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Galan D, Caban KM, Singerman L, Braga TA, Paes FM, Katz DS, Munera F. Trauma and 'Whole' Body Computed Tomography: Role, Protocols, Appropriateness, and Evidence to Support its Use and When. Radiol Clin North Am 2024; 62:1063-1076. [PMID: 39393850 DOI: 10.1016/j.rcl.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/13/2024]
Abstract
Imaging plays a crucial role in the immediate evaluation of the trauma patient, particularly using multi-detector computed tomography (CT), and especially in moderately to severely injured trauma patients. There are specific areas of relative consensus, while other aspects of whole-body computed tomography (WB-CT) use remain controversial and are subject to opinion/debate based on the current literature. Even a few hours of a delayed diagnosis may result in a detrimental outcome for the patient. One must utilize all the tools available to enhance the interpretation of images. It is also important to recognize imaging pitfalls and artifacts to avoid unnecessary intervention.
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Affiliation(s)
- Daniela Galan
- Department of Radiology, Jackson Memorial Hospital, University of Miami-Miller School of Medicine, 1611 Northwest 12th Avenue, West Wing 279, Miami, FL 33136, USA.
| | - Kim M Caban
- Department of Radiology, Jackson Memorial Hospital, University of Miami-Miller School of Medicine, 1611 Northwest 12th Avenue, West Wing 279, Miami, FL 33136, USA
| | - Leandro Singerman
- Department of Radiology, Jackson Memorial Hospital, University of Miami-Miller School of Medicine, 1611 Northwest 12th Avenue, West Wing 279, Miami, FL 33136, USA
| | - Thiago A Braga
- Department of Radiology, Jackson Memorial Hospital, University of Miami-Miller School of Medicine, 1611 Northwest 12th Avenue, West Wing 279, Miami, FL 33136, USA
| | - Fabio M Paes
- Department of Radiology, Jackson Memorial Hospital, University of Miami-Miller School of Medicine, 1611 Northwest 12th Avenue, West Wing 279, Miami, FL 33136, USA
| | - Douglas S Katz
- Department of Radiology, NYU Grossman Long Island School of Medicine, NYU Langone Hospital - Long Island, 259 First Street, Mineola, NY 11501, USA
| | - Felipe Munera
- Department of Radiology, Jackson Memorial Hospital, University of Miami-Miller School of Medicine, 1611 Northwest 12th Avenue, West Wing 279, Miami, FL 33136, USA
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Meyer HJ, Dermendzhiev T, Hetz M, Osterhoff G, Kleber C, Denecke T, Henkelmann J, Werdehausen R, Hempel G, Struck MF. Body composition parameters in initial CT imaging of mechanically ventilated trauma patients: Single-centre observational study. J Cachexia Sarcopenia Muscle 2024. [PMID: 39185615 DOI: 10.1002/jcsm.13578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Revised: 06/13/2024] [Accepted: 08/06/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND Body composition parameters provide relevant prognostic significance in critical care cohorts and cancer populations. Published results regarding polytrauma patients are inconclusive to date. The goal of this study was to analyse the role of body composition parameters in severely injured trauma patients. METHODS All consecutive patients requiring emergency tracheal intubation and mechanical ventilation before initial computed tomography (CT) at a level-1 trauma centre over a 12-year period (2008-2019) were reanalysed. The analysis included CT-derived body composition parameters based upon whole-body trauma CT as prognostic variables for 30-day mortality, intensive care unit length of stay (ICU LOS) and mechanical ventilation duration. RESULTS Four hundred seventy-two patients (75% male) with a median age of 49 years, median injury severity score of 26 and 30-day mortality rate of 22% (104 patients) met the inclusion criteria and were analysed. Regarding body composition parameters, 231 patients (49%) had visceral obesity, 75 patients had sarcopenia (16%) and 35 patients had sarcopenic obesity (7.4%). After adjustment for statistically significant univariable predictors age, body mass index, sarcopenic obesity, visceral obesity, American Society of Anesthesiologists classification ≥3, injury severity score and Glasgow Coma Scale ≤ 8 points, the Cox proportional hazard model identified sarcopenia as significant prognostic factor of 30-day mortality (hazard ratio 2.84; 95% confidence interval 1.38-5.85; P = 0.004), which was confirmed in Kaplan-Meier survival analysis (log-rank P = 0.006). In a subanalysis of 363 survivors, linear multivariable regression analysis revealed no significant associations of body composition parameters with ICU LOS and duration of mechanical ventilation. CONCLUSIONS In a multivariable analysis of mechanically ventilated trauma patients, CT-defined sarcopenia was significantly associated with 30-day mortality whereas no associations of body composition parameters with ICU LOS and duration of mechanical ventilation were observed.
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Affiliation(s)
- Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Tihomir Dermendzhiev
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Michael Hetz
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Georg Osterhoff
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Christian Kleber
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Jeanette Henkelmann
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Robert Werdehausen
- Department of Anesthesiology and Intensive Care, Medical Faculty, University of Magdeburg, Magdeburg, Germany
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Gunther Hempel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
| | - Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Leipzig, Germany
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Meyer HJ, Dermendzhiev T, Hetz M, Osterhoff G, Kleber C, Denecke T, Henkelmann J, Metze M, Werdehausen R, Hempel G, Struck MF. Coronary artery calcification detected by initial polytrauma CT in severely injured patients: retrospective single-center cohort study. Eur J Trauma Emerg Surg 2024; 50:1527-1536. [PMID: 38441580 PMCID: PMC11458666 DOI: 10.1007/s00068-024-02487-x] [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] [Received: 12/30/2023] [Accepted: 02/24/2024] [Indexed: 10/08/2024]
Abstract
OBJECTIVES Coronary artery calcifications detected by computed tomography (CT) provide prognostic relevance for vascular disorders and coronary heart disease, whereas their prognostic relevance in severely injured trauma patients remains unclear. MATERIAL AND METHODS All consecutive trauma patients requiring emergency tracheal intubation before initial CT at a level-1 trauma center and admission to the intensive care unit (ICU) over a 12-year period (2008-2019) were reanalyzed. The Weston score, a semiquantitative method to quantify coronary calcifications, was evaluated as a prognostic variable based upon whole-body trauma CT analysis. RESULTS Four hundred fifty-eight patients (74.6% male) with a median age of 49 years, median injury severity score of 26 points, 24-h mortality rate of 7.6%, and 30-day mortality rate of 22.1% met the inclusion criteria and were analyzed. Coronary artery calcification was present in 214 patients (46.7%). After adjustment for confounding factors, the Weston score was an independent predictor for 24-h mortality (hazard ratio, HR 1.19, 95% confidence interval, CI 1.06-1.32, p = .002) and 30-day mortality (HR 1.09, 95% CI 1.01-1.17, p = .027). In a subanalysis of 357 survivors, the Weston score was significantly associated with ICU length of stay (LOS) (beta weight 0.89, 95% CI 0.3-1.47, p = .003) but not with mechanical ventilation duration (beta weight 0.05, 95% CI -0.2-0.63, p = .304). CONCLUSION CT-detected coronary calcification was a significant prognostic factor for 24-h- and 30-day-mortality in severely injured trauma patients requiring tracheal intubation, and influenced ICU LOS in survivors.
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Affiliation(s)
- Hans-Jonas Meyer
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany
| | - Tihomir Dermendzhiev
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany
| | - Michael Hetz
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Georg Osterhoff
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Christian Kleber
- Department of Orthopedics, Trauma and Plastic Surgery, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Timm Denecke
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany
| | - Jeanette Henkelmann
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany
| | - Michael Metze
- Department of Cardiology, Medical Department IV, University Hospital Leipzig, Liebigstr. 20, 04103, Leipzig, Germany
| | - Robert Werdehausen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany
| | - Gunther Hempel
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany
| | - Manuel F Struck
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Leipzig, Liebigstr.20, 04103, Leipzig, Germany.
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. Pediatrics 2024; 154:e2024066855. [PMID: 38932719 DOI: 10.1542/peds.2024-066855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/28/2024] [Indexed: 06/28/2024] Open
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging, are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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5
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Marin JR, Lyons TW, Claudius I, Fallat ME, Aquino M, Ruttan T, Daugherty RJ. Optimizing Advanced Imaging of the Pediatric Patient in the Emergency Department: Technical Report. J Am Coll Radiol 2024; 21:e37-e69. [PMID: 38944445 DOI: 10.1016/j.jacr.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Advanced diagnostic imaging modalities, including ultrasonography, computed tomography, and magnetic resonance imaging (MRI), are key components in the evaluation and management of pediatric patients presenting to the emergency department. Advances in imaging technology have led to the availability of faster and more accurate tools to improve patient care. Notwithstanding these advances, it is important for physicians, physician assistants, and nurse practitioners to understand the risks and limitations associated with advanced imaging in children and to limit imaging studies that are considered low value, when possible. This technical report provides a summary of imaging strategies for specific conditions where advanced imaging is commonly considered in the emergency department. As an accompaniment to the policy statement, this document provides resources and strategies to optimize advanced imaging, including clinical decision support mechanisms, teleradiology, shared decision-making, and rationale for deferred imaging for patients who will be transferred for definitive care.
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Affiliation(s)
- Jennifer R Marin
- Departments of Pediatrics, Emergency Medicine, & Radiology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
| | - Todd W Lyons
- Division of Emergency Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - Ilene Claudius
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Mary E Fallat
- The Hiram C. Polk, Jr Department of Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | - Michael Aquino
- Cleveland Clinic Imaging Institute, and Section of Pediatric Imaging, Cleveland Clinic Lerner College of Medicine of Case Western University, Cleveland Clinic Children's Hospital, Cleveland, Ohio
| | - Timothy Ruttan
- Department of Pediatrics, Dell Medical School, The University of Texas at Austin; US Acute Care Solutions, Canton, Ohio
| | - Reza J Daugherty
- Departments of Radiology and Pediatrics, University of Virginia School of Medicine, UVA Health/UVA Children's, Charlottesville, Virginia
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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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Brunese MC, Avella P, Cappuccio M, Spiezia S, Pacella G, Bianco P, Greco S, Ricciardelli L, Lucarelli NM, Caiazzo C, Vallone G. Future Perspectives on Radiomics in Acute Liver Injury and Liver Trauma. J Pers Med 2024; 14:572. [PMID: 38929793 PMCID: PMC11204538 DOI: 10.3390/jpm14060572] [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: 04/02/2024] [Revised: 05/02/2024] [Accepted: 05/09/2024] [Indexed: 06/28/2024] Open
Abstract
Background: Acute liver injury occurs most frequently due to trauma, but it can also occur because of sepsis or drug-induced injury. This review aims to analyze artificial intelligence (AI)'s ability to detect and quantify liver injured areas in adults and pediatric patients. Methods: A literature analysis was performed on the PubMed Dataset. We selected original articles published from 2018 to 2023 and cohorts with ≥10 adults or pediatric patients. Results: Six studies counting 564 patients were collected, including 170 (30%) children and 394 adults. Four (66%) articles reported AI application after liver trauma, one (17%) after sepsis, and one (17%) due to chemotherapy. In five (83%) studies, Computed Tomography was performed, while in one (17%), FAST-UltraSound was performed. The studies reported a high diagnostic performance; in particular, three studies reported a specificity rate > 80%. Conclusions: Radiomics models seem reliable and applicable to clinical practice in patients affected by acute liver injury. Further studies are required to achieve larger validation cohorts.
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Affiliation(s)
- Maria Chiara Brunese
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
| | - Pasquale Avella
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
- Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, 81030 Castel Volturno, Italy
| | - Micaela Cappuccio
- Department of Clinical Medicine and Surgery, University of Naples Federico II, 80131 Naples, Italy
| | - Salvatore Spiezia
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
| | - Giulia Pacella
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
| | - Paolo Bianco
- Hepatobiliary and Pancreatic Surgery Unit, Pineta Grande Hospital, 81030 Castel Volturno, Italy
| | - Sara Greco
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | | | - Nicola Maria Lucarelli
- Interdisciplinary Department of Medicine, Section of Radiology and Radiation Oncology, University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Corrado Caiazzo
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
| | - Gianfranco Vallone
- Department of Medicine and Health Science “V. Tiberio”, University of Molise, 86100 Campobasso, Italy; (M.C.B.)
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Milavec H, Gasser VT, Ruder TD, Deml MC, Hautz W, Exadaktylos A, Benneker LM, Albers CE. Supplementary value and diagnostic performance of computed tomography scout view in the detection of thoracolumbar spine injuries. Emerg Radiol 2024; 31:63-71. [PMID: 38194212 DOI: 10.1007/s10140-023-02196-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/12/2023] [Indexed: 01/10/2024]
Abstract
PURPOSE Assessing the diagnostic performance and supplementary value of whole-body computed tomography scout view (SV) images in the detection of thoracolumbar spine injuries in early resuscitation phase and identifying frequent image quality confounders. METHODS In this retrospective database analysis at a tertiary emergency center, three blinded senior experts independently assessed SV to detect thoracolumbar spine injuries. The findings were categorized according to the AO Spine classification system. Confounders impacting SV image quality were identified. The suspected injury level and severity, along with the confidence level, were indicated. Diagnostic performance was estimated using the caret package in R programming language. RESULTS We assessed images of 199 patients, encompassing 1592 vertebrae (T10-L5), and identified 56 spinal injuries (3.5%). Among the 199 cases, 39 (19.6%) exhibited at least one injury in the thoracolumbar spine, with 12 (6.0%) of them displaying multiple spinal injuries. The pooled sensitivity, specificity, and accuracy were 47%, 99%, and 97%, respectively. All experts correctly identified the most severe injury of AO type C. The most common image confounders were medical equipment (44.6%), hand position (37.6%), and bowel gas (37.5%). CONCLUSION SV examination holds potential as a valuable supplementary tool for thoracolumbar spinal injury detection when CT reconstructions are not yet available. Our data show high specificity and accuracy but moderate sensitivity. While not sufficient for standalone screening, reviewing SV images expedites spinal screening in mass casualty incidents. Addressing modifiable factors like medical equipment or hand positioning can enhance SV image quality and assessment.
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Affiliation(s)
- Helena Milavec
- Department of Orthopaedic Surgery and Traumatology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.
- Department of Emergency Medicine, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.
- Etzelclinic, Center for Minimally Invasive Surgery, Pfaeffikon, SZ, Switzerland.
| | - Vera T Gasser
- Department of Emergency Medicine, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Thomas D Ruder
- Department of Diagnostic, Pediatric and Interventional Radiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Moritz C Deml
- Department of Orthopaedic Surgery and Traumatology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Wolf Hautz
- Department of Emergency Medicine, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Aristomenis Exadaktylos
- Department of Emergency Medicine, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | | | - Christoph E Albers
- Department of Orthopaedic Surgery and Traumatology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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Koch DA, Hagebusch P, Lefering R, Faul P, Hoffmann R, Schweigkofler U. Changes in injury patterns, injury severity and hospital mortality in motorized vehicle accidents: a retrospective, cross-sectional, multicenter study with 19,225 cases derived from the TraumaRegister DGU ®. Eur J Trauma Emerg Surg 2023; 49:1917-1925. [PMID: 36890307 PMCID: PMC9994772 DOI: 10.1007/s00068-023-02257-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Accepted: 02/24/2023] [Indexed: 03/10/2023]
Abstract
PURPOSE In the last 20 years, the number of fatalities due to road traffic accidents (RTA) in Germany has steadily decreased from 7503 to 2724 per year. Due to legal regulations, educational measures and the continuous development of safety technology the number of severe traumatic injuries and injury patterns are most likely to change. The aim of the study was to analyse severely injured motorcyclists (MC) and car occupants (CO) that were involved in RTAs in the last 15 years and investigate the development and changes of injury patterns, injury severity and hospital mortality. METHODS We retrospectively evaluated data from the TraumaRegister DGU® (TR-DGU) considering all RTA-related injured MCs and COs (n = 19,225) that were registered in the TR-DGU from 2006 to 2020 with a primary admission to a trauma center with continuous participation (14 of 15 years) in the TR-DGU, an Injury Severity Score (ISS) ≥ 16 and aged between 16 and 79 years. The observation period was divided into three 5-year interval subgroups for further analysis. RESULTS The mean age increased by 6.9 years and the ratio of severely injured MCs to COs changed from 1:1.92 to 1:1.45. COs were in 65.8% male and more often severely injured in the age groups under 30, while the majority of severely injured MCs were in the age group around 50 years and in 90.1% male. The ISS (- 3.1 points) as well as the mortality of both groups (CO: 14.4% vs. 11.8%; MC: 13.2% vs. 10.2%) steadily decreased over time. Nevertheless, the standardized mortality ratio (SMR) hardly changed and stayed < 1. Regarding the injury patterns, the greatest decline of injuries with AIS 3 + were to the head (CO: - 11.3%; MC: - 7.1%), in addition, a decrease of injuries to extremities (CO: - 1.5%; MC: - 3.3%), to the abdomen (CO: - 2.6%; MC: - 3.6%), to the pelvis in COs (- 4.7%) and to the spine (CO: + 0.1%; MC: - 2.4%) were observed. Thoracic injuries increased in both groups (CO: + 1.6%; MC: + 3.2%) and, furthermore, pelvic injuries in MCs (+ 1.7%). Another finding was the increase of the utilization of whole body CTs from 76.6 to 95.15%. CONCLUSION The severity of injuries and their incidence, especially head injuries, have decreased over the years and seem to contribute to a decreasing hospital mortality of polytraumatized MCs and COs injured in traffic accidents. Young drivers and an increasing number of seniors are the age groups at risk and require special attention and treatment.
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Affiliation(s)
- Daniel Anthony Koch
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389 Frankfurt am Main, Germany
| | - Paul Hagebusch
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389 Frankfurt am Main, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Ostmerheimer Straße 200, 51109 Cologne, Germany
| | - Philipp Faul
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389 Frankfurt am Main, Germany
| | - Reinhard Hoffmann
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389 Frankfurt am Main, Germany
| | - Uwe Schweigkofler
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389 Frankfurt am Main, Germany
| | - TraumaRegister DGU
- Department of Trauma and Orthopedic Surgery, BG Unfallklinik Frankfurt am Main, Friedberger Landstr. 430, 60389 Frankfurt am Main, Germany
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Ostmerheimer Straße 200, 51109 Cologne, Germany
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Ishii W, Hitosugi M, Kandori K, Miyaguni M, Iizuka R. Increased CT Use and No Change in Injury Severity among Child Motor Vehicle Victims: A National Trauma Database Study in Japan. Healthcare (Basel) 2023; 11:healthcare11091240. [PMID: 37174781 PMCID: PMC10178139 DOI: 10.3390/healthcare11091240] [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: 02/20/2023] [Revised: 04/12/2023] [Accepted: 04/25/2023] [Indexed: 05/15/2023] Open
Abstract
The number of fatalities associated with traffic accidents has been declining owing to improvements in vehicle safety performance and changes in the law. However, injuries in children can lead to social and economic losses. We examined 10-year changes in the characteristics of traffic trauma among pediatric motor vehicle passengers by analyzing data from the Japan Trauma Data Bank (JTDB). Among the 36,715 injured motor vehicle passengers under the age of 15 years who were registered in the JTDB from 2004 to 2019, we compared the groups injured during 2004-2007 (n = 94) and 2017-2019 (n = 203). Physiologically, the 2004-2007 group had a lower body temperature and Glasgow Coma Scale score as well as a higher mortality. Anatomical severity was higher in the 2004-2007 group for the head, face, and neck, according to the Abbreviated Injury Scale. In terms of treatment, only craniotomy as a primary surgery was significantly lower in the 2017-2019 group. The 2017-2019 group had significantly higher rates of receiving whole-body computed tomography (CT). Because the rate of performing CT has increased, with no changes in the injury severities of the trunk and extremities, limiting the number of CT examinations is suggested for pediatric motor vehicle passengers involved in road traffic collisions. The severity of trunk and extremity injuries has not improved in more than 10 years; further preventive measures for these injuries should be considered.
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Affiliation(s)
- Wataru Ishii
- Emergency of Medicine, Critical Care Center, Kyoto Daini Red Cross Hospital, Haruobi, Kamazamarutamachi, Kamigyo, Kyoto 602-8026, Japan
| | - Masahito Hitosugi
- Department of Legal Medicine, Shiga University of Medical Science, Tsukinowa, Seta, Otsu 520-2192, Japan
| | - Kenji Kandori
- Emergency of Medicine, Critical Care Center, Kyoto Daini Red Cross Hospital, Haruobi, Kamazamarutamachi, Kamigyo, Kyoto 602-8026, Japan
| | - Michitaro Miyaguni
- Emergency of Medicine, Critical Care Center, Kyoto Daini Red Cross Hospital, Haruobi, Kamazamarutamachi, Kamigyo, Kyoto 602-8026, Japan
| | - Ryoji Iizuka
- Emergency of Medicine, Critical Care Center, Kyoto Daini Red Cross Hospital, Haruobi, Kamazamarutamachi, Kamigyo, Kyoto 602-8026, Japan
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11
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Kutleša Z, Ordulj I, Perić I, Jerković K, Poljak D, Gavrilović V, Čapkun V, Devčić Š, Budimir Mršić D. Opportunistic measures of bone mineral density at multiple skeletal sites during whole-body CT in polytrauma patients. Osteoporos Int 2023; 34:775-782. [PMID: 36799980 DOI: 10.1007/s00198-023-06699-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/08/2023] [Indexed: 02/18/2023]
Abstract
UNLABELLED Whole-body CT in polytrauma patients revealed bone mineral density variations throughout the skeleton. Bone density was the highest in cranial bones and the lowest in proximal extremities and pelvis. Skeletal age-related changes were generally more pronounced than sex-related changes. Cranial bones did not follow the same aging pattern compared to other bones. INTRODUCTION Whole-body CT (WBCT) in polytrauma patients enables the detection of numerous incidental findings, such as estimates of bone mineral density (BMD) at multiple skeletal sites. This could help in better understanding of age- and sex-related changes in BMD through skeleton. METHODS Data were retrospectively retrieved from the WBCTs requested during a 2-year period. BMD, expressed in CT Hounsfield units (HU), was measured at frontal and occipital bone, four vertebrae (C4, Th7, L4, and S2), iliac bone, and proximal humerus and femur. Measurements were done on native and postcontrast scans. The population sample was age-, sex-, and visceral fat volume adjusted for analysis. RESULTS A total of 296 patients were included, with a median age of 51 years. BMD varied from the highest HU in cranial bones (629 HU) to the lowest HU in the pelvic bones (114 HU), P < 0.001. Sex differences were independent predictors of BMD in cranial bones and proximal humerus. The age-related decline in BMD was significant in all other bones, but the association with age differed among the measurement's sites. Visceral fat showed the strongest correlation with the lumbar spine and iliac wing, although multivariate analysis revealed it was not an independent predictor of bone density, such as age and sex. CONCLUSIONS BMD varies through skeleton, being the highest in the proximal axial skeleton. Age-related changes in BMD are significant and more pronounced than sex-related changes in almost all bones. Cranial bones do not follow the same pattern compared to other bones.
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Affiliation(s)
- Zvonimir Kutleša
- Department of Orthopaedics and Traumatology, Split-Dalmatia County Health Center, Kavanjinova 2, 21000, Split, Croatia
| | - Ivan Ordulj
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital Split, Spinčičeva 1, Šoltanska 2, 21000, Split, Croatia
| | - Iva Perić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital Split, Spinčičeva 1, Šoltanska 2, 21000, Split, Croatia
| | - Kristian Jerković
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital Split, Spinčičeva 1, Šoltanska 2, 21000, Split, Croatia
| | - Dino Poljak
- Department of Orthopaedics and Traumatology, University Hospital Split, Šoltanska 2, 21000, Split, Croatia
| | - Vlado Gavrilović
- Department of Orthopaedics and Traumatology, University Hospital Split, Šoltanska 2, 21000, Split, Croatia
| | - Vesna Čapkun
- Department of Anatomy, Histology and Embryology, University of Split School of Medicine, Šoltanska 2, 21000, Split, Croatia
| | - Šime Devčić
- Department of Orthopaedics and Traumatology, University Hospital Split, Šoltanska 2, 21000, Split, Croatia
| | - Danijela Budimir Mršić
- Clinical Department of Diagnostic and Interventional Radiology, University Hospital Split, Spinčičeva 1, Šoltanska 2, 21000, Split, Croatia.
- School of Medicine, University of Split, Šoltanska 2, 21000, Split, Croatia.
- University Department of Health Studies, University of Split, Ruđera Boškovića 35, 21000, Split, Croatia.
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12
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Yamamoto R, Suzuki M, Funabiki T, Sasaki J. Immediate CT after hospital arrival and decreased in-hospital mortality in severely injured trauma patients. BJS Open 2023; 7:zrac133. [PMID: 36680778 PMCID: PMC9866241 DOI: 10.1093/bjsopen/zrac133] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Revised: 08/10/2022] [Accepted: 09/22/2022] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Immediate whole-body CT (about 10 min after arrival) in an all-in-one resuscitation room equipped with CT has been found to be associated with shorter time to haemostasis and lower in-hospital mortality. The aim of this study was to elucidate the benefits of immediate whole-body CT after hospital arrival in patients with severe trauma with the hypothesis that immediate CT within 10 min is associated with lower in-hospital mortality. METHOD This retrospective cohort study of patients with an injury severity score of more than 15 who underwent whole-body CT was conducted using the Japanese Trauma Databank (2019-2020). An immediate CT was conducted within 10 min after arrival. In-hospital mortality, frequency of subsequent surgery, and time to surgery were compared with immediate and non-immediate CT. Inverse probability weighting was conducted to adjust for patient backgrounds, including mechanism and severity of injury, prehospital treatment, vital signs, and institutional characteristics. RESULTS Among the 7832 patients included, 646 underwent immediate CT. Immediate CT was associated with lower in-hospital mortality (12.5 versus 15.7 per cent; adjusted OR 0.77 (95 per cent c.i. 0.69 to 0.84); P < 0.001) and fewer damage-control surgeries (OR 0.75 (95 per cent c.i. 0.65 to 0.87)). There was a 10 to 20 min difference in median time to craniotomy, laparotomy, and angiography. These benefits were observed regardless of haemodynamic instability on hospital arrival, while they were identified only in elderly patients with severe injury and altered consciousness. CONCLUSION Immediate CT within 10 min after arrival was associated with decreased in-hospital mortality in severely injured trauma patients.
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Affiliation(s)
- Ryo Yamamoto
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Masaru Suzuki
- Department of Emergency Medicine, Tokyo Dental College, Ichikawa General Hospital, Chiba, Japan
| | - Tomohiro Funabiki
- Department of Emergency Medicine, Fujita Health University Hospital, Aichi, Japan
| | - Junichi Sasaki
- Department of Emergency and Critical Care Medicine, Keio University School of Medicine, Tokyo, Japan
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13
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Gianola S, Bargeri S, Biffi A, Cimbanassi S, D’Angelo D, Coclite D, Facchinetti G, Fauci AJ, Ferrara C, Di Nitto M, Napoletano A, Punzo O, Ranzato K, Tratsevich A, Iannone P, Castellini G, Chiara O. Structured approach with primary and secondary survey for major trauma care: an overview of reviews. World J Emerg Surg 2023; 18:2. [PMID: 36600301 PMCID: PMC9814503 DOI: 10.1186/s13017-022-00472-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 12/25/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND A structured approach involves systematic management of trauma patients. We aim to conduct an overview of reviews about the clinical efficacy and safety of structured approach (i.e., primary and secondary survey) by guideline checklist compared to non-structured approach (i.e. clinical examination); moreover, routine screening whole-body computer tomography (WBCT) was compared to non-routine WBCT in patients with suspected major trauma. METHODS We systematically searched MEDLINE (PubMed), EMBASE and Cochrane Database of Systematic Reviews up to 3 May 2022. Systematic reviews (SRs) that investigated the use of a structured approach compared to a non-structured approach were eligible. Two authors independently extracted data, managed the overlapping of primary studies belonging to the included SRs and calculated the corrected covered area (CCA). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology. RESULTS We included nine SRs investigating two comparisons in stable trauma patients: structured approach vs non-structured approach (n = 1) and routine WBCT vs non-routine WBCT (n = 8). The overlap of included primary studies was generally high across outcomes (CCA ranged between 20.85 and 42.86%) with some discrepancies in the directions of effects across reviews. The application of a structured approach by checklist may improve adherence to guidelines (e.g. Advanced Trauma Life Support) during resuscitation and might lead to a reduction in mortality among severely injured patients as compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30-0.89; p = 0.018; low certainty of evidence). The use of routine WBCT seems to offer little to no effects in reducing mortality and time spent in emergency room or department, whereas non-routine WBCT seems to offer little to no effects in reducing radiation dose, intensive care unit length of stay (LOS) and hospital LOS (low-to-moderate certainty of evidence). CONCLUSIONS The application of structured approach by checklist during trauma resuscitation may improve patient- and process-related outcomes. Including non-routine WBCT seems to offer the best trade-offs between benefits and harm. Clinicians should consider these findings in the light of their clinical context, the volume of patients in their facilities, the need for time management, and costs.
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Affiliation(s)
- Silvia Gianola
- Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy.
| | - Silvia Bargeri
- grid.417776.4Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Annalisa Biffi
- grid.7563.70000 0001 2174 1754National Centre for Healthcare Research and Pharmacoepidemiology,, University of Milano-Bicocca, Milan, Italy ,grid.7563.70000 0001 2174 1754Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Stefania Cimbanassi
- grid.4708.b0000 0004 1757 2822General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
| | - Daniela D’Angelo
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Daniela Coclite
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Gabriella Facchinetti
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Alice Josephine Fauci
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Carla Ferrara
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Marco Di Nitto
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Antonello Napoletano
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Ornella Punzo
- grid.416651.10000 0000 9120 6856Centro Nazionale per l Eccellenza Clinica, laQualità e la Sicurezza delle Cure, Istituto Superiore di Sanità, Rome, Italy
| | - Katya Ranzato
- grid.420421.10000 0004 1784 7240Gruppo MultiMedica, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
| | - Alina Tratsevich
- grid.7563.70000 0001 2174 1754National Centre for Healthcare Research and Pharmacoepidemiology,, University of Milano-Bicocca, Milan, Italy ,grid.7563.70000 0001 2174 1754Unit of Biostatistics, Epidemiology and Public Health, Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Milan, Italy
| | - Primiano Iannone
- grid.416290.80000 0004 1759 7093Dipartimento di Medicina Interna, Azienda USL, Ospedale Maggiore, Largo Nigrisoli 2, 40133 Bologna, Italy
| | - Greta Castellini
- grid.417776.4Unit of Clinical Epidemiology, IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
| | - Osvaldo Chiara
- grid.4708.b0000 0004 1757 2822General Surgery and Trauma Team, ASST Grande Ospedale Metropolitano Niguarda, University of Milan, Piazza Ospedale Maggiore 3, 20162 Milan, Italy
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14
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Zhu M, O'Brien M, Shaikh SP, Brahmbhatt TS, LeBedis C, Scantling D, Sanchez SE. Utilization of torso computed tomography for the evaluation of ground level falls: More imaging does not equal better care. Injury 2023; 54:105-111. [PMID: 36470767 DOI: 10.1016/j.injury.2022.11.051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Revised: 11/11/2022] [Accepted: 11/23/2022] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Computed tomography (CT) of the chest (CTC), abdomen, and pelvis (CTAP) is common when assessing trauma patients in the emergency department. However, unnecessary imaging can expose patients to unneeded radiation and increase healthcare costs. Here, we characterize the use of torso CT imaging for the evaluation of ground level falls (GLF) at a single level 1 trauma center. PATIENTS AND METHODS We conducted a retrospective review of all patients ≥18 years old presenting to a single level 1 trauma center with a GLF (1m or less) in 2015-2019. Data were obtained through chart review. Descriptive statistics were used to summarize patient characteristics. Multivariable logistic regression was used to assess factors leading to patients obtaining torso CT imaging. The utility of CT imaging in identifying injuries that changed management was also evaluated. RESULTS Of the 1,195 patients captured during the study period, 492 patients had a positive torso physical exam (PE), and 703 had a negative torso PE. Of patients with a negative torso PE, 127 CTC and 142 CTAP were obtained, with only 5.5% CTC identifying traumatic injuries not previously diagnosed on chest radiograph (CXR), and only 0.7% CTAP identifying new injuries not identified on pelvic radiograph (PXR). Multivariable logistic regression demonstrated that only a positive PE was significantly associated with the identification of abnormal imaging findings on torso CT. A negative PE, CXR, and PXR have a negative predictive value of 98%. DISCUSSION These data suggest that patients with a negative PE, even if intoxicated, intubated, or with a decreased GCS, are highly unlikely to have new, clinically relevant findings on torso CT imaging. CONCLUSION Using PE, CXR, and PXR as a screening tool in patients sustaining GLF, which if negative close to obviates the need for torso CT, may reduce healthcare costs and radiation exposure without compromising patient care.
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Affiliation(s)
- Max Zhu
- Boston University Chobanian & Avedisian School of Medicine, United States
| | - Mollie O'Brien
- Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States
| | - Shamsh P Shaikh
- Boston University Chobanian & Avedisian School of Medicine, United States
| | - Tejal S Brahmbhatt
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States
| | - Christina LeBedis
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Radiology, Division of Body Imaging, United States
| | - Dane Scantling
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States
| | - Sabrina E Sanchez
- Boston University Chobanian & Avedisian School of Medicine, United States; Boston Medical Center, Department of Surgery, Division of Trauma, Acute Care Surgery, and Surgical Critical Care, United States.
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15
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Yang AY, Patel NA, Khan M, Cherry-Bukowiec JR, Brown LR, Machado-Aranda DA, Mazza MB, Chong S. In-person radiologist to review the trauma panscan: a high-fidelity simulation training program for radiology trainees at an academic level 1 trauma center. Emerg Radiol 2022; 30:143-151. [PMID: 36542168 PMCID: PMC9769494 DOI: 10.1007/s10140-022-02109-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Radiology trainees were uncomfortable going to the CT scanner to review trauma panscans and interacting with trauma surgeons. OBJECTIVE This study aims to determine if radiology residents can be trained to accurately identify injuries requiring immediate surgical attention at the CT scanner. METHODS A high-fidelity simulation model was created to provide an immersive training experience. Between February 2015 and April 2017, 62 class 1 trauma panscans were read at the CT scanner by 11 PGY-3 radiology residents. Findings made at the scanner were compared to resident preliminary and attending radiology reports and correlated with clinical outcomes. Timestamps were recorded and analyzed. Surveys were administered to assess the impact of training on radiology residents' self-confidence and to assess trauma surgeons' preference for radiology at the scanner. Significance level was set at p < 0.05. RESULTS The mean time to provide results at the CT scanner was 11.1 min. Mean time for the preliminary report for CT head and cervical spine was 24.4 ± 9.8 min, and for the CT chest, abdomen, and pelvis was 16.3 ± 6.9 min. 53 traumatic findings on 62 panscans were identified at the scanner and confirmed at preliminary and final reports, for a concordance rate of 85%, compared to 72% for the control group. Radiology residents agreed or strongly agreed the training prepared them for trauma panscan reporting. Trauma surgeons shifted in favor of radiology presence at the scanner. CONCLUSION Radiology residents can be trained to accurately and rapidly identify injuries requiring immediate surgical attention at the CT scanner. CLINICAL IMPACT These findings support the value-added of an in-person radiologist at the CT scanner for whole-body trauma panscans to facilitate timely detection of life-threatening injuries and improve professional relations between radiologists and trauma surgeons.
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Affiliation(s)
- Allison Y. Yang
- Rocky Vista University College of Osteopathic Medicine, 8401 S Chambers Rd, Greenwood Village, CO 80112 USA
| | - Nishant A. Patel
- Radiology Imaging Associates, 10800 E Geddes Ave, Ste 300, Englewood, Denver, CO 80112 USA
| | - Mansoor Khan
- Temple University, Jones Hall 707, Temple University Hospital System, Philadelphia, PA 19140 USA
| | - Jill R. Cherry-Bukowiec
- University of Michigan, 1500 E Medical Center Dr, Floor 2 Reception C, Ann Arbor, MI 48109 USA
| | - Laura R. Brown
- University of Illinois College of Medicine, 624 NE Glen Oak Ave, Peoria, IL 61603 USA
| | - David A. Machado-Aranda
- University of California Los Angeles, 757 Westwood Plaza, Suite 8501, Los Angeles, CA 90095 USA
| | - Michael B. Mazza
- University of Michigan, UMH Radiology, TC B1-140B, Ann Arbor, MI 48109-5302 USA
| | - Suzanne Chong
- Indiana University, 550 University Blvd, Indianapolis, IN 46202 USA
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16
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Burgess J, Jenkins C, Kopelman T, Foster K, Collins J. The Development of Acute Kidney Injury in Burn Patients Undergoing Computed Tomography With Intravenous Contrast. J Burn Care Res 2022; 43:521-524. [PMID: 35279720 DOI: 10.1093/jbcr/irac033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Acute kidney injury (AKI) is a major complication of significant burn injuries and a significant cause of patient morbidity and mortality. Patients that sustain traumatic burn injuries may require computed tomography (CT) imaging as part of their initial trauma management. This multicenter retrospective chart review of patients admitted to two level I trauma centers with ≥10% TBSA burns between 2014 and 2017 aims to determine if patients with greater than 10% TBSA burns that received CT imaging with intravenous contrast were more likely to develop acute kidney injury during their admission. A total of 439 patients were included in the study. The average age was 45.3 years and average TBSA was 23.2%. Sixty-seven of the 439 patients underwent CT scans with IV contrast on admission. The rate of AKI between patients who did or did not receive CT scans was not statistically significant (9.1 vs 6.0%, P = 0.40). Patients who developed an AKI had higher TBSA (45.6 vs 21.1%, P < .01), amount of fluids per TBSA given within the first 24 hours (457.4 vs 321.6, P < .01), and mortality (71.1 vs 6.2%, P < .01) than those who did not develop an AKI. There was no significant difference in the development of acute kidney injury in burn patients who received CT scans with IV contrast on admission. Although there is a risk of contrast induced nephropathy, the risk is not increased in burn patients and this should not prevent a thorough evaluation to rule out additional life-threatening injuries in the burn trauma patient.
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Affiliation(s)
| | | | | | | | - Jay Collins
- Eastern Virginia Medical School, Norfolk, VA, USA
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17
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Villacres Mori B, Young JR, Lakra A, Chisena E. Team Approach: Management of Geriatric Acetabular Fractures. JBJS Rev 2022; 10:01874474-202205000-00009. [PMID: 35613307 DOI: 10.2106/jbjs.rvw.22.00017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
» Geriatric acetabular fractures are defined as fractures sustained by patients who are ≥60 years old. With the rapidly aging American populace and its increasingly active lifestyle, the prevalence of these injuries will continue to increase. » An interdisciplinary approach is necessary to ensure successful outcomes. This begins in the emergency department with hemodynamic stabilization, diagnosis of the fracture, identification of comorbidities and concomitant injuries, as well as early consultation with the orthopaedic surgery service. This multifaceted approach is continued when patients are admitted, and trauma surgery, geriatrics, and cardiology teams are consulted. These teams are responsible for the optimization of complex medical conditions and risk stratification prior to operative intervention. » Treatment varies depending on a patient's preinjury functional status, the characteristics of the fracture, and the patient's ability to withstand surgery. Nonoperative management is recommended for patients with minimally displaced fractures who cannot tolerate the physiologic stress of surgery. Percutaneous fixation is a treatment option most suited for patients with minimally displaced fractures who are at risk for displacing the fracture or are having difficulty mobilizing because of pain. Open reduction and internal fixation is recommended for patients with displaced acetabular fractures who are medically fit for surgery and have a displaced fracture pattern that would do poorly without operative intervention. Fixation in combination with arthroplasty can be done acutely or in delayed fashion. Acute fixation combined with arthroplasty benefits patients who have poorer bone quality and fracture characteristics that make healing unlikely. Delayed arthroplasty is recommended for patients who have had failure of nonoperative management, have a fracture pattern that is not favorable to primary total hip arthroplasty, or have developed posttraumatic arthritis.
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Li D, Basilico R, Blanco A, Calli C, Dick E, Kirkpatrick IDC, Nicolaou S, Patlas MN. Emergency Radiology: Evolution, Current Status, and Future Directions. Can Assoc Radiol J 2022; 73:697-703. [PMID: 35470687 DOI: 10.1177/08465371221088924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Emergency Radiology is a clinical practice and an academic discipline that has rapidly gained increasing global recognition among radiology and emergency/critical care departments and trauma services around the world. As with other subspecialties, Emergency Radiology practice has a unique scope and purpose and presents with its own unique challenges. There are several advantages of having a dedicated Emergency Radiology section, perhaps most important of which is the broad clinical skillset that Emergency Radiologists are known for. This multi-society paper, representing the views of Emergency Radiology societies in Canada and Europe, outlines several value-oriented contributions of Emergency Radiologists and briefly discusses the current state of Emergency Radiology as a subspecialty.
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Affiliation(s)
- David Li
- Division of Emergency/Trauma Radiology, Department of Radiology, 153003McMaster University, Hamilton, ON, Canada
| | | | - Ana Blanco
- University Hospital Morales Meseguer, Murcia, Spain
| | - Cem Calli
- 323336Ege University Medical Faculty, Bornova Izmir, Turkey
| | - Elizabeth Dick
- St Mary's Hospital, 8946Imperial College NHS Trust, London, UK
| | - Iain D C Kirkpatrick
- Department of Diagnostic Imaging, 8664University of Manitoba, Winnipeg, MB, Canada
| | - Savvas Nicolaou
- Division of Emergency Radiology, Vancouver General Hospital, Vancouver, BC, Canada
| | - Michael N Patlas
- Division of Emergency/Trauma Radiology, Department of Radiology, 153003McMaster University, Hamilton, ON, Canada
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19
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Harntaweesup S, Krutsri C, Sumritpradit P, Singhatas P, Thampongsa T, Jenjitranant P, Wongwaisayawan S, Saksobhavivat N, Kaewlai R. Usefulness and outcome of whole-body computed tomography (pan-scan) in trauma patients: A prospective study. Ann Med Surg (Lond) 2022; 76:103506. [PMID: 35495401 PMCID: PMC9052170 DOI: 10.1016/j.amsu.2022.103506] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/14/2022] [Accepted: 03/26/2022] [Indexed: 12/05/2022] Open
Abstract
Background Severe trauma can cause multi-organ injuries, and the mortality rate may increase if significant organ injuries are missed. This study was performed to determine whether whole-body computed tomography scan (pan-scan) can detect significant injury and leads to proper management, including alteration the priority of management. Methods This prospective study was conducted from January 2019 to March 2021 and involved trauma patients level 1, level 2, and dangerous mechanism of trauma. Additionally, the data of trauma patients who had selective computed tomography scan were retrospectively reviewed to compared the clinical benefits. Results Twenty-two patients were enrolled in the prospective study. The pan-scan detected significant organ injury in 86% of the patients. Prioritization of organ injury management changed after performance of the pan-scan in 64% (major change in 64.29% and minor change in 35.71%). Skull base fracture, small bowel injury, retroperitoneal injury, kidney and bladder injury, and occult pneumothorax were the majority of injuries which was not consider before underwent pan-scan (p < 0.05). The door-to-scan time tended to be shorter in the pan-scan group than in the selective scan group without a significant difference [mean (SD), 59.5 (34) and 72.0 (86) min, respectively; p = 0.13]. Pan-scan contribute 100% confidence for trauma surgeon in diagnosis of specific organ injuries in severe injured patients. Conclusions The pan-scan facilitates timely detection of significant unexpected organ injuries such as the skull base, occult pneumothorax, small bowel, and retroperitoneum. It also helps to prioritize management and increases the diagnostic confidence of trauma surgeons, leading to better outcomes without delay. The pan-scan facilitates timely detection of significant unexpected organ injuries. Pan-scan helps to prioritize management and increases the diagnostic confidence leading to better outcomes without delay. Pan-scan contribute 100% confidence for trauma surgeon in diagnosis of specific organ injuries in severe injured patients. Contrast-induced nephropathy from pan-scan is lower than that in selective CT scan accumulated on the same admission.
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20
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Whole body CT for trauma reduces emergency department time for patients with lower extremity fractures. Emerg Radiol 2022; 29:449-454. [DOI: 10.1007/s10140-022-02030-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
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21
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Studer S, van Veelen NM, van de Wall BJM, Kuner V, Schrading S, Link BC, Knobe M, Babst R, Beeres FJP. Improving the protocol for whole-body CT scans in trauma patients. Eur J Trauma Emerg Surg 2022; 48:3149-3156. [PMID: 35088109 DOI: 10.1007/s00068-021-01862-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/11/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE While whole-body computed tomography is an established diagnostic method for the work up of polytraumatized patients, the protocols used differ between trauma centers. This study aimed to compare scan duration and estimated radiation of two protocols. Secondary aim was to assess if using the revised CT protocol reduced the number of additional images of the upper extremities. METHODS Two groups of consecutive trauma patients, which both received a whole-body CT, were analyzed. Patients, who received a three-phased CT during which their arms needed to be repositioned from their side to above the head, were assigned to group A. Those, who received a CT with their arms placed on a pillow ventral to the abdomen throughout the entire scan were assigned to group B. Estimated radiation dose, scan duration, number of upper limb injuries and number of additional images of the upper limbs within 24 h after initial CT were assessed. RESULTS Group A consisted of 182 patients, group B of 218. The scan duration was 3 min shorter (p < 0.001) and the estimated radiation dose lower (15.0 vs 22.9 mSv, p < 0.001) in group B. There was no difference in the number of upper limb injuries detected or the number of upper limb additional images required within 24 h. CONCLUSION Using a whole-body CT scan protocol in which the arms remain on a pillow ventral to the torso instead of one which requires a repositioning of the arms, both scan duration and estimated radiation dose can be reduced. Despite the arms being within the scanned area in the revised protocol, the number of additional imaging of the upper extremities could not be reduced.
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Affiliation(s)
- Stephanie Studer
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Nicole Maria van Veelen
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland.
| | | | - Valerie Kuner
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Simone Schrading
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Björn-Christian Link
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Matthias Knobe
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
- Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Frank Joseph Paulus Beeres
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
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22
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Avoiding immediate whole-body trauma CT: a prospective observational study in stable trauma patients. Updates Surg 2022; 74:343-353. [PMID: 35001252 DOI: 10.1007/s13304-021-01199-w] [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: 06/18/2021] [Accepted: 10/25/2021] [Indexed: 10/19/2022]
Abstract
High energy blunt trauma patients with normal vital signs are usually investigated with a Contrast Enhanced Computed Tomography (CECT) for torso injuries. CECT involves high levels of radiations, often showing no injuries in patients over-triaged to the trauma center. The aim of our study was to suggest an alternative diagnostic protocol based on Emergency Room (ER) tests (physical exam, blood tests, extended FAST, Chest and Pelvis X-ray) to avoid CECT in selected patients. A prospective cohort study was conducted from September 2018 to September 2019. Five hundred patients fulfilled the inclusion criteria. Patients received torso-CECT scan only if they had at least one positive ER test. The validity of the single component of the protocol and the global validity of the ER tests to detect torso injuries was assessed through sensitivity, specificity, positive (PPV) and negative (NPV) predictive value, positive (+ LR) and negative (- LR) likelihood ratio. Multivariate analysis was performed to identify independent predictors of torso injuries. One hundred and seventy patients received a torso-CECT scan because of positive ER tests. ER tests showed a global sensitivity for torso injuries of 86.96% (95% CI 80.17-92.08) specificity of 83.98%(95% CI 79.79-87.60), PPV of 67.42% (95% CI 61.83-72.54), NPV of 94.41% (95% CI 91.63-96.30) + LR of 5.43 (95% CI 4.25-6.93), - LR of 0.16 (95% CI 0.10-0.24). ER tests in an experienced center seem to be able to identify more severe blunt trauma patients needing CECT. Further studies are advisable to confirm these results.
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23
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Prospective evaluation of an evidence-based decision tool to assess pediatric blunt abdominal trauma (BAT). Pediatr Surg Int 2022; 38:183-191. [PMID: 34586483 DOI: 10.1007/s00383-021-05013-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE Computed tomography (CT) is currently the standard for evaluation of intra-abdominal injury (IAI) after BAT. Pediatric patients receiving CT scans based on adult clinical protocols are potentially exposed to unnecessary radiation. The purpose of this study is to determine the rate of CT scans before and after implementation of a pediatric BAT decision tool. METHODS We adapted and implemented an evidence-based decision tool for pediatric BAT based on five clinical variables. We reviewed patient charts 18 months pre- and post-implementation. Demographics and outcomes were compared using Chi-square and Fisher's exact test, accordingly. RESULTS The pre and post-implementation groups were uniform when comparing age, sex, mechanism, and Injury Severity Score. The decision tool was utilized in 85% of patients post-implementation. Fewer CT scans were obtained in the post-implementation group (28 vs. 21%, p = 0.215) with no missed injuries or late diagnoses. CONCLUSION Implementation of a pediatric BAT decision tool decreased CT usage and radiation exposure without an obvious compromise to patient care. This experience supports the utilization of these tools for the assessment of IAI after BAT and have resulted in more selective use of CT during pediatric BAT in our program.
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24
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Savatmongkorngul S, Yuksen C, Maspol W, Sricharoen P, Wongwaisayawan S, Jenpanitpong C, Watcharakitpaisan S, Kaninworapan P, Maijan K. Mortality Rate of Trauma Patients with ESI Triage Level 1-2 Who Underwent Computerized Tomography-PANSCAN versus Conventional Computerized Tomography Scan. Open Access Emerg Med 2021; 13:457-463. [PMID: 34703331 PMCID: PMC8536882 DOI: 10.2147/oaem.s330294] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 10/06/2021] [Indexed: 12/30/2022] Open
Abstract
Objective The treatment of severe trauma patients requires a fast and accurate method to diagnose life-threatening conditions. Computerized tomography (CT)-PANSCAN has been widely used for the last 20 years to diagnose many patients in critical condition. However, no research has been performed into the efficacy of CT-PANSCAN. This research aims to compare the mortality rate of trauma patients who underwent CT-PANSCAN versus conventional CT scan. Methods This retrospective cohort study enrolled patients who were at triage ESI level 1–2 in the emergency department of Ramathibodi Hospital from January 2013 to December 2018 and analyzed the mortality rate between those who underwent CT-PANSCAN and conventional CT scan. Results The study enrolled 123 trauma patients; 61 patients underwent CT-PANSCAN, whereas 62 patients underwent conventional CT scan. There were 1 and 7 patients who expired in the CT-PANSCAN and conventional CT scan groups, respectively. After multivariate regression analysis, the result revealed that patients who underwent CT-PANSCAN had a lower mortality rate (adjusted odds ratio = 0.023; p-value = 0.018; 95% CI 0.001–0.518). Conclusion Undergoing a CT-PANSCAN can reduce the mortality rate in trauma patients, especially in ESI level 1, 2 traumatic patients, and CT-PANSCAN available facilities.
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Affiliation(s)
- Sorravit Savatmongkorngul
- Department of Emergency, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chaiyaporn Yuksen
- Department of Emergency, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wapee Maspol
- Department of Emergency, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Pungkava Sricharoen
- Department of Emergency, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sirote Wongwaisayawan
- Department of Emergency, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Sorawich Watcharakitpaisan
- Department of Emergency, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Parama Kaninworapan
- Department of Emergency, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Konwachira Maijan
- Department of Emergency, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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25
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Leenellett E, Rieves A. Occult Abdominal Trauma. Emerg Med Clin North Am 2021; 39:795-806. [PMID: 34600638 DOI: 10.1016/j.emc.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Occult abdominal injuries are common and can be associated with increased risk of morbidity and mortality. Patients with a delayed presentation to care or who are multiply injured are at increased risk of this type of injury, and a high index of suspicion must be maintained. A careful combination of history, physical examination, laboratory, and imaging can be quite helpful in mitigating the risk of a missed occult abdominal injury.
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Affiliation(s)
- Elizabeth Leenellett
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Room 1505, Cincinnati, OH 45267-0769, USA.
| | - Adam Rieves
- Department of Emergency Medicine, Washington University in Saint Louis, 660 South Euclid Avenue, BC 8072, Saint Louis, MO 63110, USA
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26
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Davies J, Johnson R, Kashef E, Khan M, Dick E. How to deliver an effective primary survey report for the trauma CT: A radiological and surgical perspective. TRAUMA-ENGLAND 2021. [DOI: 10.1177/1460408621995144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Whole body contrast-enhanced multidetector CT (WB-CE MDCT) is integral to the assessment of the severely injured patient with stable haemodynamic parameters or in those who respond to resuscitation with blood products. WB-CE MDCT is able to identify the number and severity of injuries sustained by the patient and enable time critical intervention. In this narrative review article we discuss how communication within the trauma team, including the radiologists and appropriate clinicians is crucial in optimizing the effectiveness of WB-CE MDCT. We review the time critical imaging findings and their clinical relevance, which should be included in a succinct CT primary survey report. We also discuss the process through which the effectiveness of the trauma report may be maximised and how non technical factors including teamwork may be optimised to facilitate decision making in this high pressure environment.
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Affiliation(s)
- Joseph Davies
- Maidstone & Tunbridge Wells NHS Trust, Maidstone, UK
| | - Rowena Johnson
- Nuffield Orthopaedic Centre, Oxford NHS Foundation Trust, Oxford, UK
| | - Elika Kashef
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Mansoor Khan
- Digestive Diseases Department, Brighton and Sussex University Hospitals, Brighton, UK
| | - Elizabeth Dick
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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27
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. Postreanimationsbehandlung. Notf Rett Med 2021. [DOI: 10.1007/s10049-021-00892-y] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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28
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Bunn C, Ringhouse B, Patel P, Baker M, Gonzalez R, Abdelsattar ZM, Luchette FA. Trends in utilization of whole-body computed tomography in blunt trauma after MVC: Analysis of the Trauma Quality Improvement Program database. J Trauma Acute Care Surg 2021; 90:951-958. [PMID: 34016919 PMCID: PMC8244576 DOI: 10.1097/ta.0000000000003129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The use of whole-body computed tomography (WBCT) in awake, clinically stable injured patients is controversial. It is associated with unnecessary radiation exposure and increased cost. We evaluate use of computed tomography (CT) imaging during the initial evaluation of injured patients at American College of Surgeons Levels I and II trauma centers (TCs) after blunt trauma. METHODS We identified adult blunt trauma patients after motor vehicle crash (MVC) from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2007 and 2016 at Level I or II TCs. We defined awake clinically stable patients as those with systolic blood pressure of 100 mm Hg or higher with a Glasgow Coma Scale score of 15. Computed tomography imaging had to have been performed within 2 hours of arrival. Whole-body computed tomography was defined as simultaneous CT of the head, chest and abdomen, and selective CT if only one to two aforementioned regions were imaged. Patients were stratified by Injury Severity Score (ISS). RESULTS There were 217,870 records for analysis; 131,434 (60.3%) had selective CT, and 86,436 (39.7%) had WBCT. Overall, there was an increasing trend in WBCT utilization over the study period (p < 0.001). In patients with ISS less than 10, WBCT was utilized more commonly at Level II versus Level I TCs in patients discharged from the emergency department (26.9% vs. 18.3%, p < 0.001), which had no surgical procedure(s) (81.4% vs. 80.3%, p < 0.001) and no injury of the head (53.7% vs. 52.4%, p = 0.008) or abdomen (83.8% vs. 82.1%, p = 0.001). The risk-adjusted odds of WBCT was two times higher at Level II TC vs. Level I (odds ratio, 1.88; 95% confidence interval 1.82-1.94; p < 0.001). CONCLUSION Whole-body computed tomography utilization is increasing relative to selective CT. This increasing utilization is highest at Level II TCs in patients with low ISSs, and in patients without associated head or abdominal injury. The findings have implications for quality improvement and cost reduction. LEVEL OF EVIDENCE Care management, Level IV.
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MESH Headings
- Accidents, Traffic
- Adolescent
- Adult
- Aged
- Cost Savings
- Databases, Factual/statistics & numerical data
- Emergency Service, Hospital/economics
- Emergency Service, Hospital/statistics & numerical data
- Emergency Service, Hospital/trends
- Female
- Glasgow Coma Scale
- Humans
- Injury Severity Score
- Male
- Medical Overuse/economics
- Medical Overuse/statistics & numerical data
- Medical Overuse/trends
- Middle Aged
- Practice Patterns, Physicians'/economics
- Practice Patterns, Physicians'/statistics & numerical data
- Practice Patterns, Physicians'/trends
- Quality Improvement
- Retrospective Studies
- Tomography, X-Ray Computed/economics
- Tomography, X-Ray Computed/methods
- Tomography, X-Ray Computed/statistics & numerical data
- Tomography, X-Ray Computed/trends
- Trauma Centers/economics
- Trauma Centers/statistics & numerical data
- Trauma Centers/trends
- Wounds, Nonpenetrating/diagnosis
- Wounds, Nonpenetrating/etiology
- Young Adult
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Affiliation(s)
- Corinne Bunn
- Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL, USA
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Brendan Ringhouse
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Purvi Patel
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Marshall Baker
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
- Edward Hines Jr. Veterans Affair Hospital, Hines, IL, USA
| | - Richard Gonzalez
- Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL, USA
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
| | - Zaid M. Abdelsattar
- Department of Thoracic and Cardiovascular Surgery, Loyola University Medical Center, Maywood, IL USA
- Edward Hines Jr. Veterans Affair Hospital, Hines, IL, USA
| | - Fred A. Luchette
- Burn and Shock Trauma Research Institute, Loyola University Chicago, Maywood, IL, USA
- Department of Surgery, Loyola University Medical Center, Maywood, IL, USA
- Edward Hines Jr. Veterans Affair Hospital, Hines, IL, USA
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29
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Olasveengen TM, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Med 2021; 47:369-421. [PMID: 33765189 PMCID: PMC7993077 DOI: 10.1007/s00134-021-06368-4] [Citation(s) in RCA: 468] [Impact Index Per Article: 156.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/08/2021] [Indexed: 12/13/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation and organ donation.
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Affiliation(s)
- Jerry P. Nolan
- University of Warwick, Warwick Medical School, Coventry, CV4 7AL UK
- Royal United Hospital, Bath, BA1 3NG UK
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy
- Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W. Böttiger
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Kerpener Straße 62, 50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC), Université Catholique de Louvain, Brussels, Belgium
- Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Division of Health Sciences, Warwick Medical School, University of Warwick, Room A108, Coventry, CV4 7AL UK
| | - Gisela Lilja
- Department of Clinical Sciences Lund, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Véronique R. M. Moulaert
- Department of Rehabilitation Medicine, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Markus B. Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, BS10 5NB UK
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30
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Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, Genbrugge C, Haywood K, Lilja G, Moulaert VRM, Nikolaou N, Mariero Olasveengen T, Skrifvars MB, Taccone F, Soar J. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines 2021: Post-resuscitation care. Resuscitation 2021; 161:220-269. [PMID: 33773827 DOI: 10.1016/j.resuscitation.2021.02.012] [Citation(s) in RCA: 375] [Impact Index Per Article: 125.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The European Resuscitation Council (ERC) and the European Society of Intensive Care Medicine (ESICM) have collaborated to produce these post-resuscitation care guidelines for adults, which are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. The topics covered include the post-cardiac arrest syndrome, diagnosis of cause of cardiac arrest, control of oxygenation and ventilation, coronary reperfusion, haemodynamic monitoring and management, control of seizures, temperature control, general intensive care management, prognostication, long-term outcome, rehabilitation, and organ donation.
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Affiliation(s)
- Jerry P Nolan
- University of Warwick, Warwick Medical School, Coventry CV4 7AL, UK; Royal United Hospital, Bath, BA1 3NG, UK.
| | - Claudio Sandroni
- Department of Intensive Care, Emergency Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli-IRCCS, Rome, Italy; Institute of Anaesthesiology and Intensive Care Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bernd W Böttiger
- University Hospital of Cologne, Kerpener Straße 62, D-50937 Cologne, Germany
| | - Alain Cariou
- Cochin University Hospital (APHP) and University of Paris (Medical School), Paris, France
| | - Tobias Cronberg
- Department of Clinical Sciences, Neurology, Lund University, Skane University Hospital, Lund, Sweden
| | - Hans Friberg
- Department of Clinical Sciences, Anaesthesia and Intensive Care Medicine, Lund University, Skane University Hospital, Lund, Sweden
| | - Cornelia Genbrugge
- Acute Medicine Research Pole, Institute of Experimental and Clinical Research (IREC) Université Catholique de Louvain, Brussels, Belgium; Emergency Department, University Hospitals Saint-Luc, Brussels, Belgium
| | - Kirstie Haywood
- Warwick Research in Nursing, Room A108, Division of Health Sciences, Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Gisela Lilja
- Lund University, Skane University Hospital, Department of Clinical Sciences Lund, Neurology, Lund, Sweden
| | - Véronique R M Moulaert
- University of Groningen, University Medical Center Groningen, Department of Rehabilitation Medicine, Groningen, The Netherlands
| | - Nikolaos Nikolaou
- Cardiology Department, Konstantopouleio General Hospital, Athens, Greece
| | - Theresa Mariero Olasveengen
- Department of Anesthesiology, Oslo University Hospital and Institute of Clinical Medicine, University of Oslo, Norway
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki and Helsinki University Hospital, Finland
| | - Fabio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles, Route de Lennik, 808, 1070 Brussels, Belgium
| | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol BS10 5NB, UK
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31
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Ordoñez CA, Parra MW, Holguín A, García C, Guzmán-Rodríguez M, Padilla N, Caicedo Y, Orlas C, García A, Rodríguez-Holguín F, Serna JJ, Serna C. Whole-body computed tomography is safe, effective and efficient in the severely injured hemodynamically unstable trauma patient. COLOMBIA MEDICA (CALI, COLOMBIA) 2020; 51:e4054362. [PMID: 33795900 PMCID: PMC7968424 DOI: 10.25100/cm.v51i4.4362] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Trauma is a complex pathology that requires an experienced multidisciplinary team with an inherent quick decision-making capacity, given that a few minutes could represent a matter of life or death. These management decisions not only need to be quick but also accurate to be able to prioritize and to efficiently control the injuries that may be causing impending hemodynamic collapse. In essence, this is the cornerstone of the concept of damage control trauma care. With current technological advances, physicians have at their disposition multiple diagnostic imaging tools that can aid in this prompt decision-making algorithm. This manuscript aims to perform a literature review on this subject and to share the experience on the use of whole body computed tomography as a potentially safe, effective and efficient diagnostic tool in cases of severely injured trauma patients regardless of their hemodynamic status. Our general recommendation is that, when feasible, perform a whole body computed tomography without interrupting ongoing hemostatic resuscitation in cases of severely injured trauma patients with or without signs of hemodynamic instability. The use of this technology will aid in the decision-making of the best surgical approach for these patients without incurring any delay in definitive management and/or increasing significantly their radiation exposure.
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Affiliation(s)
- Carlos A Ordoñez
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care, Fort Lauderdale , FL, USA
| | - Alfonso Holguín
- Fundación Valle del Lili, Department of Radiology. Cali, Colombia
| | - Carlos García
- Fundación Valle del Lili, Department of Radiology. Cali, Colombia
| | - Mónica Guzmán-Rodríguez
- Universidad de Chile, Facultad de Medicina, Instituto de Ciencias Biomédicas, Santiago de Chile, Chile
| | - Natalia Padilla
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Yaset Caicedo
- Fundación Valle del Lili, Centro de Investigaciones Clínicas (CIC), Cali, Colombia
| | - Claudia Orlas
- Brigham & Women's Hospital, Department of Surgery, Center for Surgery and Public Health, Boston, USA.,Harvard Medical School & Harvard T.H. Chan School of Public Health, Boston, USA
| | - Alberto García
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Fernando Rodríguez-Holguín
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - José Julián Serna
- Fundación Valle del Lili, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia.,Universidad Icesi, Cali, Colombia.,Hospital Universitario del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
| | - Carlos Serna
- Universidad del Valle, Department of Surgery, Division of Trauma and Acute Care Surgery. Cali, Colombia
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Ali A, Tatum D, Jones G, Guidry C, McGrew P, Schroll R, Harris C, Duchesne J, Taghavi S. Computed Tomography for Pediatric Pelvic Fractures in Pediatric Versus Adult Trauma Centers. J Surg Res 2020; 259:47-54. [PMID: 33279844 DOI: 10.1016/j.jss.2020.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 10/08/2020] [Accepted: 11/02/2020] [Indexed: 11/15/2022]
Abstract
BACKGROUND Pediatric pelvic fractures are a significant source of morbidity for children in the United States. In the era of specialized care, the relationship between trauma center designation and outcomes remains unknown. We hypothesized that there would be no difference in patient outcomes when treated at adult trauma centers (ATCs), pediatric trauma centers (PTCs), or dual trauma centers (DTCs). MATERIALS AND METHODS We used the National Trauma Data Bank to identify pediatric (≤14 y) patients suffering pelvic fractures in 2013-2015. DTCs were defined as centers with level I or II trauma designation for both pediatric and adult care. Primary outcomes included mortality, complications, and computed tomography (CT) utilization. RESULTS There were 4260 patients who met study criteria. Of these, 1290 (22%) were treated at ATCs, 1332 (30%) at PTCs, and 2120 (48%) at DTCs. Pediatric patients treated at ATCs were more likely to suffer a complication or receive a CT scan. On multivariate analysis, patients treated at PTCs and DTCs were significantly less likely to have a recorded complication or receive head, thoracic, or whole-body CT scans compared with ATCs. DTCs, but not PTCs, used fewer abdominal CT scans. Mortality rates were not predicted by center designation. CONCLUSIONS For pediatric pelvic fractures, centers with pediatric trauma designation (PTCs and DTCs) appear to have better outcomes despite significantly less use of CT scans. Further studies are needed to determine optimal management of pediatric pelvic fractures while minimizing exposure to ionizing radiation. LEVEL OF EVIDENCE Level III Retrospective.
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Affiliation(s)
- Ayman Ali
- Tulane University School of Medicine, New Orleans, Louisiana
| | | | - Glenn Jones
- LSU Health - Baton Rouge, Baton Rouge, Lousiana
| | - Chrissy Guidry
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Patrick McGrew
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Rebecca Schroll
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Charles Harris
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Juan Duchesne
- Tulane University School of Medicine, New Orleans, Louisiana
| | - Sharven Taghavi
- Tulane University School of Medicine, New Orleans, Louisiana.
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Zimmermann P, Schmidt T, Nelson J, Gosemann JH, Bassler S, Stahmeyer JT, Hirsch FW, Lacher M, Zeidler J. Pediatric solid organ injury - frequency of abdominal imaging is determined by the treating department. Medicine (Baltimore) 2020; 99:e23057. [PMID: 33157961 PMCID: PMC7647522 DOI: 10.1097/md.0000000000023057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
To investigate the use of abdominal CT scanning in the management of pediatric blunt abdominal trauma in pediatric and non-pediatric departments.In this observational cohort study, anonymized data were extracted from 2 large German statutory health insurances (∼5.9 million clients) in a 7-year period (2010-2016). All patients with inpatient International Classification of Diseases (ICD) codes S36.- and S37.- (injury of intra-abdominal organs; injury of urinary and pelvic organs) aged ≤18 years were included. Demographic and clinical data were analyzed by logistic regression analysis for associations with the use of abdominal CT.A total of 524 children with blunt abdominal trauma (mean age 11.0 ± 5.2 years; 62.6% males) were included; 164 patients (31.3%) received abdominal CT-imaging. There were no significant differences in traumatic non-intraabdominal comorbidity patterns (injuries of external causes; injuries to the head or thorax). There was substantial variability in the rate of abdominal CT imaging among different medical disciplines ranging from 11.6% to 44.5%. Patients admitted to pediatric departments (Pediatrics and Pediatric Surgery) underwent abdominal CT imaging significantly less frequently (19.7%; N = 55) compared to patients treated in non-pediatric departments (General/Trauma Surgery: 44.5%; N = 109) irrespective of concomitant injuries. The estimated OR for the use of abdominal CT by General/Trauma Surgery was 6.2-fold higher (OR: 6.15 [95-%-CI:3.07-13.21]; P < .001) compared to Pediatric Surgery. Other risk factors associated with the use of abdominal CT were traumatic extra-abdominal comorbidities, increasing age, male gender, and admission to a university hospital.Abdominal CT imaging was significantly less frequently used in pediatric departments. The substantial variability of the abdominal CT rate among different medical disciplines and centers indicates a potential for reduction of CT imaging by implementation of evidence-based guidelines. Furthermore, our study underlines the need for centralization of pediatric trauma care in Germany not only to improve patient outcome but to avoid radiation-induced cancer mortality.
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Affiliation(s)
| | - Torben Schmidt
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
| | - Jana Nelson
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | | | - Stefan Bassler
- AOK PLUS - Die Gesundheitskasse für Sachsen und Thüringen, Dresden
| | | | | | - Martin Lacher
- Department of Pediatric Surgery, University of Leipzig, Leipzig
| | - Jan Zeidler
- Center for Health Economics Research Hannover (CHERH), Leibniz University Hannover, Hannover
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Maghraby NH, Alshaqaq HM, AlQattan AS, Alfaraj AF, Alghamdi OA, Alzawad MJ, Farcy DA. Negative Whole-Body Computed Tomography Scans in Polytrauma Patients: A Retrospective Cohort Study. Open Access Emerg Med 2020; 12:305-313. [PMID: 33122955 PMCID: PMC7591101 DOI: 10.2147/oaem.s263754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/18/2020] [Indexed: 11/24/2022] Open
Abstract
Background Whole-body computed tomography (WBCT) has been a mainstay and an integral part of the evaluation of polytrauma patients in trauma centers and emergency departments (ED) for a comprehensive evaluation of the extent of injuries. However, routine use of WBCT remains controversial since it exposes patients to radiation and exponentially increases financial expense. The primary objective was to determine the rate of negative WBCT in polytrauma patients. Patients and Methods A retrospective cohort study was conducted at an academic hospital in the Kingdom of Saudi Arabia, which is a dedicated trauma center with a mean of 237,392 ED visits and 10,714 trauma per year. The study included all adult (≥18 years) polytrauma patients who presented to our ED, requiring trauma team activation, and underwent WBCT as part of their evaluation from January 2016 to May 2017. We excluded pediatric patients, patients transferred from another facility, and pregnant patients. The primary endpoint was to measure the rate of negative WBCT in polytraumatized patients. Results A total of 186 patients were included with a mean age of 28.8 ± 12.9 years. The rate of negative WBCT scans was 20.4%. The positive scans were subclassified based on the number of anatomical body regions that were affected radiologically. One body region was affected in 47 patients (31.8%), two body regions were affected in 50 patients (33.8%), and ≥3 body regions were affected in 51 patients (34.3%). In a subset analysis, we identified that oxygen saturation <94% and GCS ≤8 were associated with positive CT scans. Conclusion Our study revealed a slightly higher rate of utilization of WBCT in the management of trauma patients compared to studies with similar practice. We believe that in the correct setting with incorporating high index of suspicion, a physical examination with attention to vital signs and mental status, performing E-FAST, and dedicated X-Rays is a way to potentially reduce the use of WBCT in polytrauma patients.
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Affiliation(s)
- Nisreen H Maghraby
- Department of Emergency Medicine, King Fahd University Hospital-College of Medicine, Imam Abdulrahman Bin Faisal University, AlKhobar, Kingdom of Saudi Arabia
| | - Hassan M Alshaqaq
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Abdullah Saleh AlQattan
- Department of General Surgery, King Fahad Specialist Hospital-Dammam, Kingdom of Saudi Arabia
| | - Adnan Fawzi Alfaraj
- Department of Emergency Medicine, King Fahad Specialist Hospital-Dammam, Kingdom of Saudi Arabia
| | - Omar A Alghamdi
- College of Medicine, Imam Abdulrahman Bin Faisal University, Dammam, Kingdom of Saudi Arabia
| | - Malak J Alzawad
- Department of Psychiatry, Ministry of Health, Dammam, Kingdom of Saudi Arabia
| | - David A Farcy
- Mount Sinai Medical Center, Department of Emergency Medicine, Miami Beach, Florida, USA
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Chetram VK, Kopatsis AP, Kopatsis A. Validity of physical examination in the thorax and abdomen of intoxicated trauma patients following a fall: An exploratory retrospective review. TRAUMA-ENGLAND 2020. [DOI: 10.1177/1460408620905398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Whole-Body Computerized Topography (WBCT) scans can be used to identify injuries related to trauma in intoxicated patients who often cannot provide a reliable history. While WBCT scans are associated with a decreased mortality and hospital stay in patients with a high energy mechanism of injury, their utility in intoxicated patients following a fall remain unclear. The objective of this study was to evaluate the validity of physical examination in the thorax and abdomen to identify injuries in the intoxicated patient following a fall when compared to WBCT scan findings. Methods A retrospective chart review was performed over a two-year period of intoxicated trauma patients who were found down secondary to a witnessed fall <20 ft, GCS > 8 and not requiring intubation. Documented physical examination findings were compared to WBCT results. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. A t-test was used to identify differences between clinical variables of false-negative and true-negative physical examinations. Results A total of 523 intoxicated patients presented to the ED with 43 meeting the inclusion criteria. All patients had an injury that required admission to the hospital. Of 19 patients with a positive chest CT, 13 had a negative physical exam, for sensitivity of 32% and specificity of 96%. Of eight patients with a positive abdominal CT, six had a negative physical exam, sensitivity and specificity were 16% and 98% respectively. No clinical variables were found to be different between falsely negative and true negative physical exam results. Conclusion In the acutely intoxicated trauma patient, physical examination findings of the thorax and abdomen were associated with a low validity, having missed an unacceptably high number of injuries, when compared to WBCT scans.
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Affiliation(s)
- Vishaka K Chetram
- NYC Health+Hospitals/Elmhurst, Elmhurst, NY, USA
- St. Georges University, True Blue, Grenada
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Detailed information gain and therapeutic impact of whole body computed tomography supplementary to conventional radiological diagnostics in blunt trauma emergency treatment: a consecutive trauma centre evaluation. Eur J Trauma Emerg Surg 2020; 48:921-931. [PMID: 32997166 PMCID: PMC9001527 DOI: 10.1007/s00068-020-01502-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 09/15/2020] [Indexed: 12/03/2022]
Abstract
Purpose The indication of whole body computed tomography (WBCT) in the emergency treatment of trauma is still under debate. We were interested in the detailed information gain obtained from WBCT following standardized conventional imaging (CI). Methods Prospective study including all emergency trauma centre patients examined by CI (focused assessment of sonography in trauma, chest and pelvic X-ray) followed by WBCT from 2011 to 2017. Radiology reports were compared per patient for defined body regions for number and severity of injuries (Abbreviated Injury Scale, AIS; Injury Severity Score, ISS), incidental findings and treatment consequences (Wilcoxon signed rank test, Spearman rho, Chi-square). Results 1271 trauma patients (ISS 11.3) were included in this study. WBCT detected more injury findings than CI in the equivalent body regions (1.8 vs. 0.6; p < 0.001). In 44.4% of cases at least one finding was missed by CI alone. Compared to WBCT, injury severity of specified body regions was underestimated by CI on average by an AIS of 1.9 (p < 0.001). In 22.0% of cases injury severity increased by an AIS ≥ 2 following WBCT. In 16.8% of patients additional injury findings resulted in a change of treatment (number needed to profit, NNP = 6 patients): NNP decreased from 25 for patients with an ISS < 7 up to nearly 2 for patients with an ISS > 25 at final evaluation, thereby demonstrating a significant improvement in the NNP with increasing ISS (rho = 0.33, p < 0.001). Moreover, WBCT in 88.4% of patients identified ≥ 1 incidental finding (mean 3.4) vs. 28.9% by CI only (p < 0.001). Overall, WBCT had treatment consequences in 31.9% of cases (NNP = 3.1). Conclusions The application of WBCT in addition to CI in the emergency treatment of trauma had therapy consequences for almost every third patient. On the other hand, WBCT appeared not to be indicated (ISS < 8) in at least 2/5 of patients. Electronic supplementary material The online version of this article (10.1007/s00068-020-01502-1) contains supplementary material, which is available to authorized users.
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Weger K, Hammer P, McKinley T, Steenburg S. Incidence and clinical impact of lower extremity vascular injuries in the setting of whole body computed tomography for trauma. Emerg Radiol 2020; 28:265-272. [PMID: 32857232 DOI: 10.1007/s10140-020-01847-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/20/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The aims of this study are to determine the incidence of lower extremity fractures and/or vascular injuries in the setting of whole body computed tomography (WBCT) for trauma and to determine lower extremity injury outcomes in this patient population. METHODS This is a retrospective observational study performed at a large urban Level 1 trauma center. Our institutional trauma registry was queried for patients who were evaluated with WBCT and lower extremity CT angiography (CTA) as a part of their initial imaging evaluation over a 43-month period. Patients with lower extremity fractures and/or vascular injuries were identified. Those patients with both lower extremity vascular injury and fracture were then analyzed to determine the physical relationship of the fracture to the vascular injury. Physical exam findings were extracted from the medical record. Interventions and long-term outcomes were determined from the medical record. RESULTS A total of 370 patients met the inclusion criteria, with 98% experiencing blunt trauma. Of these, 290 (78.4%) were positive for lower extremity injury, including 266 (71.9%) with isolated fractures, 2 (0.6%) with isolated vascular injury, and 22 (5.9%) with vascular injury associated with long bone fracture. Of the 22 patients with combined fracture and vascular injury, 8 received vascular intervention and 10 had long-term complications as a result of their injuries. Physical exam findings were insufficient to diagnose 57% of the vascular injuries. CONCLUSIONS The inclusion of lower extremity CTA as part of a WBCT imaging exam for trauma allows for the identification of vascular injuries that otherwise may have gone undetected or resulted in delayed diagnosis. Clinically occult lower extremity vascular injuries may be associated with poor outcomes.
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Affiliation(s)
- Kendal Weger
- Indiana University School of Medicine and Indiana University Health, Indianapolis, IN, USA.
| | - Peter Hammer
- Indiana University School of Medicine and Indiana University Health, Indianapolis, IN, USA
| | - Todd McKinley
- Indiana University School of Medicine and Indiana University Health, Indianapolis, IN, USA
| | - Scott Steenburg
- Indiana University School of Medicine and Indiana University Health, Indianapolis, IN, USA
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Baig A, Drabkin MJ, Khan F, Fogel J, Shah S. Patients with falls from standing height and head or neck injury may not require body CT in the absence of signs or symptoms of body injury. Emerg Radiol 2020; 28:239-243. [PMID: 32814988 DOI: 10.1007/s10140-020-01843-9] [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: 06/05/2020] [Accepted: 08/16/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To determine the rate of clinically impactful body injury among patients who had a fall from standing height with an associated head/neck injury, but without evidence of body injury on physical exam or plain radiographs. We also examine surgical/endovascular intervention related to body injury and mortality rates for head/neck and body injury. METHODS Retrospective study of 288 patients with CT evidence of acute head/neck injury that underwent body CT despite the absence of clinical or radiographic evidence of body injury. Predictor variables were age, sex, race/ethnicity, and body mass index (BMI). RESULTS There were 11.5% (n = 33) with body injury on CT (n = 33). There were 3.1% (n = 9) with clinically impactful body injury. No patient had either surgical/endovascular intervention or mortality related to body injury. Additionally, 8.7% (n = 25) had mortality from head/neck injury. Increased age (OR = 1.05, 95% CI: 1.01, 1.08, p = 0.01) and overweight BMI (25-29.99 kg/m2) (OR = 2.85, 95% CI: 1.07, 7.62, p = 0.04) were each significantly associated with increased odds for mortality from head/neck injury. CONCLUSION Patients with falls from standing height and known head/neck injury had a low rate of clinically impactful body injury. None of the studied variables were associated with increased risk of body injury in this patient population. The low rate of clinically impactful body injury and the lack of any mortality, procedure, or transfusion resulting from body injury suggest that body CT may not be necessary in patients with head/neck injury in the absence of clinical or radiographic evidence of body injury.
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Affiliation(s)
- Asad Baig
- Department of Radiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA.
| | - Michael J Drabkin
- Department of Radiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA
| | - Fiza Khan
- Department of Radiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA
| | - Joshua Fogel
- Department of Business Management, Brooklyn College of the City University of New York, Brooklyn, NY, USA
| | - Salman Shah
- Department of Radiology, Nassau University Medical Center, 2201 Hempstead Turnpike, East Meadow, NY, 11554, USA
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Modified Split-Scan Computed Tomography (CT) Diagnostics of Severely Injured Patients: First Results from a Level I Trauma Center Using a Dedicated Head-and-Neck CT-Angiogram for the Detection of Cervical Artery Dissections. J Clin Med 2020; 9:jcm9082568. [PMID: 32784360 PMCID: PMC7464925 DOI: 10.3390/jcm9082568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Revised: 08/06/2020] [Accepted: 08/06/2020] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Traumatic cervical artery dissections are associated with high mortality and morbidity in severely injured patients. After finding even higher incidences than reported before, we decided to incorporate a dedicated head-and-neck computed tomography angiogram (CT-A) in our imaging routine for patients who have been obviously severely injured or, according to trauma mechanism, are suspected to be severely injured. MATERIALS AND METHODS A total of 134 consecutive trauma patients with an ISS ≥ 16 admitted to our level I trauma center during an 18 month period were included. All underwent standardized whole-body CT in a 256-detector row scanner with a dedicated head-and-neck CT-A realized as single-bolus split-scan routine. Incidence, mortality, patient and trauma characteristics, and concomitant injuries were recorded and analyzed in patients with carotid artery dissection (CAD) and vertebral artery dissection (VAD). RESULTS Of the 134 patients included, 7 patients had at least one cervical artery dissection (CeAD; 5.2%; 95% CI 1.5-9.0%). Six patients (85.7%) had carotid artery dissections, with one patient having a CAD of both sides and one patient having a CAD and contralateral VAD combined. Two patients (28.6%) showed a VAD. Overall mortality was 14.3%, neurologic morbidity was 28.6%. None of the patients showed any attributable neurologic symptoms on admission. The new scanning protocol led to further 5 patients with suspected CeAD during the study period, all ruled out by additional magnetic resonance imaging with angiogram (MRI/MR-A). CONCLUSION A lack of specific neurologic symptoms on admission urges the need for a dedicated imaging pathway for severely injured patients, reliable for the detection of cervical artery dissections. Although our modified CT protocol with mandatory dedicated CT-A led to false positives requiring additional magnetic resonance imaging, it likely helped reduce possible therapeutic delays.
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Bieler D, Paffrath T, Schmidt A, Völlmecke M, Lefering R, Kulla M, Kollig E, Franke A. Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®. Chin J Traumatol 2020; 23:224-232. [PMID: 32576425 PMCID: PMC7451614 DOI: 10.1016/j.cjtee.2020.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/21/2019] [Accepted: 01/02/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients. METHODS In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room. RESULTS We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention. CONCLUSION Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.
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Affiliation(s)
- Dan Bieler
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany; Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Hospital, Düsseldorf, 40225, Germany.
| | - Thomas Paffrath
- Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Faculty of Health - School of Medicine, Cologne, 51109, Germany
| | - Annelie Schmidt
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
| | - Maximilian Völlmecke
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, 51109, Germany
| | - Martin Kulla
- Department of Anaesthesiology and Intensive Care, German Armed Forces Hospital Ulm, Ulm, 89081, Germany
| | - Erwin Kollig
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
| | - Axel Franke
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
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Plaster AL, Faulks ER, Gillen JN, Tegge AN, Matos MA, Lollar DI, Bower KL, Nussbaum MS, Collier BR, Hamill ME. Different Perceptions Exist Between Health Care Providers and the General Population Regarding the Importance of Findings on Additional Imaging for Trauma Consults. Am Surg 2020; 86:830-836. [PMID: 32731746 DOI: 10.1177/0003134820940249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Approximately one-third of additional imaging for trauma consults results in the discovery of new injuries. No studies have addressed the perception of these findings in non-health care providers. Our hypothesis was that significant differences in perception of the importance of injuries would exist between health care providers (HCPs) and the general population. METHODS Six standardized scenarios were developed detailing common new injury findings on additional imaging in trauma consults. Demographics as well as information regarding the significance of findings, potential for change in care, and the importance of patient notification were collected. Surveys were electronically distributed to HCPs in our system and the public. Data analysis was performed with generalized linear modeling. RESULTS A total of 339 public and 129 HCP surveys were returned. HCPs included attending staff, residents, and advanced care providers from a variety of specialties. Significant differences in perception were found in traumatic brain injury, spine fractures, and rib fractures, with HCPs rating most findings as less clinically important than the general population, while rating patient notification as more important. Perceived importance decreased with increased age in the general population. Increasing HCP age or length in practice did not significantly affect perception of clinical importance, except for rib fractures. DISCUSSION Differences in perception exist regarding the significance of additional injuries between HCPs and the general population. Perceptions of the general population also change with age. Decisions to pursue additional imaging in trauma patients should include consideration of these differences in perception to help support quality patient-centered care.
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Affiliation(s)
- Andrew L Plaster
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,San Antonio Uniformed Services Health Education Consortium, JBSA Fort Sam Houston, TX, USA
| | - Emily R Faulks
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Jacob N Gillen
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Allison N Tegge
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,Department of Statistics, Virginia Tech, Blacksburg, VA, USA
| | - Miguel A Matos
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Daniel I Lollar
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Katie L Bower
- 22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Michael S Nussbaum
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Bryan R Collier
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
| | - Mark E Hamill
- Virginia Tech Carilion School of Medicine, Roanoke, VA, USA.,22391 Department of Surgery, Carilion Roanoke Memorial Hospital, Roanoke, VA, USA
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Bågenholm A, Løvhaugen P, Sundset R, Ingebrigtsen T. DIAGNOSTIC IMAGING AND IONIZING RADIATION EXPOSURE IN A LEVEL 1 TRAUMA CENTRE POPULATION MET WITH TRAUMA TEAM ACTIVATION: A ONE-YEAR PATIENT RECORD AUDIT. RADIATION PROTECTION DOSIMETRY 2020; 189:35-47. [PMID: 32060518 DOI: 10.1093/rpd/ncaa010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 01/10/2020] [Accepted: 01/15/2020] [Indexed: 06/10/2023]
Abstract
This audit describes ionizing and non-ionizing diagnostic imaging at a regional trauma centre. All 144 patients (males 79.2%, median age 31 years) met with trauma team activation from 1 January 2015 to 31 December 2015 were included. We used data from electronic health records to identify all diagnostic imaging and report radiation exposure as dose area product (DAP) for conventional radiography (X-ray) and dose length product (DLP) and effective dose for CT. During hospitalization, 134 (93.1%) underwent X-ray, 122 (84.7%) CT, 92 (63.9%) focused assessment with sonography for trauma (FAST), 14 (9.7%) ultrasound (FAST excluded) and 32 (22.2%) magnetic resonance imaging. One hundred and sixteen (80.5%) underwent CT examinations during trauma admissions, and 73 of 144 (50.7%) standardized whole body CT (SWBCT). DAP values were below national reference levels. Median DLP and effective dose were 2396 mGycm and 20.42 mSv for all CT examinations, and 2461 mGycm (national diagnostic reference level 2400) and 22.29 mSv for a SWBCT.
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Affiliation(s)
- Anna Bågenholm
- Department of Radiology, University Hospital of North Norway, Tromsø N-9038, Norway
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Arctic University of Norway, Tromsø N-9037, Norway
| | - Pål Løvhaugen
- PET-Imaging Center, University Hospital of North Norway, Tromsø N-9038, Norway
| | - Rune Sundset
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Arctic University of Norway, Tromsø N-9037, Norway
- PET-Imaging Center, University Hospital of North Norway, Tromsø N-9038, Norway
| | - Tor Ingebrigtsen
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Arctic University of Norway, Tromsø N-9037, Norway
- Department of Neurosurgery, ENT and Ophthalmology, University Hospital of North Norway, Tromsø N-9038, Norway
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Arruzza E, Chau M, Dizon J. Systematic review and meta-analysis of whole-body computed tomography compared to conventional radiological procedures of trauma patients. Eur J Radiol 2020; 129:109099. [PMID: 32563164 DOI: 10.1016/j.ejrad.2020.109099] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 05/19/2020] [Accepted: 05/25/2020] [Indexed: 01/15/2023]
Abstract
PURPOSE The superior diagnostic accuracy of CT makes it an attractive tool for initial trauma imaging. This meta-analysis aimed to assess the evidence regarding the value of whole-body CT (WBCT) as part of the primary survey, in comparison to conventional radiological procedures. METHODS A comprehensive systematic search of the literature was conducted using keywords applied in Scopus, Cochrane and PubMed databases. Articles were eligible if they contained original data comparing the use of WBCT in the primary survey, with conventional radiological procedures. Outcomes included overall and 24 -h mortality, emergency department (ED) time, intensive care unit (ICU) and hospital length of stay (LOS), and multiple organ dysfunction syndrome/failure (MODS/MOF) incidence. Radiation dose, mechanical ventilation duration and cost were evaluated qualitatively. Analysis was performed with Covidence, MedCalc Version 19.1.3. and Meta-Essentials. RESULTS Fourteen studies were included. Statistical pooling demonstrated comparable rates between conventional procedures and WBCT (OR = 0.854, CI = 0.715-1.021, p = 0.083) in 63,529 patients across 11 studies. A significant finding favouring WBCT was discovered for ED time (SMD = -0.709, CI -1.198 to -0.220, p = 0.004). Patients experienced similar 24 -h mortality rates (p = 0.450), MODS/MOF incidence (p = 0.274), and hospital (p = 0.541) and ICU LOS (p = 0.457). WBCT is associated with increased radiation dose and mechanical ventilation duration. CONCLUSION This review demonstrates that WBCT markedly reduces time spent in ED. No significant differences in mortality rate are suggested. WBCT currently entails greater radiation dose and mechanical ventilation time. Further research is necessitated to address limitations of predominately retrospective observational data available.
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Affiliation(s)
- Elio Arruzza
- University of South Australia, UniSA Allied Health & Human Performance, South Australia, 5000, Australia.
| | - Minh Chau
- University of South Australia, UniSA Allied Health & Human Performance, South Australia, 5000, Australia
| | - Janine Dizon
- University of South Australia, UniSA Allied Health & Human Performance, International Centre for Allied Health Evidence (iCAHE), South Australia, 5000, Australia
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Impact of contrast extravasation on computed tomography of the psoas major muscle in patients with blunt torso trauma. J Trauma Acute Care Surg 2020; 86:268-273. [PMID: 30399135 DOI: 10.1097/ta.0000000000002121] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The clinical significance of contrast extravasation (CE) on computed tomography (CT) of the psoas major muscle after blunt torso trauma and the optimal management of patients requiring transcatheter arterial embolization (TAE) of the lumbar artery have not been well elucidated. The aim of this study was to investigate the impact of CE on CT to determine the need for TAE of the lumbar artery. METHODS We examined a single-center retrospective cohort of blunt torso trauma patients who underwent contrast-enhanced CT from 2008 to 2017. Basic demographics and clinical data were obtained, including the number of lumbar transverse process fractures (LTPFs) and maximum psoas major muscle hematoma (PMMH) size and ratio. Maximum PMMH size was analyzed by measuring the cross-sectional area of hematoma size at the level of CE. Psoas major muscle hematoma size ratio was obtained by dividing maximum PMMH size by psoas major muscle size of the unaffected side at the same slice level. RESULTS A total of 762 patients were included. One hundred seventeen patients had LTPFs and/or PMMH. Of 117 patients, 25 had CE on CT of the psoas major muscle and had significantly higher rates of older age and severe injury compared with those without CE. Of the 25 patients with CE, 13 required TAE of the lumbar artery. Patients who required TAE had a significantly higher number of LTPFs (4 vs. 2, p = 0.011) and higher PMMH size ratio (2.10 vs. 1.32, p = 0.016). Psoas major muscle hematoma size ratio revealed moderate accuracy (area under the receiver operating characteristic curve, 0.782). CONCLUSIONS Approximately half of the blunt torso trauma patients with CE on CT of the psoas major muscle will require TAE of the lumbar artery. Higher number of LTPFs and larger PMMH size can be a predictor of the need for TAE of the lumbar artery among patients with CE on CT. LEVEL OF EVIDENCE Therapeutic/care management, level IV.
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Shyu JY, Khurana B, Soto JA, Biffl WL, Camacho MA, Diercks DB, Glanc P, Kalva SP, Khosa F, Meyer BJ, Ptak T, Raja AS, Salim A, West OC, Lockhart ME. ACR Appropriateness Criteria® Major Blunt Trauma. J Am Coll Radiol 2020; 17:S160-S174. [PMID: 32370960 DOI: 10.1016/j.jacr.2020.01.024] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Accepted: 01/22/2020] [Indexed: 11/20/2022]
Abstract
This review assesses the appropriateness of various imaging studies for adult major blunt trauma or polytrauma in the acute setting. Trauma is the leading cause of mortality for people in the United States <45 years of age, and the fourth leading cause of death overall. Imaging, in particular CT, plays a critical role in the management of these patients, and a number of indications are discussed in this publication, including patients who are hemodynamically stable or unstable; patients with additional injuries to the face, extremities, chest, bowel, or urinary system; and pregnant patients. Excluded from consideration in this review are penetrating traumatic injuries, burns, and injuries to pediatric patients. Patients with suspected injury to the head and spine are also discussed more specifically in other appropriateness criteria documents. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
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Affiliation(s)
- Jeffrey Y Shyu
- Research Author, Brigham & Women's Hospital, Boston, Massachusetts
| | - Bharti Khurana
- Principal Author, Brigham & Women's Hospital, Boston, Massachusetts.
| | - Jorge A Soto
- Research Author, Boston University School of Medicine, Boston, Massachusetts
| | - Walter L Biffl
- Scripps Memorial Hospital La Jolla, La Jolla, California; American Association for the Surgery of Trauma
| | - Marc A Camacho
- The University of South Florida Morsani College of Medicine, Tampa, Florida
| | - Deborah B Diercks
- University of Texas Southwestern Medical Center, Dallas, Texas; American College of Emergency Physicians
| | - Phyllis Glanc
- University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | | | - Faisal Khosa
- Vancouver General Hospital, Vancouver, British Columbia, Canada
| | | | - Thomas Ptak
- University of Maryland Medical Center, Baltimore, Maryland
| | - Ali S Raja
- Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts; Society for Academic Emergency Medicine
| | - Ali Salim
- Brigham & Women's Hospital, Boston, Massachusetts; American College of Surgeons
| | - O Clark West
- UTHealth McGovern Medical School, Houston, Texas
| | - Mark E Lockhart
- Specialty Chair, University of Alabama at Birmingham, Birmingham, Alabama
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Factors influencing vehicle passenger fatality have changed over 10 years: a nationwide hospital-based study. Sci Rep 2020; 10:3316. [PMID: 32094429 PMCID: PMC7040014 DOI: 10.1038/s41598-020-60222-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 02/10/2020] [Indexed: 11/22/2022] Open
Abstract
Traffic injury trends have changed with safety developments. To establish effective preventive measures against traffic fatalities, the factors influencing fatalities must be understood. The present study evaluated data from a national medical database to determine the changes in these factors over time, as this has not been previously investigated. This observational study retrospectively analysed data from the Japanese Trauma Data Bank. Vehicle passengers involved in collisions from 2004–2008 and 2016–2017 were included. Data were compared between the two study periods, and between fatal and non-fatal patients within each period. Multivariate logistic regression analyses were performed to determine the factors influencing fatalities. In 2016–2017, patients were older and had lower fatality rates. In 2004–2008, fatalities were more likely to involve older male front-seat passengers with low d-BP, BT, and GCS values, and high AIS of the neck and abdomen. However, in 2016–2017, fatalities were more likely to involve older males with low GCS, high AIS of the abdomen, and positive focused assessment with sonography for trauma results. Our study identified independent factors influencing vehicle passenger fatalities, which will likely continue to evolve with the aging of the population and changing manners of injury.
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Roberts GJ, Jacobson LE, Amaral MM, Jensen CD, Cooke L, Schultz JF, Kinstedt AJ, Saxe JM. Cross-sectional imaging of the torso reveals occult injuries in asymptomatic blunt trauma patients. World J Emerg Surg 2020; 15:5. [PMID: 31938035 PMCID: PMC6953148 DOI: 10.1186/s13017-019-0287-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 12/24/2019] [Indexed: 11/10/2022] Open
Abstract
Background High morbidity and mortality rates of trauma injuries make early detection and correct diagnosis crucial for increasing patient's survival and quality of life after an injury. Improvements in technology have facilitated the rapid detection of injuries, especially with the use of computed tomography (CT). However, the increased use of CT imaging is not universally advocated for. Some advocate for the use of selective CT imaging, especially in cases where the severity of the injury is low. The purpose of this study is to review the CT indications, findings, and complications in patients with low Injury Severity Scores (ISS) to determine the utility of torso CT in this patient cohort. Methods A retrospective review of non-intubated, adult blunt trauma patients with an initial GCS of 14 or 15 evaluated in an ACS verified level 1 trauma center from July 2012 to June 2015 was performed. Data was obtained from the hospital's trauma registry and chart review, with the following data included: age, sex, injury type, ISS, physical exam findings, all injuries recorded, injuries detected by torso CT, missed injuries, and complications. The statistical tests conducted in the analysis of the collected data were chi-squared, Fischer exact test, and ANOVA analysis. Results There were 2306 patients included in this study, with a mean ISS of 8. For patients with a normal chest exam that had a chest CT, 15% were found to have an occult chest injury. In patients with a negative chest exam and negative chest X-ray, 35% had occult injuries detected on chest CT. For patients with a negative abdominal exam and CT abdomen and pelvis, 16% were found to have an occult injury on CT. Lastly, 25% of patients with normal chest, abdomen, and pelvis exams with chest, abdomen, and pelvis CT scans demonstrated occult injuries. Asymptomatic patients with a negative CT had a length of stay 1 day less than patients without a corresponding CT. No incidents of contrast-induced complications were recorded. Conclusions A negative physical exam combined with a normal chest X-ray does not rule out the presence of occult injuries and the need for torso imaging. In blunt trauma patients with normal sensorium, physical exam and chest X-ray, the practice of obtaining cross-sectional imaging appears beneficial by increasing the accuracy of total injury burden and decreasing the length of stay.
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Affiliation(s)
- Gregory J Roberts
- 1Trauma Department, St. Vincent Indianapolis Hospital, 8240 Naab Road #100, Indianapolis, IN 46260 USA
| | - Lewis E Jacobson
- 1Trauma Department, St. Vincent Indianapolis Hospital, 8240 Naab Road #100, Indianapolis, IN 46260 USA
| | - Michelle M Amaral
- 2Department of Economics, University of the Pacific, Stockton, CA USA
| | - Courtney D Jensen
- 2Department of Economics, University of the Pacific, Stockton, CA USA
| | - Louis Cooke
- 1Trauma Department, St. Vincent Indianapolis Hospital, 8240 Naab Road #100, Indianapolis, IN 46260 USA
| | - Jacqueline F Schultz
- 1Trauma Department, St. Vincent Indianapolis Hospital, 8240 Naab Road #100, Indianapolis, IN 46260 USA
| | - Alexander J Kinstedt
- 1Trauma Department, St. Vincent Indianapolis Hospital, 8240 Naab Road #100, Indianapolis, IN 46260 USA
| | - Jonathan M Saxe
- 1Trauma Department, St. Vincent Indianapolis Hospital, 8240 Naab Road #100, Indianapolis, IN 46260 USA
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Bågenholm A, Dehli T, Eggen Hermansen S, Bartnes K, Larsen M, Ingebrigtsen T. Clinical guided computer tomography decisions are advocated in potentially severely injured trauma patients: a one-year audit in a level 1 trauma Centre with long pre-hospital times. Scand J Trauma Resusc Emerg Med 2020; 28:2. [PMID: 31924242 PMCID: PMC6954603 DOI: 10.1186/s13049-019-0692-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2019] [Accepted: 11/26/2019] [Indexed: 12/02/2022] Open
Abstract
BACKGROUND The International Commission on Radiological Protection's (ICRP) justification principles state that an examination is justified if the potential benefit outweighs the risk for radiation harm. Computer tomography (CT) contributes 50% of the radiation dose from medical imaging, and in trauma patients, the use of standardized whole body CT (SWBCT) increases. Guidelines are lacking, and reviews conclude conflictingly regarding the benefit. We aimed to study the degree of adherence to ICRP's level three justification, the individual dose limitation principle, in our institution. METHODS This is a retrospective clinical audit. We included all 144 patients admitted with trauma team activation to our regional Level 1 trauma centre in 2015. Injuries were categorized according to the Abbreviated Injury Scale (AIS) codes. Time variables, vital parameters and interventions were registered. We categorized patients into trauma admission SWBCT, selective CT or no CT examination strategy groups. We used descriptive statistics and regression analysis of predictors for CT examination strategy. RESULTS The 144 patients (114 (79.2%) males) had a median age of 31 (range 0-91) years. 105 (72.9%) had at least one AIS ≥ 2 injury, 26 (18.1%) in more than two body regions. During trauma admission, at least one vital parameter was abnormal in 46 (32.4%) patients, and 73 (50.7%) underwent SWBCT, 43 (29.9%) selective CT and 28 (19.4%) no CT examination. No or only minor injuries were identified in 17 (23.3%) in the SWBCT group. Two (4.6%) in the selective group were examined with a complement CT, with no new injuries identified. A significantly (p < 0.001) lower proportion of children (61.5%) than adults (89.8%) underwent CT examination despite similar injury grades and use of interventions. In adjusted regression analysis, patients with a high-energy trauma mechanism had significantly (p = 0.028) increased odds (odds ratio = 4.390, 95% confidence interval 1.174-16.413) for undergoing a SWBCT. CONCLUSION The high proportion of patients with no or only minor injuries detected in the SWBCT group and the significantly lower use of CT among children, indicate that use of a selective CT examination strategy in a higher proportion of our patients would have approximated the ICRP's justification level three, the individual dose limitation principle, better.
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Affiliation(s)
- Anna Bågenholm
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Artic University of Norway, PO box 6050 Langnes, N-9037 Tromsø, Norway
- Department of Radiology, University Hospital of North Norway, Sykehusveien 38, PO box 103, N-9038 Tromsø, Norway
| | - Trond Dehli
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Artic University of Norway, PO box 6050 Langnes, N-9037 Tromsø, Norway
- Department of Gastrointestinal Surgery, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
| | - Stig Eggen Hermansen
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
| | - Kristian Bartnes
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Artic University of Norway, PO box 6050 Langnes, N-9037 Tromsø, Norway
- Department of Cardiothoracic and Vascular Surgery, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
| | - Marthe Larsen
- Centre for Quality Improvements and Development, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
| | - Tor Ingebrigtsen
- Department of Clinical Medicine, Faculty of Health Science, UiT-The Artic University of Norway, PO box 6050 Langnes, N-9037 Tromsø, Norway
- Department of Neurosurgery, ENT and Ophthalmology, University Hospital of North Norway, PO box 103, N-9038 Tromsø, Norway
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Yumoto T, Ihoriya H, Tanabe R, Naito H, Nakao A. Higher enhanced computed tomography attenuation value of the aorta is a predictor of massive transfusion in blunt trauma patients. Clin Exp Emerg Med 2019; 6:330-339. [PMID: 31910504 PMCID: PMC6952635 DOI: 10.15441/ceem.18.090] [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: 12/28/2018] [Accepted: 02/25/2018] [Indexed: 11/26/2022] Open
Abstract
Objective Several scoring systems have been developed to identify patients who require massive transfusion (MT) after major trauma to improve survival. The primary goal of this study was to investigate the usefulness of enhanced computed tomography attenuation values (CTAVs) of major vessels to determine the need for MT in patients with major blunt trauma. Methods This single-center retrospective cohort study evaluated patients aged 16 years or older who underwent contrast-enhanced computed tomography scan of the torso after major blunt trauma. The CTAVs of six major vessel points in both the arterial and portal venous phases at initial computed tomography examination were assessed and compared between the MT and the no MT group. The capability of enhanced CTAVs to predict the necessity for MT was estimated based on the area under the receiver operating characteristic curve. Results Of the 254 eligible patients, 36 (14%) were in the MT group. Patients in the MT group had significantly higher CTAVs at all sites except the inferior vena cava in both the arterial and portal venous phases than that in the no MT group. The descending aorta in the arterial phase had the highest accuracy for predicting MT, with an AUROC of 0.901 (95% confidence interval, 0.855 to 0.947; P<0.001). Conclusion Initial elevation of enhanced CTAV of the aorta is a predictor for the need for MT. A higher CTAV of the aorta should alert the trauma surgeon or emergency physician to activate their MT protocol.
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Affiliation(s)
- Tetsuya Yumoto
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromi Ihoriya
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Ryo Tanabe
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Hiromichi Naito
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Atsunori Nakao
- Department of Emergency, Critical Care, and Disaster Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
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Yin I, Phillips A, Straus CM. Best Reporting Practices for Multipart CT Scans: A Pilot Evaluation and Construction of the Optimal Analysis Methodology. J Am Coll Radiol 2019; 16:1409-1415. [DOI: 10.1016/j.jacr.2019.02.046] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 11/16/2022]
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