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Beviss-Challinor KB, Kidd M, Pitcher RD. How useful are clinical details in blunt trauma referrals for computed tomography of the abdomen? SA J Radiol 2020; 24:1837. [PMID: 32391180 PMCID: PMC7203534 DOI: 10.4102/sajr.v24i1.1837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/02/2020] [Indexed: 11/16/2022] Open
Abstract
Background The relevance of clinical data included in blunt trauma referrals for abdominal computed tomography (CT) is not known. Objectives To analyse the clinical details provided on free-text request forms for abdominal CT following blunt trauma and assess their association with imaging evidence of intra-abdominal injury. Method A single-institution, retrospective study of abdominal CT scans was performed for blunt trauma between 01 January and 31 March 2018. Computed tomography request forms were reviewed with their corresponding CT images. Clinical details provided and scan findings were captured systematically. The relationship between individual clinical features and CT evidence of abdominal injury was tested using one-way cross tabulation and Fisher’s exact test. Results One hundred thirty-nine studies met inclusion criteria. A wide range of clinical details was communicated. Only clinical abdominal examination findings (p = 0.05), macroscopic haematuria (p < 0.01), pelvic fracture or hip dislocation (p = 0.04) and positive focused assessment with sonography in trauma (p < 0.01) demonstrated an associated trend with abdominal injury. Conclusion Key abdominal examination and basic imaging findings remain essential clinical details for the appropriate evaluation of CT abdomen requests in the setting of blunt trauma. Methods to improve consistent communication of relevant clinical details are likely to be of value.
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Affiliation(s)
- Kenneth B Beviss-Challinor
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
| | - Martin Kidd
- Centre for Statistical Consultation, Stellenbosch University, Stellenbosch, South Africa
| | - Richard D Pitcher
- Division of Radiodiagnosis, Department of Medical Imaging and Clinical Oncology, Faculty of Medicine and Health Sciences, Stellenbosch University, Cape Town, South Africa
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O'Neill SB, Hamid S, Nicolaou S, Qamar SR. Changes in Approach to Solid Organ Injury: What the Radiologist Needs to Know. Can Assoc Radiol J 2020; 71:352-361. [PMID: 32166970 DOI: 10.1177/0846537120908069] [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: 12/26/2022] Open
Abstract
This review aims to examine the challenges facing radiologists interpreting trauma computed tomography (CT) images in this era of a changing approach to management of solid organ trauma. After reviewing the pearls and pitfalls of CT imaging protocols for detection of traumatic solid organ injuries, we describe the key changes in the 2018 American Association for the Surgery of Trauma Organ Injury Scales for liver, spleen, and kidney and their implications for management strategies. We then focus on the important imaging findings in observed in patients who undergo nonoperative management and patients who are imaged post damage control surgery.
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Affiliation(s)
- Siobhán B O'Neill
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Saira Hamid
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Savvas Nicolaou
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - Sadia R Qamar
- Department of Emergency Radiology, University of British Columbia, Vancouver General Hospital, Vancouver, British Columbia, Canada
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Ilhan M, Sönmez RE, Kut A, Toprak S, Gök AFK, Günay MK, Ertekin C. Are radiological modalities really necessary for the long-term follow-up of patients having blunt solid organ injuries? A single center study. World J Emerg Med 2019; 10:177-181. [PMID: 31171949 PMCID: PMC6545375 DOI: 10.5847/wjem.j.1920-8642.2019.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 03/10/2019] [Indexed: 11/19/2022] Open
Affiliation(s)
- Mehmet Ilhan
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Recep Erçin Sönmez
- Department of General Surgery, İstanbul Medeniyet University, İstanbul, Turkey
| | - Abdullah Kut
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Safa Toprak
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Ali Fuat Kaan Gök
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Mustafa Kayıhan Günay
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
| | - Cemalettin Ertekin
- Department of General Surgery, İstanbul University İstanbul Medical Faculty, İstanbul, Turkey
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von Herrmann PF, Nickels DJ, Mansouri M, Singh A. Imaging of Blunt and Penetrating Abdominal Trauma. Emerg Radiol 2018. [DOI: 10.1007/978-3-319-65397-6_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Kim YJ, Kim JS, Cho SH, Bae JI, Sohn CH, Lee YS, Lee JH, Lim KS, Kim WY. Characteristics of computed tomography in hemodynamically unstable blunt trauma patients: Experience at a tertiary care center. Medicine (Baltimore) 2017; 96:e9168. [PMID: 29245362 PMCID: PMC5728977 DOI: 10.1097/md.0000000000009168] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Emergent exploratory laparotomy is recommended for hemodynamically unstable blunt trauma patients suspected of having hemoperitoneum. However, given the unreliability of ultrasonography and rapid scan speed of computed tomography (CT), CT might help clinicians provide accurate information even in hemodynamically unstable trauma patients. This observational study aimed to describe the bleeding site and hospital course of severe blunt trauma patients with hemoperitoneum diagnosed by CT scan.We enrolled all consecutive adult blunt trauma patients (≥18 years old) who underwent whole-body CT before operation between February 2012 and October 2016. Patients with hemoperitoneum on CT images were included and categorized into hemodynamically stable and unstable (persistent hypotension despite fluid resuscitation) groups.Among 1723 severe blunt trauma patients, 136 patients with hemoperitoneum were included. Of these, 98 (72.1%) patients had documented intraperitoneal injury, and the liver (60.2%) was most frequently damaged site, followed by spleen (23.5%) and mesentery (23.5%). The rate of intraperitoneal organ injury did not differ between hemodynamically stable (n = 107) and unstable (n = 29) groups (69.2% vs 82.8%, P = .15), while the documented active internal bleeding was high in the unstable group (29.9% vs 69.0%, P < .001). In the unstable group, 14 (48.3%) patients underwent emergent operation, while 3 patients underwent embolization, and the others were treated in a conservative manner.Even in hemodynamically unstable hemoperitoneum patients, 17.2% had no documented intraperitoneal injury and over half of the patients were treated without emergent operation.
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Beal AL, Ahrendt MN, Irwin ED, Lyng JW, Turner SV, Beal CA, Byrnes MT, Beilman GA. Prediction of blunt traumatic injuries and hospital admission based on history and physical exam. World J Emerg Surg 2016; 11:46. [PMID: 27588036 PMCID: PMC5007839 DOI: 10.1186/s13017-016-0099-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2016] [Accepted: 08/06/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We evaluated the ability of experienced trauma surgeons to accurately predict specific blunt injuries, as well as patient disposition from the emergency department (ED), based only on the initial clinical evaluation and prior to any imaging studies. It would be hypothesized that experienced trauma surgeons' initial clinical evaluation is accurate for excluding life-threatening blunt injuries and for appropriate admission triage decisions. METHODS Using only their history and physical exam, and prior to any imaging studies, three (3) experienced trauma surgeons, with a combined Level 1 trauma experience of over 50 years, predicted injuries in patients with an initial GCS (Glasgow Coma Score) of 14-15. Additionally, ED disposition (ICU, floor, discharge to home) was also predicted. These predictions were compared to actual patient dispositions and to blunt injuries documented at discharge. RESULTS A total of 101 patients with 92 blunt injuries were studied. 43/92 (46.7 %) injuries would have been missed by only performing an initial history and physical exam ("Missed injury"). A change in treatment, though often minor, was required in 19/43 (44.2 %) of the missed injuries. Only 1/43 (2.3 %) of these "missed injuries" (blunt aortic injury) required surgery. Sensitivity, specificity, and accuracy for injury prediction were 53.2, 95.9, and 92.3 % respectively. Positive and negative predictive values were 53.8 and 95.8 % respectively. Prediction of disposition from the ED was 77.8 % accurate. In 7/34 (20.6 %) patients, missed injuries led to changes in disposition. "Undertriage" occurred in 9/99 (9.1 %) patients (Predicted for floor but admitted to ICU). Additionally, 8/84 (9.5 %) patients predicted for floor admission were sent home from the ED; and 5/13 (38.5 %) patients predicted for ICU admission were actually sent to the floor after complete evaluations, giving an "overtriage" rate of 13/99 (13.1 %) patients. CONCLUSIONS In a neurologically-intact group of trauma patients, experienced trauma surgeons would have missed 46.7 % of the actual injuries, based only on their history and physical exam. Once accurate diagnoses of injuries were completed, usually with the help of CT scans, admission dispositions changed in 20.6 % of patients. Treatment changes occurred in 44.2 % of the missed injuries, though usually minimal. Broad elimination of early imaging studies in alert, blunt trauma patients cannot be advocated.
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Affiliation(s)
- Alan L Beal
- North Memorial Medical Center, 3300 Oakdale Ave N, Robbinsdale, MN 55431 USA
| | | | | | - John W Lyng
- North Memorial Medical Center, Minnesota, USA
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Gamanagatti S, Rangarajan K, Kumar A, Jineesh. Blunt abdominal trauma: imaging and intervention. Curr Probl Diagn Radiol 2015; 44:321-36. [PMID: 25801463 DOI: 10.1067/j.cpradiol.2015.02.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2014] [Revised: 02/07/2015] [Accepted: 02/07/2015] [Indexed: 02/06/2023]
Abstract
Interventional radiology, particularly percutaneous angioembolization, plays an important role in the management of blunt abdominal trauma involving solid organs and pelvic fractures. The traumatic injuries of the central nervous system, heart, and great vessels often lead to death at the site of trauma. Although patients with visceral organ injuries can also die at the site of trauma, these patients often reach the hospital thus giving us an opportunity to treat them with surgical or radiological intervention depending on the clinical condition of the patient. The management of these patients with trauma is now well codified-patients who remain unstable despite resuscitation should be shifted either to an operating room for laparotomy if the ultrasound (US) revealed hemoperitoneum or to a interventional room for angioembolization in cases of pelvic fractures. In all other cases, computed tomography is essential. Currently, multidetector computed tomography with contrast is the gold standard imaging modality for the diagnosis of traumatic abdominal injuries; it helps in assessing the extent of injuries, and further management can be planned.
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Affiliation(s)
- Shivanand Gamanagatti
- Department of Radiology, JPNA Trauma center, All India Institute of Medical Sciences, New Delhi, India.
| | - Krthika Rangarajan
- Department of Radiology, JPNA Trauma center, All India Institute of Medical Sciences, New Delhi, India
| | - Atin Kumar
- Department of Radiology, JPNA Trauma center, All India Institute of Medical Sciences, New Delhi, India
| | - Jineesh
- Department of Radiology, JPNA Trauma center, All India Institute of Medical Sciences, New Delhi, India
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Oktay C, Durmaz D, Karadeniz OO, Isik S. Pancreatic Injury Caused By A Fall From Height: Transection at the Tail. Turk J Emerg Med 2014; 14:93-5. [PMID: 27331178 PMCID: PMC4909880 DOI: 10.5505/1304.7361.2014.23230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2013] [Accepted: 07/24/2013] [Indexed: 11/12/2022] Open
Abstract
Isolated pancreatic injury due to blunt abdominal trauma is rare and may be clinically difficult to diagnose. Parenchymal injuries may not be recognized during initial evaluation. We report the case of a 30-year-old male presented to the Emergency Department (ED) with the complaint of persistent abdominal pain, nausea, and vomiting. His medical history revealed that he fell from a height of approximately 1.5 meters 1 day ago and hit an iron block. He was presented and discharged from another hospital ED. Contrast enhanced computerized tomography (CECT) of the abdomen was ordered during his second presentation and revealed pancreatic parenchymal contusion, laceration, and transection at the tail of pancreas. Our findings suggest that, when there is high index of suspicion for pancreatic injury, a CECT should always be ordered.
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Affiliation(s)
- Cem Oktay
- Department of Emergency Medicine, Akdeniz University Faculty of Medicine, Antalya
| | - Dilek Durmaz
- Department of Emergency Medicine, Sevket Yılmaz Training and Research Hospital, Bursa
| | | | - Soner Isik
- Department of Emergency, Antalya Life Hospital, Antalya
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Abstract
The morbidity, mortality, and economic costs resulting from trauma in general, and blunt abdominal trauma in particular, are substantial. The "panscan" (computed tomographic [CT] examination of the head, neck, chest, abdomen, and pelvis) has become an essential element in the early evaluation and decision-making algorithm for hemodynamically stable patients who sustained abdominal trauma. CT has virtually replaced diagnostic peritoneal lavage for the detection of important injuries. Over the past decade, substantial hardware and software developments in CT technology, especially the introduction and refinement of multidetector scanners, have expanded the versatility of CT for examination of the polytrauma patient in multiple facets: higher spatial resolution, faster image acquisition and reconstruction, and improved patient safety (optimization of radiation delivery methods). In this article, the authors review the elements of multidetector CT technique that are currently relevant for evaluating blunt abdominal trauma and describe the most important CT signs of trauma in the various organs. Because conservative nonsurgical therapy is preferred for all but the most severe injuries affecting the solid viscera, the authors emphasize the CT findings that are indications for direct therapeutic intervention.
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Affiliation(s)
- Jorge A Soto
- Department of Radiology, Boston University Medical Center, FGH Building, 3rd Floor, 820 Harrison Ave, Boston, MA 02118, USA.
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von Herrmann PF, Nickels DJ, Singh A. Imaging of Blunt and Penetrating Abdominal Trauma. Emerg Radiol 2013. [DOI: 10.1007/978-1-4419-9592-6_9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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12
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Murken DR, Weis JJ, Hill GC, Alarcon LH, Rosengart MR, Forsythe RM, Marshall GT, Billiar TR, Peitzman AB, Sperry JL. Radiographic assessment of splenic injury without contrast: is contrast truly needed? Surgery 2012; 152:676-82; discussion 682-4. [PMID: 22939750 DOI: 10.1016/j.surg.2012.07.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2012] [Accepted: 07/10/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Computed tomography (CT) has become an essential tool in the assessment of the stable trauma patient. Intravenous (i.v.) contrast is commonly relied upon to provide superior image quality, particularly for solid-organ injury. However, a substantial proportion of injured patients have contraindications to i.v. contrast. Little information exists concerning the repercussions of CT imaging without i.v. contrast, specifically for splenic injury. METHODS We performed a retrospective analysis using data from our trauma registry and chart review as part of a quality improvement project at our institution. All patients with splenic injury, during a 3-year period (2008-2010), where a CT of the abdomen without i.v. contrast (DRY) early during their admission were selected. All splenic injuries had to have been verified with abdominal CT imaging with i.v. contrast (CONTRAST) or via intraoperative findings. DRY images were independently read by a single, blinded, radiologist and assessed for parenchymal injury or "suspicious" splenic injury findings and compared with CONTRAST imaging results or intraoperative findings. RESULTS During the time period of the study, 319 patients had documented splenic injury with 44 (14%) patients undergoing DRY imaging, which was also verified by CONTRAST imaging or operative findings. Splenic parenchymal injury was only visualized in 38% of patients DRY patients. "Suspicious" splenic injury radiographic findings were common. When these less-specific findings for splenic injury were incorporated in the radiographic assessment, DRY imaging had more than 93% sensitivity for detecting splenic injury. CONCLUSION DRY imaging is increasingly being performed after injury and has a low sensitivity in detecting splenic parenchymal injury. However, less-specific radiographic findings suspicious for splenic injury in combination provide high sensitivity for the detection of splenic injury. These results suggest CONTRAST imaging is preferred to detect splenic injury; however, in those patients who have contraindications to i.v. contrast, DRY imagining may be able to select those who require close monitoring or intervention.
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Affiliation(s)
- Douglas R Murken
- Division of General Surgery and Trauma, Department of Surgery, Presbyterian Hospital, University of Pittsburgh Medical Center, Pittsburgh, PA 15213, USA
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Merchant N, Scalea T, Stein D. Can CT Angiography Replace Conventional Bi-Planar Angiography in the Management of Severe Scapulothoracic Dissociation Injuries? Am Surg 2012. [DOI: 10.1177/000313481207800823] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Severe scapulothoracic dissociation (SSTD) (Type III or IV; Zelle classification) is often life-threatening and is commonly associated with other devastating injuries. Rapid evaluation, including of the vascular system, is critical to limit the time to definitive therapy. CT angiography (CTA) has evolved as a diagnostic tool, replacing angiography (angio) as it can simultaneously evaluate bony, soft tissue, and vascular injuries. We hypothesized that CTA would be useful in evaluating patients with SSTD. We retrospectively reviewed the trauma registry between June 2002 and June 2010 to identify patients over 18 years of age who sustained SSTD. Patients that were transferred or died before diagnostic imaging were excluded. Comparisons were made between the group that underwent angio before surgery compared with CTA with regards to outcome and length of hospital and intensive care unit stay. Fourteen patients were identified with Type III or IV SSTD over the study period. In the CTA group, mean Injury Severity Score was higher, but time to definitive operative intervention was significantly shorter. There was no difference in amputation rates or mortality. Replacing arteriography with CTA in the preoperative workup of patients with SSTD reduces time to surgery. Despite a greater injury severity in the group in which CTA was used as the primary imaging modality, length of stay, amputation rates, and mortality were no different. CTA can be safely used to evaluate patients with suspected SSTD.
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Affiliation(s)
| | - Thomas Scalea
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
| | - Deborah Stein
- R. Adams Cowley Shock Trauma Center, University of Maryland, Baltimore, Maryland
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Abstract
BACKGROUND Delayed splenic rupture (DSR) is a rare manifestation of blunt splenic trauma, and splenectomy remains the primary treatment for patients with DSR. The purpose of this study was to review our experience with nonsurgical management of DSR with the use of splenic artery embolization (SAE) as an adjunct treatment. METHODS This retrospective study included patients with DSR treated at our institution from January 2001 to December 2008. Management included initial resuscitation and close observation in the intensive care unit. Further interventions were based on the patient's hemodynamic status and followed a treatment protocol. These interventions included SAE or surgery. RESULTS There were 15 patients included in the analysis. Three patients underwent emergent surgery, and 12 patients received nonsurgical management initially. Of these 12 patients, five underwent SAE. One of these five patients subsequently underwent splenectomy because of recurrent bleeding. Of the remaining seven patients who received nonoperative management, one required a splenectomy because of recurrent hemorrhage and hypotension. There were no mortalities; however, two surgery-associated complications occurred. The success rate of nonsurgical therapy was 83%. SAE was used for splenic salvage with a success rate of 80% (4 of 5). The overall failure rate of DSR was 33% (5 of 15). CONCLUSIONS Nonsurgical management can safely be used in selected patients with DSR, especially for those with a good response to resuscitation. SAE is as effective for DSR as it is for acute splenic injury. Physicians should consider SAE as an option for the treatment of DSR.
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Zaman SR. Previous iodinated contrast anaphylaxis in blunt abdominal trauma: management options. BMJ Case Rep 2012; 2012:bcr.02.2012.5919. [PMID: 22669926 DOI: 10.1136/bcr.02.2012.5919] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
A 34-year-old man presented with significant intra-abdominal and orthopaedic injuries following a high-speed motorbike crash. The man had a history of an anaphylactic reaction to iodine. As a result, the gold standard CT of the abdomen with contrast was unable to be performed to ascertain the exact nature of the intra-abdominal injuries. After stabilisation, an MRI of the abdomen was performed which localised the injuries. The previous contrast anaphylaxis delayed full assessment of the patient and subsequent management. This case discusses the current literature and the management guidelines in a patient with previous anaphylaxis to contrast.
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