ACR Appropriateness Criteria® Major Blunt Trauma

Using chest X-ray to predict tube thoracostomy in traumatic pneumothorax: A single-institution retrospective review

BACKGROUND

Traumatic pneumothorax (PTX) is a common occurrence in thoracic trauma patients, with a majority requiring tube thoracostomy (TT) for management. Recently, the "35-mm" rule has advocated for observation of patients with PTX less than 35 mm on chest computed tomography (CT) scan. This rule has not been examined in chest x-ray (CXR). We hypothesize that a similar size cutoff can be determined in CXR predictive of need for tube thoracostomy.

METHODS

We performed a single-institution retrospective review of patients with traumatic PTX from 2018 to 2022, excluding those who underwent TT prior to CXR. Primary outcomes were size of pneumothorax on CXR and need for TT; secondary outcome was failed observation, defined as TT more than 4 hours after presentation. To determine the size cutoff on CXR to predict TT need, area under the receiver operating curve (AUROC) analyses were performed and Youden's index calculated (significance at p < 0.05). Predictors of failure were calculated using logistic regression.

RESULTS

There were 341 pneumothoraces in 304 patients (94.4% blunt trauma, median injury severity score 14). Of these, 82 (24.0%) had a TT placed within the first 4 hours. Fifty-five of observed patients (21.2%) failed, and these patients had a larger PTX on CXR (8.6 mm [5.0-18.0 mm] vs. 0.0 mm [0.0-2.3 mm] ( p < 0.001)). Chest x-ray PTX size correlated moderately with CT size (r = 0.31, p < 0.001) and was highly predictive of need for TT insertion (AUC 0.75, p < 0.0001), with an optimal size cutoff predicting TT need of 38 mm.

CONCLUSION

Chest x-ray imaging size was predictive of need for TT, with an optimal size cutoff on CXR of 38 mm, approaching the "35-mm rule." In addition to size, failed observation was predicted by presenting lactic acidosis and need for supplemental oxygen. This demonstrates this cutoff should be considered for prospective study in CXR.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level IV.

ACR Appropriateness Criteria® Workup of Pleural Effusion or Pleural Disease

Pleural effusions are categorized as transudative or exudative, with transudative effusions usually reflecting the sequala of a systemic etiology and exudative effusions usually resulting from a process localized to the pleura. Common causes of transudative pleural effusions include congestive heart failure, cirrhosis, and renal failure, whereas exudative effusions are typically due to infection, malignancy, or autoimmune disorders. This document summarizes appropriateness guidelines for imaging in four common clinical scenarios in patients with known or suspected pleural effusion or pleural disease. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

ACR Appropriateness Criteria® Acute Pelvic Pain in the Reproductive Age Group: 2023 Update

This review focuses on the initial imaging in the reproductive age adult population with acute pelvic pain, including patients with positive and negative beta-human chorionic gonadotropin (β-hCG) levels with suspected gynecological and nongynecological etiology. For all patients, a combination of transabdominal and transvaginal pelvic ultrasound with Doppler is usually appropriate as an initial imaging study. If nongynecological etiology in patients with negative β-hCG is suspected, then CT of the abdomen and pelvis with or without contrast is also usually appropriate. In patients with positive β-hCG and suspected nongynecological etiology, CT of the abdomen and pelvis with contrast and MRI of the abdomen and pelvis without contrast may be appropriate. In patients with negative β-hCG and suspected gynecological etiology, CT of the abdomen and pelvis with contrast, MRI of pelvis without contrast, or MRI of pelvis with and without contrast may be appropriate. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

CETARS/CAR Practice Guideline on Imaging the Pregnant Trauma Patient

Imaging of pregnant patients who sustained trauma often causes fear and confusion among patients, their families, and health care professionals regarding the potential for detrimental effects from radiation exposure to the fetus. Unnecessary delays or potentially harmful avoidance of the justified imaging studies may result from this understandable anxiety. This guideline was developed by the Canadian Emergency, Trauma and Acute Care Radiology Society (CETARS) and the Canadian Association of Radiologists (CAR) Working Group on Imaging the Pregnant Trauma Patient, informed by a literature review as well as multidisciplinary expert panel opinions and discussions. The working group included academic subspecialty radiologists, a trauma team leader, an emergency physician, and an obstetriciangynaecologist/maternal fetal medicine specialist, who were brought together to provide updated, evidence-based recommendations for the imaging of pregnant trauma patients, including patient safety aspects (eg, radiation and contrast concerns) and counselling, initial imaging in maternal trauma, specific considerations for the use of fluoroscopy, angiography, and magnetic resonance imaging. The guideline strives to achieve clarity and prevent added anxiety in an already stressful situation of injury to a pregnant patient, who should not be imaged differently.

Does delayed phase imaging in CT angiography provide additional information in patients with suspected active bleeding?

PURPOSE

We hypothesize that delayed phase imaging does not provide additional diagnostic information in patients who undergo multi-phasic CTA for suspected active bleeding.

METHODS

Data on patients who underwent multiphasic CTA (pre-contrast, arterial, porto-venous, and delayed phases) for suspected acute bleed were retrospectively collected between January 2019 and November 2021. CTA images were reviewed by a general radiologist, an interventional radiologist, and a body imaging radiologist independently. Each reader evaluated if delayed phase images provided additional information that would change the final impression of the CTA report. Additional information regarding bleeding location, time needed for delayed image acquisition, and radiation exposure were also obtained.

RESULTS

A total of 104 patients with CTAs were analyzed with an average age of 58 years ± 22. Studies rated with absent additional findings on delayed images were 102 (98.1%) by the interventional radiologist, 101 (97.1%) by the body imaging radiologist, and 100 (96.1%) by the general radiologist with percent agreement of 96.15% (kappa 0.54, p < 0.001). All the findings were characterized as unlikely to be clinically significant. Mean time added to complete a delayed phase images was 3.61 ± 3.4 min. The average CT dose length product (DLP) for the total exam was 3621.78 ± 2129.57 mGy.cm with delayed acquisition adding a mean DLP of 847.75 ± 508.8 mGy.cm.

CONCLUSION

Delayed phase imaging does not provide significant additional diagnostic information in evaluating patients with suspected active bleeding but is associated with increased examination time and radiation exposure.

Value of contrast-enhanced arterial phase imaging in addition to portovenous phase in CT evaluation of blunt abdominopelvic trauma

OBJECTIVES

Compare the diagnostic performance of the arterial phase plus portovenous phases (AP + PVP) of abdominopelvic CT (CT) with PVP alone in the detection and characterization of traumatic vascular injury and the effects on radiologists' confidence.

METHODS

CT of 103 consecutive inpatients (median 36 years, 83 males) with blunt abdominopelvic injuries were retrospectively included if performed within 24 h after trauma and before definitive management. Images were re-reviewed by two blinded radiologists with disagreements resolved by the third radiologist.

RESULTS

Sixty vascular injuries (liver 23, spleen 15, kidneys 9, pancreas 2, adrenals 3, mesentery, and pelvis 4 each) were found with 4 injuries (liver 2, spleen, and kidneys 1 each) not detected at initial CT. Nineteen (liver 6, spleen 10, kidneys 2, adrenal 1) were visualized only on AP. The sensitivity and accuracy of AP + PVP were 89.58-91.67% and 94.44-95.15%, compared to 61.67-62.50% and 77.67-80.00% of PVP alone. The agreements on the types of injury with final diagnoses were higher for AP + PVP than for PVP alone (78.69% vs. 44.26%). The mean diagnostic radiologist confidence ((1 = 25%, 2 = 50%, 3 = 75%, 4 > 90%) increased significantly in the detection (from 3.38 to 3.71) and characterization (from 2.46 to 3.67) of vascular injuries with AP + PVP compared to PVP alone. For 19 lesions detected only on AP, 11 (spleen 8, liver 2, adrenal 1) received nonoperative management; others had transarterial embolization or surgery.

CONCLUSIONS

The addition of AP improves the detection and characterization of vascular injuries in CT evaluation of blunt abdominopelvic trauma.

KEY POINTS

• AP+PVP was more sensitive and precise than PVP alone in the detection of traumatic vascular abdominopelvic injuries. • AP+PVP improved the characterization of traumatic abdominopelvic vascular injuries. • When all abdominopelvic vascular injuries were considered, AP increased radiologists' diagnostic confidence in the detection and characterization of vascular injuries.

Dose Reduction Strategies for Pregnant Women in Emergency Settings

In modern clinical practice, there is an increasing dependence on imaging techniques in several settings, and especially during emergencies. Consequently, there has been an increase in the frequency of imaging examinations and thus also an increased risk of radiation exposure. In this context, a critical phase is a woman's pregnancy management that requires a proper diagnostic assessment to reduce radiation risk to the fetus and mother. The risk is greatest during the first phases of pregnancy at the time of organogenesis. Therefore, the principles of radiation protection should guide the multidisciplinary team. Although diagnostic tools that do not employ ionizing radiation, such as ultrasound (US) and magnetic resonance imaging (MRI) should be preferred, in several settings as polytrauma, computed tomography (CT) nonetheless remains the examination to perform, beyond the fetus risk. In addition, protocol optimization, using dose-limiting protocols and avoiding multiple acquisitions, is a critical point that makes it possible to reduce risks. The purpose of this review is to provide a critical evaluation of emergency conditions, e.g., abdominal pain and trauma, considering the different diagnostic tools that should be used as study protocols in order to control the dose to the pregnant woman and fetus.

Imaging of renal emergencies: Review of infectious, hemorrhagic, vascular, and traumatic etiologies

Diagnostic imaging allows for accurate and early recognition of acute renal pathologies, thus allowing for appropriate clinical triage, life-saving treatments, and preservation of renal function. In this review, we discuss the clinical presentation and imaging findings of renal emergencies with infectious, hemorrhagic, vascular, and traumatic etiologies.

Dual-Energy CT in the Acute Setting: Bowel Trauma

Traumatic bowel and mesenteric injuries (TBMI) have significant morbidity and mortality. The physical examination is often limited and sometimes not feasible in the trauma patient. Multidetector CT (MDCT) detection of TBMI is challenging and can be life-saving. Dual-energy CT (DECT) utilizes iodine overlay, monoenergetic imaging, and metal artifact reduction to enhance the conspicuity of TBMI. DECT may improve the conspicuity of TBMI leading to increased diagnostic accuracy and confidence. The aim of the article is to review the state of the art and applications of DECT in bowel trauma.

Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma

In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist's expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.

ACR Appropriateness Criteria® Plexopathy: 2021 Update

Plexopathy may be caused by diverse pathologies, including trauma, nerve entrapment, neoplasm, inflammation, infection, autoimmune disease, hereditary disease, and idiopathic etiologies. For patients presenting with brachial or lumbosacral plexopathy, dedicated plexus MRI is the most appropriate initial imaging modality for all clinical scenarios and can identify processes both intrinsic and extrinsic to the nerves. Other imaging tests may be appropriate for initial imaging depending on the clinical scenario. This document addresses initial imaging strategies for brachial and lumbosacral plexopathy in the following clinical situations: nontraumatic plexopathy with no known malignancy, traumatic plexopathy (not perinatal), and plexopathy occurring in the context of a known malignancy or posttreatment syndrome. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Utility of enteric contrast material in abdominal penetrating trauma: A narrative review

Penetrating trauma is an important cause of morbidity and mortality. With the possibility of conservative management for hemodynamically stable trauma patient, computed tomography (CT) has become an important tool in diagnosis and management of penetrating trauma. There have been multiple studies examining the utility and lack of perceived benefit of using enteric contrast material in the initial CT evaluation. We provide a narrative review of the surgical and radiological literature, offer our own protocol for how to approach the imaging of patients with suspected bowel injury following penetrating traumatic injury and discuss the potential of using enteric contrast material.

Imaging spectrum of traumatic urinary bladder and urethral injuries

Urinary bladder and urethral injuries usually occur as part of multiple injuries in polytrauma patients. These injuries are easily overlooked because the initial evaluation is focused on other life-threatening injuries such as traumatic brain injury, hemopneumothorax or hemoperitoneum. Although the urinary bladder and urethral injuries are not life-threatening, they pose the risk of long-term morbidity which can be burdensome. These complications include urinary incontinence, voiding dysfunction, urethrocutaneous fistula, urethral stricture and erectile dysfunction. Computed tomography (CT) findings of urinary bladder and urethral injuries are usually subtle. Retrograde fluoroscopic/CT cystography and urethrography remain the mainstay imaging techniques for complete evaluation, diagnosis, staging, and follow-up of these traumatic injuries. In this review, we discuss the pathophysiology and imaging spectrum of urinary bladder and urethral injuries with an emphasis on the classification schemes. Familiarity with the pelvic anatomy and the injury pattern leads to the prompt diagnosis, accurate classification and appropriate management, which have been associated with better prognosis.