reoperations. Eight (26%) patients died within 90 days. All patients who died had no documented AOD diagnosis and were not treated surgically. Missed AOD diagnosis was the strongest predictor of mortality. Younger age, lower Glasgow Coma Score, lower Injury Severity Score (ISS) score, and worse initial American Spinal Injury Association (ASIA) score were significantly associated with greater neurologic improvement. Higher ISS score and better ASIA score were significantly associated with missed AOD diagnosis. The average PROs metrics at time of telephone follow-up were as follows: EQ-5D=0.73±0.19, NDI=30.89±18.57, NRS-neck=2.33±2.21, NRS-arm=2.00±2.54. Of the patients with follow-up data, four were employed full-time, and five were receiving disability.

CONCLUSIONS

Our work suggests that failure to diagnose AOD is a powerful predictor of mortality. Higher ISS scores and better neurologic presentation were significantly associated with missed diagnosis. Craniocervical arthrodesis preserved neurologic function with low complication rate and unexpectedly high PROs and return-to-work. These results must be carefully interpreted because it is unclear whether missed AOD diagnosis accompanies another death-causing injury (eg, traumatic brain injury) or if failure to treat AOD contributes to mortality in a multifactorial manner.

Utility of complete trauma series radiographs in alert pediatric patients presenting to Emergency Department of a Tertiary Care Hospital

PURPOSE

To assess the utility of trauma series radiographs in the management of alert pediatric patients with traumatic injury and to ascertain whether it is necessary to acquire the entire trauma series in these children.

METHODS

A total of 176 consecutive children below the age of 15 years and having Glasgow Coma Scale score greater than 12, who presented to the emergency department of a tertiary care hospital with a history of recent trauma, were retrospectively reviewed. All the children had undergone a thorough clinical examination followed by complete trauma series radiographs, according to the American College of Surgery guidelines.

RESULTS

A total of 558 radiographs were reviewed by a consultant pediatric radiologist including 528 trauma series radiographs and 30 additional radiographs. Among the trauma series radiographs, 35 (6.63 %) had evidence of injury; 24 (4.54 %) and 11 (2.08 %) involving the chest and pelvic regions, respectively. All children with normal physical examination had normal cervical spine and chest radiographs. Among the 11 positive pelvic X-rays, only two had radiological signs of injury in the absence of localizing physical signs, and all these children were less than 3 years of age. In all the remaining cases, children had localizing signs on physical examination. Out of the 30 additional X-rays, 27 (90 %) had radiological evidence of injury.

CONCLUSIONS

The routine use of entire radiological trauma series in alert pediatric patients with a normal physical examination has a very low yield. In these children, the localizing signs and symptoms can help us in determining the specific radiological examination to be utilized.

Accuracy of contrast-enhanced ultrasound (CEUS) in the identification and characterization of traumatic solid organ lesions in children: a retrospective comparison with baseline US and CE-MDCT

INTRODUCTION

Localized low-energy abdominal trauma is very frequent in the pediatric population. The findings of several studies have shown that ultrasonography (US) can represent a useful and cost-effective tool in the evaluation of blunt abdominal trauma both in adults and children. However, many parenchymal injuries are not correctly visualized at baseline US examination. The introduction of specific US contrast agents contrast-enhanced ultrasound (CEUS) has enabled a better identification of traumatic organ injuries. The correct use of CEUS could therefore identify and select the children who need further diagnostic investigation computed tomography (CT), avoiding unnecessary radiation and iodinated contrast medium exposure. The purpose of our study was to assess the sensibility and feasibility of CEUS in the assessment of low-energy abdominal trauma compared to baseline US in pediatric patients, using contrast-enhanced MDCT as the reference standard.

MATERIALS AND METHODS

We retrospectively reviewed 73 children (51 M and 22 F; mean age 8.7 ± 2.8 years) who presented in our Emergency Department between October 2012 and October 2013, with history of minor abdominal trauma according to the Abbreviated Injury Scale and who underwent US, CEUS, and CE-MDCT. Inclusion criteria were: male or female, aged 0-16, hemodynamically stable patients with a history of minor blunt abdominal trauma. Exclusion criteria were adulthood, hemodynamical instability, history of major trauma. Sensitivity, specificity, PPV, NPV, and accuracy were determined for US and CEUS compared to MDCT.

RESULTS

6/73 patients were negative at US, CEUS, and MDCT for the presence of organ injuries. In the remaining 67 patients, US depicted 26/67 parenchymal lesions. CEUS identified 67/67 patients (67/67) with parenchymal lesions: 21 lesions of the liver (28.8 %), 26 lesions of the spleen (35.6 %), 7 lesions of right kidney (9.6 %), 13 lesions of left kidney. MDCT confirmed all parenchymal lesions (67/67). Thus, the diagnostic performance of CEUS was better than that of US, as sensitivity, specificity, PPV, NPV, and accuracy were 100, 100, 100, 100, and 100 % for CEUS and 38.8, 100, 100, 12.8, and 44 % for US. In some patients CEUS identified also prognostic factors as parenchymal active bleeding in 8 cases, partial devascularization in 1 case; no cases of vascular bleeding, no cases of urinoma. MDCT confirmed all parenchymal lesions. Parenchymal active bleeding was identified in 16 cases, vascular bleeding in 2 cases, urinoma in 2 cases, partial devascularization in 1 case.

CONCLUSIONS

CEUS is more sensitive and accurate than baseline US and almost as sensitive as CT in the identification and characterization of solid organs lesions in blunt abdominal trauma. CT is more sensitive and accurate than CEUS in identifying prognostic indicators, as active bleeding and urinoma. CEUS should be considered as a useful tool in the assessment and monitoring of blunt abdominal trauma in children.

Preliminary trauma radiographs misrepresent pubic diastasis injuries

The goal of this study was to evaluate the role of portable primary trauma survey radiographs in the evaluation and management of anteroposterior (AP) compression pelvic injuries. A retrospective analysis was conducted at a level I academic trauma center. Twenty-seven adults with AP compressive class pelvic ring injuries who received both portable pelvic radiographs and pelvic computed tomography (CT) imaging in an unbound pelvic state were included. Three orthopedic surgeons performed independent measurements of diastasis on portable pelvic radiographs and coronal pelvic CT reconstructions. Measurement techniques were standardized among observers and were repeated after 8 weeks to assess intraobserver reliability. Nonoperative vs operative treatments were correlated with the initial magnitude of pelvic injury on CT and portable radiographic images. Independent measurements of diastasis on both radiographs and CT scans showed excellent intraobserver reliability (average correlation coefficient, 0.986) and interobserver reliability (average correlation coefficient, 0.979). Compared with diastasis measurements on CT scans, portable pelvic radiographs overestimated diastasis by an average of 49%, or 12.6 mm (P<.0001; 95% confidence interval, 9.6-15.6). Portable pelvic films were less precise than standard pelvic radiographs in measuring the size of femoral head controls (R(2)=0.919 vs 0.759; P=.004). In 12 of the 27 patients evaluated, radiographic indications for operative pelvic fixation were met by portable radiographs but not CT scans, and 11 of these patients ultimately underwent operative fixation. Portable AP pelvic radiographs may distort and exaggerate pelvic bony injuries, especially those involving anterior pelvic structures. Surgeons should use caution when making management decisions based on preliminary portable pelvic radiographs.

Factors affecting success rate of Advanced Trauma Life Support (ATLS) courses

BACKGROUND

The aim of the present study was to define the factors that affect passing the assessments for successful completion of the Advanced Trauma Life Support (ATLS) Provider Courses in the United Arab Emirates (UAE).

METHODS

The ATLS Provider Course has been taught in three medical centers in the UAE since 2004. A total of 1,041 doctors completed the course during the period 2004-2010. A special protocol was designed to enter data accrued for each course, participants' demographics, and assessments, including the final results. Direct logistic regression was performed to define factors affecting success in multiple choice questions (MCQ) and in the practical initial assessment station exam. The studied variables included the year, the course site, speciality, level of practice, and pre-test score.

RESULTS

The majority of participants were surgeons (33.2 %), followed by Emergency Medicine physicians (27.3 %). The logistic regression model showed that having a low pre-test score (p < 0.0001) and being a family medicine practitioner (p < 0.0001) increased the likelihood of failing the MCQ exam. The chance of passing the end of course practical exam increased with time (p = 0.002). A low pre-test score (p < 0.0001) and being examined in site A (p = 0.04) increased the chance of failing in the initial assessment exam. The pass rate for the ATLS exam significantly increased after adoption of the interactive approach to teaching.

CONCLUSIONS

Prior knowledge and preparation is essential to passing the ATLS exam. Doctors who deal clinically with all aspects of airway, breathing, and circulation of the ATLS course are more likely to pass the MCQ exam in our setting, followed by those who usually manage only the circulation or disability aspects of ATLS. It is possible that the interactive approach to teaching ATLS has improved the overall ATLS success rate.

Diagnostic yields, charges, and radiation dose of chest imaging in blunt trauma evaluations

BACKGROUND

Chest radiography (CXR) is the most common imaging in adult blunt trauma patient evaluation. Knowledge of the yields, attendant costs, and radiation doses delivered may guide effective chest imaging utilization.

OBJECTIVES

The objectives were to determine the diagnostic yields of blunt trauma chest imaging (CXR and chest computed tomography [CT]), to estimate charges and radiation exposure per injury identified, and to delineate assessment points in blunt trauma evaluation at which decision instruments for selective chest imaging would have the greatest effect.

METHODS

From December 2009 to January 2012, we enrolled patients older than 14 years who received CXR during blunt trauma evaluations at nine U.S. Level I trauma centers in this prospective, observational study. Thoracic injury seen on chest imaging and clinical significance of the injury were defined by a trauma expert panel. Yields of imaging were calculated, as well as mean charges and effective radiation dose (ERD) per injury.

RESULTS

Of 9,905 enrolled patients, 55.4% had CXR alone, 42.0% had both CXR and CT, and 2.6% had CT alone. The yields for detecting thoracic injury were CXR 8.4% (95% confidence intervals [CIs]) = 7.8% to 8.9%), chest CT 28.8% (95% CI = 27.5% to 30.2%), and chest CT after normal CXR 15.0% (95% CI = 13.9% to 16.2%). The mean charges and ERD (millisievert [mSv]) per injury diagnosis of CXR, chest CT, and chest CT after normal CXR were $3,845 (0.24 mSv), $10,597 (30.9 mSv), and $20,347 (59.3 mSv), respectively. The mean charges and ERD per clinically major thoracic injury diagnosis on chest CT after normal CXR were $203,467 and 593 mSv.

CONCLUSIONS

Despite greater diagnostic yield, chest CT entails substantially higher charges and radiation dose per injury diagnosed, especially when performed after a normal CXR. Selective chest imaging decision instruments should identify patients who require no chest imaging and patients who may benefit from chest CT after a normal CXR.

Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients

BACKGROUND

Trauma is the fifth leading cause of death worldwide, and in people younger than 40 years of age, it is the leading cause of death. During the resuscitation of trauma patients at the emergency department, there are two different commonly used diagnostic strategies. Conventionally, there is the use of physical examination and conventional diagnostic imaging, potentially followed by selective use of computed tomography (CT). Alternatively, there is the use of physical examination and conventional diagnostics, followed by a routine (instead of selective) use of thoracoabdominal CT. It is currently unknown which of the two strategies is the better diagnostic strategy for patients with blunt high-energy trauma.

OBJECTIVES

To assess the effects of routine thoracoabdominal CT compared with selective thoracoabdominal CT on mortality in blunt high-energy trauma patients.

SEARCH METHODS

We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (Issue 4, 2013); MEDLINE (OvidSP), EMBASE (OvidSP) and CINAHL for all published randomised controlled trials (RCTs). We did not restrict the searches by language, date or publication status. We conducted the search on the 9 May 2013.

SELECTION CRITERIA

We included RCTs of trauma resuscitation algorithms using routine thoracoabdominal CT versus algorithms using selective CT in this review. We included all blunt high-energy trauma patients (including blast or barotrauma).

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the search results.

MAIN RESULTS

The systematic search identified 481 references; after removal of duplicates, 396 remained. We found no RCTs comparing routine versus selective thoracoabdominal CT in blunt high-energy trauma patients. We excluded 381 studies based on the abstracts of the publications because of irrelevance to the review topic, and a further 15 studies after full-text evaluation.

AUTHORS' CONCLUSIONS

We found no RCTs of routine versus selective thoracoabdominal CT in patients with blunt high-energy trauma. Based on the lack of evidence from RCTs, it is not possible to say which approach is better in reducing deaths.

Radiological work-up after mass casualty incidents: are ATLS guidelines applicable?

OBJECTIVES

In mass casualty incidents (MCI) a large number of patients need to be evaluated and treated fast. Well-designed radiological guidelines can save lives. The purpose of this study was to evaluate the Advanced Trauma Life Support (ATLS) radiological guidelines in the MCI of an aeroplane crash.

METHODS

Medical data of all 126 survivors of an aeroplane crash were analysed. Data included type and body region of the radiological studies performed on the survivors, Abbreviated Injury Score (AIS) and Injury Severity Score (ISS) codes and trauma care level of the hospitals.

RESULTS

Ninety patients (72 %) underwent one or more imaging studies: in total 297 radiographs, 148 CTs and 18 ultrasounds were performed. Only 18 % received diagnostic imaging of all four body regions as recommended by ATLS. Compliance with ATLS was highest (73.3 %) in severely injured victims (ISS ≥16); this group underwent two thirds of the (near) total body CTs, all performed in level I trauma centres.

CONCLUSION

Overall compliance with ATLS radiological guidelines was low, although high in severely injured patients. Level I trauma centres frequently used (near) total body CT. Deviation from ATLS guidelines in radiological work-up in less severely injured patients can be safe and did not result in delayed diagnosis of serious injury.

KEY POINTS

• Radiological imaging protocols can assist the management of mass casualty incidents needs. • Advanced Trauma Life Support (ATLS) radiological guidelines have been developed. • But radiological guidelines have not frequently been applied in aeroplane crashes. • Aircraft accidents are of high energy so ATLS guidelines should be applied. • Following mass casualty incidents total body CT seems appropriate within ATLS protocols.

Fractures of the cervical spine

OBJECTIVES

The aim of this study was to review the literature on cervical spine fractures.

METHODS

The literature on the diagnosis, classification, and treatment of lower and upper cervical fractures and dislocations was reviewed.

RESULTS

Fractures of the cervical spine may be present in polytraumatized patients and should be suspected in patients complaining of neck pain. These fractures are more common in men approximately 30 years of age and are most often caused by automobile accidents. The cervical spine is divided into the upper cervical spine (occiput-C2) and the lower cervical spine (C3-C7), according to anatomical differences. Fractures in the upper cervical spine include fractures of the occipital condyle and the atlas, atlanto-axial dislocations, fractures of the odontoid process, and hangman's fractures in the C2 segment. These fractures are characterized based on specific classifications. In the lower cervical spine, fractures follow the same pattern as in other segments of the spine; currently, the most widely used classification is the SLIC (Subaxial Injury Classification), which predicts the prognosis of an injury based on morphology, the integrity of the disc-ligamentous complex, and the patient's neurological status. It is important to correctly classify the fracture to ensure appropriate treatment. Nerve or spinal cord injuries, pseudarthrosis or malunion, and postoperative infection are the main complications of cervical spine fractures.

CONCLUSIONS

Fractures of the cervical spine are potentially serious and devastating if not properly treated. Achieving the correct diagnosis and classification of a lesion is the first step toward identifying the most appropriate treatment, which can be either surgical or conservative.

Full-body x-ray imaging to facilitate triage: a potential aid in high-volume emergency departments

The levels of traumatic injury seen in South African emergency departments (EDs) are epidemic. This is coupled with a severe lack of resources and adequately trained emergency staff. The Lodox Statscan (LS) is an X-ray scanner capable of producing rapid, low-dose, and full-body X-ray images. In this paper, a new trauma protocol-the Johannesburg trauma protocol-that implements LS scanning on entry to the ED as a triage tool is reported. A case study illustrating the use of LS to triage 63 patients in a single Saturday shift at a level 1 Trauma Centre is also presented. Because of the ability to rapidly and safely provide X-ray imaging information to support clinical decision making, the LS could be a useful tool to aid in resource allocation to improve treatment of the high levels of trauma patients that present to South African EDs daily.

A critical review of the literature and an evidence-based approach for life-threatening hemorrhage in maxillofacial surgery

BACKGROUND

Life-threatening facial hemorrhage in Maxillofacial Surgery (MFS) has an approximate incidence of 1% in the trauma patient and in elective surgery. The treatment of acute life-threatening hemorrhage in MFS to prevent hypovolemic shock or airway obstruction forms the basis of emergency care and necessitates the need for further analysis given the multitude of options proposed for treatment. A systematic review of the literature was undertaken to formulate an evidence-based approach to the treatment of life-threatening hemorrhage in MFS.

MATERIALS AND METHODS

A comprehensive search of journal articles was performed using PubMed and Ovid databases. Keywords and phrases used were "life threatening facial hemorrhage," "life threatening facial bleeding," "external carotid artery ligation," and "external carotid artery embolization." Our search yielded 1441 articles. In an attempt to focus on hemorrhage exclusively from traumatic and operative events, articles that cited hematological disorders as the underlying cause of bleeding were excluded from the study. There were 40 articles which met the full inclusion criteria and form the basis of this systematic review. The articles were rated based on the level of evidence. There was 1 Level II, 21 Level III, 12 Level IV, and 6 Level V papers.

RESULT

Seven Level III evidence-based studies noted a high association between midface injuries, particularly Lefort III fractures and massive oronasal hemorrhage. One Level II study, 8 Level III studies, and 3 Level IV studies concluded that the internal maxillary artery was most frequently associated with intractable posttraumatic hemorrhage. One Level II, 16 Level III, 3 Level IV, and 3 Level V articles cited anterior and posterior nasal packing and conservative measures as the first attempt to manage traumatic hemorrhage. Subsequently, 8 Level III studies re-enforced the importance of temporary reduction of facial fractures as an effective means to control massive hemorrhage early in the algorithm. Seven Level III studies, 4 Level IV, and 2 Level V studies documented the importance of ligation of arteries as one of the absolute measures to manage facial hemorrhage, whereas 1 Level II, 14 Level III, 2 Level IV, and 3 Level V studies alluded to embolization as the most reliable technique for control of the hemorrhage. In orthognathic surgery, the internal maxillary artery was most frequently the source of massive hemorrhage according to 2 Level III, 4 Level IV, and 1 Level V studies. Two Level III, 5 Level IV, and 1 Level V study proposed packing as the first attempt to tamponade the hemorrhage. Two Level IV and 1 Level V study cited pseudoaneurysm as a potentially life-threatening vascular complication after elective surgery.

CONCLUSIONS

Management of facial hemorrhage should be performed in a sequential and consistent manner to optimize outcome. An evidence-based algorithm for posttraumatic and elective life-threatening hemorrhage in MFS based on this critical review of the literature is presented and discussed.

Sonographic Identification of Tube Thoracostomy Study (SITTS): Confirmation of Intrathoracic Placement

INTRODUCTION

Thoracostomy tubes (TT) are commonly placed in the management of surgical, emergency, and trauma patients and chest radiographs (CXR) and computed tomography (CT) are performed to confirm placement. Ultrasound (US) has not previously been used as a means to confirm intrathoracic placement of chest tubes. This study involves a novel application of US to demonstrate chest tubes passing through the pleural line, thus confirming intrathoracic placement.

METHODS

This was an observational proof-of-concept study using a convenience sample of patients with TTs at a tertiary-care university hospital. Bedside US was performed by the primary investigator using first the low-frequency (5-1 MHz) followed by the high-frequency (10-5 MHz) transducers, in both 2-dimensional gray-scale and M-modes in a uniform manner. The TTs were identified in transverse and longitudinal views by starting at the skin entry point and scanning to where the TT passed the pleural line, entering the intrathoracic region. All US images were reviewed by US fellowship-trained emergency physicians. CXRs and CTs were used as the standard for confirmation of TT placement.

RESULTS

Seventeen patients with a total of 21 TTs were enrolled. TTs were visualized entering the intrathoracic space in 100% of cases. They were subjectively best visualized with the high-frequency (10-5 MHz) linear transducer. Sixteen TTs were evaluated using M-mode. TTs produced a distinct pattern on M-mode.

CONCLUSION

Bedside US can visualize the TT and its entrance into the thoracic cavity and it can distinguish it from the pleural line by a characteristic M-mode pattern. This is best visualized with the high-frequency (10-5 MHz) linear transducer.

[Diagnostic imaging departments' responses to terrorist attempts with multiple victims.]

OBJECTIVES

To analyze whether the radiological management of seriously injured victims from the March 11 terrorist attempt was affected by the large number of victims treated at two hospitals in Madrid. To evaluate the organization for providing imaging services, detect failings, and propose a protocol for diagnostic imaging departments.

MATERIAL AND METHODS

Two hundred and fifty one patients arrived at hospital A and 36 at hospital B. Both centers have emergency imaging areas and protocols for the treatment of patients with multiple trauma. We compared organizational aspects (classification, identification), material resources, human resources, healthcare resources (number and type of examinations), as well as the initial radiological management with the usual protocol and with the recommendations for incidents with multiple victims.

RESULTS

In hospital A, patients' injuries were classified as severe (175) or minor (76); in hospital B, injuries were classified as extremely severe (13), severe (4), or minor (19). Additional staff were assigned to the emergency imaging areas in both hospitals. In hospital A, 62 portable plain-film radiographs, 39 ultrasonographic examinations, 25 cranial CT examinations, 6 cervical CT examinations, 2 chest CT examinations, and 2 abdominopelvic CT examinations were performed. In hospital B, 19 portable plain-film radiographs (74 in total), 9 ultrasonographic examinations, 17 cranial-chest-abdominopelvic CT examinations, 2 cervical CT examinations, 2 orbital CT examinations, and 2 CT examinations of the sinuses were performed.

CONCLUSION

In both hospitals, each victim was managed as if he or she were the only patient. The discrepancies between the two hospitals were due to differences in the usual protocol for multiple trauma patients. In light of the organizational errors discovered, we propose a plan of action based on the identification and progressive activation of material and human resources until sufficient levels are achieved.