Selective Non-operative Management of Patients with Abdominal Trauma-Is CECT Scan Mandatory?

Avoiding immediate whole-body trauma CT: a prospective observational study in stable trauma patients

High energy blunt trauma patients with normal vital signs are usually investigated with a Contrast Enhanced Computed Tomography (CECT) for torso injuries. CECT involves high levels of radiations, often showing no injuries in patients over-triaged to the trauma center. The aim of our study was to suggest an alternative diagnostic protocol based on Emergency Room (ER) tests (physical exam, blood tests, extended FAST, Chest and Pelvis X-ray) to avoid CECT in selected patients. A prospective cohort study was conducted from September 2018 to September 2019. Five hundred patients fulfilled the inclusion criteria. Patients received torso-CECT scan only if they had at least one positive ER test. The validity of the single component of the protocol and the global validity of the ER tests to detect torso injuries was assessed through sensitivity, specificity, positive (PPV) and negative (NPV) predictive value, positive (+ LR) and negative (- LR) likelihood ratio. Multivariate analysis was performed to identify independent predictors of torso injuries. One hundred and seventy patients received a torso-CECT scan because of positive ER tests. ER tests showed a global sensitivity for torso injuries of 86.96% (95% CI 80.17-92.08) specificity of 83.98%(95% CI 79.79-87.60), PPV of 67.42% (95% CI 61.83-72.54), NPV of 94.41% (95% CI 91.63-96.30) + LR of 5.43 (95% CI 4.25-6.93), - LR of 0.16 (95% CI 0.10-0.24). ER tests in an experienced center seem to be able to identify more severe blunt trauma patients needing CECT. Further studies are advisable to confirm these results.

Diagnostic utility of CT for abdominal injury in the military setting: A systematic review and meta-analysis

BACKGROUND

It is critical to accurately identify patients with abdominal injury who truly need to undergo laparotomy during the war in timely fashion. The diagnostic utility of computed tomography (CT) for evaluating abdominal injury in the military setting remains uncertain.

METHODS

PubMed, EMBASE, and Cochrane Library databases were searched. Meta-analyses were performed by using a random-effect model. We pooled the area under the summary receiver operating characteristic curves with standard errors, the Q indexes with standard errors, the sensitivities with 95% confidence intervals (CIs), the specificities with 95% CIs, the positive likelihood ratios with 95% CIs, the negative likelihood ratios with 95% CIs, and the diagnostic odds ratios with 95% CIs. The heterogeneity among studies were evaluated by the I2 and P value.

RESULTS

Overall, 5 retrospective studies were included. The area under the summary receiver operating characteristic curve was 0.9761 ± 0.0215 and the Q index was 0.9302 ± 0.0378. The pooled sensitivity was 0.97 (95% CI = 0.92-0.99) without a significant heterogeneity among studies (I2 = 0%, P = .4538). The pooled specificity was 0.95 (95% CI = 0.93-0.97) with a significant heterogeneity among studies (I2 = 90.6%, P < .0001). The pooled positive likelihood ratio was 10.71 (95% CI: 2.91-39.43) with a significant heterogeneity among studies (I2 = 89.2%, P < .0001). The pooled negative likelihood ratio was 0.07 (95% CI = 0.02-0.27) with a significant heterogeneity among studies (I2 = 57.5%, P = .0516). The pooled diagnostic odds ratio was 177.48 (95% CI = 18.09-1741.31) with a significant heterogeneity among studies (I2 = 75.9%, P = .0023).

CONCLUSION

Diagnostic accuracy of CT for abdominal injury is excellent in the military setting. Further work should explore how to shrink CT equipment for a wider use in wartime.