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Paillusson W, Sesmun R, Arvieux C, Balandraud P, Martinod E, Kuczma P, Tresallet C. Surgical management of penetrating neck wounds. An update on surgical management. Part n°2 - in-hospital management. J Visc Surg 2024:S1878-7886(24)00130-9. [PMID: 39389886 DOI: 10.1016/j.jviscsurg.2024.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/12/2024]
Affiliation(s)
- Willem Paillusson
- Department of Digestive, Bariatric and Endocrine Surgery, CHU Avicenne, Assistance publique des Hôpitaux de Paris (AP-HP), 93000 Bobigny, France; Université Paris-Est Créteil, UFR de Santé Paris XII, 94000 Créteil, France
| | - Rajvansh Sesmun
- Department of Digestive, Bariatric and Endocrine Surgery, CHU Avicenne, Assistance publique des Hôpitaux de Paris (AP-HP), 93000 Bobigny, France; Université Sorbonne Paris Nord, UFR de Médecine et de Biologie Humaine, 93000 Bobigny, France
| | - Catherine Arvieux
- Department of Digestive and Emergency Surgery, CHU Grenoble-Alpes, 38043 Grenoble, France
| | - Paul Balandraud
- Department of Oncologic and General Surgery, Sainte Anne Military Hospital, 83000 Toulon, France
| | - Emmanuel Martinod
- Department of Thoracic and Vascular Surgery, CHU Avicenne, Assistance publique des Hôpitaux de Paris (AP-HP), 93000 Bobigny, France; Université Sorbonne Paris Nord, UFR de Médecine et de Biologie Humaine, 93000 Bobigny, France
| | - Paulina Kuczma
- Department of Digestive, Bariatric and Endocrine Surgery, CHU Avicenne, Assistance publique des Hôpitaux de Paris (AP-HP), 93000 Bobigny, France; Université Sorbonne Paris Nord, UFR de Médecine et de Biologie Humaine, 93000 Bobigny, France
| | - Christophe Tresallet
- Department of Digestive, Bariatric and Endocrine Surgery, CHU Avicenne, Assistance publique des Hôpitaux de Paris (AP-HP), 93000 Bobigny, France; Université Sorbonne Paris Nord, UFR de Médecine et de Biologie Humaine, 93000 Bobigny, France.
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Wood EJ, Stabo N, Garret JW, Rose S, Bartels C, Szczykutowicz TP, Avey G, Mao L, Lubner MG. Factors Contributing to Computed Tomography Trauma Scan Times at a Tertiary Center: Improving Emergency Department Trauma Imaging Workflow Through Targeted Interventions. J Comput Assist Tomogr 2023:00004728-990000000-00155. [PMID: 36944097 DOI: 10.1097/rct.0000000000001449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
PURPOSES The aims of the study are to identify factors contributing to computed tomography (CT) trauma scan turnaround time variation and to evaluate the effects of an automated intervention on time metrics. METHODS Throughput metrics were captured via picture archiving and communication system from January 1, 2018, to December 16, 2019, and included 17,709 CT trauma scans from our institution. Initial data showed that imaging technologist variation played a significant role in trauma imaging turnaround time. In December 2019, we implemented a 2-pronged intervention: (1) educational intervention to techs and (2) modified trauma CT abdomen/pelvis to autogenerate and autosend reformats to picture archiving and communication system. A total of 13,169 trauma CT scans were evaluated from the postintervention period taking place from January 2020 to March 2021. Throughput metrics such as last image to first report interval and emergency department length of stay were captured and compared with performing technologist, time of day, and weekday versus weekend scans. RESULTS Substantial variability among trauma CT scans was observed. For CT trauma abdomen/pelvis, the interval from last image to initial report decreased from 26.4 to 24.0 minutes (P = 0.001) while the interval between first and last image time decreased from 11.4 to 4.2 minutes (P < 0.001). Emergency department length of stay also decreased from 3.9 to 3.7 hours (P < 0.0001) in the postintervention period. Variation among imaging technologist was statistically significant and became less significant after intervention (P = 0.09, P = 0.54). CONCLUSIONS Factors such as imaging technologist variability, time of day, and day of the week of trauma scans played a significant role in CT trauma turnaround time variability. Automation interventions can help with efficiency in image turnaround time.
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Affiliation(s)
- Erika J Wood
- From the University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Nicholas Stabo
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - John W Garret
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Sean Rose
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX
| | - Carrie Bartels
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Timothy P Szczykutowicz
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Greg Avey
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | - Lu Mao
- Department of Diagnostic and Interventional Imaging, University of Texas Health Science Center at Houston McGovern Medical School, Houston, TX
| | - Meghan G Lubner
- Department of Radiology, University of Wisconsin School of Medicine and Public Health, Madison, WI
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Lefering R, Waydhas C. Process times of severely injured patients in the emergency room are associated with patient volume: a registry-based analysis. Eur J Trauma Emerg Surg 2022; 48:4615-4622. [PMID: 35546201 PMCID: PMC9712366 DOI: 10.1007/s00068-022-01987-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Accepted: 04/16/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Hospitals involved in the care of severely injured patients treat a varying number of such cases per year. Large hospitals were expected to show a better performance regarding process times in the emergency room. The present investigation analyzed whether this assumption was true, based on a large national trauma registry. METHODS A total of 129,193 severely injured patients admitted primarily to one of 675 German hospitals and documented in the TraumaRegister DGU® were considered for this analysis. The analysis covered a 5 years time period (2013-2017). Hospitals were grouped by their average number of annually treated severe trauma patients into five categories ranging from 'less than 10 patients' to '100 or more'. The following process times were compared: pre-hospital time; time from admission to diagnostic procedures (sonography, X-ray, computed tomography), time from admission to selected emergency interventions and time in the emergency room. RESULTS Seventy-eight high volume hospitals treated 45% of all patients, while 30% of hospitals treated less than ten cases per year. Injury severity and mortality increased with volume per year. Whole-body computed tomography (WB-CT) was used less frequently in small hospitals (53%) as compared to the large ones (83%). The average time to WB-CT fell from 28 min. in small hospitals to 19 min. in high volume hospitals. There was a linear trend to shorter performance times for all diagnostic procedures (sonography, X-ray, WB-CT) when the annual volume increased. A similar trend was observed for time to blood transfusion (58 min versus 44 min). The median time in the emergency room fell from 74 min to 53 min, but there was no clear trend for the time to the first emergency surgery. Due to longer travel times, prehospital time was about 10 min higher in patients admitted to high volume hospitals compared to patients admitted to smaller local hospitals. CONCLUSION Process times in the emergency room decreased consistently with an increase of patient volume per year. This decrease, however, was associated with a longer prehospital time.
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Affiliation(s)
- Rolf Lefering
- Institute for Research in Operative Medicine, University Witten/Herdecke, Ostmerheimer Strasse 200, (Building 38), 51109, Cologne, Germany.
| | - Christian Waydhas
- Department of Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
- Medical Faculty, University Duisburg-Essen, University Hospital, Essen, Germany
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Ghafil C, Matsushima K, Chiba H, Wu R, Shin H, Menchine M, Inaba K. Trauma Computed Tomography in the Modern Era: Not Always Quick and Safe. Am Surg 2021; 87:1690-1695. [PMID: 34780304 DOI: 10.1177/00031348211061330] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Computed tomography (CT) has emerged as the diagnostic modality of choice in trauma patients. Recent studies suggest its use in hemodynamically unstable patients is safe and potentially lifesaving; however, the incidence of adverse events (AE) during the trauma CT scanning process remains unknown. STUDY DESIGN Over a 6-month period at a Level 1 trauma center, data on patients undergoing trauma CT (whole-body CT (WBCT) +/- additional CT studies) were prospectively collected. All patients requiring a trauma team activation (TTA) were included. Adverse events and specific time intervals were recorded from the time of TTA notification to the time of return to the resuscitation bay from the CT suite. RESULTS Of the 94 consecutive patients included in the study, 47.9% experienced 1 or more AE. Median duration away from the resuscitation bay for all patients was 24 minutes. Patients with AE spent a significantly longer time away from the resuscitation bay and had longer scan times. Vasopressor support and ongoing transfusion requirement at the time of CT scanning were associated with AE. CONCLUSION Adverse events of varying clinical significance occur frequently in patients undergoing emergent trauma CT. A standard trauma CT protocol could improve the efficiency and safety of the scanning process.
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Affiliation(s)
- Cameron Ghafil
- Division of Acute Care Surgery, 23336LAC+USC Medical Center, Los Angeles, CA, USA
| | - Kazuhide Matsushima
- Division of Acute Care Surgery, 23336LAC+USC Medical Center, Los Angeles, CA, USA
| | - Hiroto Chiba
- Division of Acute Care Surgery, 23336LAC+USC Medical Center, Los Angeles, CA, USA
| | - Renqing Wu
- Division of Acute Care Surgery, 23336LAC+USC Medical Center, Los Angeles, CA, USA
| | - Heeseop Shin
- Department of Radiology, 23336LAC+USC Medical Center, Los Angeles, CA, USA
| | - Michael Menchine
- Department of Emergency Medicine, 23336LAC+USC Medical Center, Los Angeles, CA, USA
| | - Kenji Inaba
- Division of Acute Care Surgery, 23336LAC+USC Medical Center, Los Angeles, CA, USA
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Ricci KB, Oslock WM, Ingraham AM, Rushing AP, Diaz A, Paredes AZ, Daniel VT, Collins CE, Heh VK, Baselice HE, Strassels SA, Caterino JM, Santry HP. Importance of Radiologists in Optimizing Outcomes for Older Americans with Acute Abdomen. J Surg Res 2021; 261:361-368. [PMID: 33493888 DOI: 10.1016/j.jss.2020.12.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 11/06/2020] [Accepted: 12/07/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Patients presenting with acute abdominal pain often undergo a computed tomography (CT) scan as part of their diagnostic workup. We investigated the relationship between availability, timeliness, and interpretation of CT imaging and outcomes for life-threatening intra-abdominal diseases or "acute abdomen," in older Americans. METHODS Data from a 2015 national survey of 2811 hospitals regarding emergency general surgery structures and processes (60.1% overall response, n = 1690) were linked to 2015 Medicare inpatient claims data. We identified beneficiaries aged ≥65 admitted emergently with a confirmatory acute abdomen diagnosis code and operative intervention on the same calendar date. Multivariable regression models adjusted for significant covariates determined odds of complications and mortality based on CT resources. RESULTS We identified 9125 patients with acute abdomen treated at 1253 hospitals, of which 78% had ≥64-slice CT scanners and 85% had 24/7 CT technicians. Overnight CT reads were provided by in-house radiologists at 14% of hospitals and by teleradiologists at 66%. Patients were predominantly 65-74 y old (43%), white (88%), females (60%), and with ≥3 comorbidities (67%) and 8.6% died. STAT radiology reads by a board-certified radiologist rarely/never available in 2 h was associated with increased odds of systemic complication and mortality (adjusted odds ratio 2.6 [1.3-5.4] and 2.3 [1.1-4.8], respectively). CONCLUSIONS Delays obtaining results are associated with adverse outcomes in older patients with acute abdomen. This may be due to delays in surgical consultation and time to source control while waiting for imaging results. Processes to ensure timely interpretation of CT scans in patients with abdominal pain may improve outcomes in high-risk patients.
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Affiliation(s)
- Kevin B Ricci
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | | | | | - Amy P Rushing
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Adrian Diaz
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Anghela Z Paredes
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Vijaya T Daniel
- Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Courtney E Collins
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Victor K Heh
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Holly E Baselice
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Scott A Strassels
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio
| | - Jeffrey M Caterino
- Ohio State University Wexner Medical Center, Department of Emergency Medicine, Columbus, Ohio
| | - Heena P Santry
- Ohio State University Wexner Medical Center, Department of Surgery, Columbus, Ohio; Center for Surgical Health Assessment, Research and Policy (SHARP), Ohio State Wexner Medical Center, Columbus, Ohio.
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Nti BK, Laniewicz M, Skaggs T, Cross K, Fallat ME, Rominger A. A novel streamlined trauma response team training improves imaging efficiency for pediatric blunt abdominal trauma patients. J Pediatr Surg 2019; 54:1854-1860. [PMID: 30736956 DOI: 10.1016/j.jpedsurg.2018.12.013] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 12/10/2018] [Accepted: 12/12/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND/PURPOSE The morbidity and mortality of children with traumatic injuries are directly related to the time to definitive management of their injuries. Imaging studies are used in the trauma evaluation to determine the injury type and severity. The goal of this project is to determine if a formal streamlined trauma response improves efficiency in pediatric blunt trauma by evaluating time to acquisition of imaging studies and definitive management. METHODS This study is a chart review of patients <18 years who presented to a pediatric trauma center following blunt trauma requiring trauma team activation. 413 records were reviewed to determine if training changed the efficiency of CT acquisition and 652 were evaluated for FAST efficiency. The metrics used for comparison were time from ED arrival to CT image, FAST, and disposition. RESULTS Time from arrival to CT acquisition decreased from 37 (SD 23) to 28 (SD27) min (p < 0.05) after implementation. The proportion of FAST scans increased from 315 (63.5%) to 337 (80.8%) and the time to FAST decreased from 18 (SD15) to 8 (SD10) min (p < 0.05). The time to operating room (OR) decreased after implementation. CONCLUSION The implementation of a streamlined trauma team approach is associated with both decreased time to CT, FAST, OR, and an increased proportion of FAST scans in the pediatric trauma evaluation. This could result in the rapid identification of injuries, faster disposition from the ED, and potentially improve outcomes in bluntly injured children. TYPE OF STUDY Therapeutic LEVEL OF EVIDENCE: Level III.
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Affiliation(s)
- Benjamin K Nti
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Indiana University School of Medicine, 720 Eskenazi Avenus, FT 3, Indianapolis, IN 46202.
| | - Megan Laniewicz
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville School of Medicine, 571 S. Floyd St., Suite 802, Louisville, KY 40202.
| | | | - Keith Cross
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville School of Medicine, 571 S. Floyd St., Suite 802, Louisville, KY 40202.
| | - Mary E Fallat
- Division of Pediatric Surgery, Hiram C. Polk, Jr. Department of Surgery, University of Louisville School of Medicine, 315 E. Broadway, Suite 565, Louisville, KY 40202.
| | - Annie Rominger
- Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Louisville School of Medicine, 571 S. Floyd St., Suite 802, Louisville, KY 40202.
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O'Hagan S, Lombard CJ, Pitcher RD. The Role of the Integrated Digital Radiology System in Assessing the Impact of Patient Load on Emergency Computed Tomography (CT) Efficiency. J Digit Imaging 2019; 32:396-400. [PMID: 30298437 PMCID: PMC6499848 DOI: 10.1007/s10278-018-0129-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Time-critical management is of particular significance in the trauma and emergency setting, where intervals from patient arrival to diagnostic imaging and from imaging to radiology report are key determinants of outcome. This study, based in the Trauma and Emergency Unit of a large, tertiary-level African hospital with a fully digital radiology department, assessed the impact of increased workload on computerised tomography (CT) efficiency. Sequential, customised searches of the institutional radiology information system (RIS) were conducted to define two weekends in 2016 with the lowest and highest emergency CT workloads, respectively. The electronic RIS timestamps defining the intervals between key steps in the CT workflow were extracted and analysed for each weekend. With the exception of radiologist reporting time, workflow steps were significantly prolonged by increased workload. This study highlights the potential role of the integrated digital radiology system in enabling a detailed analysis of imaging workflow, thereby facilitating the identification and appropriate management of bottlenecks.
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Affiliation(s)
- Suzanne O'Hagan
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa.
| | - Carl J Lombard
- Biostatistics Unit, South African Medical Research Council, Cape Town, South Africa
| | - Richard D Pitcher
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Francie van Zijl Drive, Tygerberg, Cape Town, 7505, South Africa
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Bracco D, Deckelbaum D, Artho G, Khwaja K, Mulder DS, Gruska J, Razek T. Additional and repeated computed tomography in interfacility trauma transfers: Room for standardization. Surgery 2018; 164:872-878. [PMID: 30149940 DOI: 10.1016/j.surg.2018.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Revised: 07/02/2018] [Accepted: 07/09/2018] [Indexed: 02/03/2023]
Abstract
BACKGROUND Despite the recommendations of the Advanced Trauma Life Support course of the American College of Surgeons, patients undergo computed tomography (CT) in local hospitals before transfer to a trauma center. The problem of repeat CTs caused by technical and protocol issues is ongoing. The objective is to measure the importance of repeat CTs and CTs involving other body regions. METHODS All secondary transfers to our level 1 facility with CT at the local hospital over 9 years were reviewed. Patients were considered to have had a repeat CT if the same body region or an another body region was scanned as a part of the initial assessment but not for reasons of clinical follow-up. RESULTS Of 6,292 patients received from local hospitals, 685 (12%) had undergone 1097 CT scans at the local hospitals. Patients being scanned in local hospitals were sicker (injury severity score: 21 vs 13) and required more intensive care unit admissions (38% vs 29%) and more ventilation (32% vs 22%). Thirty-nine percent of CTs were repeated, and 55% of these patients required imaging of another body part. CONCLUSION Repeat and additional images remain a major issue in trauma transfers. Improvement requires standardization of CT protocols and change in the approach of local hospitals from "finding and requiring need level 1 trauma center" to "not missing any injuries."
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Affiliation(s)
- David Bracco
- Department of Anesthesia, Montreal General Hospital, McGill University Health Center, Montreal, Canada.
| | - Dan Deckelbaum
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - Giovanni Artho
- Department of Radiology, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - Kosar Khwaja
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - David S Mulder
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada; Department of Cardiothoracic Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - Jeremy Gruska
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada
| | - Tarek Razek
- Department of Trauma Surgery, Montreal General Hospital, McGill University Health Center, Montreal, Canada
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Ariffin AC, Ngadiron H. Does Time Difference in CT Scan Causes More Mortality? World J Surg 2017; 42:1212. [PMID: 28879497 DOI: 10.1007/s00268-017-4222-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Affirul Chairil Ariffin
- Surgery Department, Medical Faculty, Universiti Sains Islam Malaysia, Tingkat 13, Persiaran MPAJ, Jalan Pandan Utama, 55100, Kuala Lumpur, Malaysia.
| | - Hanizah Ngadiron
- Emergency and Trauma Department, Universiti Sains Islam Malaysia, Jalan Pandan Utama, 55100, Kuala Lumpur, Malaysia
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Hinzpeter R, Sprengel K, Wanner GA, Mildenberger P, Alkadhi H. Repeated CT scans in trauma transfers: An analysis of indications, radiation dose exposure, and costs. Eur J Radiol 2017; 88:135-140. [DOI: 10.1016/j.ejrad.2017.01.007] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Revised: 01/01/2017] [Accepted: 01/05/2017] [Indexed: 11/29/2022]
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Baghdanian AH, Baghdanian AA, Armetta A, Krastev M, Dechert T, Burke P, LeBedis CA, Anderson SW, Soto JA. Effect of an Institutional Triaging Algorithm on the Use of Multidetector CT for Patients with Blunt Abdominopelvic Trauma over an 8-year Period. Radiology 2017; 282:84-91. [DOI: 10.1148/radiol.2016152021] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wynell-Mayow W, Guevel B, Quansah B, O'Leary R, Carrothers AD. Cambridge Polytrauma Pathway: Are we making appropriately guided decisions? Injury 2016; 47:2117-2121. [PMID: 27496722 DOI: 10.1016/j.injury.2016.05.046] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 05/29/2016] [Indexed: 02/02/2023]
Abstract
Addenbrooke's Hospital, the Major Trauma Centre for the East of England Trauma Network, received 1070 major trauma patients between 1st January and 31st December 2014. In order to improve care, an audit was performed of 59 patients meeting our own selection criteria for orthopaedic polytrauma between 1st January 2013 and 31st December 2013. The Cambridge Polytrauma Pathway was devised through NCEPOD guidelines, literature review, internal and external discussion. It facilitates provision of best practice Early Appropriate Care, encompassing - multidisciplinary consultant decisions around the patient in our Neurological and Trauma Critical Care Unit, early full body trauma CT scans, serial measurements of lactate and fibrinogen levels, and out-of-hours orthopaedic theatre reserved for life-and-limb threatening injuries. Re-audit was conducted of 15 patients meeting selection criteria, admitted between 1st October 2014 and 31st March 2015. Significant improvements in recording of lactate and fibrinogen were demonstrated, both on admission (lactate - p<0.000, fibrinogen - p=0.015), and preoperatively (lactate - p=0.003, fibrinogen - p=0.030). Time to trauma CT was unchanged (p=0.536) with a median time to CT of 0.53h at re-audit (IQR 0.48-0.75). The number of patients receiving definitive orthopaedic intervention out-of-hours reduced from 8 to zero (p=0.195). The approach of facilitating management decisions to be made at early daytime MDT meetings has been adopted. It is anticipated that this pathway will improve outcomes in orthopaedic polytrauma patients and it is recommended that either the GOS-E, or the EQ-5D scoring systems be introduced to assess this.
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Affiliation(s)
- William Wynell-Mayow
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Borna Guevel
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Benjamin Quansah
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK
| | - Andrew D Carrothers
- Department of Trauma and Orthopaedics, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge CB2 0QQ, UK.
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Tiemesmann T, Raubenheimer J, De Vries C. Temporal evaluation of computed tomographic scans at a Level 1 trauma department in a central South African hospital. SA J Radiol 2016. [DOI: 10.4102/sajr.v20i1.836] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Background: Time is a precious commodity, especially in the trauma setting, which requires continuous evaluation to ensure streamlined service delivery, quality patient care and employee efficiency.Objectives: The present study analyses the authors’ institution’s multi-detector computed tomography (MDCT) scan process as part of the imaging turnaround time of trauma patients. It is intended to serve as a baseline for the institution, to offer a comparison with institutions worldwide and to improve service delivery.Method: Relevant categorical data were collected from the trauma patient register and radiological information system (RIS) from 01 February 2013 to 31 January 2014. A population of 1107 trauma patients who received a MDCT scan was included in the study. Temporal data were analysed as a continuum with reference to triage priority, time of day, type of CT scan and admission status. Results: The median trauma arrival to MDCT scan time (TTS) and reporting turnaround time (RTAT) were 69 (39–126) and 86 (53–146) minutes respectively. TTS was subdivided into the time when the patient arrived at trauma to the radiology referral (TTRef) and submission of the radiology request, to the arrival at the MDCT (RefTS) location. TTRef was statistically significantly longer than RefTS (p < 0.0001). RTAT was subdivided into the arrival at the MDCT to the start of the radiology report (STR) and time taken to complete the report (RT). STR was statistically significantly longer than RT (p < 0.0001). Conclusion: The time to scan (TTS) was comparable to, but unfortunately the report turnaround time (RTAT) lagged behind, the findings of some first-world institutions.
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Frellesen C, Boettcher M, Wichmann JL, Drieske M, Kerl JM, Lehnert T, Nau C, Geiger E, Wutzler S, Ackermann H, Vogl TJ, Bauer RW. Evaluation of a dual-room sliding gantry CT concept for workflow optimisation in polytrauma and regular in- and outpatient management. Eur J Radiol 2015; 84:117-122. [DOI: 10.1016/j.ejrad.2014.10.013] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2014] [Revised: 09/03/2014] [Accepted: 10/22/2014] [Indexed: 11/15/2022]
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Abstract
OBJECTIVES The purpose of the study was to review diagnostic imaging in trauma patients. We hypothesized that diagnostic musculoskeletal imaging has increased over time, but at a lesser rate than radiography performed for other purposes. Two trauma centers were compared. DESIGN Retrospective multicenter study. SETTING Two level 1 trauma centers. PATIENTS/PARTICIPANTS Five hundred patients per year from each trauma centers were reviewed for 2002, 2005, and 2008. MAIN OUTCOME MEASUREMENTS Effective doses [millisieverts (mSv)] and total charges for radiography were calculated. RESULTS Most imaging was performed within 24 hours of injury. In 2002, 15% of all radiographic studies were computed tomography (CT) scans compared with 33% in 2008 (P < 0.0001). Center 1 used more CT, and center 2 used more projection (plain) radiography. The percentage of musculoskeletal CTs increased from 26% in 2002 to 49% in 2008 (P < 0.0001), without change in patient acuity. The mean effective dose per patient was 17.3 mSv in 2002, 30.0 mSv in 2005, and 34.1 mSv in 2008 (P < 0.001). The percentage of total dose attributable to musculoskeletal studies increased from 25% in 2002, to 29% in 2005, and 31% in 2008 (P < 0.001). Mean total charges per patient were $4529 in 2002; $6922 in 2005; and $7750 in 2008 (P < 0.001), with higher 2008 mean charges at center 1 versus 2 ($8694 vs. $6806, P = 0.001), primarily because of more CT scans. CONCLUSIONS The number of diagnostic imaging tests, radiation dose, and related charges in trauma patients increased over time at both trauma centers, with CT scans accounting for most of the radiation dose and costs. A shift toward more advanced imaging from conventional projection radiography was noted at both trauma centers. Effective dose per patient more than doubled over the course of study at center 1. By 2008, half of all radiographic studies were for musculoskeletal purposes. Previous studies have suggested an increased risk of cancer with exposures of 20-40 mSv, making the mean total radiation doses in excess of 30.0 mSv since 2005 of great concern. Variability in ordering patterns between the 2 centers with similar patient acuity suggests opportunity for discussion about indications for utilization, which could result in lower radiation doses and fewer expenses.
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Kirkpatrick AW, Vis C, Dubé M, Biesbroek S, Ball CG, Laberge J, Shultz J, Rea K, Sadler D, Holcomb JB, Kortbeek J. The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: the RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations). Injury 2014; 45:1413-21. [PMID: 24560091 DOI: 10.1016/j.injury.2014.01.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 12/25/2013] [Accepted: 01/18/2014] [Indexed: 02/02/2023]
Abstract
Traumatic injury is the leading cause of potentially preventable lost years of life in the Western world and exsanguination is the most potentially preventable cause of post-traumatic death. With mature trauma systems and experienced trauma centres, extra-abdominal sites, such as the pelvis, constitute the most frequent anatomic site of exsanguination. Haemorrhage control for such bleeding often requires surgical adjuncts most notably interventional radiology (IR). With the usual paradigm of surgery conducted within an operating room and IR procedures within distant angiography suites, responsible clinicians are faced with making difficult decisions regarding where to transport the most physiologically unstable patients for haemorrhage control. If such a critical patient is transported to the wrong suite, they may die unnecessarily despite having potentially salvageable injuries. Thus, it seems only logical that the resuscitative operating room of the future would have IR capabilities making it the obvious geographic destination for critically unstable patients, especially those who are exsanguinating. Our trauma programme recently had the opportunity to conceive, design, build, and operationalise a purpose-designed hybrid trauma operating room, designated as the resuscitation with angiographic percutaneous techniques and operative resuscitation (RAPTOR) suite, which we believe to be the first such resource designed primarily to serve the exsanguinating trauma patient. The project was initiated after consultations between the trauma programme and private philanthropists regarding the greatest potential impacts on regional trauma care. The initial capital construction costs were thus privately generated but coincided with a new hospital wing construction allowing the RAPTOR to be purpose-designed for the exsanguinating patient. Many trauma programmes around the world are now starting to navigate the complex process of building new facilities, or else retrofitting existing ones, to address the need for single-site flexible haemorrhage control. This manuscript therefore describes the many considerations in the design and refinement of the physical build, equipment selection, human factors evaluation of new combined treatment paradigms, and the final introduction of a RAPTOR protocol in order that others may learn from our initial efforts.
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Affiliation(s)
- Andrew W Kirkpatrick
- Department of Surgery, Calgary, Alberta, Canada; Department of Regional Trauma Services, Calgary, Alberta, Canada; Department of Foothills Medical Centre and the University of Calgary Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada.
| | | | | | | | - Chad G Ball
- Department of Surgery, Calgary, Alberta, Canada; Department of Regional Trauma Services, Calgary, Alberta, Canada; Department of Foothills Medical Centre and the University of Calgary Calgary, Alberta, Canada
| | | | | | - Ken Rea
- Dialog Corporation, Calgary, Alberta, Canada
| | - David Sadler
- Department of Radiology, Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada
| | - John B Holcomb
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - John Kortbeek
- Department of Surgery, Calgary, Alberta, Canada; Department of Critical Care Medicine, Calgary, Alberta, Canada; Department of Regional Trauma Services, Calgary, Alberta, Canada; Department of Foothills Medical Centre and the University of Calgary Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada
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Rados A, Tiruta C, Xiao Z, Kortbeek JB, Tourigny P, Ball CG, Kirkpatrick AW. Does trauma team activation associate with the time to CT scan for those suspected of serious head injuries? World J Emerg Surg 2013; 8:48. [PMID: 24245486 PMCID: PMC4176142 DOI: 10.1186/1749-7922-8-48] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Accepted: 10/31/2013] [Indexed: 12/04/2022] Open
Abstract
Background Traumatic brain injury (TBI) constitutes the leading cause of posttraumatic mortality. Practically, the major interventions required to treat TBI predicate expedited transfer to CT after excluding other immediately life-threatening conditions. At our center, trauma responses variably consist of either full trauma activation (FTA) including an attending trauma surgeon or a non-trauma team response (NTTR). We sought to explore whether FTAs expedited the time to CT head (TTCTH). Methods Retrospective review of augmented demographics of 88 serious head injuries identified from a Regional Trauma Registry within one year at a level I trauma center. The inclusion criteria consisted of a diagnosis of head injury recorded as intubated or GCS < 13; and CT-head scanning after arriving the emergency department. Data was analyzed using STATA. Results There were 58 FTAs and 30 NTTRs; 86% of FTAs and 17% of NTTRs were intubated prehospital out of 101 charts reviewed in detail; 13 were excluded due to missing data. Although FTAs were more seriously injured (median ISS 29, MAIS head 19, GCS score at scene 6.0), NTTRs were also severely injured (median ISS 25, MAIS head 21, GCS at scene 10) and older (median 54 vs. 26 years). Median TTCTH was double without dedicated FTA (median 50 vs. 26 minutes, p < 0.001), despite similar justifiable delays (53% NTTR, 52% FTA). Without FTA, most delays (69%) were for emergency intubation. TTCTH after securing the airway was longer for NTTR group (median 38 vs. 26 minutes, p =0.0013). Even with no requirements for ED interventions, TTCTH for FTA was less than half versus NTTR (25 vs. 61 minutes, p =0.0013). Multivariate regression analysis indicated age and FTA with an attending surgeon as significant predictors of TTCTH, although the majority of variability in TTCTH was not explained by these two variables (R² = 0.33). Conclusion Full trauma activations involving attending trauma surgeons were quicker at transferring serious head injury patients to CT. Patients with FTA were younger and more seriously injured. Discerning the reasons for delays to CT should be used to refine protocols aimed at minimizing unnecessary delays and enhancing workforce efficiency and clinical outcome.
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Affiliation(s)
- Alma Rados
- Regional Trauma Services, Foothills Medical Centre, University of Calgary, 29 Street, Calgary, NW 1403, Alberta.
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A Case-matched Series of Immediate Total-body CT Scanning Versus the Standard Radiological Work-up in Trauma Patients. World J Surg 2013; 38:795-802. [DOI: 10.1007/s00268-013-2310-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Tsang B, McKee J, Engels PT, Paton-Gay D, Widder SL. Compliance to advanced trauma life support protocols in adult trauma patients in the acute setting. World J Emerg Surg 2013; 8:39. [PMID: 24088362 PMCID: PMC3851478 DOI: 10.1186/1749-7922-8-39] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 09/27/2013] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION Advanced Trauma Life Support (ATLS) protocols provide a common approach for trauma resuscitations. This was a quality review assessing compliance with ATLS protocols at a Level I trauma center; specifically whether the presence or absence of a trauma team leader (TTL) influenced adherence. METHODS This retrospective study was conducted on adult major trauma patients with acute injuries over a one-year period in a Level I Canadian trauma center. Data were collected from the Alberta Trauma Registry, and adherence to ATLS protocols was determined by chart review. RESULTS The study identified 508 patients with a mean Injury Severity Score of 24.5 (SD 10.7), mean age 39.7 (SD 17.6), 73.8% were male and 91.9% were involved in blunt trauma. The overall compliance rate was 81.8% for primary survey and 75% for secondary survey. The TTL group compared to non-TTL group was more likely to complete the primary survey (90.9% vs. 81.8%, p = 0.003), and the secondary survey (100% vs. 75%, p = 0.004). The TTL group was more likely than the non-TTL group to complete the following tasks: insertion of two large bore IVs (68.2% vs. 57.7%, p = 0.014), digital rectal exam (64.6% vs. 54.7%, p = 0.023), and head to toe exam (77% vs. 67.1%, p = 0.013). Mean times from emergency department arrival to diagnostic imaging were also significantly shorter in the TTL group compared to the non-TTL group, including times to pelvis xray (mean 68min vs. 107min, p = 0.007), CT chest (mean 133min vs. 172min, p = 0.005), and CT abdomen and pelvis (mean 136min vs. 173min, p = 0.013). Readmission rates were not significantly different between the TTL and non-TTL groups (3.5% vs. 4.5%, p = 0.642). CONCLUSIONS While many studies have demonstrated the effectiveness of trauma systems on outcomes, few have explored the direct influence of the TTL on ATLS compliance. This study demonstrated that TTL involvement during resuscitations was associated with improved adherence to ATLS protocols, and increased efficiency (compared to non TTL involvement) to diagnostic imaging. Findings from this study will guide future quality improvement and education for early trauma management.
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Affiliation(s)
- Bonnie Tsang
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, 2D WMC, 8440-112 Street NW, Edmonton, AB T6G 2B7, Canada
| | - Jessica McKee
- Alberta Centre for Injury Control and Research, School of Public Health, University of Alberta, Edmonton, AB, Canada
| | - Paul T Engels
- Department of Surgery and Division of Critical Care, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Damian Paton-Gay
- Department of Surgery and Division of Critical Care, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Sandy L Widder
- Department of Surgery, Faculty of Medicine and Dentistry, University of Alberta, 2D WMC, 8440-112 Street NW, Edmonton, AB T6G 2B7, Canada
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Tosounidis TI, Giannoudis PV. Pelvic fractures presenting with haemodynamic instability: treatment options and outcomes. Surgeon 2013; 11:344-51. [PMID: 23932669 DOI: 10.1016/j.surge.2013.07.004] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 07/08/2013] [Accepted: 07/17/2013] [Indexed: 12/29/2022]
Abstract
The management of trauma patients with haemodynamic instability and an unstable pelvic fracture is an issue of vivid debate in "trauma community". A multidisciplinary approach needs to be instituted regarding the required diagnostic and therapeutic measures. Control of haemorrhage is the first priority. Arterial embolization and/or preperitoneal pelvic packing follow the provisional skeletal pelvic stabilization. The sequence of these interventions still remains an issue of controversy. It needs to be determined on an institutional basis based on the available local resources such as angiography suite and whole-body CT scan and the expertise of the treating surgical team. Despite the fact that recent advances in diagnostic modalities and trauma care systems have improved the overall outcome of patients with pelvic fractures, the early mortality associated with high-energy pelvic injuries presenting with haemodynamic instability remains high. Any suspected injured person with pelvic ring injury should automatically be taken to a level one-trauma centre where all the facilities required are in place for these patients to survive.
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Affiliation(s)
- Theodoros I Tosounidis
- Leeds Biomedical Research Unit, Academic Department of Trauma & Orthopaedic Surgery, Clarendon Wing, Floor A, Great George Street, Leeds General Infirmary, LS1 3EX Leeds, UK
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Major trauma registry of Navarre (Spain): the accuracy of different survival prediction models. Am J Emerg Med 2013; 31:1382-8. [PMID: 23891602 DOI: 10.1016/j.ajem.2013.06.026] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Revised: 05/31/2013] [Accepted: 06/06/2013] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE To determine which factors predict death among trauma patients who are alive on arrival at hospital. METHODS Design prospective cohort study method. Data were collected on 378 trauma patients who were initially delivered by the emergency medical services of Navarre (Spain) with multiple injuries with a new injury severity score of 15 or more in 2011-2012. These data related to age, gender, presence of premorbid conditions, abbreviated injury score, injury severity score, new injury severity score (NISS), revised trauma score (RTS), and prehospital and hospital response times. Bivariate analysis was used to show the association between each variable and time until death. Mortality prediction was modeled using logistic regression analysis. RESULTS The variables related to the end result were the age of the patient, associated comorbidity, NISS, and hospital RTS. Two models were formulated: in one, the variables used were quantitative, while in the other model these variables were converted into dichotomous qualitative variables. The predictive capability of the two models was compared with the trauma and injury severity score using the area under the curve. The predictive capacities of the three models had areas under the curve of 0.93, 0.88, and 0.87. The response times of the Navarre emergency services system, measured as the sum of the time taken to reach the hospital (median time of 65 min), formulate computed tomography (46 min), and perform crucial surgery (115 min), when required, were not taken into account. CONCLUSION Age, premorbid conditions, hospital RTS, and NISS are significant predictors of death after trauma. The time intervals between the accident and arrival at the hospital, arrival at the hospital and the first computed tomography scan or the first crucial emergency intervention, do not appear to affect the risk of death.
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Total body-CT-scan bij traumapatiënten: wat, hoe, waarom? Crit Care 2013. [DOI: 10.1007/s12426-013-0052-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Dreizin D, Munera F. Blunt polytrauma: evaluation with 64-section whole-body CT angiography. Radiographics 2012; 32:609-31. [PMID: 22582350 DOI: 10.1148/rg.323115099] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Blunt polytrauma remains a leading cause of death and disability worldwide. With the major advances in computed tomography (CT) technology over the past decade, whole-body CT is increasingly recognized as the emerging standard for providing rapid and accurate diagnoses within the narrow therapeutic window afforded to trauma victims with multiple severe injuries. With a single continuous acquisition, whole-body CT angiography is able to demonstrate all potentially injured organs, as well as vascular and bone structures, from the circle of Willis to the symphysis pubis. As its use becomes more widespread, the large volume of information inherent to whole-body CT poses new challenges to radiologists in providing efficient and timely interpretation. An awareness of trauma scoring systems and injury mechanisms is essential to maintain an appropriate level of suspicion in the search for multiple injuries, and the use of multiplanar reformation and three-dimensional postprocessing techniques is important to maximize efficiency in the search. Knowledge of the key injuries that require urgent surgical or percutaneous intervention, including major vascular injuries and active hemorrhage, diaphragmatic rupture, unstable spinal fractures, pancreatic injuries with ductal involvement, and injuries to the mesentery and hollow viscera, is also necessary.
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Affiliation(s)
- David Dreizin
- Department of Radiology, University of Miami Leonard Miller School of Medicine, University of Miami Health System, Jackson Memorial Hospital, and Ryder Trauma Center, 1611 NW 12th Ave, West Wing 279, Miami, FL 33136, USA
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Easton R, Sisak K, Balogh ZJ. Time to computed tomography scanning for major trauma patients: the Australian reality. ANZ J Surg 2012; 82:644-7. [DOI: 10.1111/j.1445-2197.2012.06150.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/28/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Ruth Easton
- Department of Traumatology; Division of Surgery; John Hunter Hospital and University of Newcastle; Newcastle; New South Wales; Australia
| | - Krisztian Sisak
- Department of Traumatology; Division of Surgery; John Hunter Hospital and University of Newcastle; Newcastle; New South Wales; Australia
| | - Zsolt J. Balogh
- Department of Traumatology; Division of Surgery; John Hunter Hospital and University of Newcastle; Newcastle; New South Wales; Australia
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Abstract
BACKGROUND Computed tomography (CT) scans have become imaging modalities of choice in trauma centers. The purposes of this study were to evaluate the trend of radiation exposure in acute trauma patients. Our hypothesis was that radiation dosage and charges would increase over time without change in patient acuity or outcome. METHODS Five hundred consecutive trauma patients were retrospectively reviewed for the years 2002, 2005, and 2008. Total number of CT scans, plain radiographs, and total radiation dosage (milliSieverts [mSV]) were determined. Charges were calculated. Injury severity scores and mortality were determined. RESULTS The mean number of CT scans for category 1 patients in 2002, 2005, and 2008 was 1.5, 3.1, and 4.6, respectively (p = 0.01). This trend was similar in category 2 patients: 2.0, 3.5, 5.1, respectively (p < 0.01). Significant decreases in plain radiography were noted concurrently. This contributed to increased total radiation exposure to categories 1 and 2 patients over 2002, 2005, and 2008: 12.0 mSV, 23.6 mSV, and 33.6 mSV (p = 0.02); and 17.5 mSV, 24.1 mSV, and 37.5 mSV (p < 0.001), respectively. Charges for diagnostic imaging per patient also increased for categories 1 and 2 patients over 2002, 2005, and 2008: $2,933, $4,656, and $6,677; and $4,105, $5,344, and $7,365, respectively (all p < 0.01). Over the course of a year for 4,800 trauma patients treated at our hospital, this is expected to accrue additional charges of $13 million. CONCLUSION The number of CT scans per trauma patient has more than doubled over 6 years, generating more radiation exposure and charges per patient, despite no change in mortality or injury severity. Judicious use of advanced imaging may control risks and costs without compromising care. LEVEL OF EVIDENCE III, retrospective.
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Sierink JC, Saltzherr TP, Beenen LFM, Luitse JSK, Hollmann MW, Reitsma JB, Edwards MJR, Hohmann J, Beuker BJA, Patka P, Suliburk JW, Dijkgraaf MGW, Goslings JC. A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2). BMC Emerg Med 2012; 12:4. [PMID: 22458247 PMCID: PMC3361475 DOI: 10.1186/1471-227x-12-4] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2012] [Accepted: 03/30/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients. METHODS/DESIGN The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness. DISCUSSION The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group. TRIAL REGISTRATION ClinicalTrials.gov: (NCT01523626).
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Affiliation(s)
- Joanne C Sierink
- Trauma Unit Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Teun Peter Saltzherr
- Trauma Unit Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Ludo FM Beenen
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Jan SK Luitse
- Trauma Unit Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology Academic Medical Center, Amsterdam, The Netherlands
| | - Johannes B Reitsma
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - Michael JR Edwards
- Trauma Unit Department of Surgery, University Medical Center Sint Radboud, Nijmegen, The Netherlands
| | - Joachim Hohmann
- Department of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Benn JA Beuker
- Trauma Unit Department of Surgery, University Medical Center Groningen, Groningen, The Netherlands
| | - Peter Patka
- Trauma Unit Department of Surgery, Erasmus Medical Center, Rotterdam, The Netherlands
| | - James W Suliburk
- Trauma Unit Department of Surgery, Ben Taub General Hospital, Houston, USA
| | - Marcel GW Dijkgraaf
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Academic Medical Center, Amsterdam, The Netherlands
| | - J Carel Goslings
- Trauma Unit Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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Over reliance on computed tomography imaging in patients with severe abdominal injury: is the delay worth the risk? ACTA ACUST UNITED AC 2011; 70:278-84. [PMID: 21307722 DOI: 10.1097/ta.0b013e31820930f9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Computed tomography (CT) has a high sensitivity and specificity for detecting abdominal injuries. Expeditious abdominal imaging in "quasi-stable" patients may prevent negative laparotomy. However, the significance of potential delay to laparotomy secondary to abdominal imaging remains unknown. We sought to analyze whether the use of abdominal CT (ABD CT) in patients with abdominal injury requiring laparotomy results in a significant delay and a higher risk of poor outcome. METHODS A retrospective analysis of data from the National Trauma Data Bank (version 7.1) was performed. Inclusion criteria were adult patients (age>14 years), a scene admission (nontransfer), hypotension on arrival (emergency department systolic blood pressure<90 mm Hg), an abdominal Abbreviated Injury Scale (AIS) score>3, and undergoing a laparotomy within 90 minutes of arrival. Patients with severe brain injury (head AIS score>3) were excluded. The independent mortality risk associated with a preoperative ABD CT was determined using logistic regression after controlling important confounders. RESULTS This cohort of patients (n=3,218) was significantly injured with a median Injury Severity Score of 25 ([interquartile range, 16-34]). Patients who underwent ABD CT had similar Glasgow Coma Scale scores, a lower head AIS, longer time delays to the operating room, and a higher crude mortality (45% vs. 30%; p=0.001). Logistic regression revealed that ABD CT was independently associated with more than a 70% higher risk of mortality (odds ratios, 1.71; 95% CI, 1.2-2.2; p<0.001). When stratified by injury mechanism, intubation status and whether or not a head CT was performed, the mortality risk remained significantly increased for each subgroup. When the laparotomy was able to occur within 30 minutes of arrival, an ABD CT was independently associated with more than a sevenfold higher risk of mortality (odds ratios, 7.6; p=0.038). CONCLUSION Delay secondary to abdominal imaging in patients who require operative intervention results in an independent higher risk of mortality. ABD CT imaging is an important and useful tool after injury; however, these results suggest that delay caused by overreliance on ABD CT may result in poor outcome in specific patients. Clinicians who take care of critically injured patients should be aware of and understand these potential risks.
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Pham TN, Heinberg E, Cuschieri J, Bulger EM, O'Keefe GE, Gross JA, Jurkovich GJ. The evolution of the diagnostic work-up for stab wounds to the back and flank. Injury 2009; 40:48-53. [PMID: 19117560 DOI: 10.1016/j.injury.2008.09.014] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2008] [Revised: 09/24/2008] [Accepted: 09/26/2008] [Indexed: 02/02/2023]
Abstract
BACKGROUND Stab wounds to the back and flank infrequently cause injuries requiring operative treatment. Triple-contrast CT scan (3CT) has essentially replaced diagnostic peritoneal lavage (DPL) as the primary means of identifying patients who require operative intervention. This study aims to review the evolution of the diagnostic work-up for stab wounds to the back and flank. METHODS We performed a retrospective review of haemodynamically stable patients with stab wound to the back or flank treated at a single Level 1 trauma centre over a 10-year period. Diagnostic accuracy of DPL and 3CT screening tests were evaluated against the patient's subsequent clinical course. The elapsed time between emergency department (ED) presentation and test results was recorded and compared. RESULTS A total of 177 patients were identified. 76 patients had stab wounds isolated to the back, 90 had stab wounds isolated to the flank and 11 had wounds in both locations. CT ultimately became the predominant initial diagnostic test during the study period. Although less frequently used over time, DPL retained good sensitivity and specificity for injuries requiring operative intervention (92% and 83%, respectively). 3CT identified all injuries requiring laparotomy (100% sensitivity) and had a specificity of 96%. 3CT was a more time-consuming process, with results available at a median of 3:31h after arrival to the ED, as compared to 1:03h for DPL (p<0.01). CONCLUSIONS 3CT diagnosed all injuries requiring operative intervention, and its use was associated with a lower rate of non-therapeutic laparotomies. However, average time to diagnosis by 3CT was prolonged compared to DPL. Although 3CT has become the predominant diagnostic test when evaluating patients with stab wounds to the back and flank at our institution, efforts to further expedite the diagnostic work-up are necessary.
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Affiliation(s)
- Tam N Pham
- Department of Surgery, University of Washington, Harborview Medical Centre, Seattle, WA 98104, United States.
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