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Akkan S, Uyanik Ö, Ceyhan M, Karaarslan FN. Comparison of whole body computed tomography findings with physician predictions in high-energy blunt trauma patients: prospective observational study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02564-1. [PMID: 38886236 DOI: 10.1007/s00068-024-02564-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Accepted: 05/25/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The whole-body computed tomography (WBCT) procedure is increasingly common in evaluating patients presenting with high-energy trauma. However, it remains unclear in which population WBCT provides benefit and whether its routine application is truly beneficial. In this study, we aimed to compare physician predictions with WBCT findings in patients with high-energy blunt trauma. METHODS The study was conducted as a single-center prospective observational study at a tertiary center. Patients presenting with high-energy blunt trauma between 01.03.2021-01.03.2023 were included. Both physician predictions and WBCT findings were recorded and compared in three categories: "no pathology," "no life-threatening pathology," and "life-threatening pathology." The predictive values of physician predictions for each category were calculated. The characteristics of patients evaluated as less severe than predicted by clinicians were examined. RESULTS The study included a total of 92 patients. The median age was 27 years (IQR 25-75; 20-54). Among the patients, 27 (%) had life-threatening injuries according to CT findings in any region. A total of 34 (37%) patients were predicted by physicians to have "no pathology" in all three regions. Among these patients, none had life-threatening pathology in all three regions. There were 10 (10.9%) patients with CT findings more severe than physician predictions in at least one region. The sensitivity of physician predictions for life-threatening injury to the head/cervical region was 94.1% (95% CI: 71.3-99.9). For life-threatening injury to the chest, the sensitivity was 85.7% (95% CI: 42.1-99.6). For the presence of life-threatening abdominal pathology, the sensitivity was 100% (95% CI: 63.1-100). CONCLUSıON: It appears reasonable to utilize WBCT in patients where physicians expect life-threatening injury in any system. However, in cases where no pathology is expected in any system according to clinical prediction, we believe that performing WBCT solely based on trauma mechanism will not provide sufficient benefit.
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Affiliation(s)
- Sedat Akkan
- Emergency Medicine Department, Kahramanmaraş Elbistan State Hospital, Kahramanmaraş, Turkey
| | - Ömür Uyanik
- Emergency Medicine Department, Kahramanmaraş Elbistan State Hospital, Kahramanmaraş, Turkey
| | - Muhammet Ceyhan
- Emergency Medicine Department, Kahramanmaraş Elbistan State Hospital, Kahramanmaraş, Turkey
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Mansbridge N, Kallis G, He J, Pearce I, Fenner J. Physical examination and CT to assess thoracic injury in 137 cats presented to UK referral hospitals after trauma. J Feline Med Surg 2024; 26:1098612X241228050. [PMID: 38415622 PMCID: PMC10911304 DOI: 10.1177/1098612x241228050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
OBJECTIVES The aim of the study was to describe clinical examination and thoracic CT (TCT) findings in cats after trauma, and to identify physical examination findings associated with both abnormalities on TCT and the need for therapeutic interventions. METHODS A multicentre, retrospective, observational study was conducted. Cats admitted to the participating hospitals with a history of blunt trauma and that underwent TCT were eligible. Data were collected on signalment, history, physical examination, TCT findings and subsequent interventions. RESULTS In total, 137 cats were included. Road traffic accidents (RTAs) were the most frequently reported cause of trauma (69%). Tachypnoea (32%), pale mucous membranes (22%) and dyspnoea (20%) were the most common abnormal findings on thoracic examination. The most frequently identified thoracic pathologies on TCT were atelectasis (34%), pulmonary contusions (33%), pneumothorax (29%) and pleural effusion (20%). Thoracocentesis was the most commonly performed intervention (12%), followed by chest drain placement (7%). A total of 45 (33%) cats had no physical examination abnormalities but did have abnormalities detected on TCT; six of these cats required interventions. Increasing numbers of thoracic abnormalities on clinical examination were associated with increasing likelihood of having abnormal findings on TCT (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.21-3.44, P = 0.008) and of requiring an intervention (OR 1.82, 95% CI 1.32-2.51, P <0.001). CONCLUSIONS AND RELEVANCE RTAs were the most common reported cause of blunt trauma. Atelectasis, pulmonary contusions and pneumothorax were the most common abnormalities identified on TCT, and thoracic drainage was the most utilised intervention. TCT may be useful in identifying cats with normal thoracic physical examination findings that have significant thoracic pathology, and a high number of abnormal findings on thoracic examination should raise suspicion for both minor and major thoracic pathology. The results of this study can be used to assist in selecting appropriate cases for TCT after blunt trauma.
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Affiliation(s)
| | - Giorgio Kallis
- Davies Veterinary Specialists, Higham Gobion, Hitchin, UK
| | - Jinjing He
- Willows Veterinary Centre & Referral Service, Solihull, UK
| | | | - Joy Fenner
- Dick White Referrals, Station Farm, Six Mile Bottom, Cambridgeshire, UK
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Shapira N, Bharthulwar S, Noël PB. Convolutional Encoder-Decoder Networks for Volumetric Computed Tomography Surviews from Single- and Dual-View Topograms. RESEARCH SQUARE 2023:rs.3.rs-2449089. [PMID: 36711997 PMCID: PMC9882676 DOI: 10.21203/rs.3.rs-2449089/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Computed tomography (CT) is an extensively used imaging modality capable of generating detailed images of a patient's internal anatomy for diagnostic and interventional procedures. High-resolution volumes are created by measuring and combining information along many radiographic projection angles. In current medical practice, single and dual-view two-dimensional (2D) topograms are utilized for planning the proceeding diagnostic scans and for selecting favorable acquisition parameters, either manually or automatically, as well as for dose modulation calculations. In this study, we develop modified 2D to three-dimensional (3D) encoder-decoder neural network architectures to generate CT-like volumes from single and dual-view topograms. We validate the developed neural networks on synthesized topograms from publicly available thoracic CT datasets. Finally, we assess the viability of the proposed transformational encoder-decoder architecture on both common image similarity metrics and quantitative clinical use case metrics, a first for 2D-to-3D CT reconstruction research. According to our findings, both single-input and dual-input neural networks are able to provide accurate volumetric anatomical estimates. The proposed technology will allow for improved (i) planning of diagnostic CT acquisitions, (ii) input for various dose modulation techniques, and (iii) recommendations for acquisition parameters and/or automatic parameter selection. It may also provide for an accurate attenuation correction map for positron emission tomography (PET) with only a small fraction of the radiation dose utilized.
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Affiliation(s)
- Nadav Shapira
- Perelman School of Medicine of the University of Pennsylvania
| | | | - Peter B Noël
- Perelman School of Medicine of the University of Pennsylvania
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Rezazadeh A, Samady Khanghah A. Successful Treatment of GSW to the Intrapericardial Inferior Vena Cava wall: Case Report. Int J Surg Case Rep 2021; 82:105864. [PMID: 33866305 PMCID: PMC8060578 DOI: 10.1016/j.ijscr.2021.105864] [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: 02/21/2021] [Revised: 03/31/2021] [Accepted: 04/01/2021] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Penetrating traumas to the thorax could be potentially serious. Vena caval wounds are highly lethal, so that half of the patients die before reaching the hospital, and another 50% may die perioperatively. Although rare, most of them are the result of gunshot wounds. PRESENTATION OF CASE We report a 13-year-old boy shot by an air gun through his right hemithorax. During surgery, an air gun bullet appeared right within the wall of the intrapericardial inferior vena cava (IVC). DISCUSSION Traumas to the thoracic contents as vena cava are inevitable, presenting mostly with haemo or pneumothorax. If the victim reaches the operating room alive, the approach to his or her vena cava rupture remains a challenge in the hands of surgeons. In this case, the surgeon, following the bullet removal, repaired the penetration immediately by direct suturing because clamping the inferior vena for its thin wall can expand the rupture, also blocking systemic venous return. CONCLUSION The surgeon in a general trauma center that is almost lacking cardiopulmonary pump can repair the vital injuries to the IVC with the technique of direct suturing.
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Affiliation(s)
- Amin Rezazadeh
- Department of Surgery, Fatemi Hospital, Ardabil University of Medical Sciences, Ardabil, Iran.
| | - Ali Samady Khanghah
- Department of Surgery, Fatemi Hospital, Ardabil University of Medical Sciences, Ardabil, Iran.
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Perumal R, S DCR, P SS, Jayaramaraju D, Sen RK, Trikha V. Management of pelvic injuries in hemodynamically unstable polytrauma patients - Challenges and current updates. J Clin Orthop Trauma 2021; 12:101-112. [PMID: 33716435 PMCID: PMC7920327 DOI: 10.1016/j.jcot.2020.09.035] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/26/2020] [Accepted: 09/28/2020] [Indexed: 12/30/2022] Open
Abstract
Pelvic injuries are notorious for causing rapid exsanguination, and also due to concomitant injuries and complications, they have a relatively higher mortality rate. Management of pelvic fractures in hemodynamically unstable patients is a challenging task and has been variably approached. Over the years, various concepts have evolved, and different guidelines and protocols were established in regional trauma care centers based mainly on their previous experience, outcomes, and availability of resources. More recently, damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation are being employed in the management of these unstable injuries, without clear consensus or guidelines. In this background, we have performed a computerized search using the Cochrane Database of Systematic Reviews, Scopus, Embase, Web of Science, and PubMed databases on studies published over the past 30 years. This comprehensive review aims to consolidate available literature on the current epidemiology, diagnostics, resuscitation, and management options of pelvic fractures in polytraumatized patients with hemodynamic instability with particular focus on damage control resuscitation, pelvic angioembolization, and acute definitive internal fixation.
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Affiliation(s)
- Ramesh Perumal
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Sivakumar S. P
- Department of Orthopedics and Trauma, Ganga Hospital, Coimbatore, 641043, India
| | | | - Ramesh Kumar Sen
- Institute of Orthopedic Surgery, Max Super Specialty Hospital, Mohali, 160055, India
| | - Vivek Trikha
- Department of Orthopedics, All India Institute of Medical Science, New Delhi, 110029, India
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Thippeswamy PB, Rajasekaran RB. Imaging in polytrauma - Principles and current concepts. J Clin Orthop Trauma 2020; 16:106-113. [PMID: 33717944 PMCID: PMC7920130 DOI: 10.1016/j.jcot.2020.12.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/03/2020] [Accepted: 12/04/2020] [Indexed: 12/22/2022] Open
Abstract
Imaging forms a crucial component in reducing mortality of polytraumatized patients by aiding appropriate diagnosis and guiding the emergency and definitive treatment. With the exponential expansion in the radiological armamentarium and introduction of protocols like Extended focused assessment with sonography for trauma (EFAST) and Whole body Computed tomography (WBCT), the role of imaging has considerably increased. Emergency imaging protocols should be done for rapid diagnosis of life-threatening injuries allowing simultaneous evaluation and resuscitation. Subsequent comprehensive imaging is essential to diagnose the often clinically missed injuries to reduce the overall morbidity. Imaging protocols must adapt to the patient's clinical scenario, which can be dynamically changing. Each trauma team should devise clear guidelines, protocols, and algorithms suitable for their center depending on the local availability of types of equipment and expertise. Radiologists must efficiently communicate and adopt patient-centered approach to ensure early appropriate care to these severely injured patients. Future research should involve multicentre studies to formulate the most appropriate imaging protocol in polytrauma to increase diagnostic accuracy and thereby reduce patient mortality.
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Affiliation(s)
- Pushpa Bhari Thippeswamy
- Department of Radiology, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India,Corresponding author. Department of Radiology, Ganga Medical Centre & Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, 641043, India.
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Marro A, Chan V, Haas B, Ditkofsky N. Blunt chest trauma: classification and management. Emerg Radiol 2019; 26:557-566. [DOI: 10.1007/s10140-019-01705-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 07/02/2019] [Indexed: 12/23/2022]
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Vogl TJ, Eichler K, Marzi I, Wutzler S, Zacharowski K, Frellessen C. [Imaging techniques in modern trauma diagnostics]. Med Klin Intensivmed Notfmed 2019; 112:643-657. [PMID: 28936574 DOI: 10.1007/s00063-017-0359-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.
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Affiliation(s)
- T J Vogl
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland.
| | - K Eichler
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | - I Marzi
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - S Wutzler
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - K Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - C Frellessen
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
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9
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Awais M, Salam B, Nadeem N, Rehman A, Baloch NU. Diagnostic Accuracy of Computed Tomography Scout Film and Chest X-ray for Detection of Rib Fractures in Patients with Chest Trauma: A Cross-sectional Study. Cureus 2019; 11:e3875. [PMID: 30899626 PMCID: PMC6420333 DOI: 10.7759/cureus.3875] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Rib fractures are a major source of morbidity in patients with chest trauma. Computed tomography (CT) scout film is a low-dose image that is obtained prior to a complete chest CT study for all patients undergoing a CT scan. In this study, we evaluated the diagnostic performance of CT scout film vis-à-vis that of chest X-ray for detection of rib fractures using chest CT scan as the reference standard. METHODS A cross-sectional study was performed at the radiology department of Aga Khan University Hospital (Karachi, Pakistan) from October 1, 2013 to September 31, 2014. Patients who underwent CT chest for evaluation of thoracic trauma were included in the study. Sensitivity and specificity of chest X-ray and CT scout film were calculated. RESULTS A total of 207 patients were included in the study (193 were male). Penetrating and blunt thoracic injuries affected 104 (50.2%) and 103 (49.8%) patients respectively. On CT chest, 75 (36.2%) patients had evidence of rib fractures. Sensitivity and specificity of CT scout film for detection of rib fractures were 56% and 87.9%, while those of chest X-ray were 61.3% and 98.5% respectively. The overall accuracy of CT scout film and chest X-ray for detection of rib fractures were 76.3% and 85% respectively. CONCLUSION Diagnostic performance of CT scout film for detection of rib fractures was comparable to that of the plain chest radiograph. CT scout film does not provide any additional information or advantage over a plain chest radiograph. In patients with severe thoracic trauma, CT chest remains the modality of choice for accurate delineation of rib fractures and associated internal injuries.
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Affiliation(s)
| | - Basit Salam
- Radiology, The Aga Khan University, Karachi, PAK
| | - Naila Nadeem
- Radiology, The Aga Khan University, Karachi, PAK
| | - Abdul Rehman
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
| | - Noor U Baloch
- Internal Medicine, Rutgers New Jersey Medical School, Newark, USA
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Whole body computed tomography in multi trauma patients: Review of the current literature. Turk J Emerg Med 2018; 18:142-147. [PMID: 30533556 PMCID: PMC6261098 DOI: 10.1016/j.tjem.2018.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 01/29/2023] Open
Abstract
Many authors adopt the Selected Computed Tomography (SCT) approach of the Advanced Trauma Life Support (ATLS) for the management of multiple trauma patients. In the SCT approach, the initial physical examination is followed by conventional radiography (cervical X-ray, chest X-ray, pelvic X-ray and Focused Abdominal Sonography in Trauma (FAST)), and the computed tomography (CT) of the specific body regions if indicated. An alternative to this traditional approach is the Whole-body Computed Tomography (WBCT) protocol, which became widespread all over the world in the last two decades to minimize the rate of missed injuries and decrease the mortality rate. According to the literature, the WBCT approach is superior to the traditional SCT approach in the time of imaging, diagnostic accuracy, and mortality rates. Conversely, WBCT increases the cancer risk due to additional irradiation. Therefore, it is recommended that the WBCT protocol should be reserved for only severe multi-trauma patients. However, further studies to define severe patients, and clinical decision criteria for WBCT are needed.
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11
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Safari S, Radfar F, Baratloo A. Thoracic injury rule out criteria and NEXUS chest in predicting the risk of traumatic intra-thoracic injuries: A diagnostic accuracy study. Injury 2018; 49:959-962. [PMID: 29402426 DOI: 10.1016/j.injury.2018.01.031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2017] [Revised: 01/06/2018] [Accepted: 01/20/2018] [Indexed: 02/02/2023]
Abstract
INTRODUCTION This study aimed to compare the diagnostic accuracy of NEXUS chest and Thoracic Injury Rule out criteria (TIRC) models in predicting the risk of intra-thoracic injuries following blunt multiple trauma. METHODS In this diagnostic accuracy study, using the 2 mentioned models, blunt multiple trauma patients over the age of 15 years presenting to emergency department were screened regarding the presence of intra-thoracic injuries that are detectable via chest x-ray and screening performance characteristics of the models were compared. RESULTS In this study, 3118 patients with the mean (SD) age of 37.4 (16.9) years were studied (57.4% male). Based on TIRC and NEXUS chest, respectively, 1340 (43%) and 1417 (45.4%) patients were deemed in need of radiography performance. Sensitivity, specificity, and positive and negative predictive values of TIRC were 98.95%, 62.70%, 21.19% and 99.83%. These values were 98.61%, 59.94%, 19.97% and 99.76%, for NEXUS chest, respectively. Accuracy of TIRC and NEXUS chest models were 66.04 (95% CI: 64.34-67.70) and 63.50 (95% CI: 61.78-65.19), respectively. CONCLUSION TIRC and NEXUS chest models have proper and similar sensitivity in prediction of blunt traumatic intra-thoracic injuries that are detectable via chest x-ray. However, TIRC had a significantly higher specificity in this regard.
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Affiliation(s)
- Saeed Safari
- Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran.
| | - Fatemeh Radfar
- Emergency Department, Shohadaye Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Alireza Baratloo
- Emergency Department, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Vogl TJ, Eichler K, Marzi I, Wutzler S, Zacharowski K, Frellessen C. [Imaging techniques in modern trauma diagnostics]. Unfallchirurg 2018; 120:417-431. [PMID: 28455618 DOI: 10.1007/s00113-017-0352-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.
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Affiliation(s)
- T J Vogl
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland.
| | - K Eichler
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | - I Marzi
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - S Wutzler
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - K Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - C Frellessen
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
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Verma N, White CS, Mohammed TL. Blunt Cardiothoracic Trauma: Common Injuries and Diagnosis. Semin Roentgenol 2018; 53:171-177. [PMID: 29861008 DOI: 10.1053/j.ro.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Nupur Verma
- Department of Radiology, University of Florida, Gainesville, FL.
| | - Charles S White
- Department of Radiology, University of Maryland, Baltimore, MD
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Horst K, Andruszkow H, Weber CD, Pishnamaz M, Herren C, Zhi Q, Knobe M, Lefering R, Hildebrand F, Pape HC. Thoracic trauma now and then: A 10 year experience from 16,773 severely injured patients. PLoS One 2017; 12:e0186712. [PMID: 29049422 PMCID: PMC5648226 DOI: 10.1371/journal.pone.0186712] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Accepted: 10/09/2017] [Indexed: 01/11/2023] Open
Abstract
Background and purpose Thoracic trauma remains to be a relevant injury to the polytraumatised patient. However, literature regarding how far changes in clinical guidelines for pre- and in-hospital trauma management and diagnostic procedures affect the outcome of multiple injured patients with severe chest injury during a long-term observation period is sparse. Methods Multiple traumatised patients (age≥16y) documented in the TraumaRegister DGU® (TR-DGU) from January 1st 2005 to December 31st 2014 with severe chest trauma (AIS≥3) were included in this study. Demographic data, the pattern of injury, injury severity, radiographic emergency procedures, indication for intubation, duration of mechanical ventilation, emergency surgery, occurrence of complications and mortality were evaluated per year and over time. Results A total of 16,773 patients were analysed. The use of whole body computer tomography increased (p<0.001), while the incidence of plain x-rays decreased (p<0.001). Furthermore, incidence of AISThorax = 3 graded injuries increased (p<0.001) while AISThorax = 4 decreased (p<0.001). Both, rate of patients being intubated at the time of ICU admission decreased (p<0.001) and the time of mechanical ventilation decreased (p<0.001). Additionally, need for emergency surgery, lung failure, sepsis, and multi organ failure all decreased (p<0.001). However, mortality remained unchanged. Interpretation Severity of severe chest trauma and associated complications decreased while diagnostics and treatment improved over time. However, mortality remained unchanged. Our results are in line with those expected in the context of the incidence of CT diagnostics, which has increased parallel to the clinical outcome Thus, our data demonstrate a positive trend in the treatment of patients with severe chest trauma.
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Affiliation(s)
- Klemens Horst
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
- Harald Tscherne Research Laboratory, RWTH Aachen University, Aachen, Germany
- * E-mail:
| | - Hagen Andruszkow
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Christian D. Weber
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Miguel Pishnamaz
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Christian Herren
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Qiao Zhi
- Harald Tscherne Research Laboratory, RWTH Aachen University, Aachen, Germany
| | - Matthias Knobe
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Rolf Lefering
- IFOM - Institute for Research in Operative Medicine, Faculty of Health, Department of Medicine, Witten / Herdecke University, Cologne, Germany
| | - Frank Hildebrand
- Department of Orthopaedic Trauma, RWTH Aachen University, Aachen, Germany
| | - Hans-Christoph Pape
- Department of Trauma Surgery, University Hospital Zurich, Zurich, Switzerland
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Lang P, Kulla M, Kerwagen F, Lefering R, Friemert B, Palm HG. The role of whole-body computed tomography in the diagnosis of thoracic injuries in severely injured patients - a retrospective multi-centre study based on the trauma registry of the German trauma society (TraumaRegister DGU ®). Scand J Trauma Resusc Emerg Med 2017; 25:82. [PMID: 28810921 PMCID: PMC5558663 DOI: 10.1186/s13049-017-0427-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 08/07/2017] [Indexed: 12/14/2022] Open
Abstract
Background Thoracic injuries are a leading cause of death in polytrauma patients. Early diagnosis and treatment are of paramount importance. Whole-body computed tomography (WBCT) has largely replaced traditional imaging techniques such as conventional radiographs and focused computed tomography (CT) as diagnostic tools in severely injured patients. It is still unclear whether WBCT has led to higher rates of diagnosis of thoracic injuries and thus to a change in outcomes. Methods In a retrospective study based on the trauma registry of the German Trauma Society (TraumaRegister DGU®), we analysed data from 16,545 patients who underwent treatment in 59 hospitals between 2002 and 2012 (ISS ≥ 9). The 3 years preceding and the 3 years following the introduction of WBCT as a standard imaging modality for the investigation of severely injured patients were assessed for every hospital. Accordingly, patients were assigned to either the pre-WBCT or the WBCT group. We compared the numbers of thoracic injuries and the outcomes of patients before and after the routine use of WBCT. Results A total of 13,564 patients (pre-WBCT: n = 5005, WBCT: n = 8559) were included. Relevant thoracic injuries were detected in 47.8%. There were no major differences between the patient groups in injury severity (pre-WBCT: median ISS 21; WBCT: median ISS 22), injury patterns and demographics. After the introduction of WBCT, only minor changes were observed regarding the rates of most thoracic injuries. Clinically relevant injuries were pulmonary contusions (pre-WBCT: 18.5%; WBCT: 28.7%), injuries to the lung parenchyma (pre-WBCT: 12.6%; WBCT: 5.9%), multiple rib fractures (pre-WBCT: 10.6%; WBCT: 21.6%), and pneumothoraces (pre-WBCT: 17.3%; WBCT: 21.6%). The length of stay in the intensive care unit (pre-WBCT: 10.8 days; WBCT: 9.7 days) and in hospital (pre-WBCT: 26.2 days; WBCT: 23.3 days) decreased. There was no difference in overall mortality (pre-WBCT: 15.5%; WBCT: 15.6%). Conclusions The routine use of WBCT in the trauma room setting has led to changes in patient management that are not reflected in the rates of diagnosis of severe thoracic injuries (e.g. tension pneumothoraces, cardiac injuries, arterial injuries). By contrast, there was a relevant increase in the rates of diagnosis of minor thoracic injuries, which, however, did not result in an improvement in survival prognosis.
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Affiliation(s)
- Patricia Lang
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Martin Kulla
- Department of Anaesthesiology and Intensive Care Medicine, German Armed Forces Hospital of Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
| | - Fabian Kerwagen
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Benedikt Friemert
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Hans-Georg Palm
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
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Tomas X, Facenda C, Vaz N, Castañeda EA, Del Amo M, Garcia-Diez AI, Pomes J. Thoracic wall trauma-misdiagnosed lesions on radiographs and usefulness of ultrasound, multidetector computed tomography and magnetic resonance imaging. Quant Imaging Med Surg 2017; 7:384-397. [PMID: 28932697 DOI: 10.21037/qims.2017.08.02] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Blunt injuries to the chest wall are an important chapter on emergency room (ER) departments, being the third most common injuries in trauma patients which ominous complications could appear. This article describes different types of traumatic events affecting the chest wall, which maybe misdiagnosed with conventional X-ray. Special emphasis has been done in computed tomography (CT) and multidetector CT (MDCT) imaging. This technique is considered the "gold-standard" for those traumatic patients, due to its fast acquisition covering the whole area of interest in axial plane, reconstructing multiplanar (2D, 3D) volume-rendered images with a superb quality and angiographic CT capabilities for evaluating vascular damage. Complementary techniques such as ultrasonography (US) and magnetic resonance imaging (MRI) may improve the diagnostic accuracy due to its great capacity in visualising soft-tissue trauma (muscle-tendinous tears) and subtle fractures. All these imaging methods have an important role in quantifying the severity of chest wall trauma. The findings of this study have been exposed with cases of our archives in a didactic way.
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Affiliation(s)
- Xavier Tomas
- Department of Radiology, The Clinical Diagnostic Imaging Centre (CDIC), Hospital Clinic, Universitat de Barcelona (UB), Villarroel 170, 08036 Barcelona, Spain
| | - Catherine Facenda
- Department of Radiology, Hospital Universitari Arnau de Vilanova, Av. Alcalde Rovira Roure, 80, Lleida 25198, Spain
| | - Nuno Vaz
- Department of Radiology, The Clinical Diagnostic Imaging Centre (CDIC), Hospital Clinic, Universitat de Barcelona (UB), Villarroel 170, 08036 Barcelona, Spain
| | - Edgar Augusto Castañeda
- Department of Radiology, Hospital Universitari General de Catalunya-Grupo Quirónsalud, Pedro i Pons, 1, Sant Cugat del Vallés Barcelona 08190, Spain
| | - Montserrat Del Amo
- Department of Radiology, The Clinical Diagnostic Imaging Centre (CDIC), Hospital Clinic, Universitat de Barcelona (UB), Villarroel 170, 08036 Barcelona, Spain
| | - Ana Isabel Garcia-Diez
- Department of Radiology, The Clinical Diagnostic Imaging Centre (CDIC), Hospital Clinic, Universitat de Barcelona (UB), Villarroel 170, 08036 Barcelona, Spain
| | - Jaime Pomes
- Department of Radiology, The Clinical Diagnostic Imaging Centre (CDIC), Hospital Clinic, Universitat de Barcelona (UB), Villarroel 170, 08036 Barcelona, Spain
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Prevalence of negative CT scans in a level one trauma center. Eur J Trauma Emerg Surg 2016; 44:29-33. [PMID: 27866218 DOI: 10.1007/s00068-016-0741-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2016] [Accepted: 11/15/2016] [Indexed: 10/20/2022]
Abstract
PURPOSE The rise of computed tomography (CT) use in trauma has become the subject of concern given the harms of CT including radiation, cost, over diagnosis and identification of incidental lesions. We developed a novel metric, the Negative CT Score, (∑CT-) which quantifies how often CT imaging identifies important injuries. Our objective was to describe the pattern of CT utilization in trauma at an urban academic level one trauma center using this novel metric. METHODS This was a retrospective study of intermediate level trauma patients who received CT imaging over a 1-year study period at an urban level one trauma center. We applied the Negative CT Score, (∑CT-) to quantify the results of CT imaging. ∑CT- is computed by subtracting the number of non-extremity body regions (maximum four: head, neck, chest, abdomen) with an important positive CT finding (defined by a priori criteria) from the total number of non-extremity body regions scanned. RESULTS Of the 552 cases reviewed during the study period, 410 (74.3%) were male and the mean age was 40.3 years [SD ± 21.2]. Four hundred eighty-six patients (88.0%) suffered blunt trauma; 66 (12.0%) suffered penetrating trauma. The average injury severity score for admitted patients was seven. Four hundred ninety-five cases had at least one CT performed. The average number of regions per patient that received CT imaging was 2.36 (SD ± 1.3), and the average ∑CT- was 2.10 (SD ± 1.2). Three hundred and sixty-seven (74.3%) patients had no important findings on CT imaging. CONCLUSIONS In a consecutive series of 552 intermediate trauma patients at our urban trauma center, 2.36 body regions were scanned per patient; of these, 2.10 regions revealed no important CT findings. We hope that these results and the Negative CT Score can be used to identify trends, variations in practice, and outliers within and across departments so that CT utilization can be optimized.
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Fatihoglu E, Aydin S, Gokharman FD, Ece B, Kosar PN. X-ray Use in Chest Imaging in Emergency Department on the Basis of Cost and Effectiveness. Acad Radiol 2016; 23:1239-45. [PMID: 27426978 DOI: 10.1016/j.acra.2016.05.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2016] [Revised: 05/05/2016] [Accepted: 05/09/2016] [Indexed: 12/14/2022]
Abstract
RATIONALE AND OBJECTIVES The increasing use of imaging in the emergency department (ED) services has become an important problem on the basis of cost and unnecessary exposure to radiation. Radiographic examination of the chest has been reported to be performed in 34.4% of ED visits, and chest computerized tomography (CCT) in 15.8%, whereas some patients receive both chest radiography and CCT in the same visit. In the current study, it was aimed to establish instances of medical waste and unnecessary radiation exposure and to show how the inclusion of radiologists in the ordering process would affect the amount of unnecessary imaging studies. MATERIALS AND METHODS This retrospective study included 1012 ED patients who had both chest radiography and CCT during the same visit at Ankara Training and Research Hospital between April 2015 and January 2016. The patients were divided into subgroups of trauma and nontrauma. To detect unnecessary imaging examinations, data were analyzed according to the presence of additional findings on CCT images and the recommendation of a radiologist for CCT imaging. RESULTS In the trauma group, 77.1% (461/598) and in the nontrauma group, 80.4% (334/414) of patients could be treated without any need for CCT. In the trauma group, the radiologist recommendation only, and in the nontrauma group, both the radiologist recommendation and the age were determined to be able to predict the risk of having additional findings on CCT. CONCLUSIONS Considering only the age of the patient before ordering CCT could decrease the rate of unnecessary imaging. Including radiologists into both the evaluation and the ordering processes may help to save resources and decrease exposure to ionizing radiation.
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Chapman BC, Overbey DM, Tesfalidet F, Schramm K, Stovall RT, French A, Johnson JL, Burlew CC, Barnett C, Moore EE, Pieracci FM. Clinical Utility of Chest Computed Tomography in Patients with Rib Fractures CT Chest and Rib Fractures. ARCHIVES OF TRAUMA RESEARCH 2016; 5:e37070. [PMID: 28144607 PMCID: PMC5253201 DOI: 10.5812/atr.37070] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2016] [Revised: 05/10/2016] [Accepted: 09/04/2016] [Indexed: 12/01/2022]
Abstract
Background Chest CT is more sensitive than a chest X-ray (CXR) in diagnosing rib fractures; however, the clinical significance of these fractures remains unclear. Objectives The purpose of this study was to determine the added diagnostic use of chest CT performed after CXR in patients with either known or suspected rib fractures secondary to blunt trauma. Methods Retrospective cohort study of blunt trauma patients with rib fractures at a level I trauma center that had both a CXR and a CT chest. The CT finding of ≥ 3 additional fractures in patients with ≤ 3 rib fractures on CXR was considered clinically meaningful. Student’s t-test and chi-square analysis were used for comparison. Results We identified 499 patients with rib fractures: 93 (18.6%) had CXR only, 7 (1.4%) had chest CT only, and 399 (79.9%) had both CXR and chest CT. Among these 399 patients, a total of 1,969 rib fractures were identified: 1,467 (74.5%) were missed by CXR. The median number of additional fractures identified by CT was 3 (range, 4 - 15). Of 212 (53.1%) patients with a clinically meaningful increase in the number of fractures, 68 patients underwent one or more clinical interventions: 36 SICU admissions, 20 pain catheter placements, 23 epidural placements, and 3 SSRF. Additionally, 70 patients had a chest tube placed for retained hemothorax or occult pneumothorax. Overall, 138 patients (34.5%) had a change in clinical management based upon CT chest. Conclusions The chest X-ray missed ~75% of rib fractures seen on chest CT. Although patients with a clinical meaningful increase in the number of rib fractures were more likely to be admitted to the intensive care unit, there was no associated improvement in pulmonary outcomes.
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Affiliation(s)
- Brandon C. Chapman
- Department of Surgery, University of Colorado School of Medicine, Colorado, United States
- Corresponding author: Brandon C. Chapman, Department of Surgery, University of Colorado School of Medicine, Colorado, United States. Tel: +1-7207373858, E-mail:
| | - Douglas M. Overbey
- Department of Surgery, University of Colorado School of Medicine, Colorado, United States
| | - Feven Tesfalidet
- School of Medicine, University of Colorado, Colorado, United States
| | - Kristofer Schramm
- Department of Radiology, School of Medicine, University of Colorado, Colorado, United States
| | - Robert T. Stovall
- Department of Surgery, Denver Health Medical Center, Colorado, United States
| | - Andrew French
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, United States
| | - Jeffrey L. Johnson
- Department of Surgery, Denver Health Medical Center, Colorado, United States
| | - Clay C. Burlew
- Department of Surgery, Denver Health Medical Center, Colorado, United States
| | - Carlton Barnett
- Department of Surgery, Denver Health Medical Center, Colorado, United States
| | - Ernest E. Moore
- Department of Surgery, Denver Health Medical Center, Colorado, United States
| | - Fredric M. Pieracci
- Department of Surgery, Denver Health Medical Center, Colorado, United States
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Yigit Y, Ayhan H. Incidental CT Findings of Patients Who Admitted to ER Following a Traffic Accident. Turk J Emerg Med 2016; 14:9-14. [PMID: 27331159 PMCID: PMC4909874 DOI: 10.5505/1304.7361.2014.13284] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 12/13/2013] [Indexed: 12/21/2022] Open
Abstract
Objective The aim of this study was to investigate and analyze incidental CT findings of traffic injury patients discharged from the ER, and to determine overall notification rates. Methods All traffic injury-related patient records between 01.06.2013–01.03.2013 were obtained from Derince Training and Research Hospital Emergency Service using patient files and the hospital database. Brain, thorax and/or abdominal CT images of 340 patients aged between 0 to 84 years were included in the study. ER observation forms were investigated for the patients who had incidental findings on CT scanning and overall notification rates were recorded. Results Mean age of the 363 cases was 31.2 (SD 17.9, min 0, max 84) and 35.5% of patients were female (n=129) and 64.5% were male (n=234). A total of 537 CT scans were performed on 363 patients. 147, 319 and 71 CT scans were performed on the thorax, brain and abdominal, respectively. 27.3% (n=99) of scan results showed the presence of a coincidental pathology. The most common disease on scans were bone lesions (8%, n=29), followed by sinus abnormalities (7.7%, n=28). Incidental findings ratio in patients aged over 60 was 60.8%, while under 60 was 24.8%. It was found that seven patients (7.1%) were informed about the imaging results. Conclusion Most of the incidental findings were found to be benign; however, 16.5% of them were considered to require in-depth investigation. Further investigations are needed to understand the clinical relevance of these findings and their effects on patients.
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Affiliation(s)
- Yavuz Yigit
- Derince Training and Research Hospital, Kocaeli
| | - Harun Ayhan
- Haydarpasa Numune Training and Research Hospital, İstanbul
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Gutierrez A, Inaba K, Siboni S, Effron Z, Haltmeier T, Jaffray P, Reddy S, Lofthus A, Benjamin E, Dubose J, Demetriades D. The utility of chest X-ray as a screening tool for blunt thoracic aortic injury. Injury 2016; 47:32-6. [PMID: 26296454 DOI: 10.1016/j.injury.2015.08.003] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Revised: 07/29/2015] [Accepted: 08/01/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND The early and accurate identification of patients with blunt thoracic aortic injury (BTAI) remains a challenge. Traditionally, a portable AP chest X-ray (CXR) is utilized as the initial screening modality for BTAI, however, there is controversy surrounding its sensitivity. The purpose of this study was to assess the sensitivity of CXR as a screening modality for BTAI. METHODS After IRB approval, all adult (≥18 yo) blunt trauma patients admitted to LAC+USC (01/2011-12/2013) who underwent CXR and chest CT were retrospectively reviewed. Final radiology attending CXR readings were reviewed for mediastinal abnormalities (widened mediastinum, mediastinal to chest width ratio greater than 0.25, irregular aortic arch, blurred aortic contour, opacification of the aortopulmonary window, and apical pleural haematoma) suggestive of aortic injury. Chest CT final attending radiologist readings were utilized as the gold standard for diagnosis of BTAI. The primary outcome analyzed was CXR sensitivity. RESULTS A total of 3728 patients were included in the study. The majority of patients were male (72.6%); mean age was 43 (SD 20). Median ISS was 9 (IQR 4-17) and median GCS was 15 (IQR 14-15). The most common mechanism of injury was MVC (48.0%), followed by fall (20.6%), and AVP (16.9%). The total number of CXRs demonstrating a mediastinal abnormality was 200 (5.4%). Widened mediastinum was present on 191 (5.1%) of CXRs, blurred aortic contour on 10 (0.3%), and irregular aortic arch on 4 (0.1%). An acute aortic injury confirmed by chest CT was present in 17 (0.5%) patients. Only 7 of these with CT-confirmed BTAI had a mediastinal abnormality identified on CXR, for a sensitivity of 41% (95% CI: 19-67%). CONCLUSION The results from this study suggest that CXR alone is not a reliable screening modality for BTAI. A combination of screening CXR and careful consideration of other factors, such as mechanism of injury, will be required to effectively discriminate between those who should and should not undergo chest CT.
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Affiliation(s)
- Adam Gutierrez
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Kenji Inaba
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA.
| | - Stefano Siboni
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Zachary Effron
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Tobias Haltmeier
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Paul Jaffray
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Sravanthi Reddy
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Alexander Lofthus
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Elizabeth Benjamin
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Joseph Dubose
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
| | - Demetrios Demetriades
- Division of Trauma and Surgical Critical Care, Department of Surgery, LAC+USC Medical Center, University of Southern California, Los Angeles, CA 90033, USA
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Langdorf MI, Medak AJ, Hendey GW, Nishijima DK, Mower WR, Raja AS, Baumann BM, Anglin DR, Anderson CL, Lotfipour S, Reed KE, Zuabi N, Khan NA, Bithell CA, Rowther AA, Villar J, Rodriguez RM. Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study. Ann Emerg Med 2015; 66:589-600. [PMID: 26169926 DOI: 10.1016/j.annemergmed.2015.06.003] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Revised: 05/23/2015] [Accepted: 06/01/2015] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVE Chest computed tomography (CT) diagnoses more injuries than chest radiography, so-called occult injuries. Wide availability of chest CT has driven substantial increase in emergency department use, although the incidence and clinical significance of chest CT findings have not been fully described. We determine the frequency, severity, and clinical import of occult injury, as determined by changes in management. These data will better inform clinical decisions, need for chest CT, and odds of intervention. METHODS Our sample included prospective data (2009 to 2013) on 5,912 patients at 10 Level I trauma center EDs with both chest radiography and chest CT at physician discretion. These patients were 40.6% of 14,553 enrolled in the parent study who had either chest radiography or chest CT. Occult injuries were pneumothorax, hemothorax, sternal or greater than 2 rib fractures, pulmonary contusion, thoracic spine or scapula fracture, and diaphragm or great vessel injury found on chest CT but not on preceding chest radiography. A priori, we categorized thoracic injuries as major (having invasive procedures), minor (observation or inpatient pain control >24 hours), or of no clinical significance. Primary outcome was prevalence and proportion of occult injury with major interventions of chest tube, mechanical ventilation, or surgery. Secondary outcome was minor interventions of admission rate or observation hours because of occult injury. RESULTS Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n=672/1,120, 60.0% occult) or sternal fracture (n=269/281, 95.7% occult), 12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118 of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). CONCLUSION In a more seriously injured subset of patients with blunt trauma who had both chest radiography and chest CT, occult injuries were found by chest CT in 71% of those with thoracic injuries and one fourth of all those with blunt chest trauma. More than one third of occult injury had intervention (37.5%). Chest tubes composed 76.2% of occult injury major interventions, with observation or inpatient pain control greater than 24 hours in 32.4% of occult fractures. Only 1 in 20 patients with occult injury was discharged home from the ED. For these patients with blunt trauma, chest CT is useful to identify otherwise occult injuries.
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Affiliation(s)
- Mark I Langdorf
- Department of Emergency Medicine, University of California-Irvine, Orange, CA.
| | - Anthony J Medak
- Department of Emergency Medicine, University of California-San Diego, La Jolla, CA
| | - Gregory W Hendey
- Department of Emergency Medicine, University of California-San Francisco, Fresno, Fresno, CA
| | - Daniel K Nishijima
- Department of Emergency Medicine, University of California-Davis, Davis, CA
| | - William R Mower
- Department of Emergency Medicine, University of California-Los Angeles, Los Angeles, CA
| | - Ali S Raja
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA
| | - Brigitte M Baumann
- Department of Emergency Medicine, Cooper Medical School of Rowan University, Camden, NJ
| | - Deirdre R Anglin
- Department of Emergency Medicine, University of Southern California Keck School of Medicine, Los Angeles, CA
| | - Craig L Anderson
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Shahram Lotfipour
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Karin E Reed
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Nadia Zuabi
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Nooreen A Khan
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Chelsey A Bithell
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Armaan A Rowther
- Department of Emergency Medicine, University of California-Irvine, Orange, CA
| | - Julian Villar
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
| | - Robert M Rodriguez
- Department of Emergency Medicine, University of California-San Francisco, San Francisco, CA
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Payrastre J, Upadhye S, Worster A, Lin D, Kahnamoui K, Patterson H, Sanaee L, Clayden R. The SCRAP rule: The Derivation and Internal Validation of a Clinical Decision Rule for Computed Tomography of the Chest in Blunt Thoracic Trauma. CAN J EMERG MED 2015; 14:344-53. [DOI: 10.2310/8000.2012.120738] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
ABSTRACTObjective:To derive and internally validate a clinical decision rule that will rule out major thoracic injury in adult blunt trauma patients, reducing the unnecessary use of chest computed tomographic (CT) scans.Methods:Data were retrospectively obtained from a chart review of all trauma patients presenting to a Canadian tertiary trauma care centre from 2005 to 2008, with those from April 2006 to March 2007 being used for the validation phase. Patients were included if they had an Injury Severity Score > 12 and chest CT at admission or a documented major thoracic injury noted in the trauma database. Patients with penetrating injury, a Glasgow Coma Scale (GCS) score ≤ 8, paralysis, or age < 16 years were excluded.Results:There were 434 patients in the derivation group and 180 in the validation group who met the inclusion criteria. Using recursive partitioning, five clinical variables were found to be particularly predictive of injury. When these variables were normal, no patients had a major thoracic injury (sensitivity 100% [95% CI 98.4–100], specificity 46.9% [95% CI 44.2–46.9], and negative likelihood ratio 0.00 [95% CI 0.00–0.04]). The five variables were oxygensaturation (< 95% on room air or < 98% on any supplemental oxygen),chest radiograph, respiratoryrate ≥ 25, chestauscultation, and thoracicpalpation (SCRAP). In the validation group, the same five variables had a sensitivity of 100% (95% CI 96.2–100%), a specificity of 44.7% (95% CI 39.5–44.7%), and negative likelihood ratio of 0.00 (95% CI 0.00–0.10).Conclusions:In major blunt trauma with a GCS score > 8, the SCRAP variables have a 100% sensitivity for major thoracic injury in this retrospective study. These findings need to be prospectively validated prior to use in a clinical setting.
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Artigas Martín JM, Martí de Gracia M, Claraco Vega LM, Parrilla Herranz P. Radiology and imaging techniques in severe trauma. Med Intensiva 2015; 39:49-59. [PMID: 25438873 DOI: 10.1016/j.medin.2014.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/07/2014] [Accepted: 06/15/2014] [Indexed: 10/24/2022]
Affiliation(s)
- J M Artigas Martín
- Sección de Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario Miguel Servet, Zaragoza, España.
| | - M Martí de Gracia
- Sección de Radiología de Urgencias, Servicio de Radiodiagnóstico, Hospital Universitario «La Paz», Madrid, España
| | - L M Claraco Vega
- Unidad de Cuidados Intensivos, Hospital Universitario Miguel Servet, Zaragoza, España
| | - P Parrilla Herranz
- Servicio de Urgencias, Hospital Universitario Miguel Servet, Zaragoza, España
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Multi-detector computed tomography imaging of blunt chest trauma. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2014. [DOI: 10.1016/j.ejrnm.2014.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Diagnostic imaging in pediatric polytrauma management. Radiol Med 2014; 120:33-49. [PMID: 25376101 DOI: 10.1007/s11547-014-0469-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2014] [Accepted: 10/29/2014] [Indexed: 01/20/2023]
Abstract
Trauma is the cause of over 45% of deaths in children aged 1 to 14 years. Since multiple injuries are common among children, the emergency physician has to assess all the organs of a high-energy injured child, independent of mechanism of the trauma. Even if the principles of polytrauma management are identical both in children and in adults, the optimal pediatric patient care requires a specific understanding of some important anatomical, physiological, and psychological differences that play a significant role in the assessment and management of a pediatric patient. Emergency Radiology already plays a crucial role in the diagnostic process of a polytraumatized child according to the primary survey, through the use of multiple imaging modalities. Radiological and Ultrasound examinations play a basic role in the hemodynamically unstable patients. In the hemodynamically stable patients whole-body CT scanning is the most immediate radiological procedure that allows the examination of all the body parts of a polytraumatized child, reducing the number of minor injuries that might otherwise be neglected.
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Forouzanfar MM, Safari S, Niazazari M, Baratloo A, Hashemi B, Hatamabadi HR, Rahmati F, Sanei Taheri M. Clinical decision rule to prevent unnecessary chest X-ray in patients with blunt multiple traumas. Emerg Med Australas 2014; 26:561-6. [PMID: 25255821 DOI: 10.1111/1742-6723.12302] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/19/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND Since the diagnostic yield of chest X-ray (CXR) is not high enough, when it is ordered for all the multiple trauma patients, this study was aimed to evaluate the relationship between clinical and CXR findings in order to formulate a clinical decision rule to prevent unnecessary CXR in these patients. METHODS Stable multiple blunt trauma patients referring to the ED were included. The clinical and radiographic findings of all the patients were collected and the relationships between these variables analysed. Finally, based on the regression coefficients (β) of the variables, the Thoracic Injury Rule-out Criteria (TIRC) were designed. RESULTS A total of 2607 patients were included (males: 78.9%, mean age: 34.1 ± 15.0 years). Age over 60 (β = 0.8; 95% CI: 0.27-1.34; P = 0.003), crepitation (β = 4.33; 95% CI: 1.65-7.0; P < 0.001), loss of consciousness (β = 3.16; 95% CI: 2.44-3.88; P < 0.001), decrease in pulmonary sounds (β = 2.67; 95% CI: 1.73-3.6; P < 0.001), chest wall pain (β = 2.12; 95% CI: 1.63-2.61; P < 0.001) and tenderness (β = 1.78; 95% CI: 1.26-2.27; P < 0.001), dyspnea (β = 1.3; 95% CI: 0.41-2.18; P = 0.004) and abrasion (β = 0.5; 95% CI: 0.22-0.83; P = 0.03) were independent factors predicting thoracic injury. CXR in stable conscious multiple blunt trauma patients under 60 years, without chest wall pain and tenderness, decrease in pulmonary sounds, crepitation, skin abrasion, and dyspnea did not provide any additional findings. CONCLUSIONS Based on TIRC, it seems that CXR in stable multiple blunt trauma patients who are conscious and under 60 and have no decrease in pulmonary sounds, no dyspnea, no thoracic skin abrasion, and no crepitation can be ignored.
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Ziegler K, Feeney JM, Desai C, Sharpio D, Marshall WT, Twohig M. Retrospective review of the use and costs of routine chest x rays in a trauma setting. J Trauma Manag Outcomes 2013; 7:2. [PMID: 23656999 PMCID: PMC3658884 DOI: 10.1186/1752-2897-7-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2012] [Accepted: 05/04/2013] [Indexed: 12/03/2022]
Abstract
INTRODUCTION Chest x-rays (CXR) are routinely obtained on blunt trauma patients. Many patients also receive additional imaging with thoracic computed tomography scans for other indications. We hypothesized that in hemodynamically normal, awake and alert blunt trauma patients, CXR can be deferred in those who will also receive a TCT with significant cost savings. METHODS We retrospectively reviewed the charts of trauma patients from 1/1/2010 to 12/31/2010 who received both a CXR and TCT in the trauma room. Billing and cost data were collected from various hospital sources. RESULTS 239 patients who met inclusion and exclusion criteria and received CXR and TCT between 1/1/2010 and 12/31/2010. The sensitivity of CXR was 19% (95% CI: 10.8% to 31%) and the specificity was 91.7% (95% CI: 86.7% to 95%). The false positive rate for CXR was 35.8% (95% CI: 21.7% to 52.8%) and the false negative rate was 24.5% (95% CI: 18.8% to 31.2%). The precision of CXR was 42.3% (95% CI: 25.5% to 61.1%) and the overall accuracy was 74.1% (95% CI: 68.1% to 79.2%). If routine chest xray were eliminated in these patients, the estimated cost savings ranged from $14,641 to $142,185, using three different methods of cost analysis. CONCLUSIONS In patients who are hemodynamically normal and who will be receiving a TCT, deferring a CXR would result in an estimated cost savings up to $142,185. Additionally, TCT is more sensitive and specific than CXR in identifying injuries in patients who have sustained blunt trauma to the thorax.
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Affiliation(s)
- Kristina Ziegler
- Departments of Surgery, Stamford Hospital, 30 Shelburne Road, Stamford, CT 06904, USA
- School of Medicine, University of Connecticut, 263 Farmington Ave., Farmington, CT 06032, USA
| | - James M Feeney
- Department of Surgery, Division of Trauma, Saint Francis Hospital and Medical Center, 114 Woodland St., Hartford, CT 06103, USA
- School of Medicine, University of Connecticut, 263 Farmington Ave., Farmington, CT 06032, USA
| | - Colleen Desai
- Department of Surgery, Division of Trauma, Saint Francis Hospital and Medical Center, 114 Woodland St., Hartford, CT 06103, USA
| | - David Sharpio
- Department of Surgery, Division of Trauma, Saint Francis Hospital and Medical Center, 114 Woodland St., Hartford, CT 06103, USA
- School of Medicine, University of Connecticut, 263 Farmington Ave., Farmington, CT 06032, USA
| | - Wiiliam T Marshall
- Department of Surgery, Division of Trauma, Saint Francis Hospital and Medical Center, 114 Woodland St., Hartford, CT 06103, USA
- School of Medicine, University of Connecticut, 263 Farmington Ave., Farmington, CT 06032, USA
| | - Michael Twohig
- Department of Surgery, Division of Trauma, Saint Francis Hospital and Medical Center, 114 Woodland St., Hartford, CT 06103, USA
- School of Medicine, University of Connecticut, 263 Farmington Ave., Farmington, CT 06032, USA
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Can handheld micropower impulse radar technology be used to detect pneumothorax? Initial experience in a European trauma centre. Injury 2013; 44:650-4. [PMID: 22385903 DOI: 10.1016/j.injury.2012.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Revised: 01/25/2012] [Accepted: 02/03/2012] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pneumothoraces are a common injury pattern in emergency medicine. Rapid and safe identification can reduce morbidity and mortality. A new handheld, battery powered device, the Pneumoscan (CE 561036, PneumoSonics Inc., Cleveland, OH, USA), using micropower impulse radar (MIR) technology, has recently been introduced in Europe for the rapid and reliable detection of PTX. However, this technology has not yet been tested in trauma patients. This is the first quality control evaluation to report on emergency room performance of a new device used in the trauma setting. MATERIAL AND METHODS This study was performed at a Level I trauma centre in Switzerland. All patients with thoracic trauma and undergoing chest X-ray and CT-scan were eligible for the study. Readings were performed before the chest X-ray and CT scan. The patients had eight lung fields tested (four on each side). All readings with the Pneumoscan were performed by two junior residents in our department who had previously received an instructional tutorial of 15min. The qualitative MIR results were blinded, and stored on the device. We then compared the results of the MIR to those of the clinical examination, chest X-ray and CT-scan. RESULTS 50 patients were included, with a mean age of 46 (SD 17) years. Seven patients presented with PTX diagnosed by CT; six of these were detected by Pneumoscan, leading to an overall sensitivity of 85.7 (95% confidence interval 42.1-99.6)%. Only two of seven PTX were found during clinical examination and on chest X-ray (sensitivity 28.6 (95% CI 3.7-71.0)%). Of the remaining 43 of 50 patients without PTX, one false-positive PTX was found by the Pneumoscan, resulting in a specificity of 97.7 (95% CI 87.7-99.9)%. DISCUSSION The Pneumoscan is an easy to use handheld technology with reliable results. In this series, the sensitivity to detect a PTX by the Pneumoscan was higher than by clinical examination and chest X-ray. Further studies with higher case numbers and a prospective study design are needed to confirm our findings.
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Pinette W, Barrios C, Pham J, Kong A, Dolich M, Lekawa M. A comparison of thoracic CT and abdominal CT for the identification of thoracic blunt trauma. Am J Surg 2012; 204:927-31; discussion 931-2. [DOI: 10.1016/j.amjsurg.2012.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2012] [Revised: 10/17/2012] [Accepted: 10/17/2012] [Indexed: 11/26/2022]
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Paydar S, Johari HG. Blunt chest trauma: the role of chest x-ray, chest/abdomen computed tomography scan and physical examination. Am J Surg 2012; 204:553-4. [DOI: 10.1016/j.amjsurg.2011.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Accepted: 01/19/2011] [Indexed: 12/01/2022]
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Kepros JP, Opreanu RC, Samaraweera R, Briningstool A, Morrison CA, Mosher BD, Schneider P, Stevens P. Whole body imaging in the diagnosis of blunt trauma, ionizing radiation hazards and residual risk. Eur J Trauma Emerg Surg 2012; 39:15-24. [PMID: 26814919 DOI: 10.1007/s00068-012-0201-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 06/06/2012] [Indexed: 02/06/2023]
Abstract
Ever since the introduction of radiographic imaging, its utility in identifying injuries has been well documented and was incorporated in the workup of injured patients during advanced trauma life support algorithms [American College of Surgeons, 8th ed. Chicago, 2008]. More recently, computerized tomography (CT) has been shown to be more sensitive than radiography in the diagnosis of injury. Due to the increased use of CT scanning, concerns were raised regarding the associated exposure to ionizing radiation [N Engl J Med 357:2277-2284, 2007]. During the last several years, a significant amount of research has been published on this topic, most of it being incorporated in the BEIR VII Phase 2 report, published by the National Research Council of the National Academies [National Academy of Sciences, Washington DC, 2006]. The current review will analyze the scientific basis for the concerns over the ionizing radiation associated with the use of CT scanning and will examine the accuracy of the typical advanced trauma life support work-up for diagnosis of injuries.
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Affiliation(s)
- J P Kepros
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA. .,Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA.
| | - R C Opreanu
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA.
| | - R Samaraweera
- Department of Radiology, Sparrow Hospital, Lansing, MI, USA
| | - A Briningstool
- Emergency Department, Sparrow Hospital, Lansing, MI, USA
| | - C A Morrison
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA.,Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA
| | - B D Mosher
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA.,Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA
| | - P Schneider
- Department of Surgery, College of Human Medicine, Michigan State University, 1215 East Michigan Avenue, Suite 655, Lansing, MI, 48912, USA.,Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA
| | - P Stevens
- Trauma and Surgical Critical Care, Sparrow Hospital, Lansing, MI, USA
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Bertolaccini L, Rizzardi G, Filice MJ, Spada E, Terzi A. The "ending neglect" of roentgenograms in penetrating chest trauma. J Thorac Dis 2012; 2:197-8. [PMID: 22263046 DOI: 10.3978/j.issn.2072-1439.2010.02.04.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2010] [Accepted: 10/04/2010] [Indexed: 11/14/2022]
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Selective Use of Computed Tomography Compared With Routine Whole Body Imaging in Patients With Blunt Trauma. Ann Emerg Med 2011; 58:407-16.e15. [DOI: 10.1016/j.annemergmed.2011.06.003] [Citation(s) in RCA: 91] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2010] [Revised: 05/28/2011] [Accepted: 06/02/2011] [Indexed: 11/20/2022]
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Munroe B, Curtis K. Assessment, monitoring and emergency nursing care in blunt chest injury: A case study. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.aenj.2011.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Mommsen P, Zeckey C, Andruszkow H, Weidemann J, Frömke C, Puljic P, van Griensven M, Frink M, Krettek C, Hildebrand F. Comparison of different thoracic trauma scoring systems in regards to prediction of post-traumatic complications and outcome in blunt chest trauma. J Surg Res 2011; 176:239-47. [PMID: 22099585 DOI: 10.1016/j.jss.2011.09.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2011] [Revised: 08/12/2011] [Accepted: 09/09/2011] [Indexed: 11/29/2022]
Abstract
BACKGROUND As accurate assessment of thoracic injury severity in the early phase after trauma is difficult, we compared different thoracic trauma scores regarding their predictive ability for the development of post-traumatic complications and mortality. MATERIALS AND METHODS Two hundred seventy-eight multiple trauma patients (ISS ≥ 16) age > 16 y with severe blunt chest trauma (AIS(chest) ≥ 3) admitted between 2000 and 2009 to Level I Trauma center were included. Exclusion criteria were severe traumatic brain injury (AIS(head) ≥ 3) and penetrating thoracic trauma. The association between AIS(chest), Pulmonary Contusion score (PCS), Wagner-score and Thoracic Trauma Severity score (TTS), and duration of ventilation, length of ICU stay, development of post-traumatic complications, and mortality was investigated. Statistical analysis was performed with χ(2)-test, ANOVA, logistic regression, and receiver operating characteristic (ROC) curve. RESULTS Patients' mean age was 42.7 ± 17.0 y, the mean injury severity score was 28.7 ± 9.3 points. Overall, 60 patients (21.6%) developed ARDS, 143 patients (51.4%) SIRS, 110 patients (39.6%) sepsis, and 36 patients (13.0%) MODS. Twenty-two patients (7.9%) died. Among the examined thoracic trauma scores only the TTS was an independent predictor of mortality. With the TTS showing the best prediction power, the TTS, PCS, and Wagner-score were independent predictors of ventilation time, length of ICU stay, and the development of post-traumatic ARDS and MODS. CONCLUSIONS Thoracic trauma scores combining anatomical and physiologic parameters like the TTS seem to be most suitable for severity assessment and prediction of outcome in multiple trauma patients with concomitant blunt chest trauma.
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Affiliation(s)
- Philipp Mommsen
- Trauma Department, Hannover Medical School, Hannover, Germany.
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CT imaging of blunt chest trauma. Insights Imaging 2011; 2:281-295. [PMID: 22347953 PMCID: PMC3259405 DOI: 10.1007/s13244-011-0072-9] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2010] [Revised: 11/28/2010] [Accepted: 01/27/2011] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND: Thoracic injury overall is the third most common cause of trauma following injury to the head and extremities. Thoracic trauma has a high morbidity and mortality, accounting for approximately 25% of trauma-related deaths, second only to head trauma. More than 70% of cases of blunt thoracic trauma are due to motor vehicle collisions, with the remainder caused by falls or blows from blunt objects. METHODS: The mechanisms of injury, spectrum of abnormalities and radiological findings encountered in blunt thoracic trauma are categorised into injuries of the pleural space (pneumothorax, hemothorax), the lungs (pulmonary contusion, laceration and herniation), the airways (tracheobronchial lacerations, Macklin effect), the oesophagus, the heart, the aorta, the diaphragm and the chest wall (rib, scapular, sternal fractures and sternoclavicular dislocations). The possible coexistence of multiple types of injury in a single patient is stressed, and therefore systematic exclusion after thorough investigation of all types of injury is warranted. RESULTS: The superiority of CT over chest radiography in diagnosing chest trauma is well documented. Moreover, with the advent of MDCT the imaging time for trauma patients has been significantly reduced to several seconds, allowing more time for appropriate post-diagnosis care. CONCLUSION: High-quality multiplanar and volumetric reformatted CT images greatly improve the detection of injuries and enhance the understanding of mechanisms of trauma-related abnormalities.
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Paydar S, Johari HG, Ghaffarpasand F, Shahidian D, Dehbozorgi A, Ziaeian B, Bolandparvaz S, Abbasi HR, Sharifian M. The role of routine chest radiography in initial evaluation of stable blunt trauma patients. Am J Emerg Med 2010; 30:1-4. [PMID: 21056925 DOI: 10.1016/j.ajem.2010.08.010] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2010] [Revised: 08/12/2010] [Accepted: 08/19/2010] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Radiology plays an important role in evaluation of a trauma patient. Although chest radiography is recommended for initial evaluation of the trauma patient by the Advanced Trauma Life Support course, we hypothesized that precise physical examinations and history taking accurately identify those blunt trauma patients at low risk for chest injury, making routine radiographs unnecessary. Thus, this study was performed to investigate the role of chest radiography in initial evaluation of those trauma patients with normal physical examination. METHODS In this prospective cross-sectional study, all the hemodynamically stable blunt trauma patients with negative physical examination result referred to our trauma center during a 4-month period (March-June 2009) were included. Chest radiographies were performed and reviewed for abnormalities. RESULTS During the study period, 5091 blunt trauma patients referred to our center, out of which, 1008 were hemodynamically stable and had negative physical examination result. Only 1 (0.1%) patient had abnormal chest radiography that showed perihilar lymphadenopathy, unrelated to trauma. CONCLUSION Performing routine chest radiography in stable blunt trauma patients is of low clinical value. Thus, decision making for performing chest radiography in blunt trauma patients based on clinical findings would be efficacious and resource saving.
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Affiliation(s)
- Shahram Paydar
- Nemazee Hospital affiliated with Shiraz University of Medical Sciences, Shiraz, Iran
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Abstract
Thoracic injuries are very common among trauma victims. This article reviews the current literature on the management of multiple aspects of the care of the patient with severe chest injury. The mechanics of chest injury are complex and varied. Chest wall injuries are the most common and noticeable manifestation of thoracic trauma. Overall morbidity and mortality are primarily determined by associated injuries. New ventilatory strategies permit oxygenation of the severely hypoxic patient. Acute pain management modalities offer the potential of decreasing associated pulmonary complications. Surgical chest wall fixation is clearly indicated in extreme cases of pulmonary herniation and chest wall disruption. There are potential benefits of surgical fixation in other settings, although further trials are needed.
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Huang YK, Lu MS, Liu KS, Liu EH, Chu JJ, Tsai FC, Lin PJ. Traumatic pericardial effusion: impact of diagnostic and surgical approaches. Resuscitation 2010; 81:1682-6. [PMID: 20692760 DOI: 10.1016/j.resuscitation.2010.06.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Revised: 06/20/2010] [Accepted: 06/27/2010] [Indexed: 10/19/2022]
Abstract
INTRODUCTION In trauma patients with chest injuries, traumatic pericardial effusion is an important scenario to consider because of its close linkage to cardiac injury. Even with advances in imaging, diagnosis remains a challenge and use of which surgical approach is controversial. This study reviews the treatment algorithm, surgical outcomes, and predictors of mortality for traumatic pericardial effusion. PATIENTS AND METHODS Information on demographics, mechanisms of trauma, injury scores, diagnostic tools, surgical procedures, associated injuries, and hospital events were collected retrospectively from a tertiary trauma center. RESULTS Between June 2003 and December 2009, 31 patients (23 males and 8 females) with a median age of 31 (range 16-77), who had undergone surgical drainage of pericardial effusion were enrolled in the study. Blunt trauma accounted for 27 (87.1%) insults, and penetrating injury accounted for 4 (12.9%). Patients were diagnosed by Focused Assessment with Sonography for Trauma (FAST) (8 patients), computerized tomography (7 patients), echocardiography (9 patients), and incidentally during surgery (7 patients). Notably, sixteen (51.7%) patients required surgical repair for traumatic cardiac ruptures, including 6 (19.6%) with pericardial defects who presented initially with hemothorax. The surgical approaches were subxiphoid in 8 patients (25.8%), thoracotomy in 7 (22.6%), and sternotomy in 19 (61.2%), including 3 conversions from thoracotomy. The survival to discharge rate was 77.4% (24/31). Concomitant cardiac repair, associated pericardial defects, and initial surgical approach did not affect survival, but the need for massive transfusion, cardiopulmonary cerebral resuscitation (CPCR), trauma score, and incidental discovery at surgery all had a significant impact on the outcome. CONCLUSIONS Precise diagnoses of traumatic pericardial effusions are still challenging and easily omitted even with FAST, repeat cardiac echo and CT. The number of patients with traumatic pericardial effusion requiring surgical repair is high. Standardized therapeutic protocol, different surgical approaches have not impact on survival. Correct identification, prompt drainage, and preparedness for concomitant cardiac repair seem to be the key to better outcomes.
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Affiliation(s)
- Yao-Kuang Huang
- Division of Thoracic and Cardiovascular Surgery and Heart Failure Center, Chang Gung Memorial Hospital, Linkou Center, Chang Gung University, College of Medicine, Taiwan, ROC.
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Brink M, Deunk J, Dekker HM, Edwards MJR, Kool DR, van Vugt AB, van Kuijk C, Blickman JG. Criteria for the selective use of chest computed tomography in blunt trauma patients. Eur Radiol 2010; 20:818-28. [PMID: 19760233 PMCID: PMC2835690 DOI: 10.1007/s00330-009-1608-y] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2009] [Revised: 08/07/2009] [Accepted: 08/13/2009] [Indexed: 12/01/2022]
Abstract
PURPOSE The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury. METHODS This observational study prospectively included consecutive patients (>or=16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre. RESULTS We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age >or=55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <-3 mmol/l and haemoglobin <6 mmol/l). Of 855 patients with >or=1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant. CONCLUSION Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.
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Affiliation(s)
- Monique Brink
- Department of Radiology, Radboud University Nijmegen Medical Centre, Nijmegen, the Netherlands.
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Smith CB, Barrett TW, Berger CL, Zhou C, Thurman RJ, Wrenn KD. Prediction of blunt traumatic injury in high-acuity patients: bedside examination vs computed tomography. Am J Emerg Med 2010; 29:1-10. [PMID: 20825767 DOI: 10.1016/j.ajem.2009.05.025] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2009] [Accepted: 05/27/2009] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE The addition of spiral computed tomography (SCT) to bedside assessment in patients with major trauma may improve detection of significant injury. We hypothesized that in high-acuity trauma patients, emergency physicians' ability to detect significant injuries based solely on bedside assessment would lack the sensitivity needed to exclude serious injuries when compared with SCT. METHODS This was a prospective single-cohort study of high-acuity trauma patients routinely undergoing whole-body SCT at a level 1 trauma center from January to September 2006. Before SCT, emergency physicians assigned ratings for likelihood of injury to 5 body regions on the basis of bedside assessment. These ratings were compared with final SCT interpretations. RESULTS We enrolled 400 patients as a convenience sample; 71 were excluded. When a "very low" rating was considered negative and "low," "intermediate," "high," and "very high" were considered positive, emergency physicians were able to detect head, cervical spine, chest, abdominal/pelvic, and thoracic/lumbar spine injuries with sensitivities (95% confidence interval) of 100% (98.6%-100%), 97.4% (94.9%-98.8%), 96.9% (94.2%-98.4%), 97.9% (95.5%-99.1%), and 97.0% (94.3%-98.5%), respectively. For overall diagnostic accuracy, areas under the receiver operating characteristics curve (95% confidence interval) were 0.87 (0.82-0.92), 0.71 (0.62-0.81), 0.81 (0.76-0.86), 0.77(0.71-0.83), 0.74 (0.65-0.84), respectively. CONCLUSIONS Bedside assessment by emergency physicians before SCT was sensitive in ruling out serious injuries in high-acuity trauma patients with a "very low" rating for injury. However, overall diagnostic accuracy was low, suggesting that SCT should be considered in most high-acuity patients to prevent missing injuries.
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Affiliation(s)
- Clay B Smith
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN 37232-4700, USA.
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Rezende-Neto JB, Hoffmann J, Al Mahroos M, Tien H, Hsee LC, Spencer Netto F, Speers V, Rizoli SB. Occult pneumomediastinum in blunt chest trauma: clinical significance. Injury 2010; 41:40-3. [PMID: 19604507 DOI: 10.1016/j.injury.2009.06.161] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2009] [Revised: 06/16/2009] [Accepted: 06/16/2009] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Thoracic injuries are potentially responsible for 25% of all trauma deaths. Chest X-ray is commonly used to screen patients with chest injury. However, the use of computed tomography (CT) scan for primary screening is increasing, particularly for blunt trauma. CT scans are more sensitive than chest X-ray in detecting intra-thoracic abnormalities such as pneumothoraces and pneumomediastinums. Pneumomediastinum detected by chest X-ray or "overt pneumomediastinum", raises the concern of possible aerodigestive tract injuries. In contrast, there is scarce information on the clinical significance of pneumomediastinum diagnosed by CT scan only or "occult pneumomediastinum". Therefore we investigated the clinical consequences of occult pneumomediastinum in our blunt trauma population. METHODS A 2-year retrospective chart review of all blunt chest trauma patients with initial chest CT scan admitted to a level I trauma centre. Data extracted from the medical records include; demographics, occult, overt, or no pneumomediastinum, the presence of intra-thoracic aerodigestive tract injuries (trachea, bronchus, and/or esophagus), mechanism and severity of injury, endotracheal intubation, chest thoracostomy, operations and radiological reports by an attending radiologist. All patients with intra-thoracic aerodigestive tract injuries from 1994 to 2004 were also investigated. RESULTS Of 897 patients who met the inclusion criteria 839 (93.5%) had no pneumomediastinum. Five patients (0.6%) had overt pneumomediastinum and 53 patients (5.9%) had occult pneumomediastinum. Patients with occult pneumomediastinum had significantly higher ISS and AIS chest (p<0.0001) than patients with no pneumomediastinum. A chest thoracostomy tube was more common (p<0.0001) in patients with occult pneumomediastinum (47.2%) than patients with no pneumomediastinum (10.4%), as well as occult pneumothorax. None of the patients with occult pneumomediastinum had aerodigestive tract injuries (95%CI 0-0.06). Follow up CT scan of patients with occult pneumomediastinum showed complete resolution in all cases, in average 3 h after the initial exam. CONCLUSION Occult pneumomediastinum occurred in approximately 6% of all trauma patients with blunt chest injuries in our institution. Patients who had occult pneumomediastinum were more severely injured than those who without. However, none of the patients with occult pneumomediastinum had aerodigestive tract injuries and follow up chest CT scans demonstrated their complete and spontaneous resolution.
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Affiliation(s)
- J B Rezende-Neto
- Tory Regional Trauma Centre & Sunnybrook Health Sciences Centre, University of Toronto, ON, Canada
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Marraro GA, Denaro C, Spada C, Luchetti M, Giansiracusa C. Selective medicated (saline + natural surfactant) bronchoalveolar lavage in unilateral lung contusion. A clinical randomized controlled trial. J Clin Monit Comput 2009; 24:73-81. [PMID: 20012912 DOI: 10.1007/s10877-009-9213-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Accepted: 11/25/2009] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Open lung and low tidal volume ventilation appear to be a promising ventilation for chest trauma as it can reduce ARDS and improve outcome. Local therapy (e.g. BAL) can be synergic to remove from the lung the debris, mitigate inflammatory cascade and avoid damage spreading to not compromised lung areas. MATERIALS AND METHODS 44 pulmonary contused patients were randomized to receive broncho-suction and volume controlled low tidal volume ventilation-VCLTVV (Control Group) or the same ventilation plus medicated (saline + surfactant) BAL (Treatment Group). Tidal volume <10 ml/kg, PEEP of 10-12 cm H(2)O and PaO(2) 60-100 mm Hg and PaCO(2) 35-45 mm Hg were used in both groups. BAL was performed using a fiberscope. 4 boluses of 25 ml saline with 2.4 mg/ml of surfactant were introduced into each contused lobe in which, subsequently, 240 mg of surfactant was instilled. RESULTS All patients survived. In the Control Group 18 patients developed pneumonia, 5 ARDS and days of intubation were 11.50 (3.83) compared to 5.05 (1.21) of Treatment Group in which OI and PaO(2)/FiO(2) significantly improved from 36 h. CONCLUSIONS VCLTVV alone was not able to prevent ARDS and infection in the Control Group as the reduction of intubation. In the Treatment Group, VCLTVV and medicated BAL facilitated the removal of degradated lung material and recruited the contused lung regions, enabling the healing of the lung pathology.
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Affiliation(s)
- Giuseppe A Marraro
- Anesthesia and Intensive Care Department, A.O. Fatebenefratelli and Ophthalmiatric Hospital, Milan, Italy.
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Perry M. Maxillofacial trauma--developments, innovations and controversies. Injury 2009; 40:1252-9. [PMID: 19486969 DOI: 10.1016/j.injury.2008.12.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Revised: 12/07/2008] [Accepted: 12/17/2008] [Indexed: 02/02/2023]
Abstract
Despite seat belt and alcohol legislation, craniofacial trauma still remains a common health problem and significant workload in many maxillofacial units. Although management has evolved considerably from "wiring teeth together", complex fractures can still result in cosmetic and functional deformity. Today's challenge is to consistently restore patients back to their pre-injury form and function-but this is not always possible. Greater understanding and developments have significantly improved outcomes, although controversy still exists in some areas. This review outlines some of these topics.
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Affiliation(s)
- Michael Perry
- Consultant Oral and Maxillofacial Surgeon, Ulster Hospital, Dundonald, Belfast, Northern Ireland, UK.
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Stengel D, Frank M, Matthes G, Schmucker U, Seifert J, Mutze S, Wich M, Hanson B, Giannoudis PV, Ekkernkamp A. Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts? Injury 2009; 40 Suppl 4:S36-46. [PMID: 19895951 DOI: 10.1016/j.injury.2009.10.035] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Single-pass, whole-body computed tomography (pan-CT) was proposed in the late 1990s as a new concept for the diagnostic work-up of severely injured patients. Since its introduction, it has led to considerable debate among clinicians and scientists, triggered by concerns about its immediate safety, questionable therapeutic advantages and exposure to radiation. However, it was recently shown that pan-CT scanning may be associated with a reduction in trauma mortality. In this article, we provide an overview of current knowledge of the value of this compelling concept. The diagnostic accuracy of multidetector row CT (MDCT) for clearing various anatomical regions in trauma patients is, at best, unclear. Little is known about the accuracy of pan-CT as a whole, which weakens statements about its effectiveness and prevents inferences about survival advantages. This last point may be explained by a stage-migration or "Will Rogers" phenomenon: Pan-CT increases injury severity by detecting lesions that would not have been recognized by conventional methods but still do not affect treatment decisions, thus artificially lowering the ratio of observed to expected deaths. In order to maintain the credibility of pan-CT technology for trauma, a rigorous, large-scale evaluation of its accuracy is required. Such an evaluation requires consensus about the definition of true and false positive and negative findings in the setting of blunt multiple trauma. In addition, triage criteria need to be refined to increase specificity and reduce the number of unnecessary scans.
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Affiliation(s)
- Dirk Stengel
- Dept of Trauma and Orthopaedic Surgery, Unfallkrankenhaus Berlin and University of Greifswald, Germany.
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Predictors of abnormal chest CT after blunt trauma: a critical appraisal of the literature. Clin Radiol 2009; 64:272-83. [DOI: 10.1016/j.crad.2008.09.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2008] [Revised: 09/15/2008] [Accepted: 09/21/2008] [Indexed: 01/07/2023]
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Brink M, Deunk J, van Tongeren P, Blickman JG. Observational research in trauma radiology: should patients be informed? J Am Coll Radiol 2008; 6:51-7. [PMID: 19111272 DOI: 10.1016/j.jacr.2008.07.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2008] [Indexed: 10/21/2022]
Abstract
The need for prospective studies in trauma radiology emerges as knowledge on the appropriate use of imaging becomes increasingly important in this field. Prospective observational studies enroll patients after research questions are articulated but only observe medical practice and should not compromise or change patient treatment. However, controversy exists regarding the requirement of informed consent from trauma patients in this type of study. This is reflected not only in differences in reporting informed consent in recent scientific publications on trauma radiology but also by the fact that policies regarding this topic vary in different parts of the world. The authors consider whether requesting informed consent is appropriate in prospective observational studies in trauma radiology from practical and different ethical perspectives.
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Affiliation(s)
- Monique Brink
- Department of Diagnostic Imaging, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands.
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Kaewlai R, Avery LL, Asrani AV, Novelline RA. Multidetector CT of blunt thoracic trauma. Radiographics 2008; 28:1555-70. [PMID: 18936021 DOI: 10.1148/rg.286085510] [Citation(s) in RCA: 179] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Thoracic injuries are significant causes of morbidity and mortality in trauma patients. These injuries account for approximately 25% of trauma-related deaths in the United States, second only to head injuries. Radiologic imaging plays an important role in the diagnosis and management of blunt chest trauma. In addition to conventional radiography, multidetector computed tomography (CT) is increasingly being used, since it can quickly and accurately help diagnose a wide variety of injuries in trauma patients. Furthermore, multiplanar and volumetric reformatted CT images provide improved visualization of injuries, increased understanding of trauma-related diseases, and enhanced communication between the radiologist and the referring clinician.
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Affiliation(s)
- Rathachai Kaewlai
- Division of Emergency Radiology, Department of Radiology, Massachusetts General Hospital, Boston, MA 02114, USA.
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An evaluation of a Shockroom located CT scanner: a randomized study of early assessment by CT scanning in trauma patients in the bi-located trauma center North-West Netherlands (REACT trial). BMC Emerg Med 2008; 8:10. [PMID: 18721455 PMCID: PMC2532999 DOI: 10.1186/1471-227x-8-10] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2008] [Accepted: 08/22/2008] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Trauma is a major source of morbidity and mortality, especially in people below the age of 50 years. For the evaluation of trauma patients CT scanning has gained wide acceptance in and provides detailed information on location and severity of injuries. However, CT scanning is frequently time consuming due to logistical (location of CT scanner elsewhere in the hospital) and technical issues. An innovative and unique infrastructural change has been made in the AMC in which the CT scanner is transported to the patient instead of the patient to the CT scanner. As a consequence, early shockroom CT scanning provides an all-inclusive multifocal diagnostic modality that can detect (potentially life-threatening) injuries in an earlier stage, so that therapy can be directed based on these findings. METHODS/DESIGN The REACT-trial is a prospective, randomized trial, comparing two Dutch level-1 trauma centers, respectively the VUmc and AMC, with the only difference being the location of the CT scanner (respectively in the Radiology Department and in the shockroom). All trauma patients that are transported to the AMC or VUmc shockroom according to the current prehospital triage system are included. Patients younger than 16 years of age and patients who die during transport are excluded. Randomization will be performed prehospitally. Study parameters are the number of days outside the hospital during the first year following the trauma (primary outcome), general health at 6 and 12 months post trauma, mortality and morbidity, and various time intervals during initial evaluation. In addition a cost-effectiveness analysis of this shockroom concept will be performed. Regarding primary outcome it is estimated that the common standard deviation of days spent outside of the hospital during the first year following trauma is a total of 12 days. To detect an overall difference of 2 days within the first year between the two strategies, 562 patients per group are needed. (alpha 0.95 and beta 0.80). DISCUSSION The REACT-trial will provide evidence on the effects of a strategy involving early shockroom CT scanning compared with a standard diagnostic imaging strategy in trauma patients on both patient outcome and operations research. TRIAL REGISTRATION ISRCTN55332315.
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