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Shaikh SP, Zhu M, Beaulieu-Jones BR, LeBedis C, Richman A, Brahmbhatt TS, Sanchez SE. Utility of Torso Imaging for Elderly Patients Sustaining Ground-Level Falls. J Surg Res 2024; 301:296-301. [PMID: 38996720 DOI: 10.1016/j.jss.2024.05.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 04/21/2024] [Accepted: 05/27/2024] [Indexed: 07/14/2024]
Abstract
INTRODUCTION Computed tomography (CT) of the torso has become increasingly common for assessment of fall patients in the emergency department. Some data suggest that older adults (≥65) may benefit from torso imaging more than younger patients. We sought to evaluate the usage and utility of CT imaging for elderly patients presenting after ground-level falls (GLFs) from 1 meter or less at our level 1 trauma center. METHODS Patients ≥18 presenting with GLF in 2015-2019 were included. Data were obtained through chart and trauma registry review. Descriptive statistics were used to summarize the use of CT imaging for patients younger than versus older than 65 y old. Three multivariate logistic regression models with age as a continuous, binary (<65 versus ≥65), or categorical (in multiples of 5) variable were used to investigate whether age is associated with an increased identification of traumatic injury not previously suspected or known based on physical exam (PE) or plain radiograph after GLF. RESULTS A total of 522 patients <65 and 673 patients ≥65 y old were included. Older patients were significantly more likely to receive screening chest radiograph, screening pelvic radiograph, brain CT, and neck CT (all P < 0.001), but not torso (chest, abdomen, and pelvis) CT (P = 0.144). On multivariate logistic regression, age was not significantly associated with an increased odds of identification of traumatic injury after torso CT (continuous: adjusted odds ratio [aOR] = 1.01, 95% confidence interval [CI] = 0.99-1.03, P = 0.379; binary: aOR = 0.86, 95% CI = 0.46-1.58, P = 0.619; categorical: aOR = 1.03, 95% CI = 0.94-1.14, P = 0.453). A positive PE was the only variable associated with significantly increased odds of having an abnormal torso CT scan in all models. Only two patients ≥65 y old had injuries identified on torso CT in the context of a negative PE and negative screening imaging. CONCLUSIONS The rate of torso injury identification in patients sustaining GLF is not associated with age, but is strongly associated with positive PE findings. In the subset of elderly GLF patients without positive torso PE findings, more conservative use of CT imaging could decrease health-care utilization costs without compromising patient care.
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Affiliation(s)
- Shamsh P Shaikh
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Department of Radiology, Boston Medical Center, Boston, Massachusetts
| | - Max Zhu
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts
| | | | - Christina LeBedis
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Department of Surgery, Boston Medical Center, Boston, Massachusetts
| | - Aaron Richman
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Department of General Surgery, Riverside University Hospital, Moreno Valley, California
| | - Tejal S Brahmbhatt
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Department of General Surgery, Riverside University Hospital, Moreno Valley, California
| | - Sabrina E Sanchez
- Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts; Department of General Surgery, Riverside University Hospital, Moreno Valley, California.
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van Westendorp S, Robben SHM, van Hooft MAA, Dierckx SAA, Maas HAAM. The clinical implications of using a low threshold for computed tomography scans in older patients presenting with a proximal femur fracture. Eur Geriatr Med 2024:10.1007/s41999-024-01007-9. [PMID: 38896388 DOI: 10.1007/s41999-024-01007-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 06/10/2024] [Indexed: 06/21/2024]
Abstract
PURPOSE Current guidelines recommend a low threshold for computerized tomography (CT) scanning in older patients presenting with low-energy trauma (LET). With the ageing of the population, this results in increased use of healthcare resources and costs. We aim to assess (1) the number of CT scans performed as part of the initial trauma screening, (2) their traumatic clinical implications, and (3) their non-traumatic clinical implications. METHODS A retrospective study in patients ≥ 70 years presenting at a Dutch trauma centre with a proximal femur fracture following a LET between 2021 and 2022. We collected data concerning demographics, Clinical Frailty Scale, Injury Severity Score, number of CT scans and whether the results of these scans altered clinical management. RESULTS We included 278 patients. Median age was 83.0 years (IQR 77.0-89.0), median ISS was 9 (IQR 9-10) and, most common mechanism of injury was a ground level fall (n = 159, 57.2%). In 49 patients (17.6%) one or more CT scans were performed. These scans did not reveal co-existing traumatic injuries altering clinical management. In 2 patients (0.7%) incidental findings were found that immediately affected treatment. CONCLUSION Our study concludes that (1) approximately one in five patients with a proximal femur fracture received a CT scan as part of the initial trauma screening, resulting in (2) no traumatic and (3) minimal non-traumatic clinical implications. Therefore, a restrictive policy can be justified in patients with no additional clinical signs or symptoms and admission to the hospital. Further prospective research would be valuable to confirm our results.
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Affiliation(s)
- S van Westendorp
- Department of Geriatric Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands.
| | - S H M Robben
- Department of Geriatric Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - M A A van Hooft
- Emergency Department, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - S A A Dierckx
- Emergency Department, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
| | - H A A M Maas
- Department of Geriatric Medicine, Elisabeth-Tweesteden Hospital, Tilburg, The Netherlands
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Beaulieu-Jones BR, Zhu M, Shaikh SP, Brahmbhatt TS, Scantling D, Sanchez SE. Re-thinking the value of cross-sectional torso imaging for ground-level fall patients with altered mental status: Outcomes from a level 1 trauma center. Injury 2024; 55:111239. [PMID: 38071125 DOI: 10.1016/j.injury.2023.111239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 10/29/2023] [Accepted: 11/24/2023] [Indexed: 12/24/2023]
Abstract
INTRODUCTION Patients with altered mental status (AMS) are often excluded from studies evaluating the utility of computed tomography of the torso (CTT) after ground level falls (GLF). It is not known whether CTT identifies otherwise undetectable injuries in patients with AMS after GLF. We sought to describe the value of performing CTT in patients with AMS after GLF, and hypothesized that CTT would not identify new, clinically significant injuries in patients with a normal torso physical exam (PE) and normal chest and pelvic radiographs (CXR/PXR). METHODS Single-institution retrospective cohort study of GLF patients (≤1 m) with and without AMS (GCS <15, blood alcohol level >150 mg/dL, intubation prior to hospital evaluation), 2015-2019. Traumatic injury identification on CTT was evaluated in the context of normal/abnormal torso PE (based on provider documentation) and normal CXR/PXR. RESULTS 1195 patients met inclusion criteria; 344 had AMS, of which 129 (37.5 %) underwent CTT. A further 851 patients had normal mental status, of which 180 (21.2 %) underwent CTT. Patients with a normal PE with AMS (N = 79) and without AMS (N = 38) had a similar rate of new injury discovery on CTT (6.3% vs. 7.9 %, p = 1.00). Negative PE had a negative predictive value (NPV) for identification of a new, acute traumatic injury of 92.4 % (95 % CI: 0.84-0.96) in patients with AMS while normal PE, CXR, and PXR had a NPV of 96.0 % (95 % CI: 0.80-0.99). Among patients with CTT, patients with AMS had a significantly lower rate of acute traumatic injury on CTT compared to alert patients (26.4 % vs. 48.9 %, p < 0.001). On multivariate analysis, AMS was not positively associated with likelihood of identifying acute traumatic injury on CTT. CONCLUSIONS In patients sustaining GLFs who present with AMS and who otherwise have a negative PE, CXR, and PXR, CTT is very unlikely to identify new traumatic injuries. Strong consideration should be given to forego cross-sectional imaging in this patient population.
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Affiliation(s)
- Brendin R Beaulieu-Jones
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Max Zhu
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Shamsh P Shaikh
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Tejal S Brahmbhatt
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Dane Scantling
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States
| | - Sabrina E Sanchez
- Department of Surgery, Boston Medical Center, Boston, MA, United States; Boston University Chobanian & Avedisian School of Medicine, Boston, MA, United States.
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Zhu M, O'Brien M, Shaikh SP, Brahmbhatt TS, LeBedis C, Scantling D, Sanchez SE. Utilization of torso computed tomography for the evaluation of ground level falls: More imaging does not equal better care. Injury 2023; 54:105-111. [PMID: 36470767 DOI: 10.1016/j.injury.2022.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Computed tomography (CT) of the chest (CTC), abdomen, and pelvis (CTAP) is common when assessing trauma patients in the emergency department. However, unnecessary imaging can expose patients to unneeded radiation and increase healthcare costs. Here, we characterize the use of torso CT imaging for the evaluation of ground level falls (GLF) at a single level 1 trauma center. PATIENTS AND METHODS We conducted a retrospective review of all patients ≥18 years old presenting to a single level 1 trauma center with a GLF (1m or less) in 2015-2019. Data were obtained through chart review. Descriptive statistics were used to summarize patient characteristics. Multivariable logistic regression was used to assess factors leading to patients obtaining torso CT imaging. The utility of CT imaging in identifying injuries that changed management was also evaluated. RESULTS Of the 1,195 patients captured during the study period, 492 patients had a positive torso physical exam (PE), and 703 had a negative torso PE. Of patients with a negative torso PE, 127 CTC and 142 CTAP were obtained, with only 5.5% CTC identifying traumatic injuries not previously diagnosed on chest radiograph (CXR), and only 0.7% CTAP identifying new injuries not identified on pelvic radiograph (PXR). Multivariable logistic regression demonstrated that only a positive PE was significantly associated with the identification of abnormal imaging findings on torso CT. A negative PE, CXR, and PXR have a negative predictive value of 98%. DISCUSSION These data suggest that patients with a negative PE, even if intoxicated, intubated, or with a decreased GCS, are highly unlikely to have new, clinically relevant findings on torso CT imaging. CONCLUSION Using PE, CXR, and PXR as a screening tool in patients sustaining GLF, which if negative close to obviates the need for torso CT, may reduce healthcare costs and radiation exposure without compromising patient care.
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Affiliation(s)
- Max Zhu
- Boston University Chobanian & Avedisian School of Medicine, United States
| | - Mollie O'Brien
- Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States
| | - Shamsh P Shaikh
- Boston University Chobanian & Avedisian School of Medicine, United States
| | - Tejal S Brahmbhatt
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States
| | - Christina LeBedis
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Radiology, Division of Body Imaging, United States
| | - Dane Scantling
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States
| | - Sabrina E Sanchez
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States.
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Yeates EO, Grigorian A, Inaba K, Dolich M, Schubl SD, Lekawa M, Schellenberg M, de Virgilio M, Nahmias J. Blunt Trauma Massive Transfusion (B-MaT) Score: A Novel Scoring Tool. J Surg Res 2021; 270:321-326. [PMID: 34731729 DOI: 10.1016/j.jss.2021.09.034] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Revised: 08/14/2021] [Accepted: 09/22/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Multiple tools predicting massive transfusion (MT) in trauma have been developed but utilize variables that are not immediately available. Additionally, they only differentiate blunt from penetrating trauma and do not account for the large range of blunt mechanisms and their difference in force. We aimed to develop a Blunt trauma Massive Transfusion (B-MaT) score that accounts for high-risk blunt mechanisms and predicts MT needs in blunt trauma patients (BTPs) prior to arrival. MATERIALS AND METHODS The adult 2017 Trauma Quality Improvement Program database was used to identify BTPs who were divided into 2 sets at random (derivation/validation). First, multiple logistic regression models were created to determine risk factors of MT (≥6 units of PRBCs within 4-hours or ≥10 units within 24-hours). Next, the weighted average and relative impact of each independent predictor was used to derive a B-MaT score. Finally, the area under the receiver-operating curve (AROC) was calculated. RESULTS Of 172,423 patients in the derivation-set, 1,160 (0.7%) required MT. Heart rate ≥ 120bpm, systolic blood pressure ≤ 90mmHg, and high-risk blunt mechanisms were identified as independent predictors for MT. B-MaT scores were derived ranging from 0 -9, with scores of 6, 7, and 9 yielding a MT rate of 11.7%, 19.4%, and 32.4%, respectively. The AROC was 0.86. The validation-set had an AROC of 0.85. CONCLUSIONS B-MaT is a novel scoring tool that predicts need for MT in BTPs and can be calculated prior to arrival. B-MaT warrants prospective validation to confirm its accuracy and assess its ability to improve patient outcomes and blood product allocation.
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Affiliation(s)
- Eric O Yeates
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Areg Grigorian
- Department of Surgery, University of California Irvine (UCI), Orange, California; Department of Surgery, University of Southern California (USC), Los Angeles, California
| | - Kenji Inaba
- Department of Surgery, University of Southern California (USC), Los Angeles, California
| | - Matthew Dolich
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Sebastian D Schubl
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Michael Lekawa
- Department of Surgery, University of California Irvine (UCI), Orange, California
| | - Morgan Schellenberg
- Department of Surgery, University of Southern California (USC), Los Angeles, California
| | | | - Jeffry Nahmias
- Department of Surgery, University of California Irvine (UCI), Orange, California.
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Lightfoot A, Chan J. Unexpected severe intra-abdominal injuries resulting from a ground-level fall in an elderly patient with a large staghorn calculus. BMJ Case Rep 2021; 14:14/3/e239829. [PMID: 33753381 PMCID: PMC7986652 DOI: 10.1136/bcr-2020-239829] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 70-year-old woman on warfarin was transported to the emergency department after a ground-level fall, injuring her left backside. Criteria for geriatric trauma activation was not met. An episode of haematuria created suspicion for an intra-abdominal injury, prompting a point-of-care ultrasound (POCUS) Focused Assessment with Sonography for Trauma scan, which was positive. Subsequent pan-scanning discovered a multitude of injuries, including low-grade left renal and splenic lacerations, multiple left rib fractures and a haemothorax. Patient also had a supratherapeutic International Normalized Ratio (INR), which was reversed with 4-factor Prothrombin Complex Concentrate (4F-PCC). She was admitted to the intensive care unit, underwent urgent thoracostomy and had a complicated hospital course. Moreover, an incidental large staghorn calculus in the left kidney might have contributed shearing forces. In summary, under triage of this patient emphasised the importance of performing detailed primary and secondary surveys, including POCUS, for all geriatric ground-level fall patients on anticoagulants to allow for rapid diagnosis and treatment of potential serious injuries.
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Affiliation(s)
- Alexandre Lightfoot
- Mercy Health St Rita's Medical Center, Department of Emergency Medicine, Bon Secours Health System, Lima, Ohio, USA
| | - James Chan
- Mercy Health St Rita's Medical Center, Department of Emergency Medicine, Bon Secours Health System, Lima, Ohio, USA
- Emergency Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
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Lepkowsky E, Simcox T, Rogoff H, Barzideh O, Islam S. Is There a Role for CT Pan-Scans in the Initial Workup of Fragility Fracture Patients? Geriatr Orthop Surg Rehabil 2020; 11:2151459320916937. [PMID: 32313714 PMCID: PMC7153176 DOI: 10.1177/2151459320916937] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Accepted: 03/09/2020] [Indexed: 11/27/2022] Open
Abstract
Introduction: Computed tomography (CT) pan-scans have become increasingly commonplace as part of the initial diagnostic workup for patients sustaining traumatic injuries. They have proven effective in improving diagnostic accuracy in those with high-energy mechanisms of injury. However, the utility of pan-scans in the geriatric population sustaining low-energy traumatic injuries remains unproven. Methods: A retrospective review was conducted of patients who sustained a fragility fracture at a level-1 trauma center over a 15-month period. Radiologist interpretations of any CT pan-scans were reviewed for acute findings, and charts were reviewed for resulting changes in orthopedic and nonorthopedic management. Additionally, mechanism of injury, definitive management, time to surgery, length of stay, level of care at discharge, and demographic data were compared against similar patients who did not receive a pan-scan. Results: Of the 109 patients who underwent a CT pan-scan, 1 (0.92%) had a change in orthopedic treatment. Twelve (11.01%) patients had changes to their nonorthopedic management. In addition, 14 other patients had one or more consultations obtained based on pan-scan results that did not result in any change in management. Discussion: This study found that only 1 of the included patients had a change in orthopedic management and 12 had a change in nonorthopedic management, despite over half of the study population being found to have additional findings. Furthermore, patients who underwent a pan-scan did not have expedited surgical intervention or earlier discharges compared to those who were not pan-scanned. Conclusion: This study demonstrates whole-body CT imaging provides little benefit in geriatric patients who sustain fragility fractures and should be utilized judiciously and in a targeted fashion instead of as a routine part of trauma surgery or emergency department protocol in this patient population. Level of Evidence: Level III Retrospective Study.
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Affiliation(s)
- Eric Lepkowsky
- Department of Orthopedic Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Trevor Simcox
- Department of Orthopedic Surgery, NYU Winthrop Hospital, Mineola, NY, USA
| | - Hunter Rogoff
- Department of Orthopedic Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Omid Barzideh
- Department of Orthopedic Surgery, NYU Winthrop Hospital, Mineola, NY, USA
| | - Shahidul Islam
- Department of Orthopedic Surgery, NYU Winthrop Hospital, Mineola, NY, USA
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