Utility of Torso Imaging for Elderly Patients Sustaining Ground-Level Falls

INTRODUCTION

Computed tomography (CT) of the torso has become increasingly common for assessment of fall patients in the emergency department. Some data suggest that older adults (≥65) may benefit from torso imaging more than younger patients. We sought to evaluate the usage and utility of CT imaging for elderly patients presenting after ground-level falls (GLFs) from 1 meter or less at our level 1 trauma center.

METHODS

Patients ≥18 presenting with GLF in 2015-2019 were included. Data were obtained through chart and trauma registry review. Descriptive statistics were used to summarize the use of CT imaging for patients younger than versus older than 65 y old. Three multivariate logistic regression models with age as a continuous, binary (<65 versus ≥65), or categorical (in multiples of 5) variable were used to investigate whether age is associated with an increased identification of traumatic injury not previously suspected or known based on physical exam (PE) or plain radiograph after GLF.

RESULTS

A total of 522 patients <65 and 673 patients ≥65 y old were included. Older patients were significantly more likely to receive screening chest radiograph, screening pelvic radiograph, brain CT, and neck CT (all P < 0.001), but not torso (chest, abdomen, and pelvis) CT (P = 0.144). On multivariate logistic regression, age was not significantly associated with an increased odds of identification of traumatic injury after torso CT (continuous: adjusted odds ratio [aOR] = 1.01, 95% confidence interval [CI] = 0.99-1.03, P = 0.379; binary: aOR = 0.86, 95% CI = 0.46-1.58, P = 0.619; categorical: aOR = 1.03, 95% CI = 0.94-1.14, P = 0.453). A positive PE was the only variable associated with significantly increased odds of having an abnormal torso CT scan in all models. Only two patients ≥65 y old had injuries identified on torso CT in the context of a negative PE and negative screening imaging.

CONCLUSIONS

The rate of torso injury identification in patients sustaining GLF is not associated with age, but is strongly associated with positive PE findings. In the subset of elderly GLF patients without positive torso PE findings, more conservative use of CT imaging could decrease health-care utilization costs without compromising patient care.

Re-thinking the value of cross-sectional torso imaging for ground-level fall patients with altered mental status: Outcomes from a level 1 trauma center

INTRODUCTION

Patients with altered mental status (AMS) are often excluded from studies evaluating the utility of computed tomography of the torso (CTT) after ground level falls (GLF). It is not known whether CTT identifies otherwise undetectable injuries in patients with AMS after GLF. We sought to describe the value of performing CTT in patients with AMS after GLF, and hypothesized that CTT would not identify new, clinically significant injuries in patients with a normal torso physical exam (PE) and normal chest and pelvic radiographs (CXR/PXR).

METHODS

Single-institution retrospective cohort study of GLF patients (≤1 m) with and without AMS (GCS <15, blood alcohol level >150 mg/dL, intubation prior to hospital evaluation), 2015-2019. Traumatic injury identification on CTT was evaluated in the context of normal/abnormal torso PE (based on provider documentation) and normal CXR/PXR.

RESULTS

1195 patients met inclusion criteria; 344 had AMS, of which 129 (37.5 %) underwent CTT. A further 851 patients had normal mental status, of which 180 (21.2 %) underwent CTT. Patients with a normal PE with AMS (N = 79) and without AMS (N = 38) had a similar rate of new injury discovery on CTT (6.3% vs. 7.9 %, p = 1.00). Negative PE had a negative predictive value (NPV) for identification of a new, acute traumatic injury of 92.4 % (95 % CI: 0.84-0.96) in patients with AMS while normal PE, CXR, and PXR had a NPV of 96.0 % (95 % CI: 0.80-0.99). Among patients with CTT, patients with AMS had a significantly lower rate of acute traumatic injury on CTT compared to alert patients (26.4 % vs. 48.9 %, p < 0.001). On multivariate analysis, AMS was not positively associated with likelihood of identifying acute traumatic injury on CTT.

CONCLUSIONS

In patients sustaining GLFs who present with AMS and who otherwise have a negative PE, CXR, and PXR, CTT is very unlikely to identify new traumatic injuries. Strong consideration should be given to forego cross-sectional imaging in this patient population.

Physical exam is not an accurate predictor of injury in geriatric patients with low-energy blunt trauma - A retrospective cohort study

Background

When evaluating trauma patients, many centers perform computed tomography of the head, cervical spine, chest, abdomen, and pelvis, the so-called “pan-scan.” Here, we evaluate the utility of physical exam against pan-scan in geriatric patients who sustained ground-level falls.

Methods

We performed a single-centered retrospective cohort review of consecutive patients from the trauma registry of a large, urban Level 1 trauma center. Inclusion criteria were registration during the 2019 calendar year, age ≥65, mechanism of fall from either sitting or standing, and performance of “pan-scan” at time of assessment. The sensitivity, specificity, positive and negative predictive values of the physical exam for significant injuries were calculated. The effect of such injuries on disposition from the emergency department and hospital were determined.

Results

An initial query for patients age ≥65 yielded 1280 patients. After exclusion of patients who did not undergo pan-scan or who had GCS <14, 751 patients were included in analysis. Median age was 84 years old. 351 patients had at least one injury identified on pan-scan. Physical exam was determined to have a sensitivity of 0.69 when compared to pan-scan as a gold standard. Patients with injury identified on CT scan had significantly more admissions, mortalities, and ICU and OR requirements.

Conclusion

Approximately half of all patients were found to have at least one injury on pan-scan. Physical examination was insensitive at identifying such injuries which ultimately altered patient management, disposition, and outcomes. Pan-scan is recommended in this vulnerable population.

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A selective approach to CT scan may not be appropriate for elderly patients with low-energy blunt falls.

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Approximately half of all elderly patients who fall from sitting or standing have at least one traumatic injury.

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Traumatic injuries alter the hospital course and disposition of elderly fall patients.

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Physical exam is neither sensitive nor specific enough to detect these injuries.

Characterizing and quantifying low-value diagnostic imaging internationally: a scoping review

BACKGROUND

Inappropriate and wasteful use of health care resources is a common problem, constituting 10-34% of health services spending in the western world. Even though diagnostic imaging is vital for identifying correct diagnoses and administrating the right treatment, low-value imaging-in which the diagnostic test confers little to no clinical benefit-is common and contributes to inappropriate and wasteful use of health care resources. There is a lack of knowledge on the types and extent of low-value imaging. Accordingly, the objective of this study was to identify, characterize, and quantify the extent of low-value diagnostic imaging examinations for adults and children.

METHODS

A scoping review of the published literature was performed. Medline-Ovid, Embase-Ovid, Scopus, and Cochrane Library were searched for studies published from 2010 to September 2020. The search strategy was built from medical subject headings (Mesh) for Diagnostic imaging/Radiology OR Health service misuse/Medical overuse OR Procedures and Techniques Utilization/Facilities and Services Utilization. Articles in English, German, Dutch, Swedish, Danish, or Norwegian were included.

RESULTS

A total of 39,986 records were identified and, of these, 370 studies were included in the final synthesis. Eighty-four low-value imaging examinations were identified. Imaging of atraumatic pain, routine imaging in minor head injury, trauma, thrombosis, urolithiasis, after thoracic interventions, fracture follow-up and cancer staging/follow-up were the most frequently identified low-value imaging examinations. The proportion of low-value imaging varied between 2 and 100% inappropriate or unnecessary examinations.

CONCLUSIONS

A comprehensive list of identified low-value radiological examinations for both adults and children are presented. Future research should focus on reasons for low-value imaging utilization and interventions to reduce the use of low-value imaging internationally.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO: CRD42020208072.

The Value of Abdominal and Pelvic CT Scan in Trauma Patients With Low Injury Severity Score and High Glasgow Coma Scale

INTRODUCTION

Computed tomography scans became the mainstay of emergency department (ED) evaluation of trauma patients including those with a high Glasgow Coma Scale (GCS) and a low Injury Severity Score (ISS). We elected to find the value of abdominal and pelvic CT in patients with negative physical examination and Focused Assessment of Sonography for Trauma (FAST) on arrival to the ED.

METHODS

This study is a retrospective analysis of 901 consecutive patients from 2017 to 2019 who presented to the ED with level 2 and 3 activation criteria. Each patient received a physical examination, CT abdomen and pelvis, and FAST exam. Data were collected on external factor including GCS, ISS, age, sex, comorbidities, anticoagulation use, and surgical intervention. The patients were divided into 2 groups, Group A and B. Group A consisted of patients with a negative physical exam, FAST, and CT result. Group B included patients with a negative physical exam and FAST exam with positive CT findings. Statistical analysis was done using a Student's t-test and chi-square test for significance value of P < .05. Institutional Review Board approval was obtained for this study.

RESULTS

A total of 901 patients were analyzed which included 489 (54.3%) male and 412 (45.7%) female with a mean age of 56.2 (SD = 22.62) years. Out of the 901 patients, 461 patients received a physical, FAST, and CT exam. Group A consisted of 442 (95.9%) patients and Group B had 19 (4.1%) patients. Both groups were similar in GCS and ISS scoring with no significance difference in age, sex, comorbidities, and anticoagulation use. There was a significant difference in the ICU and hospital mean length of stay when CT scan was positive [2 (SD = 4.23) days vs. .6 (SD = 1.33) days with P < .0001 and 4.57 (SD ± 4.17) days vs. 2.5 (SD = 2.00) days with P < .0001, respectively]. The CT findings of the 19 patients in group B consisted of 6 incidentalomas, 5 vertebral compression fractures, 4 pelvic bone fractures, 1 minor liver contusion, 1 non-specific bowel thickening, 1 non-displaced rib fracture, and 1 case of small amount of free fluid in the pelvis. None of the CT findings required surgical intervention.

CONCLUSION

Computed tomography of the abdomen and pelvis in trauma patients with high GCS and low ISS with initial negative physical and FAST examination did not provide additional critical information.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Cross-sectional imaging of the torso reveals occult injuries in asymptomatic blunt trauma patients

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.

Torso injuries after fall from standing-empiric abdominal or thoracic CT imaging is not indicated

PURPOSE

Falls from standing (FFS) have become the most common mechanism of injury at many trauma centers. Liberal imaging of low energy trauma has questionable value. We hypothesize that torso trauma intervention is rare in the FFS population, and physical examination sufficiently screens for torso injuries needing intervention.

METHODS

We queried our ACS-verified Level 1 trauma center registry for falls from standing from 1/1/14 to 12/31/16. Exclusion criteria were: falls from height, falls associated with penetrating trauma, lack of an abdominal or chest CT, a Glasgow Coma Scale Score (GCS) less than 15, and surgical intervention at another facility prior to arrival at our center. Demographics, historical details, hemodynamics, injuries, injury severity, procedures, initial vital signs, and outcome were recorded.

RESULTS

1,654 patients had a FFS during our study period. 728 had an abdominal or chest CT and a GCS of 15 and comprised the evaluable population. Mean age was 56.5 years. 55.8% were female. The mortality rate was 8%. There were 179 chest injuries in 121 patients, and 54 abdominal injuries in 43 patients. 379 patients had a GCS of 15 and underwent thoracic CT, yet only 11 (3%) underwent intervention. The negative predictive value for physical exam was 100% for chest intervention. 349 patients had a GCS of 15 and abdominal CT, yet only 13 (3.7%) underwent procedural intervention. Abdominal physical exam had a negative predictive value of 99.7% for intervention, but when combined with vital signs, the value was 100%.

CONCLUSION

Torso injuries in FFS are rare. Of our study population, 13 abdominal injuries underwent intervention, and 11 chest injuries underwent intervention. Screening patients by physical examination and vital signs is sufficient and safely allows for the use of selective abdominal and chest CT.

Is clinician assessment accurate or is routine pan-body CT needed in the stable intoxicated trauma patient?

BACKGROUND

We sought to determine if clinician suspicion of injury was useful in predicting injuries found on pan-body computed tomography (PBCT) in clinically intoxicated patients.

METHODS

We prospectively enrolled awake, intoxicated patients with low-energy mechanism of injury. For each of four body regions (head/face, neck, thorax and abdomen/pelvis), clinician suspicion for injury was recorded as "low index" or "more than a low index". The reference standard was the presence of any pre-defined significant finding (SF) on CT. Sensitivity, specificity, positive (LR+) and negative (LR-) likelihood ratios were calculated.

RESULTS

Enrollment of 103 patients was completed. Sensitivity, specificity, LR+ and LR-for clinician index of suspicion were: 56%, 68%, 1.75, 0.64 (head/face), 50%, 92%, 6.18, 0.54 (neck), 10%, 96%, 2.60, 0.94 (thorax) and 67%, 93%, 9.56, 0.36 (abdomen/pelvis).

CONCLUSION

Clinician judgement was most useful to guide need for CT imaging in the neck and abdomen/pelvis. Routine PBCT may not be necessary.

SUMMARY

For awake, stable intoxicated patients after falls and assaults, clinician index of suspicion was most useful to guide the need for CT imaging in the neck and abdomen/pelvis. Our findings support selective use of CT if the index of suspicion is low. Routine PBCT may not be necessary.