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Strahl A, Willemsen JF, Schoof B, Reinshagen K, Frosch KH, Wintges K. The paediatric polytrauma CT-indication (PePCI)-score-Development of a prognostic model to reduce unnecessary CT scans in paediatric trauma patients. Injury 2024; 55:111494. [PMID: 38521635 DOI: 10.1016/j.injury.2024.111494] [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: 07/09/2023] [Revised: 02/03/2024] [Accepted: 03/07/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Whole-Body CT (WBCT) is frequently used in emergency situations for promptly diagnosing paediatric polytrauma patients, given the challenges associated with obtaining precise details about the mechanism and progression of trauma. However, WBCT does not lead to reduced mortality in paediatric patients, but is associated with high radiation exposure. We therefore wanted to develop a screening tool for CT demand-driven emergency room (ER)-trauma diagnostic to reduce radiation exposure in paediatric patients. METHODS A retrospective study in a Level I trauma centre in Germany was performed. Data from 344 paediatric emergency patients with critical mechanism of injury who were pre-announced by the ambulance for the trauma room were collected. Patients' symptoms, clinical examination, extended Focused Assessment with Sonography for Trauma (eFAST), routinely, laboratory tests and blood gas and - when obtained - WBCT images were analysed. To identify potential predictors of severe injuries (ISS > 23), 300 of the 344 cases with complete data were subjected to regression analyses model. RESULTS Multiple regression analysis identified cGCS, base excess (BE), medically abnormal results from eFAST screening, initial unconsciousness, and injuries involving three or more body regions as significant predictors for a screening tool for decision-making to perform WBCT or selective CT. The developed Paediatric polytrauma CT-Indication (PePCI)-Score was divided into three risk categories and achieved a sensitivity of 87 % and a specificity of 71 % when comparing the low and medium risk groups with the high risk group. Comparing only the low-risk group with the high-risk group for the decision to perform WBCT, 32/35 (91 %) of patients with an ISS >23 were correctly identified, as were 124/137 (91 %) with lower ISS scores. CONCLUSION With the newly developed PePCI-Score, the frequency of WBCT in a paediatric emergency patients collective can be significantly reduced according to our data. After prospective validation, the initial assessment of paediatric trauma patients in the future could be made not only by the mechanism of injury, but also by the new PePCI-Score, deriving on clinical findings after thorough clinical assessment and the discretion of the trauma team.
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Affiliation(s)
- André Strahl
- Department of Trauma and Orthopaedic Surgery, Division of Orthopeadics, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jan Fritjof Willemsen
- Department of Paediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Benjamin Schoof
- Department of Paediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Konrad Reinshagen
- Department of Paediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; Department of Trauma Surgery, Orthopedics and Sportstraumatology, BG Hospital Hamburg, 21033 Hamburg, Germany
| | - Kristofer Wintges
- Department of Paediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
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Larraga-García B, Castañeda López L, Monforte-Escobar F, Quintero Mínguez R, Quintana-Díaz M, Gutiérrez Á. Design and Development of an Objective Evaluation System for a Web-Based Simulator for Trauma Management. Appl Clin Inform 2023; 14:714-724. [PMID: 37673097 PMCID: PMC10482499 DOI: 10.1055/s-0043-1771396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 06/15/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND Trauma injuries are one of the main leading causes of death in the world. Training with guidelines and protocols is adequate to provide a fast and efficient treatment to patients that suffer a trauma injury. OBJECTIVES This study aimed to evaluate deviations from a set protocol, a new set of metrics has been proposed and tested in a pilot study. METHODS The participants were final-year students from the Universidad Autónoma de Madrid and first-year medical residents from the Hospital Universitario La Paz. They were asked to train four trauma scenarios with a web-based simulator for 2 weeks. A test was performed pre-training and another one post-training to evaluate the evolution of the treatment to those four trauma scenarios considering a predefined trauma protocol and based on the new set of metrics. The scenarios were pelvic and lower limb traumas in a hospital and in a prehospital setting, which allow them to learn and assess different trauma protocols. RESULTS The results show that, in general, there is an improvement of the new metrics after training with the simulator. CONCLUSION These new metrics provide comprehensive information for both trainers and trainees. For trainers, the evaluation of the simulation is automated and contains all relevant information to assess the performance of the trainee. And for trainees, it provides valuable real-time information that could support the trauma management learning process.
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Affiliation(s)
- Blanca Larraga-García
- Escuela Técnica Superior de Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | - Luis Castañeda López
- Escuela Técnica Superior de Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
| | | | | | - Manuel Quintana-Díaz
- Servicio de Medicina Intensiva, Hospital La Paz Institute for Health Research, IdiPAZ, Madrid, Spain
| | - Álvaro Gutiérrez
- Escuela Técnica Superior de Ingenieros de Telecomunicación, Universidad Politécnica de Madrid, Madrid, Spain
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3
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Findakly S, Zia A, Kavnoudias H, Mathew J, Varma D, Di Muzio B, Lee R, Moriarty HK, Joseph T, Clements W. The use of whole-body trauma CT should be based on mechanism of injury: A risk analysis of 3920 patients at a tertiary trauma centre. Injury 2023:110828. [PMID: 37225543 DOI: 10.1016/j.injury.2023.05.059] [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: 09/25/2022] [Revised: 04/27/2023] [Accepted: 05/13/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Mechanism of injury (MOI) plays a significant role in a decision to perform whole-body computed tomography (CT) imaging for trauma patients. Various mechanisms have unique patterns of injury and therefore form an important variable in decision making. METHODS Retrospective cohort study including all patients >18 years old who received a whole-body CT scan between 1 January 2019 and 19 February 2020. The outcomes were divided into CT 'positive' if any internal injuries were detected and CT 'negative' if no internal injuries were detected. The MOI, vital sign parameters, and other relevant clinical examination findings at presentation were recorded. RESULTS 3920 patients met the inclusion criteria, of which 1591 (40.6%) had a positive CT. The most common MOI was fall from standing height (FFSH), accounting for 23.0%, followed by motor vehicle accident (MVA), accounting for 22.4%. Covariates significantly associated with a positive CT included age, MVA >60 km/h, motor bike, bicycle, or pedestrian accident >30 km/h, prolonged extrication >30 min, fall from height above standing, penetrating chest or abdominal injury, as well as hypotension, neurological deficit, or hypoxia on arrival. FFSH was shown to reduce the risk of a positive CT overall, however, sub-analysis of FFSH in patients >65 years showed a significant association with a positive CT (OR 2.34, p < 0.001) compared to <65 years. CONCLUSIONS Pre-arrival information including MOI and vital signs have significant impact on identifying subsequent injuries with CT imaging. In high energy trauma, we should consider the need for whole-body CT based on MOI alone regardless of the clinical examination findings. However, for low-energy trauma, including FFSH, in the absence of clinical examination findings which support an internal injury, a screening whole-body CT is unlikely to yield a positive result, particularly in the age group <65yo.
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Affiliation(s)
- Salam Findakly
- Department of Radiology, Alfred Health, Melbourne, Australia. https://twitter.com/https//twitter.comSalamfindalky
| | - Adil Zia
- Department of Radiology, Alfred Health, Melbourne, Australia. https://twitter.com/https//twitter.comAdilFZia
| | - Helen Kavnoudias
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia
| | - Joseph Mathew
- National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia; Department of Trauma, Alfred Health, Melbourne, Australia. https://twitter.com/https//twitter.comtrauma_jm
| | - Dinesh Varma
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia; National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia
| | - Bruno Di Muzio
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Robin Lee
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Heather K Moriarty
- Department of Radiology, Cork University Hospital, Cork, Ireland. https://twitter.com/https//twitter.comHeatherKateIR
| | - Tim Joseph
- Department of Radiology, Alfred Health, Melbourne, Australia
| | - Warren Clements
- Department of Radiology, Alfred Health, Melbourne, Australia; Department of Surgery, Monash University, Australia; National Trauma Research Institute, Central Clinical School, Monash University, Melbourne, Australia.
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Wada D, Maruyama S, Yoshihara T, Saito F, Yoshiya K, Nakamori Y. Hybrid emergency room: Installation, establishment, and innovation in the emergency department. Acute Med Surg 2023; 10:e856. [PMID: 37266185 PMCID: PMC10231267 DOI: 10.1002/ams2.856] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 06/03/2023] Open
Abstract
A novel trauma workflow system called the hybrid emergency room (Hybrid ER) that combines a sliding computed tomography (CT) scanning system with interventional radiology features was first installed in Osaka General Medical Center in 2011. The Hybrid ER enables CT diagnosis and emergency therapeutic interventions without transferring the patient to another examination room. In this article, the history of CT in trauma care, the world's first installation of the Hybrid ER, clinical experiences, and evidence for the Hybrid ER in trauma workflow and nontrauma fields are summarized, and the future and innovation of the Hybrid ER are reviewed.
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Affiliation(s)
- Daiki Wada
- Department of Emergency and Critical Care MedicineKansai Medical University General Medical CenterMoriguchiJapan
| | - Shuhei Maruyama
- Department of Emergency and Critical Care MedicineKansai Medical University General Medical CenterMoriguchiJapan
| | - Tomoyuki Yoshihara
- Department of Emergency and Critical Care MedicineKansai Medical University General Medical CenterMoriguchiJapan
| | - Fukuki Saito
- Department of Emergency and Critical Care MedicineKansai Medical University General Medical CenterMoriguchiJapan
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care MedicineKansai Medical University General Medical CenterMoriguchiJapan
| | - Yasushi Nakamori
- Department of Emergency and Critical Care MedicineKansai Medical University General Medical CenterMoriguchiJapan
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5
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Lucas B, Meng M, Schirrmeister W, Pliske G, Walcher F, Schüttrumpf JP. Lessons learned during the sliding gantry CT implementation in a trauma suite. Eur J Trauma Emerg Surg 2022:10.1007/s00068-022-02080-0. [PMID: 35988107 DOI: 10.1007/s00068-022-02080-0] [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: 03/19/2022] [Accepted: 08/08/2022] [Indexed: 11/24/2022]
Abstract
PURPOSE Early detection of bleeding is important for managing trauma cases in the emergency department (ED). Several trauma suites are equipped with computed tomography (CT) scanners to reduce the time to CT. In the last decade, sliding gantry CT has been implemented in trauma suites, highlighting conventional techniques' advantages. We investigated the change in the time to CT and the challenges faced during the implementation. METHODS Trauma suite treatments with a conventional CT scanner between January and December 2016 formed the control group. From January to April 2017, trauma suites were modified, and treatment was outsourced to an interim trauma suite. By May 2017, trauma suites were equipped with a sliding gantry CT scanner. Treatments from May to July 2017 formed the transition group, and those from August to December 2017 formed the routine use group. We evaluated the time to CT in all groups and considered the reasons for the delays in the transition and routine use groups. RESULTS On sliding gantry CT implementation, although time to CT remained unaffected in the transition group, it significantly reduced in the routine use group, independent of injury severity score. The incidence of cable management problems was significantly higher in the latter group. CONCLUSIONS We have demonstrated a decrease in the time to CT with the implementation of a sliding gantry CT. However, due to a higher number of cable management problems in the routine use group, we recommend regular refresher team training with routine use.
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Affiliation(s)
- Benjamin Lucas
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany.
| | - Matthias Meng
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Wiebke Schirrmeister
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Gerald Pliske
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Felix Walcher
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
| | - Jan Philipp Schüttrumpf
- Department of Trauma Surgery, Otto-Von-Guericke University Magdeburg, Leipziger Str. 44, 39120, Magdeburg, Germany
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Ernstberger A, Reske SU, Brandl A, Kulla M, Huber-Wagner S, Popp D, Kerschbaum M, Dendl LM, Braunschweig R, Schreyer AG. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. ROFO-FORTSCHR RONTG 2021; 194:505-514. [PMID: 34911138 DOI: 10.1055/a-1682-7377] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
PURPOSE Systematic data collection regarding the integration of radiology as well as structural and process characteristics of radiological diagnostics of severely injured patients in Germany using a structured questionnaire. MATERIALS AND METHODS Personal contact with all certified Level I and Level II Trauma Centers in Germany. Data on infrastructure, composition of the trauma room team, equipment, and data on the organization/performance of primary major trauma diagnostics were collected. RESULTS With a participation rate of 46.9 % (n = 151) of all German trauma centers (N = 322), a solid database is available. There were highly significant differences in the structural characteristics incl. CT equipment between the level I and II centers: In 63.8 % of the level II centers, the CT unit was located more than 50 m away from the trauma room (34.2 % in the level I centers). A radiologist was part of the trauma room team in 59.5 % of level II centers (level I 88.1 %). Additionally, highly significant differences were found comparing 24-h provision of other radiologic examinations and interventions, such as MRI (level II 44.9 %, level I 92.8 %) and angiography (level II 69.2 %, level I 97.1 %). CONCLUSION Heterogeneous structural and process characteristics of the diagnosis of severely injured patients in Germany were revealed, with highly significant differences between level I and level II centers. KEY POINTS · This is the first study on the diagnostic reality of radiology in severely injured patients in Germany. Despite a high level of standardization, significant differences were observed.. CITATION FORMAT · Ernstberger A, Reske SU, Brandl A et al. Structural and Process Data on Radiological Imaging in the Treatment of Severely Injured Patients - Results of a Survey of Level I and II Trauma Centers in Germany. Fortschr Röntgenstr 2021; DOI: 10.1055/a-1682-7377.
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Affiliation(s)
- Antonio Ernstberger
- Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Osnabrücker Zentrum für muskuloskelettale Chirurgie (OZMC), Klinikum Osnabrück GmbH, Osnabrueck, Germany
| | - Stefan Ulrich Reske
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Heinrich-Braun-Klinikum gemeinnützige GmbH, Zwickau, Germany
| | - Alexandra Brandl
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Germany
| | - Martin Kulla
- Klinik für Anästhesiologie, Intensivmedizin, Notfallmedizin und Schmerztherapie, Bundeswehrkrankenhaus Ulm, Germany
| | - Stefan Huber-Wagner
- Klinik für Unfallchirurgie, Wirbelsäulenchirurgie, Alterstraumatologie, Diakonie-Klinikum Schwäbisch Hall gGmbH, Schwabisch Hall, Germany
| | - Daniel Popp
- Klinik und Poliklinik für Unfallchirurgie, Universitätsklinikum Regensburg, Germany
| | | | - Lena Marie Dendl
- Institute for Diagnostic and Interventional Radiology, Brandenburg Medical School Theodor Fontane, Brandenburg a.d. Havel, Germany
| | - Rainer Braunschweig
- Direktor (em.) der Klinik für Bildgebende Diagnostik und Interventionsradiologie BG-Klinik Bergmannstrost Halle/S., Vorstandsmitglied der AG MSK der DRG, BG Klinikum Bergmannstrost Halle, 10587 Berlin, Germany
| | - Andreas G Schreyer
- Institute for Diagnostic and Interventional Radiology, Brandenburg Medical School Theodor Fontane, Brandenburg a.d. Havel, Germany
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Wada D, Hayakawa K, Saito F, Yoshiya K, Nakamori Y, Kuwagata Y. Combined brain and thoracic trauma surgery in a hybrid emergency room system: a case report. BMC Surg 2021; 21:219. [PMID: 33906660 PMCID: PMC8076875 DOI: 10.1186/s12893-021-01218-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 04/20/2021] [Indexed: 11/17/2022] Open
Abstract
Background A novel trauma workflow system called the hybrid emergency room (Hybrid ER), which combines a sliding CT scanner system with interventional radiology features (IVR-CT), was initially instituted in our emergency department in 2011. Use of the Hybrid ER enables CT diagnosis and emergency therapeutic interventions without transferring the patient to another room. We describe an illustrative case of severe multiple blunt trauma that included injuries to the brain and torso to highlight the ability to perform multiple procedures in the Hybrid ER. Case presentation A 46-year-old man sustained multiple injuries after falling from height. An early CT scan performed in the Hybrid ER revealed grade IIIa thoracic aortic injury, left lung contusion, and right subdural haematoma and subarachnoid haemorrhage. Without relocating the patient, all definitive procedures, including trepanation, total pneumonectomy, and thoracic endovascular aneurysm repair were performed in the Hybrid ER. At 5.72 h after definitive surgery was begun, the patient was transferred to the intensive care unit. Conclusions The Hybrid ER has the potential to facilitate the performance of multiple definitive procedures in combination to treat severe multiple blunt trauma including injuries to the brain and torso. Emergency departments with more than one resuscitation room would benefit from a Hybrid ER to treat complex emergency cases.
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Affiliation(s)
- Daiki Wada
- Department of Emergency and Critical Care Medicine, Kansai Medical University General Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan.
| | - Koichi Hayakawa
- Coordination Office for Emergency Medicine and International Response, Nagasaki University, 1-7-1 Sakamoto, Nagasaki, Nagasaki, 852-8501, Japan
| | - Fukuki Saito
- Department of Emergency and Critical Care Medicine, Kansai Medical University General Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Kazuhisa Yoshiya
- Department of Emergency and Critical Care Medicine, Kansai Medical University General Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Yasushi Nakamori
- Department of Emergency and Critical Care Medicine, Kansai Medical University General Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine, Kansai Medical University Hospital, 2-3-1 Shinmachi, Hirakata, Osaka, 573-1191, Japan
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Murao S, Yamakawa K, Kabata D, Kinoshita T, Umemura Y, Shintani A, Fujimi S. Effect of Earlier Door-to-CT and Door-to-Bleeding Control in Severe Blunt Trauma: A Retrospective Cohort Study. J Clin Med 2021; 10:jcm10071522. [PMID: 33917338 PMCID: PMC8038745 DOI: 10.3390/jcm10071522] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Revised: 03/31/2021] [Accepted: 04/02/2021] [Indexed: 01/03/2023] Open
Abstract
Blunt trauma is a potentially life-threatening injury that requires prompt diagnostic examination and therapeutic intervention. Nevertheless, how impactful a rapid response time is on mortality or functional outcomes has not been well-investigated. This study aimed to evaluate effects of earlier door-to-computed tomography time (D2CT) and door-to-bleeding control time (D2BC) on clinical outcomes in severe blunt trauma. This was a single-center, retrospective cohort study of patients with severe blunt trauma (Injury Severity Score > 16). To assess the effect of earlier D2CT and D2BC on clinical outcomes, we conducted multivariable regression analyses with a consideration for nonlinear associations. Among 671 patients with severe blunt trauma who underwent CT scanning, 163 patients received an emergency bleeding control procedure. The median D2CT and D2BC were 19 min and 57 min, respectively. In a Cox proportional hazard regression model, earlier D2CT was not associated with improved 28-day mortality (p = 0.30), but it was significantly associated with decreased mortality from exsanguination (p = 0.003). Earlier D2BC was significantly associated with improved 28-day mortality (p = 0.026). In conclusion, earlier time to a hemostatic procedure was independently associated with decreased mortality. Meanwhile, time benefits of earlier CT examination were not observed for overall survival but were observed for decreased mortality from exsanguination.
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Affiliation(s)
- Shuhei Murao
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
- Department of Emergency Medicine, Osaka Medical College, Takatsuki 569-8686, Japan
- Correspondence: ; Tel.: +81-6-6692-1201; Fax: +81-6-6692-1155
| | - Daijiro Kabata
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (D.K.); (A.S.)
| | - Takahiro Kinoshita
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Suita 565-0871, Japan;
| | - Yutaka Umemura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
| | - Ayumi Shintani
- Department of Medical Statistics, Osaka City University Graduate School of Medicine, Osaka 545-8586, Japan; (D.K.); (A.S.)
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Osaka 558-8558, Japan; (S.M.); (Y.U.); (S.F.)
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Fromm J, Meuwly E, Wendling-Keim D, Lehner M, Kammer B. Clival fractures in children: a challenge in the trauma room setting! Childs Nerv Syst 2021; 37:1199-1208. [PMID: 33245407 DOI: 10.1007/s00381-020-04963-2] [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: 06/13/2020] [Accepted: 11/04/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE A clival fracture is a rare but life-threatening traumatic brain injury in the adult and pediatric populations. To date, there are very few conclusive recommendations in the literature concerning the diagnosis and treatment of pediatric clival fractures. METHODS In 2014 and 2015, two pediatric patients with severe blunt head trauma and clival fractures were evaluated and treated at a level I trauma center. Both cases are documented and supplemented by an extensive review of the literature focusing on the diagnostic workup, classification, and clinical course of clival fractures in children. RESULTS The clinical course of two children (8 and 9 years old) with clival fractures in concert with other intra- and extracranial injuries was analyzed. A total of 17 papers encompassing 37 patients (age range, 1-18 years) were included for a systematic review. The literature review revealed a mortality rate of 23% in pediatric patients with a clival fracture. Over 50% of the patients presented with cranial nerve damage, and two-thirds suffered from intracranial vascular damage or intracerebral bleeding. CONCLUSIONS Clival fractures are a very rare but severe consequence of blunt head trauma in the pediatric population and may be challenging to diagnose, especially in cases with an unfused sphenooccipital synchondrosis. Vascular damage following clival fractures appears to be as common in pediatric patients as in adults. Therefore, contrast-enhanced CT of the cervical spine and head and/or magnetic resonance angiography is strongly recommended to rule out vascular injury of the extra- and intracranial brain-supplying vessels within the trauma room setting.
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Affiliation(s)
- Julian Fromm
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Eliane Meuwly
- Department of Pediatric Surgery, Children's Hospital Lucerne, Luzerner Kantonsspital, Spitalstrasse 20, 6000, Lucerne 16, Switzerland
| | - Danielle Wendling-Keim
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany
| | - Markus Lehner
- Department of Pediatric Surgery, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Lindwurmstr. 4, 80337, Munich, Germany. .,Department of Pediatric Surgery, Children's Hospital Lucerne, Luzerner Kantonsspital, Spitalstrasse 20, 6000, Lucerne 16, Switzerland.
| | - Birgit Kammer
- Pediatric Radiology, Department of Clinical Radiology, Ludwig-Maximilians-University Munich, Lindwurmstr. 4, 80337, Munich, Germany
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10
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Jakob DA, Benjamin ER, Cho J, Demetriades D. Combined head and abdominal blunt trauma in the hemodynamically unstable patient: What takes priority? J Trauma Acute Care Surg 2021; 90:170-176. [PMID: 33048908 DOI: 10.1097/ta.0000000000002970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The management of hypotensive patients with severe combined head and abdominal trauma is challenging, regarding the need, timing, and sequence of craniotomy or laparotomy. The purpose of the present study was to determine whether rare situations requiring craniotomy prior to laparotomy can be identified on admission with simple clinical parameters. We hypothesized that hypotension is rarely associated with the need of a combined procedure, especially in patients with mildly depressed consciousness. METHODS National Trauma Data Bank study, including adult blunt trauma patients with combined severe head (Abbreviated Injury Scale score, ≥ 3) and abdominal injury (Abbreviated Injury Scale score, ≥ 3). Data collection included demographic and clinical characteristics, laparotomy, and craniotomy within 24 hours of admission, types of intracranial pathologies, survival, and hospital stay. Multivariate regression analysis was used to determine factors predictive for the need of both operative procedures. RESULTS Of 25,585 patients with severe combined head and abdominal trauma, 8,744 (34.2%) needed only laparotomy, 534 (2.1%) only craniotomy, and 394 (1.5%) required both procedures within 24 hours of admission. In the subgroup of 4,667 hypotensive patients, 2,421 (51.9%) underwent only laparotomy, 54 (1.2%) only craniotomy, and 79 (1.7%) both procedures within 24 hours of admission. Only 5 (0.7%) of 711 hypotensive patients with Glasgow Coma Scale (GCS) score above 8 who required a laparotomy also needed a craniotomy. Among clinical parameters available on patient's arrival, GCS score of 7 to 8 was independently associated with the highest need for craniotomy in hypotensive patients requiring laparotomy (odds ratio, 7.94; p = 0.004). CONCLUSION The need for craniotomy in patients with severe combined head and abdominal injury requiring exploratory laparotomy is very low. In hypotensive patients requiring laparotomy, GCS score of 7 to 8 was an independent predictor of the need for craniotomy. In hemodynamically unstable patients with a GCS score greater than 8, it may be safer to proceed with a laparotomy first and address the head with a computed tomography scan at a later stage. LEVEL OF EVIDENCE Therapeutic, Level IV.
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Affiliation(s)
- Dominik A Jakob
- From the Division of Trauma and Surgical Critical Care, Department of Surgery, Los Angeles County + University of Southern California Medical Center, University of Southern California, Los Angeles, California
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Zhang B, Jia C, Wu R, Lv B, Li B, Li F, Du G, Sun Z, Li X. Improving rib fracture detection accuracy and reading efficiency with deep learning-based detection software: a clinical evaluation. Br J Radiol 2020; 94:20200870. [PMID: 33332979 DOI: 10.1259/bjr.20200870] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To investigate the impact of deep learning (DL) on radiologists' detection accuracy and reading efficiency of rib fractures on CT. METHODS Blunt chest trauma patients (n = 198) undergoing thin-slice CT were enrolled. Images were read by two radiologists (R1, R2) in three sessions: S1, unassisted reading; S2, assisted by DL as the concurrent reader; S3, DL as the second reader. The fractures detected by the readers and total reading time were documented. The reference standard for rib fractures was established by an expert panel. The sensitivity and false-positives per scan were calculated and compared among S1, S2, and S3. RESULTS The reference standard identified 865 fractures on 713 ribs (102 patients) The sensitivity of S1, S2, and S3 was 82.8, 88.9, and 88.7% for R1, and 83.9, 88.7, and 88.8% for R2, respectively. The sensitivity of S2 and S3 was significantly higher compared to S1 for both readers (all p < 0.05). The sensitivity between S2 and S3 did not differ significantly (both p > 0.9). The false-positive per scan had no difference between sessions for R1 (p = 0.24) but was lower for S2 and S3 than S1 for R2 (both p < 0.05). Reading time decreased by 36% (R1) and 34% (R2) in S2 compared to S1. CONCLUSIONS Using DL as a concurrent reader can improve the detection accuracy and reading efficiency for rib fracture. ADVANCES IN KNOWLEDGE DL can be integrated into the radiology workflow to improve the accuracy and reading efficiency of CT rib fracture detection.
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Affiliation(s)
- Bin Zhang
- Department of Radiology, Linyi Cancer Hospital, Shandong, China
| | - Chunxue Jia
- Clinical Research Center, Linyi People's Hospital, Shandong, China
| | - Runze Wu
- United Imaging Research, Shanghai, China
| | - Baotao Lv
- Department of Radiology, Linyi People's Hospital, Shandong, China
| | - Beibei Li
- Department of Radiology, Linyi Central Hospital, Shandong, China
| | - Fuzhou Li
- Department of Radiology, Linyi People's Hospital, Shandong, China
| | - Guijin Du
- Department of Radiology, Linyi People's Hospital, Shandong, China
| | - Zhenchao Sun
- Department of Radiology, Linyi People's Hospital, Shandong, China
| | - Xiaodong Li
- Department of Radiology, Linyi People's Hospital, Shandong, China
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Azuma M, Nakada H, Kitatani K, Shinkawa N, Khant ZA, Ochiai H, Hirai T. Conditional unnecessity of head CT for whole-body CT of traffic accident victims: a pilot study. Emerg Radiol 2020; 28:273-278. [PMID: 32918636 DOI: 10.1007/s10140-020-01851-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/04/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate whether head CT should be included in whole-body CT in road traffic accident victims. METHODS A review of electronic medical records identified 124 patients (81 males, 43 females; age 4 to 92 years, mean 47.7 years) involved in a road traffic accident in a 12-month period. All had undergone whole-body CT and physical and neurologic examinations. We recorded their age, sex, Glasgow Coma Scale (GCS), systolic blood pressure (SBP), the type of traffic accident, and the presence/absence of visible trauma above the clavicles (VTCs) and of acute traumatic brain injury (TBI) on CT. Statistical analyses were performed to evaluate predictors of acute TBI. RESULTS Of 124 patients, 34 (27%) manifested acute TBI on CT. Univariate analysis identified their age, GCS, SBP, VTCs, and the accident type as statistically significant factors for acute TBI (p < 0.05). Multivariate analysis demonstrated VTCs, GCS score < 15, and SBP ≤ 90 mmHg were significant independent predictors of acute TBI (p = 0.001, p = 0.001, and p = 0.004, respectively); the odds ratio was 16.07 for VTCs, 14.85 for GCS score < 15, and 13.78 for SBP ≤ 90 mmHg. No patients without both decrease in GCS score and VTCs manifested acute TBI. CONCLUSION Our pilot study showed that visible trauma above the clavicles and decrease in GCS score were highly associated with the presence of acute TBI in road traffic accident victims. In whole-body CT, a head CT may not be indicated in patients without these factors.
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Affiliation(s)
- Minako Azuma
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.
| | - Hiroshi Nakada
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Keiji Kitatani
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Norihiro Shinkawa
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Zaw Aung Khant
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Hidenobu Ochiai
- Center for Emergency and Critical Care Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Toshinori Hirai
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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Giuseppe G, Ilaria M, Federico D, Alessandro C, Simona G, Nazerian P, Marco B, Stefano G. Severe thoracic or abdominal injury in major trauma patients can safely be ruled out by "Valutazione Integrata Bed Side" evaluation without total body CT scan. Ir J Med Sci 2020; 190:799-805. [PMID: 32888166 DOI: 10.1007/s11845-020-02351-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 08/22/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND During the initial assessment of trauma patients, the severity of injury is very often not immediately recognizable. In trauma centers, a total body CT (TBCT) scan is routinely used to evaluate this kind of patients, even if it is burdened with health risk, economical costs, and logistical difficulties. AIM We investigated the use of a clinical guide to establish a safe alternative to this routine practice. METHODS We enrolled retrospectively 438 patients referring to the Emergency Department of Careggi University Hospital in Florence (Italy) over a 1-year period from 2014 to 2015, with the evidence of trauma and high-priority triage codes and then subjected to TBCT. We created a tool called VIBS ("Valutazione Integrata Bed Side") (from the Italian translation of "Bed Side Integrated Evaluation") which included all clinical, laboratory, and diagnostic data acquired bedside during the primary survey. Every VIBS profile was dichotomized in negative or positive if there was at least one altered item. We performed an analysis of correlation between VIBS and TBCT to determine sensibility, specificity, positive, and negative predictive value and likelihood ratio of VIBS. RESULTS Sensibility of VIBS in the prediction of positive CT scan was 100% and specificity was 31.7%. Positive and negative predictive value (95% C.I.) was 44.3 (38.8-49.5) and 100 (94.0-99.9). Positive and negative likelihood ratios were 1.464 and 0. Failure rate resulted in 0% and efficiency was 20.54%. CONCLUSIONS VIBS can safely rule out severe thoracic or abdominal injuries. This approach could limit the use of TBCT in one-fifth of suspected major trauma patients.
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Affiliation(s)
| | - Melara Ilaria
- Emergency Medicine Fellowship Program, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | | | - Coppa Alessandro
- Department of Emergency Medicine, S.Giuseppe Hospital, Empoli, Italy
| | | | | | - Bartolini Marco
- Department of Radiology, Careggi University Hospital, Florence, Italy
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Amiri F, Hale J, Thiel J, Vo B, Murray J, Winalski J. Improvement in Time to CT Imaging in Trauma Evaluations. Am Surg 2020; 87:1994-1996. [PMID: 32783531 DOI: 10.1177/0003134820940277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Farzad Amiri
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jessica Hale
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jordyn Thiel
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Bradley Vo
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jenny Murray
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jonathan Winalski
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
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Qamar SR, Evans D, Gibney B, Redmond CE, Nasir MU, Wong K, Nicolaou S. Emergent Comprehensive Imaging of the Major Trauma Patient: A New Paradigm for Improved Clinical Decision-Making. Can Assoc Radiol J 2020; 72:293-310. [PMID: 32268772 DOI: 10.1177/0846537120914247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Modern advances in the medical imaging layered onto sophisticated trauma resuscitation strategies in highly organized regionalized trauma systems have created a paradigm shift in the management of severely injured patients. Although immediate exploratory surgery to identify and control life-threatening injuries still has its place, accelerated image acquisition and interpretation procedures now make it rare for trauma surgeons in major centers to venture into damage control surgery unaided by computed tomography (CT) or other imaging, particularly in cases of blunt trauma. Indeed, because of the high incidence of clinically occult injuries associated with major mechanism trauma, and even lower energy trauma in frail or elderly patients, CT imaging has become as invaluable as physical examination, if not more so, in critical decision-making in support of optimal outcomes. In particular, whole-body computed tomography (WBCT) completed promptly after initial assessment of a major trauma provides a quick, comprehensive survey of injuries that enables better surgical planning, obviates the need for multiple subsequent studies, and permits specialized reconstructions when needed. For those at risk for problematic occult injury after modest trauma, WBCT facilitates safer discharge planning and simplified follow-up. Through standardized guidelines, streamlined protocols, synoptic reporting, accessible web-based platforms, and active collaboration with clinicians, radiologists dedicated to trauma and emergency imaging enable clearer understanding of complex injuries in high-risk patients which leads to superior clinical decision-making. Whereas dated dogma has long warned that the CT scanner is the last place to take a challenging trauma patient, modern practice suggests that, more often than not, early comprehensive imaging can be done safely and efficiently and is in the patient's best interest. This article outlines how the role of diagnostic imaging for major trauma has evolved considerably in recent years.
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Affiliation(s)
- Sadia Raheez Qamar
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - David Evans
- Department of Surgery, 8167Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Gibney
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Ciaran E Redmond
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Muhammad Umer Nasir
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
| | - Kenneth Wong
- Department of Radiology, 71511Royal Columbian Hospital, New Westminster, British Columbia, Canada
| | - Savvas Nicolaou
- Department of Emergency and Trauma Radiology, Vancouver General Hospital, 8166University of British Columbia, Vancouver, British Columbia, Canada
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Abstract
Time to hemorrhage control is critical, as mortality in patients with severe hemorrhage that arrive to trauma centers with sign of life remains over 40%. Prompt identification and management of severe hemorrhage is paramount to reducing mortality. In traditional US trauma systems, the early hospital course of a severely hemorrhaging patient typically proceeds from the trauma resuscitation bay to the operating room or angiography suite with a potential stop for radiological imaging. This protracted journey can prove fatal as it consumes valuable minutes. In contrast to the current US system is a newly developed and increasingly adopted system in Japan called the hybrid emergency room system (HERS). The hybrid ER is equipped to allow resuscitation, imaging, and damage control intervention to occur in the ER without the need to transport the patient to a subsequent destination. The HERS is relatively new and remains restricted to a small number of institutions, limiting the ability to robustly examine impact(s) on patient outcomes. Even if proven to yield superior outcomes, there are significant obstacles to adopting the HERS in the US. Challenges such as the high cost of building and implementing a HER system, return on investment, and the significant differences between the US and Japan in terms of physician training, trauma center, and reimbursement schemes may render the hybrid ER system to be unfeasible in most current trauma centers. Barriers aside, the Japanese hybrid ER system remains the most novel recent advancement in the quest to reduce potentially preventable mortality from hemorrhage.
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The Survival Benefit of a Novel Trauma Workflow that Includes Immediate Whole-body Computed Tomography, Surgery, and Interventional Radiology, All in One Trauma Resuscitation Room: A Retrospective Historical Control Study. Ann Surg 2019; 269:370-376. [PMID: 28953551 PMCID: PMC6325752 DOI: 10.1097/sla.0000000000002527] [Citation(s) in RCA: 91] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Supplemental Digital Content is available in the text Objective: The aim of this study was to evaluate the impact of a novel trauma workflow, using an interventional radiology (IVR)–computed tomography (CT) system in severe trauma. Background: In August 2011, we installed an IVR-CT system in our trauma resuscitation room. We named it the Hybrid emergency room (ER), as it enabled us to perform all examinations and treatments required for trauma in a single place. Methods: This retrospective historical control study conducted in Japan included consecutive severe (injury severity score ≥16) blunt trauma patients. Patients were divided into 2 groups: Conventional (from August 2007 to July 2011) or Hybrid ER (from August 2011 to July 2015). We set the primary endpoint as 28-day mortality. The secondary endpoints included cause of death and time course from arrival to start of CT and surgery. Multivariable logistic regression analysis adjusted for clinically important variables was performed to evaluate the clinical outcomes. Results: We included 696 patients: 360 in the Conventional group and 336 in the Hybrid ER group. The Hybrid ER group was significantly associated with decreased mortality [adjusted odds ratio (OR), 0.50 (95% confidence interval, 95% CI, 0.29–0.85); P = 0.011] and reduced deaths from exsanguination [0.17 (0.06–0.47); P = 0.001]. The time to CT initiation [Conventional 26 (21 to 32) minutes vs Hybrid ER 11 (8 to 16) minutes; P < 0.0001] and emergency procedure [68 (51 to 85) minutes vs 47 (37 to 57) minutes; P < 0.0001] were both shorter in the Hybrid ER group. Conclusion: This novel trauma workflow, comprising immediate CT diagnosis and rapid bleeding control without patient transfer, as realized in the Hybrid ER, may improve mortality in severe trauma.
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Kirberger RM, Leisewitz AL, Rautenbach Y, Lim CK, Stander N, Cassel N, Arnot L, deClercq M, Burchell R. Association between computed tomographic thoracic injury scores and blood gas and acid-base balance in dogs with blunt thoracic trauma. J Vet Emerg Crit Care (San Antonio) 2019; 29:373-384. [PMID: 31231948 DOI: 10.1111/vec.12863] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Revised: 06/21/2017] [Accepted: 06/28/2017] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the association between thoracic injuries evaluated by computed tomography (CT) and arterial blood gas and acid-base status in dogs with blunt thoracic trauma caused by motor vehicle accidents. DESIGN Prospective observational clinical study. SETTING University teaching hospital. ANIMALS Thirty-one client owned traumatized dogs and 15 healthy dogs. PROCEDURES All trauma group dogs underwent a CT scan and simultaneous arterial blood gas analysis within 24 hours, but not before 4 hours, after the traumatic incident within a 45-month enrollment period. MEASUREMENTS AND MAIN RESULTS Thorax injuries were classified as pulmonary, pleural space, or rib cage and each of these components was scored for severity using a CT composite pulmonary, pleural, and rib score. The trauma group arterial blood gas and acid-base status were evaluated for statistical difference from the control group. The pulmonary-arterial oxygen pressure was significantly lower in the trauma group compared to the control group that was supported by significant differences in the calculated variables of arterial blood oxygenation as well. There was also a significant correlation between the composite lung score and pleural score and the variables of arterial oxygen status. The pulmonary-arterial carbon dioxide pressure was not significantly different to any of the thoracic injury variables indicating normal alveolar ventilation. Acid-base imbalances were generally mild, insignificant, and variable. CONCLUSIONS AND CLINICAL RELEVANCE Blunt thoracic trauma causes significant pulmonary and pleural injury and the blood oxygen economy is significantly affected by this. The functional measures of arterial blood oxygenation were well correlated with thoracic CT pathology. Alveolar ventilation was mostly spared but a clinically significant ventilation perfusion mismatch was present.
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Affiliation(s)
- Robert M Kirberger
- Faculty of Veterinary Science, Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
| | - Andrew L Leisewitz
- Faculty of Veterinary Science, Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
| | - Yolandi Rautenbach
- Faculty of Veterinary Science, Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
| | - Chee Kin Lim
- Faculty of Veterinary Science, Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
| | - Nerissa Stander
- Faculty of Veterinary Science, Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
| | - Nicky Cassel
- Faculty of Veterinary Science, Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
| | - Luke Arnot
- Faculty of Veterinary Science, Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
| | - Marizelle deClercq
- Faculty of Veterinary Science, Department of Companion Animal Clinical Studies, University of Pretoria, Onderstepoort, South Africa
| | - Richard Burchell
- Veterinary and Biomedical Sciences, James Cook University, Townsville, Australia
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Vogl TJ, Eichler K, Marzi I, Wutzler S, Zacharowski K, Frellessen C. [Imaging techniques in modern trauma diagnostics]. Med Klin Intensivmed Notfmed 2019; 112:643-657. [PMID: 28936574 DOI: 10.1007/s00063-017-0359-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.
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Affiliation(s)
- T J Vogl
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland.
| | - K Eichler
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | - I Marzi
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - S Wutzler
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - K Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - C Frellessen
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
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The hybrid emergency room system: a novel trauma evaluation and care system created in Japan. Acute Med Surg 2019; 6:247-251. [PMID: 31304025 PMCID: PMC6603312 DOI: 10.1002/ams2.412] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 03/08/2019] [Indexed: 11/06/2022] Open
Abstract
The ultimate trauma management system should allow the completion of all time-consuming life-saving procedures in one trauma resuscitation room. In 2011, the Hybrid Emergency Room System (HERS) was developed in Japan as a novel trauma care system that allows clinicians to perform all life-saving procedures for severely injured patients, including whole-body computed tomography examination, damage control surgery, and transcatheter arterial embolization by interventional radiology, on the same table in the same room without transferring the patient. Since then, the number of HERS installations has rapidly increased around Japan. To promote further innovation and dissemination of this new and creative concept of trauma management, the Japanese Association for Hybrid Emergency Room System was launched on June 21, 2018. In this article, the concept, history, and current evidence behind this new trauma workflow system are summarized. This is the first review to show the next direction of trauma care using HERS.
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Automatic rib cage unfolding with CT cylindrical projection reformat in polytraumatized patients for rib fracture detection and characterization: Feasibility and clinical application. Eur J Radiol 2019; 110:121-127. [DOI: 10.1016/j.ejrad.2018.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2018] [Revised: 11/10/2018] [Accepted: 11/12/2018] [Indexed: 11/23/2022]
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Kinoshita T, Hayashi M, Yamakawa K, Watanabe A, Yoshimura J, Hamasaki T, Fujimi S. Effect of the Hybrid Emergency Room System on Functional Outcome in Patients with Severe Traumatic Brain Injury. World Neurosurg 2018; 118:e792-e799. [PMID: 30026142 DOI: 10.1016/j.wneu.2018.07.053] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 07/04/2018] [Accepted: 07/05/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE The timely treatment of severe traumatic brain injury (TBI) is essential for limiting the effects of damage; however, there is no consensus regarding an effective method for early intervention. In August 2011, our hospital launched a novel trauma workflow using the hybrid emergency room (ER), consisting of an interventional radiology-computed tomography (CT) unit installed in the trauma resuscitation room to facilitate early interventions. The aim of this study was to evaluate effects of the hybrid ER system on functional outcomes in patients with severe TBI. METHODS We conducted a retrospective historical control study of patients with severe TBI (Glasgow Coma Scale score ≤8) who received conventional treatment (August 2007-July 2011) or treatment in the hybrid ER (August 2011-July 2015). The primary end point was unfavorable outcome at 6 months after injury (death, vegetative state, or lower severe disability) as evaluated by the Glasgow Outcome Scale-Extended. Secondary end points included time from arrival to the start of CT examination and emergency intracranial operation. Potential confounders were adjusted with multivariable logistic regressions. RESULTS Among 158 included patients, 88 were in the conventional group and 70 were in the hybrid ER group. After model adjustment, the hybrid ER group was significantly associated with a reduction in unfavorable outcomes. Times to CT examination and intracranial operation were significantly shorter in the hybrid ER group than that in the conventional group. CONCLUSIONS The hybrid ER system is useful for realizing immediate CT examination and emergency surgery and improving functional outcomes in patients with severe TBI.
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Affiliation(s)
- Takahiro Kinoshita
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Motohisa Hayashi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Kazuma Yamakawa
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan.
| | - Atsushi Watanabe
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Jumpei Yoshimura
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
| | - Toshimitsu Hamasaki
- Department of Data Science, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Satoshi Fujimi
- Division of Trauma and Surgical Critical Care, Osaka General Medical Center, Sumiyoshi-ku, Osaka, Japan
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Kenngott HG, Preukschas AA, Wagner M, Nickel F, Müller M, Bellemann N, Stock C, Fangerau M, Radeleff B, Kauczor HU, Meinzer HP, Maier-Hein L, Müller-Stich BP. Mobile, real-time, and point-of-care augmented reality is robust, accurate, and feasible: a prospective pilot study. Surg Endosc 2018; 32:2958-2967. [PMID: 29602988 DOI: 10.1007/s00464-018-6151-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 03/21/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Augmented reality (AR) systems are currently being explored by a broad spectrum of industries, mainly for improving point-of-care access to data and images. Especially in surgery and especially for timely decisions in emergency cases, a fast and comprehensive access to images at the patient bedside is mandatory. Currently, imaging data are accessed at a distance from the patient both in time and space, i.e., at a specific workstation. Mobile technology and 3-dimensional (3D) visualization of radiological imaging data promise to overcome these restrictions by making bedside AR feasible. METHODS In this project, AR was realized in a surgical setting by fusing a 3D-representation of structures of interest with live camera images on a tablet computer using marker-based registration. The intent of this study was to focus on a thorough evaluation of AR. Feasibility, robustness, and accuracy were thus evaluated consecutively in a phantom model and a porcine model. Additionally feasibility was evaluated in one male volunteer. RESULTS In the phantom model (n = 10), AR visualization was feasible in 84% of the visualization space with high accuracy (mean reprojection error ± standard deviation (SD): 2.8 ± 2.7 mm; 95th percentile = 6.7 mm). In a porcine model (n = 5), AR visualization was feasible in 79% with high accuracy (mean reprojection error ± SD: 3.5 ± 3.0 mm; 95th percentile = 9.5 mm). Furthermore, AR was successfully used and proved feasible within a male volunteer. CONCLUSIONS Mobile, real-time, and point-of-care AR for clinical purposes proved feasible, robust, and accurate in the phantom, animal, and single-trial human model shown in this study. Consequently, AR following similar implementation proved robust and accurate enough to be evaluated in clinical trials assessing accuracy, robustness in clinical reality, as well as integration into the clinical workflow. If these further studies prove successful, AR might revolutionize data access at patient bedside.
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Affiliation(s)
- Hannes Götz Kenngott
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Anas Amin Preukschas
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Martin Wagner
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Felix Nickel
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany
| | - Michael Müller
- Division of Medical and Biological Informatics, German Cancer Research Center, Heidelberg, Germany
| | - Nadine Bellemann
- Department of Diagnostic and Interventional Radiology, Heidelberg University, Heidelberg, Germany
| | - Christian Stock
- Institute for Medical Biometry and Informatics, Heidelberg University, Heidelberg, Germany
| | - Markus Fangerau
- Department of Diagnostic and Interventional Radiology, Heidelberg University, Heidelberg, Germany
| | - Boris Radeleff
- Department of Diagnostic and Interventional Radiology, Heidelberg University, Heidelberg, Germany
| | - Hans-Ulrich Kauczor
- Department of Diagnostic and Interventional Radiology, Heidelberg University, Heidelberg, Germany
| | - Hans-Peter Meinzer
- Division of Medical and Biological Informatics, German Cancer Research Center, Heidelberg, Germany
| | - Lena Maier-Hein
- Division of Medical and Biological Informatics, German Cancer Research Center, Heidelberg, Germany
| | - Beat Peter Müller-Stich
- Department of General, Visceral and Transplantation Surgery, Heidelberg University, Im Neuenheimer Feld 110, 69120, Heidelberg, Germany.
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Furugori S, Kato M, Abe T, Iwashita M, Morimura N. Treating patients in a trauma room equipped with computed tomography and patients' mortality: a non-controlled comparison study. World J Emerg Surg 2018; 13:16. [PMID: 29599816 PMCID: PMC5870518 DOI: 10.1186/s13017-018-0176-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/12/2018] [Indexed: 11/16/2022] Open
Abstract
Background To improve acute trauma care workflow, the number of trauma centers equipped with a computed tomography (CT) machine in the trauma resuscitation room has increased. The effect of the presence of a CT machine in the trauma room on a patient’s outcome is still unclear. This study evaluated the association between a CT machine in the trauma room and a patient’s outcome. Methods Our study included all trauma patients admitted to a trauma center in Yokohama, Japan, between April 2014 and March 2016. We compared 140 patients treated using a conventional resuscitation room with 106 patients treated in new trauma rooms equipped with a CT machine. Results For the group treated in a trauma room with a CT machine, the Injury Severity Score (13.0 vs. 9.0; p = 0.002), CT scans of the head (78.3 vs. 66.4%; p = 0.046), CT scans of the body trunk (75.5 vs. 58.6%; p = 0.007), intubation in the emergency department (48.1 vs. 30.7%; p = 0.008), and multiple trauma patients (47.2 vs. 30.0%; p = 0.008) were significantly higher and Trauma and Injury Severity Score probability of survival (96.75 vs. 97.80; p = 0.009) was significantly lower than the group treated in a conventional resuscitation room. In multivariate analysis and propensity score matched analysis, being treated in a trauma room with a CT machine was an independent predictor for fewer hospital deaths (odds ratio 0.002; 95% CI 0.00–0.75; p = 0.04, and 0.07; 0.00–0.98, respectively). Conclusions Equipping a trauma room with a CT machine reduced the time in decision-making for treating a trauma patient and subsequently lowered the mortality of trauma patients.
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Affiliation(s)
- Shintaro Furugori
- 1Department of Emergency Medicine, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Makoto Kato
- 2Department of Surgery, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Takeru Abe
- 1Department of Emergency Medicine, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Masayuki Iwashita
- 1Department of Emergency Medicine, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Naoto Morimura
- 3Department of Acute Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan
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Vogl TJ, Eichler K, Marzi I, Wutzler S, Zacharowski K, Frellessen C. [Imaging techniques in modern trauma diagnostics]. Unfallchirurg 2018; 120:417-431. [PMID: 28455618 DOI: 10.1007/s00113-017-0352-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.
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Affiliation(s)
- T J Vogl
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland.
| | - K Eichler
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | - I Marzi
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - S Wutzler
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - K Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - C Frellessen
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
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Wada D, Nakamori Y, Kanayama S, Maruyama S, Kawada M, Iwamura H, Hayakawa K, Saito F, Kuwagata Y. First installation of a dual-room IVR-CT system in the emergency room. Scand J Trauma Resusc Emerg Med 2018; 26:17. [PMID: 29506552 PMCID: PMC5836362 DOI: 10.1186/s13049-018-0484-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Accepted: 02/27/2018] [Indexed: 11/26/2022] Open
Abstract
Computed tomography (CT) embedded in the emergency room has gained importance in the early diagnostic phase of trauma care. In 2011, we implemented a new trauma workflow concept with a sliding CT scanner system with interventional radiology features (IVR-CT) that allows CT examination and emergency therapeutic intervention without relocating the patient, which we call the Hybrid emergency room (Hybrid ER). In the Hybrid ER, all life-saving procedures, CT examination, damage control surgery, and transcatheter arterial embolisation can be performed on the same table. Although the trauma workflow realized in the Hybrid ER may improve mortality in severe trauma, the Hybrid ER can potentially affect the efficacy of other in/outpatient diagnostic workflow because one room is occupied by one severely injured patient undergoing both emergency trauma care and CT scanning for long periods. In July 2017, we implemented a new trauma workflow concept with a dual-room sliding CT scanner system with interventional radiology features (dual-room IVR-CT) to increase patient throughput. When we perform emergency surgery or interventional radiology for a severely injured or ill patient in the Hybrid ER, the sliding CT scanner moves to the adjacent CT suite, and we can perform CT scanning of another in/outpatient. We believe that dual-room IVR-CT can contribute to the improvement of both the survival of severely injured or ill patients and patient throughput.
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Affiliation(s)
- Daiki Wada
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan.
| | - Yasushi Nakamori
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Shuji Kanayama
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Shuhei Maruyama
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Masahiro Kawada
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Hiromu Iwamura
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Koichi Hayakawa
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Fukuki Saito
- Department of Emergency and Critical Care Medicine, Kansai Medical University Medical Center, 10-15 Fumizono-cho, Moriguchi, Osaka, 570-8507, Japan
| | - Yasuyuki Kuwagata
- Department of Emergency and Critical Care Medicine, Kansai Medical University Hospital, 2-3-1 Shinmachi, Hirakata, Osaka, 573-1191, Japan
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Bildgebende Verfahren der modernen Schockraumdiagnostik. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Horst K, Andruszkow H, Weber CD, Pishnamaz M, Herren C, Zhi Q, Knobe M, Lefering R, Hildebrand F, Pape HC. Thoracic trauma now and then: A 10 year experience from 16,773 severely injured patients. PLoS One 2017; 12:e0186712. [PMID: 29049422 PMCID: PMC5648226 DOI: 10.1371/journal.pone.0186712] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 10/09/2017] [Indexed: 01/11/2023] Open
Abstract
Background and purpose Thoracic trauma remains to be a relevant injury to the polytraumatised patient. However, literature regarding how far changes in clinical guidelines for pre- and in-hospital trauma management and diagnostic procedures affect the outcome of multiple injured patients with severe chest injury during a long-term observation period is sparse. Methods Multiple traumatised patients (age≥16y) documented in the TraumaRegister DGU® (TR-DGU) from January 1st 2005 to December 31st 2014 with severe chest trauma (AIS≥3) were included in this study. Demographic data, the pattern of injury, injury severity, radiographic emergency procedures, indication for intubation, duration of mechanical ventilation, emergency surgery, occurrence of complications and mortality were evaluated per year and over time. Results A total of 16,773 patients were analysed. The use of whole body computer tomography increased (p<0.001), while the incidence of plain x-rays decreased (p<0.001). Furthermore, incidence of AISThorax = 3 graded injuries increased (p<0.001) while AISThorax = 4 decreased (p<0.001). Both, rate of patients being intubated at the time of ICU admission decreased (p<0.001) and the time of mechanical ventilation decreased (p<0.001). Additionally, need for emergency surgery, lung failure, sepsis, and multi organ failure all decreased (p<0.001). However, mortality remained unchanged. Interpretation Severity of severe chest trauma and associated complications decreased while diagnostics and treatment improved over time. However, mortality remained unchanged. Our results are in line with those expected in the context of the incidence of CT diagnostics, which has increased parallel to the clinical outcome Thus, our data demonstrate a positive trend in the treatment of patients with severe chest trauma.
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Affiliation(s)
- Klemens Horst
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
- Harald Tscherne Research Laboratory, RWTH Aachen University, Aachen, Germany
- * E-mail:
| | - Hagen Andruszkow
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Christian D. Weber
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Miguel Pishnamaz
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Christian Herren
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Qiao Zhi
- Harald Tscherne Research Laboratory, RWTH Aachen University, Aachen, Germany
| | - Matthias Knobe
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Rolf Lefering
- IFOM - Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten / Herdecke University, Cologne, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
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van den Hout WJ, van der Wilden GM, Boot F, Idenburg FJ, Rhemrev SJ, Hoencamp R. Early CT scanning in the emergency department in patients with penetrating injuries: does it affect outcome? Eur J Trauma Emerg Surg 2017; 44:607-614. [PMID: 28868591 PMCID: PMC6096612 DOI: 10.1007/s00068-017-0831-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Accepted: 08/24/2017] [Indexed: 02/03/2023]
Abstract
Background To be a level I trauma center in the Netherlands a computed tomography (CT) scanner in the emergency department (ED) is considered desirable, as it is presumed that this optimizes the diagnostic process and that therapy can be directed based on these findings. Aim of this study was to assess the effects of implementing a CT scanner in the ED on outcomes in patients with penetrating injuries. Methods In this retrospective descriptive study, patients with penetrating injuries (shot and/or stab wounds), presented between 2000 and 2014 were analysed using the hospital’s electronic database, and data from the West Netherlands trauma registry and the financial department. Results 405 patients were included: performing a CT scan upon arrival increased significantly from 26.7 to 67.0% (p = 0.00) after implementation of a CT scanner in the ED, with the mean cost of a CT being 96.85 euros. Overall mortality decreased from 6.9 to 3.7%, although not statistically significant. Intensive care unit admission (ICU-admission) and median hospital length of stay (H-LOS) decreased from 30.9 to 24.5% resp. 3.2 to 1.8 days (p ≤ 0.05). Overall mortality, adjusted for injury severity score (ISS), revised trauma score (RTS), and types of injuries, did not change significantly. Conclusion Patients with penetrating injuries more often received a CT scan on admission after implementation of a CT scanner in the ED. Early CT scanning is useful since it significantly reduces ICU-admissions and decreases H-LOS. It is a cheap and non-invasive diagnostic tool with significant clinical impact, resulting in directed treatment, and improvement of outcomes.
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Affiliation(s)
- W J van den Hout
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - G M van der Wilden
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands.
- Division of Surgery, Department of Traumatology, Alrijne Hospital, Simon, Smitweg 1, 2353 GA, Leiderdorp, The Netherlands.
| | - F Boot
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
| | - F J Idenburg
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
| | - S J Rhemrev
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands
| | - R Hoencamp
- Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Division of Surgery, Department of Traumatology, Alrijne Hospital, Simon, Smitweg 1, 2353 GA, Leiderdorp, The Netherlands
- Ministry of Defense, The Hague, The Netherlands
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Lang P, Kulla M, Kerwagen F, Lefering R, Friemert B, Palm HG. The role of whole-body computed tomography in the diagnosis of thoracic injuries in severely injured patients - a retrospective multi-centre study based on the trauma registry of the German trauma society (TraumaRegister DGU ®). Scand J Trauma Resusc Emerg Med 2017; 25:82. [PMID: 28810921 PMCID: PMC5558663 DOI: 10.1186/s13049-017-0427-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 08/07/2017] [Indexed: 12/14/2022] Open
Abstract
Background Thoracic injuries are a leading cause of death in polytrauma patients. Early diagnosis and treatment are of paramount importance. Whole-body computed tomography (WBCT) has largely replaced traditional imaging techniques such as conventional radiographs and focused computed tomography (CT) as diagnostic tools in severely injured patients. It is still unclear whether WBCT has led to higher rates of diagnosis of thoracic injuries and thus to a change in outcomes. Methods In a retrospective study based on the trauma registry of the German Trauma Society (TraumaRegister DGU®), we analysed data from 16,545 patients who underwent treatment in 59 hospitals between 2002 and 2012 (ISS ≥ 9). The 3 years preceding and the 3 years following the introduction of WBCT as a standard imaging modality for the investigation of severely injured patients were assessed for every hospital. Accordingly, patients were assigned to either the pre-WBCT or the WBCT group. We compared the numbers of thoracic injuries and the outcomes of patients before and after the routine use of WBCT. Results A total of 13,564 patients (pre-WBCT: n = 5005, WBCT: n = 8559) were included. Relevant thoracic injuries were detected in 47.8%. There were no major differences between the patient groups in injury severity (pre-WBCT: median ISS 21; WBCT: median ISS 22), injury patterns and demographics. After the introduction of WBCT, only minor changes were observed regarding the rates of most thoracic injuries. Clinically relevant injuries were pulmonary contusions (pre-WBCT: 18.5%; WBCT: 28.7%), injuries to the lung parenchyma (pre-WBCT: 12.6%; WBCT: 5.9%), multiple rib fractures (pre-WBCT: 10.6%; WBCT: 21.6%), and pneumothoraces (pre-WBCT: 17.3%; WBCT: 21.6%). The length of stay in the intensive care unit (pre-WBCT: 10.8 days; WBCT: 9.7 days) and in hospital (pre-WBCT: 26.2 days; WBCT: 23.3 days) decreased. There was no difference in overall mortality (pre-WBCT: 15.5%; WBCT: 15.6%). Conclusions The routine use of WBCT in the trauma room setting has led to changes in patient management that are not reflected in the rates of diagnosis of severe thoracic injuries (e.g. tension pneumothoraces, cardiac injuries, arterial injuries). By contrast, there was a relevant increase in the rates of diagnosis of minor thoracic injuries, which, however, did not result in an improvement in survival prognosis.
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Affiliation(s)
- Patricia Lang
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Martin Kulla
- Department of Anaesthesiology and Intensive Care Medicine, German Armed Forces Hospital of Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
| | - Fabian Kerwagen
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Benedikt Friemert
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Hans-Georg Palm
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
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Wulffeld S, Rasmussen LS, Højlund Bech B, Steinmetz J. The effect of CT scanners in the trauma room - an observational study. Acta Anaesthesiol Scand 2017. [PMID: 28635146 DOI: 10.1111/aas.12927] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND A CT scanner incorporated in the trauma resuscitation bay may benefit trauma patients by fastening work-up times; however, evidence in the area is still sparse. We assessed if time from admission to first CT scan was lower after incorporation of a CT scanner in the resuscitation bay. METHODS We included trauma patients admitted in two 1-year periods, before and after a major rebuilding of the trauma room. Beforehand, one CT scanner was located in an adjacent room. After the rebuilding, two mobile CT scanners were placed in the resuscitation bays, where a moving gantry was combined with a trauma resuscitation table. Subgroup analyses were performed on severely injured and patients with traumatic brain injury. RESULTS We included 784 patients before and 742 patients after the reconstruction. Case-mix differed between study periods as there was a higher proportion of severe injuries, traumatic brain injury and penetrating trauma in the after period. We found a minor increase in time to CT in the after period (20 vs. 21 min, P = 0.008). In a multivariate regression analysis adjusted for differences in case-mix and with time to CT as outcome, period was an insignificant explanatory variable [β (before vs. after): 0.96 min 95% CI: 0.9-1.02, P = 0.3]. In both subgroups, we found no significant difference in time to CT. CONCLUSION We found no reduction in time to CT scan, when comparing a period with mobile CT scanners incorporated in the resuscitation bay to an earlier period with a CT scanner next to the trauma room.
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Affiliation(s)
- S. Wulffeld
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - L. S. Rasmussen
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - B. Højlund Bech
- Department of Diagnostic Radiology; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
| | - J. Steinmetz
- Department of Anaesthesia; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
- Trauma Centre; Centre of Head and Orthopaedics; Rigshospitalet; University of Copenhagen; Copenhagen Denmark
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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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Swarbrick MT, Powell SE, Haggett EF. Computed tomography of nuchal ligament andsemispinalis capitistendon avulsions in a foal. EQUINE VET EDUC 2016. [DOI: 10.1111/eve.12627] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hong ZJ, Chen CJ, Yu JC, Chan DC, Chou YC, Liang CM, Hsu SD. The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma: A retrospective cohort study. Medicine (Baltimore) 2016; 95:e4653. [PMID: 27631215 PMCID: PMC5402558 DOI: 10.1097/md.0000000000004653] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We aimed to evaluate the benefit of whole-body computed tomography (WBCT) scanning for unconscious adult patients suffering from high-energy multiple trauma compared with the conventional stepwise approach of organ-selective CT.Totally, 144 unconscious patients with high-energy multiple trauma from single level I trauma center in North Taiwan were enrolled from January 2009 to December 2013. All patients were managed by a well-trained trauma team and were suitable for CT examination. The enrolled patients are all transferred directly from the scene of an accident, not from other medical institutions with a definitive diagnosis. The scanning regions of WBCT include head, neck, chest, abdomen, and pelvis. We analyzed differences between non-WBCT and WBCT groups, including gender, age, hospital stay, Injury Severity Score, Glasgow Coma Scale, Revised Trauma Score, time in emergency department (ED), medical cost, and survival outcome.Fifty-five patients received the conventional approach for treating trauma, and 89 patients received immediate WBCT scanning after an initial examination. Patients' time in ED was significantly shorter in the WBCT group in comparison with the non-WBCT group (158.62 ± 80.13 vs 216.56 ± 168.32 min, P = 0.02). After adjusting for all possible confounding factors, we also found that survival outcome of the WBCT group was better than that of the non-WBCT group (odds ratio: 0.21, 95% confidence interval: 0.06-0.75, P = 0.016).Early performing WBCT during initial trauma management is a better approach for treating unconscious patients with high-energy multiple trauma.
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Affiliation(s)
- Zhi-Jie Hong
- General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
- Trauma Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
- Graduate Institute of Medical Sciences, National Defense Medical Center
| | - Cheng-Jueng Chen
- General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
- Trauma Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
| | - Jyh-Cherng Yu
- General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
| | - De-Chuan Chan
- General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
| | - Yu-Ching Chou
- School of Public Health, National Defense Medical Center, Taipei, Taiwan, ROC
| | - Chia-Ming Liang
- General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
- Trauma Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
| | - Sheng-Der Hsu
- General Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
- Trauma Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center
- Correspondence: Sheng-Der Hsu, General Surgery and Trauma Surgery, Department of Surgery, Tri-Service General Hospital, National Defense Medical Center, 325, Sec 2, Chen-Kung Road, Neihu 114, Taipei, Taiwan, ROC (e-mail: )
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Sierink JC, Treskes K, Edwards MJR, Beuker BJA, den Hartog D, Hohmann J, Dijkgraaf MGW, Luitse JSK, Beenen LFM, Hollmann MW, Goslings JC. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet 2016; 388:673-83. [PMID: 27371185 DOI: 10.1016/s0140-6736(16)30932-1] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma. METHODS We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ(2) test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626. FINDINGS Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0.92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0.46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0.31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died. INTERPRETATION Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT. FUNDING ZonMw, the Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Joanne C Sierink
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Kaij Treskes
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Michael J R Edwards
- Trauma Unit, Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Benn J A Beuker
- Trauma Unit, Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Joachim Hohmann
- Department of Radiology and Nuclear Medicine, University of Basel Hospital, Basel, Switzerland
| | | | - Jan S K Luitse
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Academic Medical Center, Amsterdam, Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, Netherlands
| | - J Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands.
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Affiliation(s)
- Thomas Erik Wurmb
- Department of Anaesthesiology, Section of Emergency Medicine, University Hospital of Wuerzburg, 97080 Wuerzburg, Germany.
| | - Michael Bernhard
- Emergency Department, University Hospital of Leipzig, 04105 Leipzig, Germany
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Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patients. J Trauma Acute Care Surg 2016; 80:597-602; discussion 602-3. [PMID: 26808032 DOI: 10.1097/ta.0000000000000975] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Dynamic and efficient resuscitation strategies are now being implemented in severely injured hemodynamically unstable (HU) patients as blood products become readily and more immediately available in the trauma room. Our ability to maintain aggressive resuscitation schemes in HU patients allows us to complete diagnostic imaging studies before rushing patients to the operating room (OR). As the criteria for performing computed tomography (CT) scans in HU patients continue to evolve, we decided to compare the outcomes of immediate CT versus direct admission to the OR and/or angio suite in a retrospective study at a government-designated regional Level I trauma center in Cali, Colombia. METHODS During a 2-year period (2012-2013), blunt and penetrating trauma patients (≥ 15 years) with an Injury Severity Score (ISS) greater than 15 who met criteria of hemodynamic instability (systolic blood pressure [SBP] <100 mm Hg and/or heart rate >100 beats/min and/or ≥ 4 U of packed red blood cells transfused in the trauma bay) were included. Isolated head trauma and patients who experienced a prehospital cardiac arrest were excluded. The main study outcome was mortality. RESULTS We reviewed 171 patients. CT scans were performed in 80 HU patients (47%) immediately upon arrival (CT group); the remaining 91 patients (53%) went directly to the OR (63 laparotomies, 20 thoracotomies) and/or 8 (9%) to the angio suite (OA group). Of the CT group, 43 (54%) were managed nonoperatively, 37 (46%) underwent surgery (15 laparotomies, 3 thoracotomies), and 2 (5%) underwent angiography (CT OA subgroup). None of the mortalities in the CT group occurred in the CT suite or during their intrahospital transfers. CONCLUSION There was no difference in mortality between the CT and OA groups in HU patients. CT scan was attainable in 47% of HU patients and avoided surgery in 54% of the cases. Furthermore, CT scan was helpful in deciding definitive/specific surgical management in 46% scanned HU patients who necessitated surgery after CT. LEVEL OF EVIDENCE Therapy/care management study, level IV.
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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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Hilbert-Carius P, Hofmann G, Stuttmann R. [Hemoglobin-oriented and coagulation factor-based algorithm : Effect on transfusion needs and standardized mortality rate in massively transfused trauma patients]. Anaesthesist 2015; 64:828-38. [PMID: 26453580 DOI: 10.1007/s00101-015-0093-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Revised: 08/14/2015] [Accepted: 08/23/2015] [Indexed: 01/09/2023]
Abstract
BACKGROUND Bleeding and trauma-induced coagulopathy (TIC) are major contributors to death related to trauma in the first 24 h and the major preventable contributors. Early surgical therapy and aggressive correction of TIC are key steps to prevent death in patients suffering from hemorrhage. Therefore, a standard operating procedure (SOP) using a hemoglobin (Hb)-oriented and coagulation factor-based algorithm for early correction of TIC was introduced in this level 1 trauma center. This SOP uses the correlation of the Hb values measured in the trauma bay and standard coagulation tests as the basis for various aggressive coagulation therapies. OBJECTIVE The aim was to investigate the effectiveness of the SOP in trauma patients requiring massive transfusions. The main objective was the effect on the transfusion requirements and the standardized mortality ratio (SMR), the ratio of observed deaths to expected/predicted deaths, in the cohort of massively transfused trauma patients after introduction of the SOP compared with a historical cohort. METHOD A retrospective, single center study was carried out at a supraregional trauma center between 2005 and 2014. After introduction of the Hb-oriented, coagulation factor-based SOP for correction of TIC in 2011 a before/after comparison of all trauma patients requiring massive transfusions during trauma bay resuscitation and intensive care unit (ICU) admission was carried out. Main outcome parameters were the transfusion requirement and the SMR. The historical cohort of massively transfused trauma patients before introduction of the SOP (group 1) was compared with the cohort after introduction of the SOP (group 2). Furthermore, the two cohorts were compared regarding injury severity, expected death calculated with the revised injury severity classification (RISC), hemostatic results on trauma bay and ICU admission, clotting therapy and outcome. RESULTS Of the 952 patients investigated 86 (9%) required massive transfusion (45 in group 1 and 41 in group 2). Both groups were comparable regarding injury severity but showed slight differences in hemostatic results on trauma bay admission, with a trend to worse results in group 2. Differences were recorded for platelet count on trauma bay admission with significantly lower values in group 2. The RISC predicted a significant difference in the mortality rate (46.5% group 1 and 65.3% group 2) but no significant differences in the observed mortality (44.4% group 1 and 47% group 2) were recorded. The SMR decreased from 0.95 in group 1 to 0.72 in group 2, meaning that in group 1 from 21 predicated trauma deaths 20 occurred and in group 2 from 27 predicated trauma deaths 19 occurred. This difference is not statistically significant (p = 0.16) due to the small sample size but is clinically relevant. A significant reduction in the requirement of red blood cell transfusions (22.8 ± 8.1 units vs 17.6 ± 7.6 units) was achieved (p = 0.003). Significant differences between the groups were observed regarding frequency and quantity of the coagulation-promoting drugs. Compared with group 1 the SOP used in group 2 achieved significantly better hemostatic results on ICU admission for fibrinogen and Quick's value and a clear trend to better results for international normalized ratio (INR) and PTT. CONCLUSION The SOP based on coagulation factor values and standardized clotting therapy showed a clear trend to reduction of the SMR in massively transfused trauma patients. On the other hand the SOP achieved a significant reduction in the transfusion requirements and a significant improvement in the hemostatic results in the most severely injured patients. This can be interpreted as an effective use of coagulation factors in the early hospital treatment of trauma patients with ongoing bleeding.
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Affiliation(s)
- P Hilbert-Carius
- Klinik für Anästhesiologie, Intensiv- u. Notfallmedizin, BG-Kliniken Bergmannstrost Halle (Saale), Merseburgerstr. 165, 06112, Halle (Saale), Deutschland.
| | - G Hofmann
- Klinik für Unfall- u. Wiederherstellungschirurgie, BG-Kliniken Bergmannstrost Halle (Saale), Halle (Saale), Deutschland.,Klinik für Unfall-, Hand- u. Wiederherstellungschirurgie, Friedrich-Schiller-Universität Jena, Jena, Deutschland
| | - R Stuttmann
- Klinik für Anästhesiologie, Intensiv- u. Notfallmedizin, BG-Kliniken Bergmannstrost Halle (Saale), Merseburgerstr. 165, 06112, Halle (Saale), Deutschland
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Facial Fracture in the Setting of Whole-Body CT for Trauma: Incidence and Clinical Predictors. AJR Am J Roentgenol 2015; 205:W4-10. [PMID: 26102417 DOI: 10.2214/ajr.14.13589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The objective of our study was to identify the incidence and clinical predictors of facial fracture in the setting of whole-body MDCT for trauma. MATERIALS AND METHODS The clinical data from the electronic medical records, including the final radiology reports, of 486 consecutive patients who underwent MDCT for trauma (head, cervical spine, chest, abdomen, and pelvis examinations) with dedicated maxillofacial reconstructions from October 1, 2011, to July 31, 2013, were studied. The clinical variables were compared between cohorts of patients with and those without facial fracture. The two-sample t test was used to compare continuous variables, and the Fisher exact test was used to compare categoric variables. RESULTS Two hundred sixteen (44.4%) patients had at least one fracture on the dedicated maxillofacial CT examinations, 215 of whom had facial physical examination findings (sensitivity = 99.5%). Of the 28 patients without documented physical examination findings, 27 did not have a facial fracture (negative predictive value = 96.4%). Statistically significant differences were found between positive and negative cases of facial fracture in patients with a Glasgow coma scale (GCS) score of 8 or less (p < 0.0001), an injury severity score of 16 or greater (p < 0.0001), acute alcohol intoxication according to blood alcohol concentration (BAC) (p = 0.0387), intubation at presentation (p < 0.0001), positive physical examination findings (p < 0.0001), and loss of consciousness (p = 0.0364). Falls from a height greater than standing height and open-vehicle collisions had the highest fracture rates (80.0% and 58.3%, respectively). CONCLUSION A negative finding at facial physical examination reliably excluded fracture. Clinical variables positively associated with facial fracture included the following: GCS score of 8 or less, ISS of 16 or greater, alcohol intoxication according to BAC, intubation at presentation, loss of consciousness, and the presence of abnormal facial findings at physical examination.
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Hajibandeh S, Hajibandeh S. Systematic review: effect of whole-body computed tomography on mortality in trauma patients. J Inj Violence Res 2015; 7:64-74. [PMID: 26104319 PMCID: PMC4522317 DOI: 10.5249/jivr.v7i2.613] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 07/10/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The initial diagnostic evaluation and management of trauma patients is mainly based on Advanced Trauma Life Support (ATLS) guidelines worldwide. Based on ATLS principles, conventional diagnostics such as conventional radiography (CR) and focused abdominal sonography in trauma (FAST) should precede selective use of CT. Whole-body CT (WBCT) is highly accurate and allows detection of life threatening injuries with good sensitivity and specificity. WBCT is faster than conventional diagnostics and saves more time in management of trauma patients. This study aims to review studies investigating the effect of WBCT on mortality in trauma patients. METHODS Literatures were found by searching keywords in Medline, PubMed and Cochrane library. The relevant articles were selected by two independent reviewers based on title, abstract and introduction sections. Full-texts of selected articles were reviewed and those investigating effect of WBCT on mortality in trauma patients were included. RESULTS Searching the keywords in Medline and PubMed resulted in 178 and 167 articles, respectively. Nine studies met the inclusion criteria and were reviewed. These included 8 retrospective and 1 prospective cohort studies. Mortality was measured as mortality rate or standardised mortality ratio (SMR) in the included studies. CONCLUSIONS Unlike previous systematic reviews, this review indicates that use of WBCT in blunt trauma patients is associated with reduced overall mortality rate and that WBCT can potentially improve the probability of survival in haemodynamically stable and unstable blunt trauma patients. High quality RCTs are required to describe a causal relationship between WBCT and mortality in trauma patients.
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Affiliation(s)
- Shahab Hajibandeh
- School of Medicine, University of Liverpool, Liverpool, United Kingdom. E-mail:
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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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Huber-Wagner S, Mand C, Ruchholtz S, Kühne CA, Holzapfel K, Kanz KG, van Griensven M, Biberthaler P, Lefering R. Effect of the localisation of the CT scanner during trauma resuscitation on survival -- a retrospective, multicentre study. Injury 2014; 45 Suppl 3:S76-82. [PMID: 25284240 DOI: 10.1016/j.injury.2014.08.022] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Whole-body computed tomography (WBCT) is increasingly becoming the standard diagnostic technique during the resuscitation of severely injured patients. However, little is known about the ideal localisation of the CT scanner within the emergency setting. We intended to analyse the potential effect of the localisation of the CT scanner on outcome. PATIENTS AND METHODS In a retrospective multicentre cohort study involving 8004 adult blunt major trauma patients out of 312 hospitals, we analysed the effect of the distance of the trauma room to the CT scanner on the outcome. Three groups were built: 1. CT in the trauma room 2. CT equal or less than 50 m away and 3. CT more than 50 m away. Using data derived from the 2007-2011 version of TraumaRegister DGU(®) and the structure data bank of the TraumaNetzwerk DGU(®) (trauma network, TNW; German Trauma Society, DGU) we determined the observed and predicted mortality and calculated the standardised mortality ratio (SMR) as well as logistic regressions. RESULTS n=8004 patients fulfilled the inclusion criteria: their mean age was 46.4 ± 21.0 years. 72.8% of them were male and the mean injury severity score (ISS) was 28.6 ± 11.8. The overall mortality rate was 16.0%. The mean time from hospital admission to whole-body CT was 17.1 ± 12.3 min for group 1, 22.7 ± 15.5 min for group 2 and 27.7 ± 17.1 min for group 3, p<0.001. Risk adjusted SMR was 0.74 (CI 95% 0.67-0.81) in group 1, 0.81 (CI 95% 0.76-0.87) in group 2, and 0.88 (CI 95% 0.79-0.98) in group 3. SMR group 1 vs. SMR group 2: p=0.130. SMR group 2 vs. SMR group 3: p=0.170. SMR group 1 vs. SMR group 3: p=0.016. SMR groups 1+2 vs. SMR group 3: p=0.046. Comparable data were found for the subgroup analysis of Level-I trauma centres only. Logistic regression confirmed the positive effect of a close localisation of the CT to the trauma room. The odds ratio (OR) was lowest for the localisation of the CT in the trauma room (OR 0.68, CI 95% 0.54-0.86, p<0.001). CONCLUSIONS It was proven for the first time that a close distance of the CT scanner to the trauma room has a significant positive effect on the probability of survival of severely injured patients. The closer the CT is located to the trauma room, the better the probability of survival. Distances of more than 50 m had a significant negative effect on the outcome. If new emergency departments are planned or rebuilt, the CT scanner should be placed less than 50 m away from or preferably in the trauma room.
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Affiliation(s)
- Stefan Huber-Wagner
- Klinikum rechts der Isar, Technical University Munich - TUM, Department of Trauma Surgery, Ismaninger Str. 22, D-81675 Munich, Germany.
| | - Carsten Mand
- University Hospital Marburg, Department of Trauma, Hand and Reconstructive Surgery, Campus Marburg, Baldingerstraße, D-35043 Marburg, Germany
| | - Steffen Ruchholtz
- University Hospital Marburg, Department of Trauma, Hand and Reconstructive Surgery, Campus Marburg, Baldingerstraße, D-35043 Marburg, Germany
| | - Christian A Kühne
- University Hospital Marburg, Department of Trauma, Hand and Reconstructive Surgery, Campus Marburg, Baldingerstraße, D-35043 Marburg, Germany
| | - Konstantin Holzapfel
- Klinikum rechts der Isar, Technical University Munich - TUM, Institute of Radiology, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Karl-Georg Kanz
- Klinikum rechts der Isar, Technical University Munich - TUM, Department of Trauma Surgery, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Martijn van Griensven
- Klinikum rechts der Isar, Technical University Munich - TUM, Department of Trauma Surgery, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Peter Biberthaler
- Klinikum rechts der Isar, Technical University Munich - TUM, Department of Trauma Surgery, Ismaninger Str. 22, D-81675 Munich, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Str. 200, D-51109 Cologne, Germany
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Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, Zhang M. Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis. Scand J Trauma Resusc Emerg Med 2014; 22:54. [PMID: 25178942 PMCID: PMC4347587 DOI: 10.1186/s13049-014-0054-2] [Citation(s) in RCA: 69] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2014] [Accepted: 08/25/2014] [Indexed: 11/10/2022] Open
Abstract
Introduction The purpose of this meta-analysis was to explore the value of whole-body computed tomography (WBCT) in major trauma patients (MTPs). Methods A comprehensive search for articles from Jan 1, 1980 to Dec 31, 2013 was conducted through PubMed, Cochrane Library database, China biology medical literature database, Web of knowledge, ProQuest, EBSCO, OvidSP, and ClinicalTrials.gov. Studies which compared whole-body CT with conventional imaging protocol (X-ray of the pelvis and chest, trans-abdominal sonography, and/or selective CT) in MTPs were eligible. The primary endpoint was all-cause mortality. The second endpoints included: time spent in the emergency department (ED), the duration of mechanical ventilation, ICU and hospital length of stay (LOS), the incidence of Multiple Organ Dysfunction Syndrome (MODS) /Multiple Organ Failure (MOF). Analysis was performed with Review Manager 5.2.10 and Stata 12.0. Results Eleven trials enrolling 26371 patients were analyzed. In MTPs, the application of WBCT was associated with lower mortality rate (pooled OR: 0.66, 95% CI: 0.52 to 0.85) and a shorter stay in the ED (weighted mean difference (WMD), −27.58 min; 95% CI, −43.04 to −12.12]. There was no effect of WBCT on the length of ICU stay (WMD, 0.95 days; 95% CI: −0.08 to 1.98) and the length of hospital stay (WMD, 0.56 days; 95% CI: −0.03 to 1.15). Patients in the WBCT group had a longer duration of mechanical ventilation (WMD, 0.96 days, 95% CI: 0.32 to 1.61) and higher incidence of MODS/MOF (OR, 1.44, 95% CI: 1.35-1.54; P = 0.00001). Conclusions The present meta-analysis suggests that the application of whole-body CT significantly reduces the mortality rate of MTPs and markedly reduces the time spent in the emergency department.
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Affiliation(s)
- Libing Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Yuefeng Ma
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Shouyin Jiang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Ligang Ye
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Zhongjun Zheng
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Yongan Xu
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, No 88, Jiefang Rd, Hangzhou, 310009, China.
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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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Harvey J, West A. The right scan, for the right patient, at the right time: The reorganization of major trauma service provision in England and its implications for radiologists. Clin Radiol 2013; 68:871-86. [DOI: 10.1016/j.crad.2013.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 01/02/2013] [Accepted: 01/08/2013] [Indexed: 12/30/2022]
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Wada D, Nakamori Y, Yamakawa K, Yoshikawa Y, Kiguchi T, Tasaki O, Ogura H, Kuwagata Y, Shimazu T, Hamasaki T, Fujimi S. Impact on survival of whole-body computed tomography before emergency bleeding control in patients with severe blunt trauma. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R178. [PMID: 24025196 PMCID: PMC4057394 DOI: 10.1186/cc12861] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/17/2013] [Indexed: 12/24/2022]
Abstract
Introduction Whole-body computed tomography (CT) has gained importance in the early diagnostic phase of trauma care. However, the diagnostic value of CT for seriously injured patients is not thoroughly clarified. This study assessed whether preoperative CT beneficially affected survival of patients with blunt trauma who required emergency bleeding control. Methods This retrospective study was conducted from January 2004 to December 2010 in two tertiary trauma centers in Japan. The primary inclusion criterion was patients with blunt trauma who required emergency bleeding control (surgery or transcatheter arterial embolization). CT before emergency bleeding control was performed at the attending physician's discretion based on individual patient condition (for example, hemodynamic stability or certain abnormalities in the primary survey). We assessed covariates associated with 28-day mortality with multivariate logistic regression analysis and evaluated standardized mortality ratio (SMR, ratio of observed to predicted mortality by Trauma and Injury Severity Score (TRISS) method) in two subgroups of patients who did or did not undergo CT. Results The inclusion criterion was fulfilled by 152 patients with a median Injury Severity Score of 35.3. During the early resuscitation phase, 132 (87%) patients underwent CT and 20 (13%) did not. Severity of injury was significantly higher in the non-CT versus CT group patients. Observed mortality rate was significantly lower in the CT versus non-CT group (18% vs. 80%, P <0.001). Multivariate adjustment for the probability of survival (Ps) by TRISS method confirmed CT as an independent predictor for 28-day mortality (adjusted OR, 7.22; 95% CI, 1.76 to 29.60; P = 0.006). In the subgroup with less severe trauma (TRISS Ps ≥50%), SMR in the CT group was 0.63 (95% CI, 0.23 to 1.03; P = 0.066), indicating no significant difference between observed and predicted mortality in the CT group. In contrast, in the subgroup with more severe trauma (TRISS Ps <50%), SMR was 0.65 (95% CI, 0.41 to 0.90; P = 0.004) only in the CT group, whereas the difference between observed and predicted mortality was not significant in the non-CT group, suggesting a possible beneficial effect of CT on survival only in trauma patients at high risk of death. Conclusion CT performed before emergency bleeding control might be associated with improved survival, especially in severe trauma patients with TRISS Ps of <50%.
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Huber-Wagner S, Biberthaler P, Häberle S, Wierer M, Dobritz M, Rummeny E, van Griensven M, Kanz KG, Lefering R. Whole-body CT in haemodynamically unstable severely injured patients--a retrospective, multicentre study. PLoS One 2013; 8:e68880. [PMID: 23894365 PMCID: PMC3722202 DOI: 10.1371/journal.pone.0068880] [Citation(s) in RCA: 160] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 05/31/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The current common and dogmatic opinion is that whole-body computed tomography (WBCT) should not be performed in major trauma patients in shock. We aimed to assess whether WBCT during trauma-room treatment has any effect on the mortality of severely injured patients in shock. METHODS In a retrospective multicenter cohort study involving 16719 adult blunt major trauma patients we compared the survival of patients who were in moderate, severe or no shock (systolic blood pressure 90-110,<90 or >110 mmHg) at hospital admission and who received WBCT during resuscitation to those who did not. Using data derived from the 2002-2009 version of TraumaRegister®, we determined the observed and predicted mortality and calculated the standardized mortality ratio (SMR) as well as logistic regressions. FINDINGS 9233 (55.2%) of the 16719 patients received WBCT. The mean injury severity score was 28.8±12.1. The overall mortality rate was 17.4% (SMR = 0.85, 95%CI 0.81-0.89) for patients with WBCT and 21.4% (SMR = 0.98, 95%CI 0.94-1.02) for those without WBCT (p<0.001). 4280 (25.6%) patients were in moderate shock and 1821 (10.9%) in severe shock. The mortality rate for patients in moderate shock with WBCT was 18.1% (SMR 0.85, CI95% 0.78-0.93) compared to 22.6% (SMR 1.03, CI95% 0.94-1.12) to those without WBCT (p<0.001, p = 0.002 for the SMRs). The mortality rate for patients in severe shock with WBCT was 42.1% (SMR 0.99, CI95% 0.92-1.06) compared to 54.9% (SMR 1.10, CI95% 1.02-1.16) to those without WBCT (p<0.001, p = 0.049 for the SMRs). Adjusted logistic regression analyses showed that WBCT is an independent predictor for survival that significantly increases the chance of survival in patients in moderate shock (OR = 0.73; 95%CI 0.60-0.90, p = 0.002) as well as in severe shock (OR = 0.67; 95%CI 0.52-0.88, p = 0.004). The number needed to scan related to survival was 35 for all patients, 26 for those in moderate shock and 20 for those in severe shock. CONCLUSIONS WBCT during trauma resuscitation significantly increased the survival in haemodynamically stable as well as in haemodynamically unstable major trauma patients. Thus, the application of WBCT in haemodynamically unstable severely injured patients seems to be safe, feasible and justified if performed quickly within a well-structured environment and by a well-organized trauma team.
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Affiliation(s)
- Stefan Huber-Wagner
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
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