Routine versus selective multidetector-row computed tomography (MDCT) in blunt trauma patients: level of agreement on the influence of additional findings on management

Comparative study of National Emergency X-Radiography Utilization Study (NEXUS) chest algorithm and extended focused assessment with sonography for trauma (E-FAST) in the early detection of blunt chest injuries in polytrauma patients

Introduction

Chest imaging plays a prominent role in the assessment of patients with blunt trauma. Selection of the right approach at the right time is fundamental in the management of patients with blunt chest trauma.[1] A reliable, economic, bedside, and rapidly accomplished screening test can be pivotal. [2].

Objective

The aim of this study was to compare the accuracy of extended- focused assessment with sonography for trauma (E-FAST) to that of the National Emergency X-Radiography Utilisation Study (NEXUS) chest algorithm in detecting blunt chest injuries.

Methods

This descriptive cross-sectional study included 50 polytrauma patients with blunt chest trauma from the emergency centre of Suez Canal University Hospital. E-FAST and computed tomography (CT) were conducted, followed by reporting of NEXUS criteria for all patients. Blinding of the E-FAST performer and CT reporter were confirmed. The results of both the NEXUS algorithm and E-FAST were compared with CT chest results.

Results

The NEXUS algorithm had 100% sensitivity and 15.3% specificity, and E-FAST had 70% sensitivity and 96.7% specificity, in the detection of pneumothorax.In the detection of hemothorax, the sensitivity and specificity of the NEXUS algorithm were 90% and 7.5%, respectively, whereas E-FAST had a lower sensitivity of 80% and a higher specificity of 97.5%.

Conclusion

E-FAST is highly specific for the detection of hemothorax, pneumothorax, and chest injuries compared with the NEXUS chest algorithm, which demonstrated the lowest specificity. However, the NEXUS chest algorithm showed a higher sensitivity than E-FAST and hence can be used effectively to rule out thoracic injury.

The Role of Abdominal and Pelvic Computed Tomography Scans for Geriatric Blunt Trauma Patients on Antiplatelet and/or Anticoagulation Medications

Blunt trauma is the most common mechanism of injury in the geriatric population. The benefits of computed tomography (CT) scanning have demonstrated improved outcomes for blunt trauma patients with head injuries. The purpose of our study is to evaluate the clinical value of using a CT scan of the abdomen and pelvis on geriatric blunt trauma patients on antiplatelet/anticoagulation (AP/AC) therapy. A retrospective study reviewing geriatric patients admitted to our urban level 1 trauma center from December 2012 to September 2014 was performed. The inclusion criteria for the study included patients older than 65 years of age, admission after a blunt trauma, and on AP/AC therapy. Male and female patients with dementia were more likely to have a CT scan of the abdomen and pelvis (P = 0.002 and P = 1 × 10−6, respectively). There was no statistical significance in the difference in outcomes between the demented patients who received a CT scan of the abdomen and pelvis and the ones who did not. Our study demonstrated that there is no benefit in terms of length of stay, morbidity, or mortality, regardless of sex, after a CT scan of the abdomen and pelvis.

Trauma care before and after optimisation in a level I trauma Centre: Life-saving changes

BACKGROUND

The implementation of trauma systems has led to a significant reduction in mortality and length of hospital stay. In our level I trauma centre, 24/7 in-hospital coverage was implemented, and a renovation of the trauma room took place to improve the trauma care. The aim of the present study was to examine the effect of the optimised in-hospital infrastructure in terms of mortality, processes and clinical outcomes.

METHODS

We performed a retrospective cohort study of prospectively collected data. All adult trauma patients admitted to our trauma centre directly during two time periods (2010-2012 and 2014-2016) were included. Any patients below the age of 18 years and patients who underwent primary trauma screening in another hospital were excluded. Logistic and linear regression were used and adjusted for demographics and characteristics of trauma. The primary endpoint was mortality. The secondary endpoints were subgroups of earlier mortality rates and severely injured patients, processes and clinical outcomes.

RESULTS

In period I, 1290 patients were included, and in period II, 2421. The adjusted mortality in the trauma room (odds ratio (OR): 0.18; CI: 0.05-0.63) and the total in-hospital mortality (OR: 0.63 CI: 0.42-0.95) showed a significant reduction in period II. The trauma room (TR) time decreased by 30 min (p < 0.001), and the time until CT decreased by 22 min (p < 0.001). The number of delayed diagnoses and complications were significantly lower in the second period, with an OR of 0.2 (CI: 0.1-0.2) and 0.4 (CI: 0.3-0.6), respectively. The hospital length of stay and ICU length of stay decreased significantly, -1.5 day (p = 0.010) and -1.8 days (p = 0.022) respectively.

CONCLUSIONS

Optimisation of the in-hospital infrastructure related to trauma care resulted in improved survival rates in both severely injured patients as well as in the whole trauma population. Moreover, the processes and clinical outcomes improved, showing a shorter hospital length of stay, shorter TR time, fewer complications and fewer delayed diagnoses.

Whole-body computed tomography in severely injured patients

PURPOSE OF REVIEW

To provide an update on the relevant and recent studies on whole-body computed tomography (WBCT) imaging of severely injured patients.

RECENT FINDINGS

The advantages of WBCT in time saving, diagnostic accuracy and even in survival have been proven in numerous studies. WBCT can also be beneficial in haemodynamically unstable major trauma patients. The CT scanner should be located close to the emergency department or even in the trauma room. The issue of radiation is still quite important, however, iterative as well as split-bolus protocols can nowadays reduce radiation significantly. The question: which trauma patient should receive WBCT and which not is not yet solved sufficiently. Postmortem WBCT has a promising potential to promptly define the definitive cause of death of trauma victims comparably to traditional autopsy.

SUMMARY

On account of the recent advances, whole-body CT has become a crucial part of the initial in-hospital assessment of severely injured patients. It is recommended as the standard radiological tool for the emergency diagnostic work-up in major trauma patients.

Whole-body computed tomography as a factor associated with lower mortality in severe geriatric trauma with thoracic-abdominal-pelvic injury

OBJECTIVE

To determine the relationship between the use of whole-body computed tomography (WB-CT) and hospital mortality in elderly patients with thoracic-abdominal-pelvic injury requiring admission to an intensive care unit.

PATIENTS AND METHOD

An observational, descriptive and retrospective study was conducted on 140 patients aged 65 years and older admitted to the intensive care unit after a thoracic-abdominal-pelvic injury. Two groups were established, depending on whether a WB-CT was performed as a routine part of the study or the diagnosis was established by conventional radiography or ultrasound. A comparative analysis was performed on both groups, as well as an analysis of mortality through logistic regression.

RESULTS

The mean age of the patients was 75.16±8.89 years. The mean score on the APACHE II scale was 16.25±8.4 points, and on the Injury Severity Score scale, 22.38±15.45 points. WB-CT was performed on 102 patients (72.9%). In these patients, there was a lower mortality rate (15.7 vs. 52.6%, P˂.001), a lower need for mechanical ventilation (47.1 vs. 65.8%, P=.049), and a lower score on the APACHE II scale (14.75±7.19 vs. 20.26±10.06 points, P=.003). The multivariate analysis showed a lower mortality in the patients in whom WB-CT was performed, with an OR of 0.21 (95% CI 0.07-0.68; (P=.010), after adjusting for the APACHE II and ISS scores.

CONCLUSIONS

Performing a WB-CT scan as part of the trauma study could improve the management of elderly patients with thoracic-abdominal-pelvic involvement admitted to the intensive care unit.

A meta-analysis of the efficacy of whole-body computed tomography imaging in the management of trauma and injury

BACKGROUND

Traumatic injury is the third leading cause of death overall. To optimize the outcomes in these patients, hospitals employ whole-body computed tomography (WBCT) imaging due to the high diagnostic yield and potential to identify missed injuries. However, this delays time-critical interventions. Currently, there is an absence of any high-level evidence to support or refute either view. We present a meta-analysis of the available literature to elucidate the efficacy of WBCT in improving the outcomes of trauma, specifically the mortality rate.

METHODS

A systematic review of studies comparing WBCT and selective CT imaging in secondary survey was conducted, using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. The articles were evaluated for intervention using WBCT to reduce mortality rate, followed by subgroup analysis for other secondary measures, using Review Manager 5.3 software.

RESULTS

Eleven studies of 32,207 patients were included. There were lower overall (OR=0.79; 95% CI 0.74,0.83, p<0.05) and 24h mortality rates (OR=0.72, 95% CI 0.66,0.79, p<0.05) in the WBCT cohort. Additionally, patients in the WBCT arm spent less time in the emergency room (MD=-14.81; 95% CI -17.02, -12.60, p<0.00001) and needing ventilation (MD=-2.01; 95% CI -2.41, -1.62, p<0.05) despite a higher baseline injury severity score.

CONCLUSION

The analysis shows that WBCT is associated with better outcomes, including a lower overall and 24h mortality rate, however the included studies are mostly observational and show considerable heterogeneity. Further work is required to make definitive clinical recommendations for a tailored algorithm in managing trauma patients.

The significance of routine thoracic computed tomography in patients with blunt chest trauma

PURPOSE

The purpose of this study is to investigate whether the use of thoracic computed tomography (TCT) as part of nonselective computed tomography (CT) guidelines is superior to selective CT during the diagnosis of blunt chest trauma.

SUBJECTS AND METHODS

This study was planned as a prospective cohort study, and it was conducted at the emergency department between 2013 and 2014. A total of 260 adult patients who did not meet the exclusion criteria were enrolled in the study. All patients were evaluated by an emergency physician, and their primary surveys were completed based on the Advanced Trauma Life Support (ATLS) principles. Based on the initial findings and ATLS recommendations, patients in whom thoracic CT was indicated were determined (selective CT group). Routine CTs were then performed on all patients.

RESULTS

Thoracic injuries were found in 97 (37.3%) patients following routine TCT. In 53 (20%) patients, thoracic injuries were found by selective CT. Routine TCT was able to detect chest injury in 44 (16%) patients for whom selective TCT would not otherwise be ordered based on the EP evaluation (nonselective TCT group). Five (2%) patients in this nonselective TCT group required tube thoracostomy, while there was no additional treatment provided for thoracic injuries in the remaining 39 (15%).

CONCLUSION

In conclusion, we found that the nonselective TCT method was superior to the selective TCT method in detecting thoracic injuries in patients with blunt trauma. Furthermore, we were able to demonstrate that the nonselective TCT method can change the course of patient management albeit at low rates.

The key role of the radiologist in the management of polytrauma patients: indications for MDCT imaging in emergency radiology

Trauma causes greater losses of life years and it is the most common cause of death for people under the age of 45. Time is one of the most relevant factors for the survival of injured patients, particularly the time elapsed from trauma until the resuscitation procedures. As a member of the trauma team, the radiologist contributes to the rapid diagnosis of traumatic disorders, with appropriate imaging modalities. Based on the evidence, the most appropriate diagnostic tool for severe/multiple trauma is computed tomography (CT). With the advent of multidetector CT (MDCT), radiologists are able to more effectively characterize life-threatening traumatic disorders within a few seconds in stable or stabilized patients. Considering the diagnostic potential of MDCT, conventional radiographs could be virtually abandoned in the diagnostic algorithms for adult polytraumatized patients. The radiologist helps to facilitate triage and to assess the optimal individual treatment for polytrauma patients, thus contributing to the improvement of patient outcomes. In this article, the indications for MDCT in the polytrauma setting are discussed.

Systematic review of the benefits and harms of whole-body computed tomography in the early management of multitrauma patients: are we getting the whole picture?

BACKGROUND

There is considerable interest in whether routine whole-body computed tomography (WBCT) imaging produces different patient outcomes in blunt trauma patients when compared with selective imaging. This article aimed to systematically review the literature for all outcomes measured in comparing WBCT with selective imaging in trauma patients and to evaluate the comprehensiveness of relevant dimensions for this comparison.

METHODS

We performed a systematic review of studies comparing WBCT and selective imaging approaches during the initial assessment of multitrauma patients. Peer-reviewed studies including cohort studies, randomized controlled trials, meta-analyses, and systematic reviews were identified through large database searches and filtered through methodologic inclusion criteria. Data on study characteristics, hypotheses and conclusions made, outcomes assessed, and references to potential benefits and harms were extracted.

RESULTS

Eight retrospective cohort studies and two systematic reviews were identified. Six primary studies evaluated mortality as an outcome, and four studies found a significant difference in results favoring WBCT imaging over selective imaging. All five articles assessing various time intervals in hospital following imaging after injury found significantly reduced times with WBCT. Radiation exposure was found to be increased after WBCT imaging compared with selective imaging in the only study in which it was evaluated. The two systematic reviews analyzed the same three articles with regard to mortality but concluded differently about overall benefits.

CONCLUSION

WBCT imaging seems to be associated with reduced times to events in hospital following traumatic injury and seems to be associated with decreased mortality. Whether this is a true effect mediated through an as yet unsubstantiated change in management or the result of hospital- or individual-level confounders is unclear. When evaluating these outcomes, it seems that the authors of both primary studies and systematic reviews have often been selective in their choice of short-term outcomes, painting an incomplete picture of the issue.

LEVEL OF EVIDENCE

Systematic review, level III.

Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients

BACKGROUND

Trauma is the fifth leading cause of death worldwide, and in people younger than 40 years of age, it is the leading cause of death. During the resuscitation of trauma patients at the emergency department, there are two different commonly used diagnostic strategies. Conventionally, there is the use of physical examination and conventional diagnostic imaging, potentially followed by selective use of computed tomography (CT). Alternatively, there is the use of physical examination and conventional diagnostics, followed by a routine (instead of selective) use of thoracoabdominal CT. It is currently unknown which of the two strategies is the better diagnostic strategy for patients with blunt high-energy trauma.

OBJECTIVES

To assess the effects of routine thoracoabdominal CT compared with selective thoracoabdominal CT on mortality in blunt high-energy trauma patients.

SEARCH METHODS

We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (Issue 4, 2013); MEDLINE (OvidSP), EMBASE (OvidSP) and CINAHL for all published randomised controlled trials (RCTs). We did not restrict the searches by language, date or publication status. We conducted the search on the 9 May 2013.

SELECTION CRITERIA

We included RCTs of trauma resuscitation algorithms using routine thoracoabdominal CT versus algorithms using selective CT in this review. We included all blunt high-energy trauma patients (including blast or barotrauma).

DATA COLLECTION AND ANALYSIS

Two authors independently evaluated the search results.

MAIN RESULTS

The systematic search identified 481 references; after removal of duplicates, 396 remained. We found no RCTs comparing routine versus selective thoracoabdominal CT in blunt high-energy trauma patients. We excluded 381 studies based on the abstracts of the publications because of irrelevance to the review topic, and a further 15 studies after full-text evaluation.

AUTHORS' CONCLUSIONS

We found no RCTs of routine versus selective thoracoabdominal CT in patients with blunt high-energy trauma. Based on the lack of evidence from RCTs, it is not possible to say which approach is better in reducing deaths.

[German trauma centers: level-dependent differences in polytrauma care regarding resources and diagnostic concepts]

BACKGROUND

The aim was to survey the radiological diagnostics and type of primary radiological examination of polytraumatized patients treated in German hospitals at various levels in the three-tiered system.

MATERIAL AND METHODS

A questionnaire was sent in October 2007 to every traumatology department registered in the DGU (German Society for Trauma Surgery) databank and forms returned by January 2008 were included in this study.

RESULTS

A total of 273 (54.71 %) of forms were returned and were applicable to statistical analysis. In the three-tiered hospital system 35.9 % of returned questionnaires came from third-tier hospitals, 41.02 % from second-tier and 23.08 % from highest tier (maximum care) hospitals. With a higher hospital level of inpatient care more computed tomography (CT) scans were examined by a radiologist during 24 h daily (p = 0.0014) and CT scanners were located closer to the resuscitation room (p < 0.0001). We found significant differences in the ratios of primary whole-body CTs (WBCT) performed depending on the hospital level: third-tier hospitals 44 %, second tier hospitals 67 % and maximum care hospitals 84 % (p < 0.05).

CONCLUSIONS

Standardized structures regarding radiological diagnostics of polytraumatized patients do not exist at either the same level of the three-tiered hospital system or between levels of care of German hospitals..

The Subaxial Cervical Spine Injury Classification System: an external agreement validation study

BACKGROUND CONTEXT

In 2007, the Subaxial Cervical Spine Injury Classification (SLIC) system was introduced demonstrating moderate reliability in an internal validation study.

PURPOSE

To assess the agreement on the SLIC system using clinical data from a spinal trauma population and whether the SLIC treatment algorithm outcome improved agreement on treatment decisions among surgeons.

STUDY DESIGN

An external classification validation study.

PATIENT SAMPLE

Twelve spinal surgeons (five consultants and seven fellows) assessed 51 randomly selected cases.

OUTCOME MEASURES

Raw agreement, Fleiss kappa, and intraclass correlation coefficient statistics were used for reliability analysis. Majority rules and latent class modeling were used for accuracy analysis.

METHODS

Fifty-one randomly selected cases with significant injuries of the cervical spine from a prospective consecutive series of trauma patients were assessed using the SLIC system. Neurologic details, plain radiographs, and computed tomography scans were available for all cases as well as magnetic resonance imaging in 21 cases (41%). No funds were received in support of this study. The authors have no conflict of interest in the subject of this article.

RESULTS

The inter-rater agreement on the most severely affected level of injury was strong (κ=0.76). The agreement on the morphologic injury characteristics was poor (κ=0.29) and agreement on the integrity of the discoligamentous complex was average (κ=0.46). The inter-rater agreement on the treatment verdict after the total SLIC injury severity score was slightly lower than the surgeons' agreement on personal treatment preference (κ=0.55 vs. κ=0.63). Latent class analysis was not converging and did not present accurate estimations of the true classification categories. Based on these findings, no second survey for testing intrarater agreement was performed.

CONCLUSIONS

We found poor agreement on the morphologic injury characteristics of the SLIC system, and its treatment algorithm showed no improved agreement on treatment decisions among surgeons. The authors discuss that the reproducibility of the SLIC system is likely to improve when unambiguous true morphologic injury characteristics are being implemented.

Retrospective review of the use and costs of routine chest x rays in a trauma setting

INTRODUCTION

Chest x-rays (CXR) are routinely obtained on blunt trauma patients. Many patients also receive additional imaging with thoracic computed tomography scans for other indications. We hypothesized that in hemodynamically normal, awake and alert blunt trauma patients, CXR can be deferred in those who will also receive a TCT with significant cost savings.

METHODS

We retrospectively reviewed the charts of trauma patients from 1/1/2010 to 12/31/2010 who received both a CXR and TCT in the trauma room. Billing and cost data were collected from various hospital sources.

RESULTS

239 patients who met inclusion and exclusion criteria and received CXR and TCT between 1/1/2010 and 12/31/2010. The sensitivity of CXR was 19% (95% CI: 10.8% to 31%) and the specificity was 91.7% (95% CI: 86.7% to 95%). The false positive rate for CXR was 35.8% (95% CI: 21.7% to 52.8%) and the false negative rate was 24.5% (95% CI: 18.8% to 31.2%). The precision of CXR was 42.3% (95% CI: 25.5% to 61.1%) and the overall accuracy was 74.1% (95% CI: 68.1% to 79.2%). If routine chest xray were eliminated in these patients, the estimated cost savings ranged from $14,641 to $142,185, using three different methods of cost analysis.

CONCLUSIONS

In patients who are hemodynamically normal and who will be receiving a TCT, deferring a CXR would result in an estimated cost savings up to $142,185. Additionally, TCT is more sensitive and specific than CXR in identifying injuries in patients who have sustained blunt trauma to the thorax.

Radiographic assessment of splenic injury without contrast: is contrast truly needed?

INTRODUCTION

Computed tomography (CT) has become an essential tool in the assessment of the stable trauma patient. Intravenous (i.v.) contrast is commonly relied upon to provide superior image quality, particularly for solid-organ injury. However, a substantial proportion of injured patients have contraindications to i.v. contrast. Little information exists concerning the repercussions of CT imaging without i.v. contrast, specifically for splenic injury.

METHODS

We performed a retrospective analysis using data from our trauma registry and chart review as part of a quality improvement project at our institution. All patients with splenic injury, during a 3-year period (2008-2010), where a CT of the abdomen without i.v. contrast (DRY) early during their admission were selected. All splenic injuries had to have been verified with abdominal CT imaging with i.v. contrast (CONTRAST) or via intraoperative findings. DRY images were independently read by a single, blinded, radiologist and assessed for parenchymal injury or "suspicious" splenic injury findings and compared with CONTRAST imaging results or intraoperative findings.

RESULTS

During the time period of the study, 319 patients had documented splenic injury with 44 (14%) patients undergoing DRY imaging, which was also verified by CONTRAST imaging or operative findings. Splenic parenchymal injury was only visualized in 38% of patients DRY patients. "Suspicious" splenic injury radiographic findings were common. When these less-specific findings for splenic injury were incorporated in the radiographic assessment, DRY imaging had more than 93% sensitivity for detecting splenic injury.

CONCLUSION

DRY imaging is increasingly being performed after injury and has a low sensitivity in detecting splenic parenchymal injury. However, less-specific radiographic findings suspicious for splenic injury in combination provide high sensitivity for the detection of splenic injury. These results suggest CONTRAST imaging is preferred to detect splenic injury; however, in those patients who have contraindications to i.v. contrast, DRY imagining may be able to select those who require close monitoring or intervention.

Whole body imaging in the diagnosis of blunt trauma, ionizing radiation hazards and residual risk

Ever since the introduction of radiographic imaging, its utility in identifying injuries has been well documented and was incorporated in the workup of injured patients during advanced trauma life support algorithms [American College of Surgeons, 8th ed. Chicago, 2008]. More recently, computerized tomography (CT) has been shown to be more sensitive than radiography in the diagnosis of injury. Due to the increased use of CT scanning, concerns were raised regarding the associated exposure to ionizing radiation [N Engl J Med 357:2277-2284, 2007]. During the last several years, a significant amount of research has been published on this topic, most of it being incorporated in the BEIR VII Phase 2 report, published by the National Research Council of the National Academies [National Academy of Sciences, Washington DC, 2006]. The current review will analyze the scientific basis for the concerns over the ionizing radiation associated with the use of CT scanning and will examine the accuracy of the typical advanced trauma life support work-up for diagnosis of injuries.

Delays in diagnosis in early trauma care: evaluation of diagnostic efficiency and circumstances of delay

BACKGROUND

Trauma centers, trauma management concepts, damage control surgery and the integration of whole-body CT scanning into early trauma care have reduced mortality in traumatized patients significantly. However, some injuries are still initially missed. In this study, the diagnostic efficiency of early trauma care and the circumstances of delays in diagnosis were evaluated.

MATERIALS AND METHODS

Initially missed diagnoses in 111 traumatized patients were recorded retrospectively. "Primary diagnoses" after the emergency room (ER) phase including CT scanning with immediate data evaluation were compared to "secondary diagnoses" after a secondary survey of the CT data, as well as to discharge diagnoses. Circumstances of delay were assessed according to injury severity score (ISS), hospital admission, mechanism of injury, diagnostics, treatment, time in the intensive care unit, hospitalization and mortality.

RESULTS

73% of the patients arrived at the ER during on-call hours. In 23% of all patients, diagnoses were missed after the ER phase, while in 12% of the patients diagnoses were missed after the secondary survey of the CT data. One half of the missed diagnoses were almost impossible to detect; the other half were judged to be acceptable. During on-call hours, 9% more patients with delays in diagnosis were observed. Injury severity in patients with delays in diagnosis was significantly higher than in patients without.

CONCLUSIONS

Although diagnostic quality in early trauma care has improved, some diagnoses are initially missed. Severely injured patients with life-threatening or potentially life-threatening injuries arriving at the ER during on-call hours were at higher risk for delays in diagnosis. A secondary evaluation of acquired CT data and repetitive examinations are essential.

ACR Appropriateness Criteria(®) blunt chest trauma--suspected aortic injury

The purpose of these guidelines is to recommend appropriate imaging for patients with blunt chest trauma. These patients are most often imaged in the emergency room, and thus emergency radiologists play a substantial role in prompt, accurate diagnoses that, in turn, can lead to life-saving interventions. The ACR Appropriateness Criteria® are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment. Imaging largely focuses on the detection and exclusion of traumatic aortic injury; a large proportion of patients are victims of motor vehicle accidents. For those patients who survive the injury and come to emergency radiology, rapid, appropriate assessment of patients who require surgery is paramount.

Multidetector-row computed tomography of thoracic trauma

Imaging in trauma patients has dramatically evolved since the advent of computed tomography (CT), particularly multidetector CT (MDCT) technology. Axial MDCT images of the body can be acquired in seconds and shown any plane, allowing immediate viewing and interpreting. These factors make CT an invaluable means to detect many injuries not previously visible by any other noninvasive imaging techniques. Potentially subtle, but significant, thoracic injuries such as pneumothorax, haemothorax, aortic injury, sternal and spinal fractures can be detected on MDCT easily. In this article, the author will discuss the use of MDCT in the diagnosis of various thoracic injuries.

Earthquake-related crush injury versus non-earthquake injury in abdominal trauma patients on emergency multidetector computed tomography: a comparative study

The aim of this study was to investigate features of abdominal earthquake-related crush traumas in comparison with non-earthquake injury. A cross sectional survey was conducted with 51 survivors with abdominal crush injury in the 2008 Sichuan earthquake, and 41 with abdominal non-earthquake injury, undergoing non-enhanced computed tomography (CT) scans, serving as earthquake trauma and control group, respectively. Data were analyzed between groups focusing on CT appearance. We found that injury of abdominal-wall soft tissue and fractures of lumbar vertebrae were more common in earthquake trauma group than in control group (28 vs 13 victims, and 24 vs 9, respectively; all P < 0.05); and fractures were predominantly in transverse process of 1-2 vertebrae among L1-3 vertebrae. Retroperitoneal injury in the kidney occurred more frequently in earthquake trauma group than in control group (29 vs 14 victims, P < 0.05). Abdominal injury in combination with thoracic and pelvic injury occurred more frequently in earthquake trauma group than in control group (43 vs 29 victims, P < 0.05). In conclusion, abdominal earthquake-related crush injury might be characteristic of high incidence in injury of abdominal-wall soft tissue, fractures of lumbar vertebrae in transverse process of 1-2 vertebrae among L1-3 vertebrae, retroperitoneal injury in the kidney, and in combination with injury in the thorax and pelvis.

Incidental radiographic findings after injury: dedicated attention results in improved capture, documentation, and management

BACKGROUND

With liberal use of computed tomography in the diagnostic management of trauma patients, incidental findings are common and represent a major patient-care and medical-legal concern. Consequently, we began an initiative to capture, notify, and documentadequately incidental finding events with a dedicated incidental finding coordinator. We hypothesized a dedicated incidental finding coordinator would increase incidental finding capture and promote notification, follow-up, and documentation of incidental finding events.

METHODS

A quality-improvement project to record and follow-up incidental findings postinjury was initiated at our level I trauma center (April 2007-March 2008, prededicated incidental finding). Because of concerns for inadequate documentation of identified incidental finding events, we implemented a dedicated incidental finding coordinator (April 2008-March 2009, postdedicated incidental finding). The dedicated incidental finding coordinator documented incidental findings daily from trauma admission radiology final reads. Incidental findings were divided into 3 groups; category 1: attention prior to discharge; category 2: follow-up with primary doctor within 2 weeks; category 3: no specific follow-up. For category 1 incidental findings, in-hospital consultation of the appropriate service was verified. On discharge, patient notification, follow-up, and documentation of events were confirmed. Certified mail or telephone contact was used to notify either the patient or the primary doctor in those who lacked appropriate notification or documentation.

RESULTS

Admission rates and incidental finding categories were similar across the 2 time periods. Implementation of a dedicated incidental finding coordinator resulted in more than a 165% increase in incidental finding capture (n = 802 vs n = 302; P < .001). Patient notification was attempted, and appropriate documentation of events was confirmed in 99.8% of patients. Patient notification was verified, and follow-up was initiated in 95.8% of cases.

CONCLUSION

The implementation of a dedicated incidental finding coordinator resulted in more than a 2.5-fold higher capture of incidental findings. Dedicated attention to incidental findings resulted in a near complete initiation of patient notification, follow-up, and hospital record documentation of incidental finding events. Inadequate patient notification and follow-up would delay appropriate care and potentially would result in morbidity or even mortality. A dedicated incidental finding coordinator represents a potential solution to this patient-care and medical-legal dilemma.