Admission or observation is not necessary after a negative abdominal computed tomographic scan in patients with suspected blunt abdominal trauma: results of a prospective, multi-institutional trial

Predictive parameters for early detection of clinically relevant abdominal trauma in multiple-injury or polytraumatised patients: a retrospective analysis

Diagnosis of relevant organ injury after blunt abdominal injury (AI) in multiple-injury/polytraumatised patients is challenging. AI can be distinguished between injuries of parenchymatous organs (POI) of the upper abdomen (liver, spleen) and bowel and mesenteric injuries (BMI). Still, such injuries may be associated with delays in diagnosis and treatment. The present study aimed to verify laboratory parameters, imaging diagnostics, physical examination and related injuries to predict intraabdominal injuries. This retrospective, single-centre study includes data from multiple-injury/polytraumatised patients between 2005 and 2017. Two main groups were defined with relevant abdominal injury (AI+) and without abdominal injury (AI-). The AI+ group was divided into three subgroups: BMI+, BMI+/POI+, and POI+. Groups were compared in a univariate analysis for significant differences. Logistic regression analysis was used to determine predictors for AI+, BMI+ and POI+. 26.3% (271 of 1032) of the included patients had an abdominal injury. Subgroups were composed of 4.7% (49 of 1032) BMI+, 4.7% (48 of 1032) BMI+/POI+ and 16.8% (174 of 1032) POI+. Pathological abdominal signs had a sensitivity of 48.7% and a specificity of 92.4% for AI+. Transaminases were significantly higher in cases of AI+. Pathological computed tomography (CT) (free fluid, parenchymal damage, Bowel Injury Prediction Score (BIPS), CT Grade > 4) was summarised and had a sensitivity of 94.8%, a specificity of 98%, positive predictive value (PPV) of 94.5% and, negative predictive value (NPV) of 98.2% for AI+. The detected predictors for AI+ were pathological abdominal findings (odds ratio (OR) 3.93), pathological multi-slice computed tomography (MSCT) (OR 668.9), alanine (ALAT) ≥ 1.23 µmol/ls (OR 2.35) and associated long bone fractures (OR 3.82). Pathological abdominal signs, pathological MSCT and lactate (LAC) levels ≥ 1.94 mmol/l could be calculated as significant risk factors for BMI+. For POI+ pathological abdominal MSCT, ASAT ≥ 1.73 µmol/ls and concomitant thoracic injuries had significant relevance. The study presents reliable risk factors for abdominal injury and its sub-entities. The predictors can be explained by the anatomy of the trunk and existing studies. Elevated transaminases predicted abdominal injury (AI+) and, specifically, the POI+. The pathological MSCT was the most reliable predictive parameter. However, it was essential to include further relevant parameters.

Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department

OBJECTIVES

Blunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period.

METHODS

We performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death.

RESULTS

We included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01-1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported.

CONCLUSION

The incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.

Performance of three predictive scores to avoid delayed diagnosis of significant blunt bowel and mesenteric injury: A 12-year retrospective cohort study

BACKGROUND

Avoiding missed diagnosis and therapeutic delay for significant blunt bowel and mesenteric injuries (sBBMIs) after trauma is still challenging despite the widespread use of computed tomography (CT). Several scoring tools aiming at reducing this risk have been published. The purpose of the present work was to assess the incidence of delayed (>24 hours) diagnosis for sBBMI patients and to compare the predictive performance of three previously published scores using clinical, radiological, and laboratory findings: the Bowel Injury Prediction Score (BIPS) and the scores developed by Raharimanantsoa Score (RS) and by Faget Score (FS).

METHODS

A population-based retrospective observational cohort study was conducted; it included adult trauma patients after road traffic crashes admitted to Lausanne University Hospital, Switzerland, between 2008 and 2019 (n = 1,258) with reliable information about sBBMI status (n = 1,164) and for whom all items for score calculation were available (n = 917). The three scores were retrospectively applied on all patients to assess their predictive performance.

RESULTS

The incidence of sBBMI after road traffic crash was 3.3% (38 of 1,164), and in 18% (7 of 38), there was a diagnostic and treatment delay of more than 24 hours. The diagnostic performances of the FS, the RS, and the BIPS to predict sBBMI, expressed as the area under the receiver operating characteristic curve, were 95.3% (95% confidence interval [CI], 92.7-97.9%), 89.2% (95% CI, 83.2-95.3%), and 87.6% (95% CI, 81.8-93.3%) respectively.

CONCLUSION

The present study confirms that diagnostic delays for sBBMI still occur despite the widespread use of abdominal CT. When CT findings during the initial assessment are negative or equivocal for sBBMI, using a score may be helpful to select patients for early diagnostic laparoscopy. The FS had the best individual diagnostic performance. However, the BIPS or the RS, relying on clinical and laboratory variables, may be helpful to select patients for early diagnostic laparoscopy when there are unspecific CT signs of bowel or mesenteric injury.

LEVEL OF EVIDENCE

Prognostic and Epidemiological; Level III.

Development and Validation of a Novel Hollow Viscus Injury Prediction Score for Abdominal Seatbelt Sign: A Pacific Coast Surgical Association Multicenter Study

BACKGROUND

High-quality CT can exclude hollow viscus injury (HVI) in patients with abdominal seatbelt sign (SBS) but performs poorly at identifying HVI. Delay in diagnosis of HVI has significant consequences necessitating timely identification.

STUDY DESIGN

This multicenter, prospective observational study conducted at 9 trauma centers between August 2020 and October 2021 included adult trauma patients with abdominal SBS who underwent abdominal CT before surgery. HVI was determined intraoperatively and physiologic, examination, laboratory, and imaging findings were collected. Least absolute shrinkage and selection operator- and probit regression-selected predictor variables and coefficients were used to assign integer points for the HVI score. Validation was performed by comparing the area under receiver operating curves (AUROC).

RESULTS

Analysis included 473 in the development set and 203 in the validation set. The HVI score includes initial systolic blood pressure <110 mmHg, abdominal tenderness, guarding, and select abdominal CT findings. The derivation set has an AUROC of 0.96, and the validation set has an AUROC of 0.91. The HVI score ranges from 0 to 17 with score 0 to 5 having an HVI risk of 0.03% to 5.36%, 6 to 9 having a risk of 10.65% to 44.1%, and 10 to 17 having a risk of 58.59% to 99.72%.

CONCLUSIONS

This multicenter study developed and validated a novel HVI score incorporating readily available physiologic, examination, and CT findings to risk stratify patients with an abdominal SBS. The HVI score can be used to guide decisions regarding management of a patient with an abdominal SBS and suspected HVI.

Contribution by Dr Timothy C Fabian: liver trauma

The liver is the most commonly injured organ within the abdomen. Dr Fabian and his associates have made remarkable contributions to our understanding and management of these injuries. The current review summarizes the contributions.

Acute kidney injury development in polytrauma and the safety of early repeated contrast studies: A retrospective cohort study

BACKGROUND

The role of repeat intravenous contrast doses beyond initial contrast imaging in the development of acute kidney injury (AKI) for multiple injury patients admitted to the intensive care unit (ICU) is not fully understood. We hypothesized that additional contrast doses are potentially modifiable risk factors for worse outcomes.

METHODS

An 8-year retrospective study of our institutional prospective postinjury multiple organ failure database was performed. Adult ICU admissions that survived >72 hours with Injury Severity Score (ISS) of >15 were included. Patients were grouped based on number of repeat contrast studies received after initial imaging. Initial vital signs, resuscitation data, and laboratory parameters were collected. Primary outcome was AKI (Kidney Disease: Improving Global Outcomes criteria), and secondary outcomes included contrast-induced acute kidney injury (CI-AKI; >25% or >44 μmol/L increase in creatinine within 72 hours of contrast administration), multiple organ failure, length of stay, and mortality.

RESULTS

Six-hundred sixty-three multiple injury patients (age, 45.3 years [SD, 9.1 years]; males, 75%; ISS, 25 (interquartile range, 20-34); mortality, 5.4%) met the inclusion criteria. The incidence of AKI was 13.4%, and CI-AKI was 14.5%. Multivariate analysis revealed that receiving additional contrast doses within the first 72 hours was not associated with AKI (odds ratio, 1.33; confidence interval, 0.80-2.21; p = 0.273). Risk factors for AKI included higher ISS ( p < 0.0007), older age ( p = 0.0109), higher heart rate ( p = 0.0327), lower systolic blood pressure ( p = 0.0007), and deranged baseline blood results including base deficit ( p = 0.0042), creatinine ( p < 0.0001), lactate ( p < 0.0001), and hemoglobin ( p = 0.0085). Acute kidney injury was associated with worse outcomes (ICU length of stay: 8 vs. 3 days, p < 0.0001; mortality: 16% vs. 3.8%, p < 0.0001; MOF: 42% vs. 6.6%, p < 0.0001).

CONCLUSION

There is a limited role of repeat contrast administration in AKI development in ICU-admitted multiple injury patients. The clinical significance of CI-AKI is likely overestimated, and it should not compromise essential secondary imaging from the ICU. Further prospective studies are needed to verify our results.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

Excluding Hollow Viscus Injury for Abdominal Seat Belt Sign Using Computed Tomography

Importance

Abdominal seat belt sign (SBS) has historically entailed admission and observation because of the diagnostic limitations of computed tomography (CT) imaging and high rates of hollow viscus injury (HVI). Recent single-institution, observational studies have questioned the utility of this practice.

Objective

To evaluate whether a negative CT scan can safely predict the absence of HVI in the setting of an abdominal SBS.

Design, Setting, and Participants

This prospective, observational cohort study was conducted in 9 level I trauma centers between August 2020 and October 2021 and included adult trauma patients with abdominal SBS.

Exposures

Inclusion in the study required abdominal CT as part of the initial trauma evaluation and before any surgical intervention, if performed. Results of CT scans were considered positive if they revealed any of the following: abdominal wall soft tissue contusion, free fluid, bowel wall thickening, mesenteric stranding, mesenteric hematoma, bowel dilation, pneumatosis, or pneumoperitoneum.

Main Outcomes and Measures

Presence of HVI diagnosed at the time of operative intervention.

Results

A total of 754 patients with abdominal SBS had an HVI prevalence of 9.2% (n = 69), with only 1 patient with HVI (0.1%) having a negative CT (ie, none of the 8 a priori CT findings). On bivariate analysis comparing patients with and without HVI, there were significant associations between each of the individual CT scan findings and the presence of HVI. The strongest association was found with the presence of free fluid, with a more than 40-fold increase in the likelihood of HVI (odds ratio [OR], 42.68; 95% CI, 20.48-88.94; P < .001). The presence of free fluid also served as the most effective binary classifier for presence of HVI (area under the receiver operator characteristic curve [AUC], 0.87; 95% CI, 0.83-0.91). There was also an association between a negative CT scan and the absence of HVI (OR, 41.09; 95% CI, 9.01-727.69; P < .001; AUC, 0.68; 95% CI, 0.66-0.70).

Conclusions and Relevance

The prevalence of HVI among patients with an abdominal SBS and negative findings on CT is extremely low, if not zero. The practice of admitting and observing all patients with abdominal SBS should be reconsidered when a high-quality CT scan is negative, which may lead to significant resource and cost savings.

Multi-center validation of the Bowel Injury Predictive Score (BIPS) for the early identification of need to operate in blunt bowel and mesenteric injuries

INTRODUCTION

The Bowel Injury Prediction Score (BIPS) is a tool for identifying patients at risk for blunt bowel and mesenteric injury (BBMI) requiring surgery. BIPS is calculated by assigning one point for each of the following: (1) WBC ≥ 17,000, (2) abdominal tenderness, and (3) injury grade ≥ 4 (mesenteric contusion or hematoma with bowel wall thickening or adjacent interloop fluid collection) on CT scan. A total score ≥ 2 is associated with BBMI requiring surgery. We aimed to validate the BIPS as a predictor for patients with BBMIs requiring operative intervention in a multi-center prospective study.

MATERIALS AND METHODS

Patients were prospectively enrolled at 15 U.S. trauma centers following blunt trauma with suspicion of BBMI on CT scan between July 1, 2018 and July 31, 2019. The BIPS was calculated for each patient enrolled in the study.

RESULTS

Of 313 patients, 38% had BBMI requiring operative intervention. Patients were significantly more likely to require surgery in the presence of abdominal tenderness (OR, 3.6; 95% CI, 1.6-8.0) and CT grade ≥ 4 (OR, 11.7; 95% CI, 5.7-23.7). Patients with a BIPS ≥ 2 were more than ten times more likely to require laparotomy than those with a BIPS < 2 (OR, 10.1; 95% CI, 5.0-20.4). The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of a BIPS ≥ 2 for BBMI requiring surgery was 72% (CI 0.6-0.8), 78% (CI 0.7-0.8), 67% (CI 0.6-0.8), and 82% (CI 0.8-0.9), respectively. The AUROC curve for BIPS ≥ 2 was 0.75. The sensitivity, specificity, PPV, and NPV of a BIPS ≥ 2 for BBMI requiring surgery in patients with severe alteration in mental status (GCS 3-8) was 70% (CI 0.5-0.9), 92% (CI 0.8-1.0), 82% (CI 0.6-1.0), and 86% (CI 0.7-1.0), respectively.

CONCLUSION

This prospective multi-center trial validates BIPS as a predictor of BBMI requiring surgery. Calculation of BIPS during the initial evaluation of trauma patients is a useful adjunct to help general surgeons taking trauma call determine operative versus non-operative management of patients with BBMI including those with severe alteration in mental status.

Occult Abdominal Trauma

Occult abdominal injuries are common and can be associated with increased risk of morbidity and mortality. Patients with a delayed presentation to care or who are multiply injured are at increased risk of this type of injury, and a high index of suspicion must be maintained. A careful combination of history, physical examination, laboratory, and imaging can be quite helpful in mitigating the risk of a missed occult abdominal injury.

Trends in utilization of whole-body computed tomography in blunt trauma after MVC: Analysis of the Trauma Quality Improvement Program database

BACKGROUND

The use of whole-body computed tomography (WBCT) in awake, clinically stable injured patients is controversial. It is associated with unnecessary radiation exposure and increased cost. We evaluate use of computed tomography (CT) imaging during the initial evaluation of injured patients at American College of Surgeons Levels I and II trauma centers (TCs) after blunt trauma.

METHODS

We identified adult blunt trauma patients after motor vehicle crash (MVC) from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2007 and 2016 at Level I or II TCs. We defined awake clinically stable patients as those with systolic blood pressure of 100 mm Hg or higher with a Glasgow Coma Scale score of 15. Computed tomography imaging had to have been performed within 2 hours of arrival. Whole-body computed tomography was defined as simultaneous CT of the head, chest and abdomen, and selective CT if only one to two aforementioned regions were imaged. Patients were stratified by Injury Severity Score (ISS).

RESULTS

There were 217,870 records for analysis; 131,434 (60.3%) had selective CT, and 86,436 (39.7%) had WBCT. Overall, there was an increasing trend in WBCT utilization over the study period (p < 0.001). In patients with ISS less than 10, WBCT was utilized more commonly at Level II versus Level I TCs in patients discharged from the emergency department (26.9% vs. 18.3%, p < 0.001), which had no surgical procedure(s) (81.4% vs. 80.3%, p < 0.001) and no injury of the head (53.7% vs. 52.4%, p = 0.008) or abdomen (83.8% vs. 82.1%, p = 0.001). The risk-adjusted odds of WBCT was two times higher at Level II TC vs. Level I (odds ratio, 1.88; 95% confidence interval 1.82-1.94; p < 0.001).

CONCLUSION

Whole-body computed tomography utilization is increasing relative to selective CT. This increasing utilization is highest at Level II TCs in patients with low ISSs, and in patients without associated head or abdominal injury. The findings have implications for quality improvement and cost reduction.

LEVEL OF EVIDENCE

Care management, Level IV.

Evidence of Prolonged Monitoring of Trauma Patients Admitted via Trauma Resuscitation Unit without Primary Proof of Severe Injuries

Introductio: Although management of severely injured patients in the Trauma Resuscitation Unit (TRU) follows evidence-based guidelines, algorithms for treatment of the slightly injured are limited. Methods: All trauma patients in a period of eight months in a Level I trauma center were followed. Retrospective analysis was performed only in patients ≥18 years with primary TRU admission, Abbreviated Injury Scale (AIS) ≤ 1, Maximum Abbreviated Injury Scale (MAIS) ≤ 1 and Injury Severity Score (ISS) ≤3 after treatment completion and ≥24 h monitoring in the units. Cochran’s Q-test was used for the statistical evaluation of AIS and ISS changes in units. Results: One hundred and twelve patients were enrolled in the study. Twenty-one patients (18.75%) reported new complaints after treatment completion in the TRU. AIS rose from the Intermediate Care Unit (IMC) to Normal Care Unit (NCU) 6.2% and ISS 6.9%. MAIS did not increase >2, and no intervention was necessary for any patient. No correlation was found between computed tomography (CT) diagnostics in TRU and AIS change. Conclusions: The data suggest that AIS, MAIS and ISS did not increase significantly in patients without a severe injury during inpatient treatment, regardless of the type of CT diagnostics performed in the TRU, suggesting that monitoring of these patients may be unnecessary.

Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis

BACKGROUND

Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT.

METHODS

A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project.

RESULTS

In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model.

CONCLUSIONS

ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.

Predictive Model for Operative Intervention after Blunt Abdominal Trauma in Children with Equivocal CT Findings: A Pilot Study

BACKGROUND

To study the clinical and radiologic factors predicting the need for surgical intervention after blunt abdominal trauma (BAT) in children with equivocal computed tomography (CT) scan findings.

METHODS

We performed a retrospective review of the trauma database at our level I pediatric trauma center between 2011 and 2019. We selected patients with BAT and equivocal findings for surgical intervention on CT scan. We studied five factors: abdominal wall bruising (AWB), abdominal pain/tenderness (APT), thoracolumbar fracture, the presence of free fluid (FF), and the presence of solid organ injury, all previously reported in the literature to predict the need for operative intervention. We used t-test, the Kruskal-Wallis test and logistic regression to study the association of these factors with the need for operation in our pediatric cohort.

RESULTS

Of 3044 blunt trauma patients, 288 had abdominal CT scans with 61 patients demonstrating equivocal findings. Operation was performed for 12 patients (19.7%) confirming surgically correctable traumatic injuries. The need for surgical intervention was significantly associated with the age of the patients (P = 0.03), the presence of APT (P = 0.001), AWB (P = 0.01), and FF (P = 0.04). The presence of thoracolumbar fracture and solid organ injury were not significantly associated with the need for operation. For the subset of 37 patients who were injured in a motor vehicle crash, five (13.5%) required surgical intervention, which was significantly associated with the presence of AWB (P = 0.04), APT (P = 0.01), and FF (P = 0.03). A predictive model that used these factors produced a receiver operating characteristic curve of 0.86.

CONCLUSIONS

In cases of equivocal abdominal CT scan findings to evaluate BAT in children, the presence of abdominal wall tenderness, AWB, or FF may be significant factors predicting more accurately the need for operative intervention. A predictive model using the combination of clinical and image findings might determine with more certainty, the need for surgical intervention in children with BAT and equivocal CT findings. Validation on a larger multi-institutional data set should be done.

Traumatic spleen rupture diagnosed during postmortem dissection: A STROBE-compliant retrospective study

Spleen is typically injured in blunt abdominal trauma. Spleen injuries make 42% of all blunt abdominal injuries. The aim of this study was to perform a retrospective assessment of the cases of acute and subacute isolated traumatic spleen ruptures.A retrospective study performed on 50 patients, whose cause of death was isolated spleen rupture and bleeding into the abdominal cavity.An acute spleen rupture was diagnosed in 47 cases, whereas the rest 3 cases demonstrated a subacute rupture. In cases of acute spleen rupture, the mean weight of spleen was 309.6 g, whereas in 3 cases of subacute rupture the mean weight of the organ achieved 710 g. The mean weight of spleen in the control group with no spleen rupture was 144.7 g.Recording of the cases of isolated acute and subacute traumatic spleen ruptures and morphological assessment of them are important in forensic pathology science and in clinical practice as well.

The Prognosis of Blunt Bowel and Mesenteric Injury-the Pitfall in the Contemporary Image Survey

Delayed diagnosis and intervention of blunt bowel and mesenteric injury (BBMI) is a hazard because of poor prognosis. Computed tomography (CT) is the standard imaging tool to evaluate blunt abdominal trauma (BAT). However, a high missed diagnosis rate for BMMI was reported. In this study, we would like to evaluate the presentation of CT in BBMI. Moreover, we want to evaluate the impact of deferred surgical intervention of BBMI on final prognosis. We performed a retrospective study from 2013–2017, including patients with BAT and BBMI who underwent surgical intervention. We evaluated clinical characteristics, CT images, and surgical timing, as well as analyzed the prognosis of BBMI. There were 6164 BAT patients and 188 BMI patients included. The most common characteristics of CT were free fluid (71.3%), free air (43.6%), and mesenteric infiltration (23.4%). There were no single characteristics of a CT image that can predict BBMI significantly. However, under close monitoring, we find that deferred intervention did not prolong the hospital and intensive care unit stays and did not worsen the prognosis and mortality.

A negative computed tomography may be sufficient to safely discharge patients with abdominal seatbelt sign from the emergency department: A case series analysis

BACKGROUND

The presence of an abdominal seatbelt sign (ASBS) following a motor vehicle collision (MVC) is associated with a high risk for occult intra-abdominal injury, prompting imaging studies and a prolonged period of clinical observation. The aim of this study was to determine how a negative computed tomography (CT) of the abdomen/pelvis (A/P) can serve in the safe disposition of these patients. Our hypothesis was that in the setting of a negative CT, the presence of occult intra-abdominal injuries requiring a delayed intervention is extremely unlikely.

METHODS

The medical charts of patients admitted from January 2014 to December 2016 to a Level I trauma center following an MVC were reviewed for a documentation of an ASBS. Patients who did not have a CT A/P upon admission were excluded. The CT A/P of the remaining patients were then classified as negative if there were no findings of acute vascular, visceral or bony injury or positive if any of these findings was present. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of CT A/P for the presence of an intra-abdominal injury were calculated.

RESULTS

Over the 3-year study period, 1,108 patients were admitted after an MVC. Of those, 196 (17.7%) had an ASBS upon presentation and 183 (93.4%) of 196 underwent a CT A/P. A total of 114 (62.3%) of 183 had a negative CT A/P. These patients remained hospitalized for a median of 2 (1-35) days with none (0.0%) requiring a delayed laparotomy. The sensitivity of CT A/P in identifying patients requiring an exploratory laparotomy was 100.0%, specificity was 67.9%, NPV was 100.0%, and PPV was 21.7%. The negative likelihood ratio was 0.00.

CONCLUSION

For patients with an ASBS following an MVC, a negative CT A/P may be sufficient for safe discharge from the emergency department without any need for additional clinical observation.

LEVEL OF EVIDENCE

Therapuetic, level IV.

The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury

Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.

The Impact of Prior Laparotomy and Intra-abdominal Adhesions on Bowel and Mesenteric Injury Following Blunt Abdominal Trauma

BACKGROUND

Early recognition of bowel and mesenteric injury following blunt abdominal trauma remains difficult. We hypothesized that patients with intra-abdominal adhesions from prior laparotomy would be subjected to visceral sheering deceleration forces and increased risk for bowel and mesenteric injury following blunt abdominal trauma.

METHODS

We performed a multicenter retrospective cohort analysis of 267 consecutive adult trauma patients who underwent operative exploration following moderate-critical (abdominal injury score 2-5) blunt abdominal trauma, comparing patients with prior laparotomy (n = 31) to patients with no prior laparotomy (n = 236). Multivariable regression was performed to identify predictors of bowel or mesenteric injury.

RESULTS

There were no significant differences between groups for injury severity scores or findings on abdominal ultrasound, diagnostic peritoneal aspirate/lavage, pelvic radiography, or preoperative CT scan. The prior laparotomy cohort had greater incidence of full thickness bowel injury (26 vs. 9%, p = 0.010) and mesenteric injury (61 vs. 31%, p = 0.001). The proportion of bowel and mesenteric injuries occurring at the ligament of Treitz or ileocecal region was greater in the no prior laparotomy group (52 vs. 25%, p = 0.003). Prior laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI 1.6-16.8) along with prior abdominal inflammation and free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74-0.88).

CONCLUSIONS

Patients with a prior laparotomy are at increased risk for bowel and mesenteric injury following blunt abdominal trauma. The distribution of bowel and mesenteric injuries among patients with no prior laparotomy favors embryologic transition points tethering free intraperitoneal structures to the retroperitoneum.

Negative computed tomography can safely rule out clinically significant intra-abdominal injury in the asymptomatic patient after blunt trauma: Prospective evaluation of 1193 patients

BACKGROUND

Computed tomography of the abdomen and pelvis (CTAP) is highly specific for injury identification and commonly used in the evaluation of blunt trauma patients. Despite this, there is no consensus on the required clinical observation period after negative imaging, often impacting patient flow and hospital cost. The purpose of this study was to evaluate the use of CTAP after blunt trauma and the need for observation after negative imaging.

METHODS

A prospective analysis at a large Level I trauma center was conducted from November 2014 to May 2015. All blunt trauma patients, older than 14 years with CTAP on admission were included. Symptomatic patients were defined as having abdominal pain or external signs of trauma on admission. The main outcome was missed injury.

RESULTS

Over the study period, there were 1,468 blunt trauma admissions, of which 1,193 patients underwent CTAP. Eight hundred six (67.6%) patients were evaluable on admission (Glasgow Coma Scale score, 15), and of these, 327 (40.6%) were symptomatic, 479 (59.4%) asymptomatic. Among the evaluable asymptomatic patients, there were 65 (13.6%) positive computed tomography scans including 11 patients with grade III, IV, or V solid organ injury and three that required operation. In the 414 evaluable asymptomatic patients with negative imaging, median length of stay was 3 days, and there were zero missed injuries. All images were reviewed by an attending radiologist.

CONCLUSION

Abdominal imaging after trauma is justified in the appropriate clinical setting to evaluate for significant abdominal injury regardless of symptomatology. In asymptomatic, evaluable patients with a negative CTAP, clinically significant abdominal injury is unlikely, and these patients may be considered for early discharge or disposition to another treatment service.

LEVEL OF EVIDENCE

Diagnostic, level III; Therapy, level IV.

Identification of Hollow Viscus Injury with FAST Examination in Kurdistan, Iraq

Point-of-care ultrasound has become indispensable in the evaluation of trauma, particularly in low resource areas, where it may be the only rapidly available imaging modality. The FAST (Focused Assessment with Sonography in Trauma) in particular can be lifesaving, by rapidly detecting signs of intra-abdominal hemorrhage. However, the FAST is primarily designed to identify free fluid associated with solid organ injury and is thought to have less sensitivity and power in identifying evidence of hollow viscus injury. We present a case of an unidentified man that presented to a hospital in the Kurdistan region of northern Iraq, a region of low resources, surrounded by war. The FAST exam proved to be the key to identifying this patient's injuries.

Avoiding delayed diagnosis of significant blunt bowel and mesenteric injuries: Can a scoring tool make the difference? A 7-year retrospective cohort study

INTRODUCTION

Significant blunt bowel and mesenteric injuries (sBBMI) are frequently missed despite the widespread use of computed tomography (CT). Early treatment improves the outcome related to these injuries. The aim of this study was to assess the prevalence of sBBMI, the incidence of delayed diagnosis and to test the performance of the Bowel Injury Prediction Score (BIPS), determined by the white blood cell (WBC) count, presence or absence of abdominal tenderness and CT grade of mesenteric injury.

PATIENTS AND METHODS

Single-centre, registry-based retrospective cohort study, screening all consecutive trauma patients admitted to Lausanne University Hospital Trauma Centre from 2008 to 2015 after a road traffic accident. All patients with reliable information about the presence or absence of sBBMI who underwent abdominal CT and for whom calculation of the BIPS was possible were included for analysis. The incidence of delayed (>24h after admission) diagnosis in the patient group with sBBMI was determined and the diagnostic performance of the BIPS for sBBMI was assessed.

RESULTS

For analysis, 766 patients with reliable information about the presence or absence of sBBMI were included. The prevalence of sBBMI was 3.1% (24/766). In 24% (5/21) of stable trauma patients undergoing CT, a diagnostic delay of more than 24h occurred. Abdominal tenderness (p<0.0001) and CT grade ≥4 (p<0.0001) were associated with sBBMI, whereas CT grade 4 alone (p=0.93) and WBC count ≥17G/l (p=0.30) were not. A BIPS ≥2 had a sensitivity of 89% (95% CI, 67-99), specificity of 89% (95% CI, 86-91), positive likelihood ratio of 8 (95% CI, 6.1-10), negative likelihood ratio of 0.12 (95% CI, 0.03-0.44), positive predictive value (PPV) of 19% (95% CI, 15-24) and negative predictive value (NPV) of 99.7% (95% CI, 98.7-99.9). CT alone identified 79% (15/19) and the BIPS 89% (17/19) of patients with sBBMI (p=0.66).

CONCLUSIONS

Diagnostic delays in patients with sBBMI are common (24%), despite the routine use of abdominal CT. Application of the BIPS on the present cohort would have led to a high number of non-therapeutic abdominal explorations without identifying significantly more sBBMI early than CT alone.

Elevated Aminotransferases are Predictors of Hepatic Injury in Blunt Abdominal Trauma Patients

Objective

Computed tomography (CT) scan is currently the most commonly used tool for evaluating solid-organ injuries in trauma management. However, liberal use of CT scanning increases the risk of excess radiation exposure and toxicity from contrast material. Animal studies and clinical research on the paediatric population indicated that liver enzymes elevations were related to hepatic injury. The present study was undertaken to determine whether elevated liver enzymes were associated with the occurrence of hepatic injury in adult patients with blunt abdominal trauma.

Methods

This is a cross-sectional study from August 2003 to October 2006. All adult patients with blunt injury to abdomino-pelvic organs documented by CT or surgery who were admitted to Chi-Mei Medical Centre in the captioned period were included. The study population sorted to hepatic injury (HI) and no hepatic injury (NHI) groups according to the presence or absence of hepatic injury. Variables including liver enzymes were compared between the groups.

Results

Totally 419 patients were included, including 150 patients in the HI group and 269 patients in the NHI group. The HI group was younger and had a lower rate of laparotomy (36.3 years old vs 41.4 years old; 26% vs 42%, respectively). The mean levels of aspartate aminotransferase (AST) and alanine aminotransferase (ALT) in the HI group were significantly higher than levels in the NHI group (439.6 IU/L vs 104.7 IU/L; 353.5 IU/L vs 76.6 IU/L, p<0.01). We define AST >200 IU/L or ALT level >125 IU/L as abnormal according to previous studies. The diagnostic characteristics of hepatic injury were 87.3% sensitivity, 80.3% specificity, 71.2% positive predictive value, and 91.9% negative predictive value.

Conclusion

In adults who have experienced blunt abdominal trauma, AST >200 U/L or of ALT >125 U/L are practical predictors of hepatic injury. Screening serum aminotransferases will have a role in detecting occult hepatic injury and may reduce the hazards of excessive CT scanning. (Hong Kong j.emerg.med. 2013;20:337-342)

Duodenal Perforation following Blunt Abdominal Trauma Presenting as Normal in Abdominal Computed Tomography

Most emergency department (ED) physicians implement the Advanced Trauma Life Support (ATLS) approach, including primary and secondary survey, for the assessment of blunt abdominal trauma (BAT) patients. This report emphasizes the need for repeat Focused Assessment with Sonography for Trauma (FAST) and abdominal computed tomography (CT) if a BAT patient's condition persists or worsens. After initial negative FAST and abdominal CT findings, it is recommended that BAT patients with suspected intraabdominal injury should receive repeat examination in an optimal time. We report a patient who sustained duodenal perforation following BAT diagnosed by repeat ultrasound examination and abdominal CT scan. (Hong Kong j.emerg.med. 2014;21:396-399)

Focused Assessment with Sonography in Trauma (FAST): Experience of a Tertiary Hospital in Southeast Asia

Objective

This study compares the positive predictive value (PPV) and negative predictive value (NPV) of focused assessment with sonography in trauma (FAST) versus abdominal-pelvic computed tomography scans (CTAP) after blunt abdominal injury as well as the need for abdominal surgery. We also sought to determine if any false negative ultrasound studies were associated with significant morbidity. The results were compared with other studies.

Design

Retrospective cross-sectional study.

Setting

A tertiary hospital.

Methods

Cases were retrieved from the trauma registry and electronic medical records in a tertiary hospital in Singapore over a two year period from 1 January 2009 to 31 December 2010. Exclusion criteria included penetrating trauma and burns. The sonographic finding, computed tomography finding, and the outcome of the patients were retrieved. Diagnostic characteristics including predictive values were calculated.

Results

A total of 476 patients were enrolled. Four hundred fifty-nine patients had FAST performed with fifty (10.9%) being positive. Forty-nine patients (21.7%) out of 226 patients had CTAP which showed abnormalities and nineteen (4.0%) patients underwent surgery. Comparing FAST to detect abnormalities on CTAP, the PPV and NPV were 0.590 and 0.863 respectively. Comparing FAST with the need for surgery, the PPV and NPV were 0.280 and 0.990 respectively. Four patients (0.98%) had negative FAST but required surgery. There were no significant adverse outcomes or surgical intervention in patients with normal vital signs, normal initial physical examination and negative FAST findings but who did not have a CTAP.

Conclusions

In patients with an initial normal physical examination and negative FAST, emergent CTAP may be avoided. (Hong Kong j.emerg.med. 2014;21:230-236)

Isolated Traumatic Duodenal Rupture Due to Bicycle Handlebar Injury in an Adult Patient

Because of the well-developed abdominal musculature, the possibility of injury of the retroperitoneal organs such as the duodenum is not as high as that in children. Adult cases of isolated traumatic duodenal rupture caused by bicycle handlebar injury are extremely rare. We report a patient who experienced persistent abdominal pain after having a bicycle handlebar injury. Since the injury is hard to identify, abdominal computed tomography is performed to confirm the diagnosis. We also present a management flow chart to help physicians managing handlebar injuries in adults. (Hong Kong j.emerg.med. 2015;22:113-117)

Correlating abdominal pain and intra-abdominal injury in patients with blunt abdominal trauma

Background

A thorough history and physical examination in patients with blunt abdominal trauma (BAT) is important to safely exclude clinically significant intra-abdominal injury (IAI). We seek to evaluate a correlation between self-reported abdominal pain, abdominal tenderness on examination and IAI discovered on CT or during exploratory laparotomy.

Methods

This retrospective analysis assessed patients with BAT ≥13 years old who arrived to the emergency department following BAT during the 23-month study period. Upon arrival, the trauma team examined all patients. Only those who underwent an abdominal and pelvic CT scan were included. Patients were excluded if they were unable to communicate or lacked documentation, had obvious evidence of extra-abdominal distracting injuries, had a positive drug or alcohol screen, had a Glasgow Coma Scale ≤13, or had a positive pregnancy screening. The primary objective was to assess the agreement between self-reported abdominal pain and abdominal tenderness on examination and IAI noted on CT or during exploratory laparotomy.

Results

Among the 594 patients included in the final analysis, 73.1% (n=434) had no self-reported abdominal pain, 64.0% (n=384) had no abdominal tenderness on examination, and 22.2% (n=132) had positive CT findings suggestive of IAI. Among the 352 patients who had no self-reported abdominal pain and no abdominal tenderness on examination, a significant number of positive CT scan results (14%, n=50) were still recorded. Furthermore, a small but clinically significant portion of these 50 patients underwent exploratory laparotomy (1.1%, n=4). All four of these patients ultimately underwent a splenectomy and all were completed on hospital day one.

Conclusion

Lack of abdominal pain and tenderness in patients with BAT with non-distracting injuries was associated with a small portion of patients who underwent a splenectomy. Patients with BAT without abdominal pain or tenderness may need a period of observation or CT scan to rule out IAI prior to discharge home.

Level of evidence

Level III, therapeutic/care management.

Is it safe to discharge blunt abdominal trauma patients with normal initial findings?

BACKGROUND

Trauma is the leading health concern among young adults. Blunt abdominal trauma (BAT) is the most common type of blunt traumas. BAT patients may prove normal in the initial clinical assessments, but since the time required for an intra-abdominal injury to be clinically apparent is not predictable, deciding when to safely discharge these patients could be a dilemma. The purpose of this study is to determine whether follow-up of the early discharged or further diagnostic assessment of the later discharged BAT patients with normal initial findings reveals any abnormal findings.

METHODS

Totally, 389 hemodynamically-stable patients suspected of BAT who arrived at the emergency department (ED) of two university hospitals in Tehran from September 2013 to September 2014 were included in this study. Upon arrival at the ED, all subjects underwent abdominal examination and FAST, and were assessed for hematocrit and base deficit levels and presence of hematuria. These assessments were repeated in the patients who were discharged after 6 h, at 6 or 12 h post-arrival. All patients were followed-up after 24 h and one week by phone call.

RESULTS

Out of all study participants, 158 patients (40.6%) had normal findings in all initial assessments. These patients were discharged from the ED after a median of 5 h. After one week of follow-up, none of them had any symptom or complication, or had sought medical attention after being discharged from the study hospitals. Out of these patients, 78 patients (49.4%) were discharged after 6 hours by their physician's decision, and underwent the same diagnostic assessments for the second or third time. None of these assessments revealed any abnormal findings.

CONCLUSIONS

A combination of normal abdominal exam, normal FAST, normal hematocrit, normal base deficit, and absence of hematuria rules out intra-abdominal injury in BAT patients. It is safe to discharge patients after they prove normal for these assessments. Longer observation and repeated diagnostic assessment of these patients does not yield any new findings, and seems to be unnecessary.

Repeat computed tomography is highly sensitive in determining need for delayed exploration in blunt abdominal trauma

BACKGROUND

Computed tomography (CT) imaging has an established role in the initial evaluation of blunt abdominal trauma. What is less clear is the role of CT in guiding delayed exploration in patients initially managed nonoperatively after blunt trauma. We hypothesized that a repeat CT would accurately identify the need for an exploratory laparotomy in this patient population.

MATERIALS AND METHODS

From 2005 to 2014, we reviewed all blunt abdominal trauma patients at our institution who received an admission CT scan. We identified patients who underwent repeat CT of the abdomen within 72 h for the documented purpose of reevaluating potential intra-abdominal injuries. CT findings were categorized as either having a CT indication for exploration or not, allowing a sensitivity analysis.

RESULTS

Of the 50 patients who met our inclusion criteria, 9 underwent surgical exploration of the abdomen and 41 did not. Admission clinical indicators such as Glasgow Coma Scale, Injury Severity Score, and vitals were similar between the operative and nonoperative groups (P > 0.05). When compared with initial CT scan, repeat scan was found to increase the sensitivity from 67% to 100%, while also improving the specificity to 86%, positive predictive value to 50%, and negative predictive value to 100%.

CONCLUSIONS

Repeat CT scan of the abdomen may be useful in evaluating blunt trauma patients initially managed nonoperatively. The second CT scan increases the sensitivity of CT evaluation to 100% while also improving the specificity, positive predictive value, and negative predictive value.

The evolution of computed tomography from organ-selective to whole-body scanning in managing unconscious patients with multiple trauma: A retrospective cohort study

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.

Prediction of blunt traumatic injuries and hospital admission based on history and physical exam

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.

Can clinical prediction tools predict the need for computed tomography in blunt abdominal? A systematic review

INTRODUCTION

Blunt abdominal trauma is a common reason for admission to the Emergency Department. Early detection of injuries is an important goal but is often not straightforward as physical examination alone is not a good predictor of serious injury. Computed tomography (CT) has become the primary method for assessing the stable trauma patient. It has high sensitivity and specificity but there remains concern regarding the long term consequences of high doses of radiation. Therefore an accurate and reliable method of assessing which patients are at higher risk of injury and hence require a CT would be clinically useful. We perform a systematic review to investigate the use of clinical prediction tools (CPTs) for the identification of abdominal injuries in patients suffering blunt trauma.

MATERIALS AND METHODS

A literature search was performed using Medline, Embase, The Cochrane Library and NHS Evidence up to August 2014. English language, prospective and retrospective studies were included if they derived, validated or assessed a CPT, aimed at identifying intra-abdominal injuries or the need for intervention to treat an intra-abdominal after blunt trauma. Methodological quality was assessed using a 14 point scale. Performance was assessed predominantly by sensitivity.

RESULTS

Seven relevant studies were identified. All studies were derivative studies and no CPT was validated in a separate study. There were large differences in the study design, composition of the CPTs, the outcomes analysed and the methodological quality of the included studies. Sensitivities ranged from 86 to 100%. The highest performing CPT had a lower limit of the 95% CI of 95.8% and was of high methodological quality (11 of 14). Had this rule been applied to the population then 25.1% of patients would have avoided a CT scan.

CONCLUSIONS

Seven CPTs were identified of varying designs and methodological quality. All demonstrate relatively high sensitivity with some achieving very high sensitivity whilst still managing to reduce the number of CTs performed by a significant amount. Further studies are required to validate the results obtained by the highest performing CPTs before any firm recommendation can be used regarding their use in routine clinical practice.

Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma

BACKGROUND

Ultrasonography (performed by means of a four-quadrant, focused assessment of sonography for trauma (FAST)) is regarded as a key instrument for the initial assessment of patients with suspected blunt abdominal and thoraco-abdominal trauma in the emergency department setting. FAST has a high specificity but low sensitivity in detecting and excluding visceral injuries. Proponents of FAST argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of unnecessary multi-detector computed tomography (MDCT) scans, and enable quicker triage to surgical and non-surgical care. Given the proven accuracy, increasing availability of, and indication for, MDCT among patients with blunt abdominal and multiple injuries, we aimed to compile the best available evidence of the use of FAST-based assessment compared with other primary trauma assessment protocols.

OBJECTIVES

To assess the effects of diagnostic algorithms using ultrasonography including in FAST examinations in the emergency department in relation to the early, late, and overall mortality of patients with suspected blunt abdominal trauma.

SEARCH METHODS

The most recent search was run on 30th June 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), clinical trials registers, and screened reference lists. Trial authors were contacted for further information and individual patient data.

SELECTION CRITERIA

We included randomised controlled trials (RCTs). Participants were patients with blunt torso, abdominal, or multiple trauma undergoing diagnostic investigations for abdominal organ injury. The intervention was diagnostic algorithms comprising emergency ultrasonography (US). The control was diagnostic algorithms without US examinations (for example, primary computed tomography (CT) or diagnostic peritoneal lavage (DPL)). Outcomes were mortality, use of CT or invasive procedures (DPL, laparoscopy, laparotomy), and cost-effectiveness.

DATA COLLECTION AND ANALYSIS

Two authors (DS and CG) independently selected trials for inclusion, assessed methodological quality, and extracted data. Methodological quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible, data were pooled and relative risks (RRs), risk differences (RDs), and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed-effect or random-effects models as appropriate.

MAIN RESULTS

We identified four studies meeting our inclusion criteria. Overall, trials were of poor to moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. Strong heterogeneity amongst the trials prompted discussion between the review authors as to whether the data should or should not be pooled; we decided in favour of a quantitative synthesis to provide a rough impression about the effect sizes achievable with US-based triage algorithms. We pooled mortality data from three trials involving 1254 patients; the RR in favour of the FAST arm was 1.00 (95% CI 0.50 to 2.00). FAST-based pathways reduced the number of CT scans (random-effects model RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result was unclear.

AUTHORS' CONCLUSIONS

The experimental evidence justifying FAST-based clinical pathways in diagnosing patients with suspected abdominal or multiple blunt trauma remains poor. Because of strong heterogeneity between the trial results, the quantitative information provided by this review may only be used in an exploratory fashion. It is unlikely that FAST will ever be investigated by means of a confirmatory, large-scale RCT in the future. Thus, this Cochrane Review may be regarded as a review which provides the best available evidence for clinical practice guidelines and management recommendations. It can only be concluded from the few head-to-head studies that negative US scans are likely to reduce the incidence of MDCT scans which, given the low sensitivity of FAST (or reliability of negative results), may adversely affect the diagnostic yield of the trauma survey. At best, US has no negative impact on mortality or morbidity. Assuming that major blunt abdominal or multiple trauma is associated with 15% mortality and a CT-based diagnostic work-up is considered the current standard of care, 874, 3495, or 21,838 patients are needed per intervention group to demonstrate non-inferiority of FAST to CT-based algorithms with non-inferiority margins of 5%, 2.5%, and 1%, power of 90%, and a type-I error alpha of 5%.

How's the weather? Relationship between weather and trauma admissions at a Level I Trauma Center

BACKGROUND

It is believed commonly that the rate of trauma admissions is affected by weather, particularly temperature.

OBJECTIVE

We hypothesized that there are significant relationships between temperature and trauma admission rates.

MATERIALS AND METHODS

Trauma admission data (moderate-to-severe injuries as reported to the NY State Department of Health) from a Level I Trauma Center in Queens, NY were linked with archived hourly weather service data for John F. Kennedy International Airport (4.8 miles distant) from the National Oceanic and Atmospheric Administration for the period January 2000-December 2009. The incidence rate ratio (IRR) of trauma admissions was analyzed by Poisson regression as a function of temperature (per 10 °F as well as other weather parameters); night shift, day of week, and month were added to the model as control variables.

RESULTS

There were 9,490 reportable admissions over 87,144 h, (average 0.109 admissions/h). By mechanism, 7,157 (75.4%) were blunt and 1,967 (20.7%) were penetrating; the remainder were burns, ingestions, or unknown. By Poisson regression analysis, temperature was significantly associated with trauma admissions [IRR 1.19, 95% confidence interval (CI) 1.16-1.22], and had a stronger association with penetrating trauma (IRR 1.24, 95% CI 1.17-1.31). Precipitation, overcast sky, and snow depth were negatively associated with trauma admissions overall, but these did not reach significance for the penetrating subgroup.

CONCLUSIONS

Trauma admission rate is significantly associated with temperature. Taking weather forecasts into account may be important for planning of care provision, staffing, and resource allocation in trauma units and emergency departments.

An abdominal computed tomography may be safe in selected hypotensive trauma patients with positive Focused Assessment with Sonography in Trauma examination

BACKGROUND

Positive Focused Assessment with Sonography in Trauma examination and hypotension often indicate urgent surgery. An abdomen/pelvis computed tomography (apCT) may allow less invasive management but the delay may be associated with adverse outcomes.

METHODS

Patients in the Prospective Observational Multicenter Major Trauma Transfusion study with hypotension and a positive Focused Assessment with Sonography in Trauma (HF+) examination who underwent a CT (apCT+) were compared with those who did not.

RESULTS

Of the 92 HF+ identified, 32 (35%) underwent apCT during initial evaluation and apCT was associated with decreased odds of an emergency operation (odds ratio .11, 95% confidence interval .001 to .116) and increased odds of angiographic intervention (odds ratio 14.3, 95% confidence interval 1.5 to 135). There was no significant difference in 30-day mortality or need for dialysis.

CONCLUSIONS

An apCT in HF+ patients is associated with reduced odds of emergency surgery, but not mortality. Select HF+ patients can safely undergo apCT to obtain clinically useful information.

Trauma team

The introduction of trauma teams has improved patient outcome independently. The aim of establishing a trauma team is to ensure the early mobilization and involvement of more experienced medical staff and thereby to improve patient outcome. The team approach allows for distribution of the several tasks in assessment and resuscitation of the patient in a 'horizontal approach', which may lead to a reduction in time from injury to critical interventions and thus have a direct bearing on the patient's ultimate outcome. A trauma team leader or supervisor, who coordinates the resuscitation and ensures adherence to guidelines, should lead the trauma team. There is a major national and international variety in trauma team composition, however crucial are a surgeon, an Emergency Medicine physician or both and anaesthetist. Advanced Trauma Life Support training, simulation-based training, and video review have all improved patient outcome and trauma team performance. Developments in the radiology, such as the use of computed tomography scanning in the emergency room and the endovascular treatment of bleeding foci, have changed treatment algorithms in selected patients. These developments and new insights in shock management may have a future impact on patient management and trauma team composition.

Iterative reconstruction improves image quality and preserves diagnostic accuracy in the setting of blunt solid organ injuries

This study aims to investigate the effect of iterative reconstruction (IR) on MDCT image quality and radiologists' ability to diagnose and grade blunt solid organ injuries. One hundred (100) patients without and 52 patients with solid organ injuries were scanned on a 64-slice MDCT scanner using reference 300 mAs, 120 kVp, and fixed 75 s delay. Raw data was reconstructed using filtered back projection (FBP) and three levels of iterative reconstruction (Philips iDose levels 2, 4, and 6). Four emergency radiologists, blinded to the reconstruction parameters and original interpretation, independently reviewed each case, assessed image quality, and assigned injury grades. Each reader was then asked to determine if they thought that IR was used and, if so, what level. There was no significant difference in diagnostic accuracy between FBP and the various IR levels or effect on the detection and grading of solid organ injuries (p > 0.8). Images reconstructed using iDose level 2 were judged to have the best overall image quality (p < 0.01). The radiologists had high sensitivity in detecting if IR was used (80 %, 95 % CI 76-84 %). IR performed comparably to FBP with no effect on radiologist ability to accurately detect and grade blunt solid organ injuries.

New and old tools for abdominal imaging in critically ill patients

Diagnostic imaging technology has advanced considerably during the past two decades. Different imaging techniques have been proposed for abdominal imaging in critically ill patients like plain radiography, sonography, computed tomography (CT), magnetic resonance and positron emission tomography. Sonography has been proven to be effective to detect free intra-peritoneal fluid and it is considered one of the primary diagnostic modalities for abdominal evaluation for trauma assessment. In our opinion sonography should replace other invasive techniques to rapidly triage blunt trauma patients with unstable vital signs and examine the peritoneal cavity as a site of major haemorrhage to expedite exploratory laparotomy. On the other hand, CT has become the imaging modality of choice in hemodynamically stable patients with multisystem blunt and penetrating trauma. New developments in the quantitative analysis of the CT images will improve our knowledge of pathophysiology, diagnostic and therapeutic management of abdominal pathologies in critically ill patients.

A novel practical scoring for early diagnosis of traumatic bowel injury without obvious solid organ injury in hemodynamically stable patients

OBJECTIVES

To develop a scoring tool based on clinical and radiological findings for early diagnosis and intervention in hemodynamically stable patients with traumatic bowel and mesenteric injury (TBMI) without obvious solid organ injury (SOI).

METHODS

A retrospective analysis was conducted for all traumatic abdominal injury patients in Qatar from 2008 to 2011. Data included demographics and clinical, radiological and operative findings. Multivariate logistic regression was performed to analyze the predictors for the need of therapeutic laparotomy.

RESULTS

A total of 105 patients met the inclusion criteria with a mean age of 33 ± 15. Motor Vehicle Crashes (58%) and fall (21%) were the major MOI. Using Receiver operating characteristic curve, Z-score of >9 was the cutoff point (AUC = 0.98) for high probability of the presence of TBMI requiring surgical intervention. Z-Score >9 was found to have sensitivity (96.7%), specificity (97.4%), PPV (93.5%) and NPV (98.7%). Multivariate regression analysis found Z-score (>9) to be an independent predictor for the need of exploratory laparotomy (OR7.0; 95% CI: 2.46-19.78, p = 0.001).

CONCLUSION

This novel tool for early diagnosis of TBMI is found to be simple and helpful in selecting stable patients with free intra-abdominal fluid without SOI for exploratory Laparotomy. However, further prospective studies are warranted.