Multidetector Computed Tomography and Blunt Thoracoabdominal Trauma

Blunt liver trauma: effectiveness and evolution of non-operative management (NOM) in 145 consecutive cases

In recent decades, haemodynamically stable patients with traumatic liver injuries have been managed conservatively. The primary aim of this study is to retrospectively analyse the outcomes of the authors' approach to blunt hepatic trauma according to the degree of injury. The secondary aim is to analyse the changes in the decision-making process for blunt liver trauma management over the last 10 years. A total of 145 patients with blunt liver trauma managed by one trauma team were included in the study. Causes, sites and grades of injury, clinical conditions, ultrasonography and CT results, associated injuries, laboratory data, types of treatment (surgical or non-operative management/NOM), blood transfusions, complications, and lengths of hospitalization were recorded and analysed. A total of 85.5% of patients had extrahepatic injuries. The most frequently involved liver segments were VII (50.3%), VI (48.3%) and V (40.7%). The most common injury was grade III OIS (40.6%). Fifty-nine patients (40.7%) were treated surgically, with complications in 23.7% of patients, whereas 86 patients (59.3%) underwent NOM, with a complication rate of only 10.5%. The evolution over the last 10 years showed an overall increase in the NOM rate. This clinical experience confirmed that NOM was the most appropriate therapeutic choice for blunt liver trauma even in high-grade injuries and resulted in a 100% effectiveness rate with a 0% rate of conversion to surgical treatment. The relevant increase in the use of NOM did not influence the effectiveness or safety levels over the last 10 years; this was certainly related to the increasing experience of the team and the meticulous selection and monitoring of patients.

The Importance of the Mediastinal Triangle in Traumatic Lesions of the Aorta

Background: Trauma-induced aortic injuries continue to be an important factor in morbimortality in patients with blunt trauma. Objectives: To determine the characteristics of aortic lesions in patients with closed thoracic trauma and associated thoracic injuries. Methods: Multicenter cohort study conducted during the years 1994 to 2014 in the radiology service in the University Hospital Complex of A Coruña. Patients >15 years with closed thoracic trauma were included. Sociodemographic and clinical variables were studied in order to determine the lesion cause, location, and degree. Results: We analyzed 232 patients with a mean age of 46.9 ± 18.7 years, consisting of 81.4% males. The most frequent location was at the level of the isthmus (55.2%). The most frequent causes of injury were traffic accidents followed by falls. Patients with aortic injury had more esophageal, airway, and cardiopericardial lesions. More than 85% of the patients had lung parenchyma and/or chest wall injury, which was more prevalent among those who did not have an aortic lesion. Conclusions: Patients with trauma due to traffic accidents or being run over presented three times more risk of aortic injury than from other causes. Those with an aortic lesion also had a higher frequency of cardiopericardial, airway, and esophageal lesions.

The management of pancreatic injuries

Pancreatic injuries are relatively uncommon, but considerable morbidity and mortality may result if associated vascular and duodenal injuries are present or if the extent of the injury is underestimated and appropriate intervention is delayed. Optimal management includes the need for early diagnosis and accurate definition of the site and extent of injury. Prognosis is influenced by the cause and complexity of the pancreatic injury, the amount of blood lost, duration of shock, the rapidity of resuscitation and the quality and appropriateness of surgical intervention. Early mortality results from uncontrolled or major bleeding due to associated injuries while late mortality is generally a consequence of infection or multiple organ failure. Initial management of pancreatic trauma is similar to that of any patient with a severe abdominal injury. Stable patients with a suspected pancreatic injury should have non-invasive imaging including a CT scan or MRI. Urgent laparotomy is required in patients with evidence of major intraperitoneal bleeding, associated visceral trauma, or peritonitis. Operative intervention is guided by the integrity of the main pancreatic duct. External drainage is adequate for parenchymal injuries with an intact duct, while duct injuries of the neck, body and tail require a distal pancreatectomy. Pancreatic head injuries are more complex. If the duodenum is reparable and the ampulla is intact, external drainage suffices. Rarely, complex injuries may require a pancreatoduodenectomy after damage control surgery if the patient has multiple injuries and is unstable. Postoperative pancreatic complications including fistula and pseudocysts are common but can usually be treated endoscopically.

Investigation of complications secondary to chest compressions before and after the 2010 cardiopulmonary resuscitation guideline changes by using multi-detector computed tomography: a retrospective study

Background

The purpose of this study was to identify the relationship between the deeper and faster chest compressions suggested by the 2010 cardiopulmonary resuscitation guidelines and complications arising from chest compressions, using multi-detector computed tomography.

Methods

We performed a retrospective analysis of prospective registry data. This study was conducted with in- and out-of-hospital cardiac arrest patients who underwent successful resuscitation in the emergency departments of two academic tertiary care centres from October 2006 to September 2010 (pre-2010 group) and from October 2011 to September 2015 (post-2010 group). We examined chest injuries related to chest compressions, classified as follows: rib fracture, sternal fracture, and other uncommon complications.

Results

We enrolled 185 patients in this study. The most frequent complication to occur in both groups was rib fracture: 27 (62.8%) and 112 (78.9%) patients in the pre-2010 and post-2010 groups, respectively (p = 0.03). However, we observed no statistical differences in sternum fracture, the second most common complication (p = 0.80). Retrosternal and mediastinal haematoma were not reported in the pre-2010 group but 13 patients (9.1%) in the post-2010 group were reported to have haematoma (p = 0.04). Nine serious, life-threatening complications occurred, all in the post-2010 group. Among the younger group (less than 65 years old), 8 (38.1%) patients in the pre-2010 group and 40 (64.5%) in the post-2010 group sustained rib fractures.

Discussion

The deeper and faster chest compressions for enhancing ROSC are associated with increased occurrence of complications. Additional studies are needed to compensate for the limitations of our study design.

Conclusions

This study found that the 2010 guidelines, recommending deeper and faster chest compressions, led to an increased proportion of rib fractures and retrosternal and mediastinal haematoma.

Comparison of complications secondary to cardiopulmonary resuscitation between out-of-hospital cardiac arrest and in-hospital cardiac arrest

OBJECTIVE

The aim of this study was to assess whether there was a significant difference in the complications of cardiopulmonary resuscitation (CPR) between out-of-hospital cardiac arrest (OHCA) and in-hospital cardiac arrest (IHCA) survivors using multidetector computed tomography (MDCT).

SUBJECTS AND METHODS

We performed a retrospective analysis of prospective registry data. We enrolled both OHCA and IHCA patients who underwent successful CPR. We classified chest injuries secondary to chest compression into rib fractures, sternum fractures, and uncommon complications such as lung contusions and extrathoracic complications. We compared these complications according to CPR locations. We also analysed risk factors for CPR complications using multiple regression analysis and classification and regression tree analysis.

RESULTS

During the study period, a total of 148 patients were included in the primary analysis. Rib fractures were detected more in OHCA survivors than in IHCA survivors (74 patients (83.2%) vs. 37 patients (62.7%), p=0.05), and frequency of multiple rib fractures was higher in OHCA survivors than IHCA survivors (69 patients (77.5%) vs. 34 patients (57.6%), p=0.01). Although other complications were not significantly different between the groups, there was a trend for OHCA survivors to sustain more serious and direct high-energy related complications. Older age, longer CPR, and OHCA were significantly associated with incidence of rib fractures, multiple rib fractures, and number of rib fractures.

CONCLUSIONS

Rib fractures were more likely to occur in OHCA survivors, and serious complications tended to occur more often in OHCA compared to IHCA survivors.

Imaging of Pancreatic and Duodenal Trauma

Pancreatic and duodenal injuries are rare but life-threatening occurrences, often occurring in association with other solid organ injuries. Findings of pancreatic and duodenal trauma on computed tomography and MR imaging are often nonspecific, and high levels of clinical suspicion and understanding of mechanism of injury are imperative. Familiarity with the grading schemes of pancreatic and duodenal injury is important because they help in assessing for key imaging findings that directly influence management. This article presents an overview of imaging of blunt and penetrating pancreatic and duodenal injuries, including pathophysiology, available imaging techniques, and variety of imaging features.

Multidetector computer tomography: evaluation of blunt chest trauma in adults

Imaging plays an essential part of chest trauma care. By definition, the employed imaging technique in the emergency setting should reach the correct diagnosis as fast as possible. In severe chest blunt trauma, multidetector computer tomography (MDCT) has become part of the initial workup, mainly due to its high sensitivity and diagnostic accuracy of the technique for the detection and characterization of thoracic injuries and also due to its wide availability in tertiary care centers. The aim of this paper is to review and illustrate a spectrum of characteristic MDCT findings of blunt traumatic injuries of the chest including the lungs, mediastinum, pleural space, and chest wall.

Blunt hepatic trauma: comparison between surgical and nonoperative treatment

OBJECTIVE

To examine the outcomes of blunt hepatic trauma, and compare surgical and non-surgical treatment in patients admitted with hemodynamic stability and with no obvious indications of laparotomy.

METHODS

This is a retrospective study of cases admitted to a university teaching hospital between the years 2000 and 2010. Patients undergoing surgical treatment were divided into two groups: (a) all patients undergoing surgical treatment, and (b) patients with obvious need for surgery.

RESULTS

In this period, 120 patients were admitted with blunt hepatic trauma. Sixty five patients (54.1%) were treated non-operatively and fifty five patients were operated upon. Patients treated non-operatively had better physiologic conditions on admission, demonstrated less severe injuries (except the grade of hepatic injury), received less blood components and had lower morbidity and mortality than the patients operated upon. Patients who underwent non-operative treatment had a lower need for blood transfusion but higher rates of complications and mortality than the patients operated upon. Patients who were operated upon, with no obvious indications for surgery, had higher rates of complication and mortality than patients not operated upon.

CONCLUSION

A non-operative approach resulted in lower complications, a lower need for blood transfusions and lower mortality.

Nonoperative management for patients with grade IV blunt hepatic trauma

Introduction

The treatment of complex liver injuries remains a challenge. Nonoperative treatment for such injuries is increasingly being adopted as the initial management strategy. We reviewed our experience, at a University teaching hospital, in the nonoperative management of grade IV liver injuries with the intent to evaluate failure rates; need for angioembolization and blood transfusions; and in-hospital mortality and complications.

Methods

This is a retrospective analysis conducted at a single large trauma centre in Brazil. All consecutive, hemodynamically stable, blunt trauma patients with grade IV hepatic injury, between 1996 and 2011, were analyzed. Demographics and baseline characteristics were recorded. Failure of nonoperative management was defined by the need for surgical intervention. Need for angioembolization and transfusions, in-hospital death, and complications were also assessed

Results

Eighteen patients with grade IV hepatic injury treated nonoperatively during the study period were included. The nonoperative treatment failed in only one patient (5.5%) who had refractory abdominal pain. However, no missed injuries and/or worsening of bleeding were observed during the operation. None of the patients died nor need angioembolization. No complications directly related to the liver were observed. Unrelated complications to the liver occurred in three patients (16.7%); one patient developed a tracheal stenosis (secondary to tracheal intubation); one had pleural effusion; and one developed an abscess in the pleural cavity. The hospital length of stay was on average 11.56 days.

Conclusions

In our experience, nonoperative management of grade IV liver injury for stable blunt trauma patients is associated with high success rates without significant complications.

Multidetector computed tomography of chest trauma: indications, technique and interpretation

Background

Chest traumas are a significant cause of mortality and morbidity, especially in the younger population.MethodsDiagnostic imaging plays a key role in their management. Multidetector computed tomography (MDCT) is the most important imaging method in this field. Its advantages include especially high speed and high geometric resolution in any plane.ResultsThe method allows us to view large parts of the body with minimal motion artifacts and to create accurate multiplanar and three-dimensional (3D) reformations, which make the diagnosis significantly more accurate. Because of its advantages MDCT has become the first-choice method in high-energy traumas.ConclusionThis article summarises the position of MDCT in the diagnostic algorithm of chest injuries, technical aspects of the examination and imaging findings in traumas of the individual chest compartments.

Teaching Points

• Diagnostic imaging plays a key role in the management of high-energy chest trauma.

• MDCT is the most important imaging method in this kind of injury, as detailed information can be acquired in a short acquisition time.

• Multiplanar and three-dimensional (3D) reformattings make the diagnosis significantly more accurate.

Changing patterns in diagnostic strategies and the treatment of blunt injury to solid abdominal organs

Background

In recent years there has been increasing interest shown in the nonoperative management (NOM) of blunt traumatic injury. The growing use of NOM for blunt abdominal organ injury has been made possible because of the progress made in the quality and availability of the multidetector computed tomography (MDCT) scan and the development of minimally invasive intervention options such as angioembolization.

Aim

The purpose of this review is to describe the changes that have been made over the past decades in the management of blunt trauma to the liver, spleen and kidney.

Results

The management of blunt abdominal injury has changed considerably. Focused assessment with sonography for trauma (FAST) examination has replaced diagnostic peritoneal lavage as diagnostic modality in the primary survey. MDCT scanning with intravenous contrast is now the gold standard diagnostic modality in hemodynamically stable patients with intra-abdominal fluid detected with FAST. One of the current discussions in the literature is whether a whole body MDCT survey should be implemented in the primary survey.

A comparison of the diagnostic performances of visceral organ-targeted versus spine-targeted protocols for the evaluation of spinal fractures using sixteen-channel multidetector row computed tomography: is additional spine-targeted computed tomography necessary to evaluate thoracolumbar spinal fractures in blunt trauma victims?

BACKGROUND

It remains to be determined whether spine-targeted computed tomography (thoracolumbar spine computed tomography [TLS-CT]) images and visceral organ-targeted CT (abdominopelvic [AP]-CT) images are comparable for the evaluation of thoracolumbar spinal fractures using 16-channel multidetector row CT. The elimination of an additional spine-targeted CT protocol would substantially reduce time, the storage burden, and potential patient radiation exposure.

METHODS

A total of 420 vertebrae in 72 consecutive patients who underwent AP-CT to assess blunt traumatic injury and an additional CT examination using a TLS-CT protocol to evaluate spinal fractures were retrospectively evaluated. The AP-CT set (set A, reconstructed with using a wide display field of view [FOV] and a soft algorithm) and the TLS-CT set (set S, reconstructed using a narrow display FOV and a hard algorithm) were composed of axial plus reformatted sagittal or coronal images or both. Three radiologists independently reviewed all CT data retrospectively. Performances for detecting and typing fractures were compared by using areas under receiver operating characteristic curves and by determining concordance rates.

RESULTS

The overall areas under the curves for sets S and A for fracture detection were 0.996 and 0.995, respectively; no significant difference was found between the two sets. Concordance rates for typing performance also showed no statistical significance between the two sets for any of the three observers.

CONCLUSION

Sixteen-channel multidetector row CT images reconstructed using a soft algorithm and a wide display FOV that cover the entire abdomen using a visceral organ-targeted protocol with 1.5-mm collimation are sufficient for the evaluation of spine fractures in trauma patients, given that multiplanar-reformatted images are provided.

Abdominal trauma: from operative to nonoperative management

The nonoperative care of intraabdominal trauma in the polytraumatised patient greatly depends on imaging techniques. The haemodynamically unstable patient should undergo expedient sonography to rule out abdominal haemorrhage. The use of computer tomography (CT) in this difficult patient group is also currently evaluated, however it takes specific amendments to the protocol and institution. In the hemodynamically stable patient however, computer tomography is the modality of choice to evaluate the injured abdomen. Nonoperative treatment can be successful in up to 80% of selected cases. Adjuncts to nonoperative care include embolisation of the spleen and liver in cases of arterial bleeding, and endoscopic retrograde cholangio pancreaticography (ERCP) and stenting for injuries to the biliary tree.

Traumatic Retroperitoneal Injuries: Review of Multidetector CT Findings

Multidetector computed tomography (CT) represents a significant advance in CT technology and can allow the accurate assessment of trauma patients, including the detection of traumatic retroperitoneal injuries, many of which are clinically occult. Retroperitoneal injuries include duodenal, pancreatic, vascular, renal, and adrenal injuries. Abnormal blood, fluid, or air within the retroperitoneal spaces may be isolated findings but can also occur in association with these injuries, and their recognition is the key to correctly identifying the injury. Accurate characterization of injury with CT can affect clinical management and can help minimize unnecessary laparotomies. Equivocal findings at initial abdominal CT should prompt close clinical follow-up with possible imaging follow-up, particularly for suspected occult duodenal and pancreatic injuries.

Diagnosis and classification of pancreatic and duodenal injuries in emergency radiology

Pancreatic and duodenal injuries after blunt abdominal trauma are rare; however, delays in diagnosis and treatment can significantly increase morbidity and mortality. Multidetector computed tomography (CT) has a major role in early diagnosis of pancreatic and duodenal injuries. Detecting the often subtle signs of injury with whole-body CT can be difficult because this technique usually does not include a dedicated protocol for scanning the pancreas. Specific injury patterns in the pancreas and duodenum often have variable expression at early posttraumatic multidetector CT: They may be hardly visible, or there may be considerable exudate, hematomas, organ ruptures, or active bleeding. An accurate multidetector CT technique allows optimized detection of subtle abnormalities. In duodenal injuries, differentiation between a contusion of the duodenal wall or mural hematoma and a duodenal perforation is vital. In pancreatic injuries, determination of involvement of the pancreatic duct is essential. The latter conditions require immediate surgical intervention. Use of organ injury scales and a surgical classification adapted for multidetector CT enables classification of organ injuries for trauma scoring, treatment planning, and outcome control. In addition, multidetector CT reliably demonstrates potential complications of duodenal and pancreatic injuries, such as posttraumatic pancreatitis, pseudocysts, fistulas, exudates, and abscesses.

Management of pancreatic trauma

BACKGROUND

Pancreatic injury can pose a formidable challenge to the surgeon, and failure to manage it correctly may have devastating consequences for the patient. Management options for pancreatic trauma are reviewed and technical issues highlighted.

METHOD

The English-language literature on pancreatic trauma from 1970 to 2006 was reviewed.

RESULTS AND CONCLUSIONS

Most pancreatic injuries are minor and can be treated by external drainage. Injuries involving the body, neck and tail of the pancreas, and with suspicion or direct evidence of pancreatic duct disruption, require distal pancreatectomy. Similar injuries affecting the head of the pancreas are best managed by simple external drainage, even if there is suspected pancreatic duct injury. Pancreaticoduodenectomy should be reserved for extensive injuries to the head of the pancreas, and should be practised as part of damage control. Most complications should initially be treated by a combination of nutrition, percutaneous drainage and endoscopic stenting.

The role of negative CT of the abdomen and pelvis in the decision to admit adults from the emergency department after blunt trauma

RATIONALE AND OBJECTIVES

Computed tomography (CT) is widely used in the initial evaluation of blunt trauma patients and is associated with a high rate of negative imaging. A described benefit of negative imaging is prompt discharge. This study examined a single level 1 trauma center to determine whether adult blunt trauma patients are discharged from the emergency department (ED) after negative CT of the abdomen and pelvis (CT AP).

MATERIALS AND METHODS

The authors retrospectively created a data set of adult blunt trauma patients who received CT AP in the ED from August to November 2003. Statistical analysis of admission rates on the basis of positivity or negativity on CT AP was performed to determine if the test influenced admission rates. Additional subgroup analysis was made between the patients admitted with negative CT AP and those who were discharged from the ED.

RESULTS

Two thirds (316/469) had negative CT AP. Whereas 80.4% of the patients (254/316) with negative CT AP were admitted, 98.0% (148/151) with positive CT AP were admitted, a statistically significant difference in admission rate (P < .0001). The vast majority (208/254, 81.9%) of patients with negative CT AP were admitted for extra-abdominal injuries. There was no statistical difference in the characteristics of a subgroup of 45 patients who were admitted without any documented injuries from the group discharged from the ED in terms of age, gender, comorbidity, Glasgow Coma Scale score, or intoxication.

CONCLUSION

Under current practice, negative CT AP after blunt trauma results in a statistically significant decrease in admissions.

CT of blunt pancreatic trauma: a pictorial essay

Blunt trauma to pancreas is uncommon and clinical features are often non-specific and unreliable leading to possible delays in diagnosis and therefore increased morbidity. CT has been established as the imaging modality of choice for the diagnosis of abdominal solid-organ injury in the blunt trauma patient. The introduction of multidetector-row CT allows for high resolution scans and multiplanar reformations that improve diagnosis. Detection of pancreatic injuries on CT requires knowledge of the subtle changes produced by pancreatic injury. The CT appearance of pancreatic injury ranges from a normal initial appearance of the pancreas to active pancreatic bleeding. Knowledge of CT signs of pancreatic trauma and a high index of suspicion is required in diagnosing pancreatic injury.

Blunt traumatic injuries of the lung parenchyma, pleura, thoracic wall, and intrathoracic airways: multidetector computer tomography imaging findings

This pictorial review discusses multi-detector computed tomography (MDCT) cases of non-vascular traumatic chest injuries, with a brief clinical and epidemiological background of each of the pathology. The purpose of this review is to familiarize the reader with common and rare imaging patterns of chest trauma and substantiate the advantages of MDCT as a screening and comprehensive technique for the evaluation of these patients. Images from a level 1 trauma center were reviewed to illustrate these pathologies. Pulmonary laceration, pulmonary hernia, and their different degrees of severity are illustrated as examples of parenchymal traumatic lesions. Pleural space abnormalities (pneumothorax and hemothorax) and associated complications are shown. Diaphragmatic rupture, fracture of the sternum, sternoclavicular dislocation, fracture of the scapula, rib fracture, and flail chest are shown as manifestations of blunt trauma to the chest wall. Finally, direct and indirect imaging findings of intrathoracic airway rupture and post-traumatic foreign bodies are depicted. The advantage of high quality reconstructions, volume rendered images, and maximal intensity projection for the detection of severe complex traumatic injuries is stressed. The limitations of the initial chest radiography and the benefits of MDCT authenticate this imaging technique as the best modality in the diagnosis of chest trauma.

Blunt traumatic abdominal aortic rupture: CT imaging

Blunt abdominal aortic trauma is a rare but potentially lethal event. It is commonly associated with high-speed motor vehicle accidents. Intimal flap, thrombosis, and pseudoaneurysm of the abdominal aorta are the more common findings. We present a case of blunt abdominal aortic trauma in which CT disclosed free aortic rupture with intraabdominal bleeding and a huge retroperitoneal hematoma, an extremely rare finding among patients reaching the hospital alive, due to its high and immediate mortality rate.

Diaphragmatic rupture: a frequently missed injury in blunt thoracoabdominal trauma patients

In the US and Western Europe, trauma is the fourth most common cause of death and the leading cause of death in the population less than 45 years of age [Mullinix and Foley, J Comput Assist Tomogr 28(Suppl 1):S20-S27, 2004]. Diaphragmatic injuries occur in 0.8 to 8% of patients after blunt trauma (Gray H, The muscles of the thorax. Anatomy of the human body. Lea & Febiger, Philadelphia, 1918) and may be a predictor of severity of injury in the blunt trauma patient [Worthy et al., Radiology 194(3):885-888, 1995]. The clinical diagnosis of diaphragmatic rupture (DR) is difficult and is missed in anywhere from 7 to 66% of patients [Cantwell, Radiology 238(2):752-753, 2006]. The accurate diagnosis and prognosis of this pathology depend on a complete knowledge of the clinical and radiological presentation. Computed tomography is the imaging modality of choice in the assessment of patients with clinical or radiographic findings suggestive of DR.

Multidetector CT Angiography of the Abdomen

Multidetector CT angiography (MDCTA) is redefining traditional imaging strategies of the vascular structures of the abdomen. Angiographic depiction of normal and variant anatomy is becoming the standard for evaluation and has a significant impact in transplant and oncologic surgery. MDCTA is increasingly being used for assessing diseases affecting the vasculature of the abdominal organs, including the abdominal aorta for treatment planning and post therapy follow-up.