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Fathi M, Mirjafari A, Yaghoobpoor S, Ghanikolahloo M, Sadeghi Z, Bahrami A, Myers L, Gholamrezanezhad A. Diagnostic utility of whole-body computed tomography/pan-scan in trauma: a systematic review and meta-analysis study. Emerg Radiol 2024; 31:251-268. [PMID: 38396199 PMCID: PMC10995012 DOI: 10.1007/s10140-024-02213-5] [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: 01/05/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024]
Abstract
Trauma is a significant cause of mortality and morbidity. It is crucial to diagnose trauma patients quickly to provide effective treatment interventions in such conditions. Whole-body computed tomography (WBCT)/pan-scan is an imaging technique that enables a faster and more efficient diagnosis for polytrauma patients. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of WBCT in diagnosing injuries in polytrauma patients. We will also assess its impact on the mortality rate and length of hospital stay among trauma centers between patients who underwent WBCT and those who did not (non-WBCT). Twenty-seven studies meeting our inclusion criteria were selected among PubMed, Scopus, Web of Science, and Google Scholar. The criteria were centered on the significance of WBCT/pan-scan application in trauma patients. Stata version 15 was used to perform statistical analysis on the data. The authors have also used I2 statistics to evaluate heterogeneity. Egger and Begg's tests were performed to rule out any publication bias. Total of twenty-seven studies including 68,838 trauma patients with a mean age of 45.0 ± 24.7 years were selected. Motor vehicle collisions were the most common cause of blunt injuries (80.0%). Head, neck, and face injuries were diagnosed in 44% (95% CI, 0.28-0.60; I2 = 99.8%), 6% (95% CI, 0.02-0.09; I2 = 97.2%), and 9% (95% CI, 0.05-0.13; I2 = 97.1%), respectively. Chest injuries were diagnosed by WBCT in 39% (95% CI, 0.28-0.51; I2 = 99.8%), abdominal injuries in 23% (95% CI, 0.03-0.43; I2 = 99.9%) of cases, spinal injuries 19% (95% CI, 0.11-0.27; I2 = 99.4%), extremity injuries 33% (95% CI, 0.23-0.43; I2 = 99.2%), and pelvic injuries 11% (95% CI, 0.04-0.18; I2 = 97.4%). A mortality odd ratio of 0.94 (95% CI, 0.83-1.06; I2 = 40.1%) was calculated while comparing WBCT and non-WBCT groups. This systematic review and meta-analysis provide insight into the possible safety, efficacy, and efficiency of WBCT/pan-scan as a diagnostic tool for trauma patients with serious injuries, regardless of their hemodynamic status. In patients with serious injuries from trauma, whether or not there are indicators of hemodynamic instability, our recommended approach is to, wherever possible, perform a WBCT without stopping the hemostatic resuscitation. By using this technology, the optimal surgical strategy for these patients can be decided upon without causing any delays in their final care or greatly raising their radiation dose.
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Affiliation(s)
- Mobina Fathi
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arshia Mirjafari
- Center for Minimally Invasive Therapeutics (C-MIT), University of California, Los Angeles, CA, USA
- Department of Bioengineering, University of California, Los Angeles, CA, USA
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Terasaki Institute for Biomedical Innovation, Los Angeles, CA, USA
| | - Shirin Yaghoobpoor
- Student Research Committee, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | | | - Zohre Sadeghi
- Department of Radiology, Imam Khomeini Hospital Complex, Tehran, Iran
| | - Ashkan Bahrami
- Faculty of Medicine, Kashan University of Medical Science, Kashan, Iran
| | - Lee Myers
- Department of Radiology, Keck School of Medicine, University of Southern California, Los Angeles, CA, USA
| | - Ali Gholamrezanezhad
- Department of Radiology, Keck School of Medicine, University of Southern California (USC), Los Angeles, USA.
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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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Changing the Patient's Position: Pitfalls and Benefits for Radiation Dose and Image Quality of Computed Tomography in Polytrauma. Diagnostics (Basel) 2022; 12:diagnostics12112661. [PMID: 36359504 PMCID: PMC9689596 DOI: 10.3390/diagnostics12112661] [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: 10/15/2022] [Revised: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/06/2022] Open
Abstract
For computed tomography (CT), representing the diagnostic standard for trauma patients, image quality is essential. The positioning of the patient’s arms next to the abdomen causes artifacts and is also considered to increase radiation exposure. The aim of this study was to evaluate the effect of various positionings during different CT examination steps on the extent of artifacts as well as radiation dose using iterative reconstruction (IR). 354 trauma-CTs were analyzed retrospectively. All datasets were reconstructed using IR and three different examination protocols were applied. Arm elevation led to a significant improvement of the image quality across all examination protocols (p < 0.001). Variation in arm positioning during image acquisition did not lead to a reduction of radiation dose (p = 0.123). Only elevation during scout acquisition resulted in the reduction of radiation exposure (p < 0.001). To receive high-quality CT images, patients should be placed with elevated arms for the trunk scan, as artifacts remain even with the IR. Arm repositioning during the examination itself had no effect on the applied radiation dose because its modulation refers to the initial scout obtained. In order to achieve a dose effect by different positioning, a two-scout protocol (dual scout) should be used.
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Ozcete E, Uz I, Arslan B, Yalcinli S, Altunci YA. Whole-body CT indications in emergency medicine trauma patients. Niger J Clin Pract 2022; 25:496-501. [PMID: 35439910 DOI: 10.4103/njcp.njcp_1727_21] [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: 11/04/2022]
Abstract
Background Whole-body computerized tomography (CT) scan designed as early diagnosis of traumatic injuries and prevention of unnoticeable injuries. Using Whole-body CT in trauma patients still controversial, there is no consensus on indications. Aims The aim of this study is to clarify indications and cut-off levels in vital parameters in trauma patients who undergo Whole-body CT to prevent unnecessary or negative scans. Patients and Methods We evaluated patients with trauma who applied our emergency service between 01.09.2019 and 30.09.2020. Patients above 18 years old with Whole-body CT scan included. Whole-body CT reports were evaluated according to five categories; cranial-face, vertebra, thorax, abdomen, pelvis-bone. Results The review of whole-body CT reports, 46.3% detected normally. But, 53.7% of patients had injuries at least one zone, 23.3% at least two zones, and 7.4% at least three zones respectively. Prediction criteria of Whole-body CT for the patients with two or three zones injury, systolic blood pressure (SBP) ≤100 mm Hg, Glasgow coma scale (GCS) <15, and free fluid in Focused Assessment with Sonography for Trauma (FAST) were independent variables in regression analysis. When patients had at least one of three variables, the negative predictive value of whole-body CT was 96% for three zones and 91% for two zones. Conclusion The cut-off values of GCS <15 and SBP ≤100 mm Hg were useful vital parameters in making whole-body CT decisions in trauma patients in the emergency service. Also, free fluid detection in FAST can be used for whole-body CT decisions.
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Affiliation(s)
- E Ozcete
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - I Uz
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - B Arslan
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - S Yalcinli
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| | - Y A Altunci
- Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
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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: 1] [Impact Index Per Article: 0.5] [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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Sepuya RG, Dozeman ET, Prittie JE, Fischetti AJ, Weltman JG. Comparing diagnostic findings and cost of whole body computed tomography to traditional diagnostic imaging in polytrauma patients. J Vet Emerg Crit Care (San Antonio) 2022; 32:334-340. [PMID: 35199929 DOI: 10.1111/vec.13189] [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: 06/12/2020] [Revised: 10/07/2020] [Accepted: 12/02/2020] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To compare the diagnostic utility of traditional diagnostic tests (ie, radiographs and focused assessment using sonography for trauma [FAST] scans) to whole-body computed tomography (WBCT) for characterizing injuries in polytrauma patients. A secondary objective was to compare costs of traditional diagnostic tests to WBCT. DESIGN Prospective, observational study. SETTING Private, level 1 veterinary trauma center. ANIMALS Convenience sample of 21 client-owned cats and dogs presenting with polytrauma. INTERVENTIONS Abdominal and thoracic FAST were performed by the primary clinician, if indicated. Radiographs were performed on areas concerning for trauma at the primary clinician's discretion. A WBCT was performed on each patient within 24 h of presentation and was blindly interpreted by a board-certified radiologist. Patients were only placed under anesthesia if further procedures were planned. IV contrast administration was employed at the discretion of the primary clinician and radiologist. MEASUREMENTS AND MAIN RESULTS Twenty-one patients (14 dogs and 7 cats) were enrolled. Sources of trauma included blunt force (80%), penetrating wounds (10%), and unknown sources (10%). Twelve injuries were missed on traditional diagnostics tests. Injuries missed on traditional diagnostic workup included pneumothorax, pneumomediastinum, pulmonary contusions, pleural effusion, traumatic bulla, peritoneal effusion, and an appendicular skeleton fracture. A distal metacarpal fracture was missed on WBCT. Traditional diagnostic tests misdiagnosed a diaphragmatic hernia and a ruptured urinary bladder, whereas WBCT was able to rule out these injuries. There were no adverse outcomes associated with missed injuries. The median cost of traditional diagnostic tests was significantly less than the cost of WBCT (P < 0.001). CONCLUSIONS Although cost is higher, WBCT is a single test that can provide more comprehensive information and may help decrease the risk of missed injuries compared to traditional diagnostic tests. WBCT may be considered as a first-line diagnostic in severely traumatized patients.
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Affiliation(s)
- Rebecca G Sepuya
- Department of Emergency and Critical Care, North Carolina State Veterinary Hospital, Raleigh, North Carolina, USA
| | - Emily T Dozeman
- Department of Emergency and Critical Care, MedVet Chicago, Chicago, Illinois, USA
| | - Jennifer E Prittie
- Department of Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
| | - Anthony J Fischetti
- Department of Diagnostic Imaging, The Animal Medical Center, New York, New York, USA
| | - Joel G Weltman
- Department of Emergency and Critical Care, The Animal Medical Center, New York, New York, USA
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Edwards MJ, Jenkel T, Weller B, Weber A, Zhu K, Parikh R, Ata A, Danziger C. Computed Tomography Scan Utilization in Pediatric Trauma: Impact on Length of Stay and Incidence of False Positive Findings. Pediatr Emerg Care 2021; 37:e1478-e1481. [PMID: 32205803 DOI: 10.1097/pec.0000000000002087] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Computerized tomography (CT) scans are the mainstay of diagnostic imaging in blunt trauma. Particularly in pediatric trauma, utilization of CT scans has increased exponentially in recent years. Concerns regarding radiation exposure to this vulnerable population have resulted in increased scrutiny of practice. What is not known is if liberal imaging practices decrease length of stay by eliminating the need for clinical observation, and the impact of false-positive rates from liberal use of CT scanning on clinical outcomes. METHODS Medical records from a nonaccredited pediatric trauma center with a practice of liberal imaging were reviewed over a 2-year period. Total CT scans obtained were recorded, in addition to length of stay, age, and Injury Severity Score (ISS). Rates of clinically significant imaging findings were recorded, as were false positive findings and complications of imaging. RESULTS Out of 735 children, 58% underwent CT scanning, and if scanned, received an average of 2.4 studies. Clinically significant findings were documented in 20% of head CTs, 2% of cervical spine CTs, 3.5% of chest CTs, 24% of facial CTs, and 14.7% of abdominal CTs. False-positive findings were found in 1.5% of head CTs, 1.2% of cervical spine CTs, 2.4% of chest CTs, and 2.5% of abdominal CTs. Liberal CT scanning was not associated with decreased length of stay. In contrast, obtaining CT scans on more than 4 body regions was independently predictive of longer length of stay, independent of ISS. CONCLUSIONS False-positive rates of CT scans for trauma were low in this cohort. However, when scanning the cervical spine or the chest, for every 2 clinically significant findings obtained, there was at least one false positive result, calling into question the practice of liberal imaging of these regions. Liberal utilization of CT scan did not allow for more rapid discharge home, and for more than 4 CTs was independently associated with longer hospital stay.
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Affiliation(s)
- Mary J Edwards
- From the Department of Surgery, Albany Medical College, Albany, NY
| | | | | | - Alexis Weber
- From the Department of Surgery, Albany Medical College, Albany, NY
| | | | | | - Ashar Ata
- From the Department of Surgery, Albany Medical College, Albany, NY
| | - Carrie Danziger
- Department of Emergency Medicine, Albany Medical College, Albany, NY
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Evaluation of the role of whole body computed tomography in the management of minor trauma patients. JOURNAL OF CONTEMPORARY MEDICINE 2021. [DOI: 10.16899/jcm.980536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Nagasawa K, Iwata M, Nihashi T, Terasawa T. Diagnostic accuracy, yield, and comparative effectiveness of whole-body computed tomography in blunt trauma: A protocol for systematic review and meta-analysis. Medicine (Baltimore) 2021; 100:e24205. [PMID: 33466198 PMCID: PMC7808510 DOI: 10.1097/md.0000000000024205] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 12/15/2020] [Indexed: 01/05/2023] Open
Abstract
OBJECTIVES Controversies emerge over routine performances of whole-body computed tomography (WBCT) in patients with blunt polytrauma. The existing randomized and non-randomized evidence is inconclusive, and during observations of non-trauma, incidental findings, detected by WBCT, have left uncertainty regarding their consequences and optimal management. Additionally, previous meta-analyses have failed to address the limitations of primary studies and issues associated with incidental findings. Therefore, we planned a new systematic review to address these points. METHODS We will search the PubMed, EMBASE, and Cochrane Central databases from inception to December 31, 2020, with no language restriction and perform full-text evaluation of potentially relevant articles. We will include prospective and retrospective studies with a single-gate design that assessed diagnostic accuracy and/or yield of WBCT to detect traumatic injuries, and studies that assessed incidental findings detected by WBCT. Additionally, we will include randomized controlled trials and non-randomized comparative studies that assessed the effectiveness of WBCT against conventional care, including selective computed tomography (CT). Studies of patients of all ages with blunt traumatic injuries, assessed at an emergency department, will be included. Two reviewers will extract data and rate the study validity via standard quality assessment tools. The primary outcome of interest will be reduction in mortality. Our secondary outcomes will include diagnostic accuracy and yield, detection of incidental findings and clinical outcomes associated with these detections, and improvement in other non-mortality clinical outcomes. We will qualitatively assess study, patient, and intervention characteristics and clinical outcomes. If appropriate, we will perform random-effects model meta-analyses to obtain summary estimates. Finally, we will assess the certainty of evidence by the grading the quality of evidence and strength of recommendations. ETHICS AND DISSEMINATION Ethics approval is not applicable, as this is a secondary analysis of publicly available data. The review results will be submitted for publication in peer-reviewed journals. PROSPERO REGISTRATION CRD42020187852.
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Affiliation(s)
- Kyohei Nagasawa
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi
- Department of Diagnostic and Interventional Radiology, Aichi Cancer Center Hospital, Nagoya
| | - Mitsunaga Iwata
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi
| | - Takashi Nihashi
- Department of Radiology, National Center for Geriatrics and Gerontology, Obu
- Department of Radiology, Fujita Health University, School of Medicine, Toyoake, Aichi, Japan
| | - Teruhiko Terasawa
- Department of Emergency and General Internal Medicine, Fujita Health University School of Medicine, Toyoake, Aichi
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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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Amiri F, Hale J, Thiel J, Vo B, Murray J, Winalski J. Improvement in Time to CT Imaging in Trauma Evaluations. Am Surg 2020; 87:1994-1996. [PMID: 32783531 DOI: 10.1177/0003134820940277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Farzad Amiri
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jessica Hale
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jordyn Thiel
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Bradley Vo
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jenny Murray
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
| | - Jonathan Winalski
- 4034 Surgery Department, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA
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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: 9] [Impact Index Per Article: 2.3] [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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Ordoñez C, García C, Parra MW, Angamarca E, Guzmán-Rodríguez M, Orlas CP, Herrera-Escobar JP, Rincón E, Meléndez JJ, Serna JJ, Padilla N, Del Valle AM, García AF, Holguín A. Implementation of a new Single-Pass Whole-Body Computed Tomography Protocol: Is it safe, effective and efficient in patients with severe trauma? Colomb Med (Cali) 2020; 51:e4224. [PMID: 32952231 PMCID: PMC7467117 DOI: 10.25100/cm.v51i1.4224] [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] [Indexed: 01/09/2023] Open
Abstract
Purpose: The objective of this study was to evaluate the implementation of a new single-pass whole-body computed tomography Protocol in the management of patients with severe trauma. Methods: This was a descriptive evaluation of polytrauma patients who underwent whole-body computed tomography. Patients were divided into three groups: 1. Blunt trauma hemodynamically stable 2. Blunt trauma hemodynamically unstable and 3. Penetrating trauma. Demographics, whole-body computed tomography parameters and outcome variables were evaluated. Results: Were included 263 patients. Median injury severity score was 22 (IQR: 16-22). Time between arrival to the emergency department and completing the whole-body computed tomography was under 30 minutes in most patients [Group 1: 28 minutes (IQR: 14-55), Group 2: 29 minutes (IQR: 16-57), and Group 3: 31 minutes (IQR: 13-50; p= 0.96)]. 172 patients (65.4%) underwent non-operative management. The calculated and the real survival rates did not vary among the groups either [Group 1: TRISS 86.4% vs. real survival rate 85% (p= 0.69); Group 2: TRISS 69% vs. real survival rate 74% (p= 0.25); Group 3: TRISS 93% vs. real survival rate 87% (p= 0.07)]. Conclusion: This new single-pass whole-body computed tomography protocol was safe, effective and efficient to decide whether the patient with severe trauma requires a surgical intervention independently of the mechanism of injury or the hemodynamic stability of the patient. Its use could also potentially reduce the rate of unnecessary surgical interventions of patients with severe trauma including those with penetrating trauma.
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Affiliation(s)
- Carlos Ordoñez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y EmergenciasCali, Colombia.,Hospital Universitario del Valle Evaristo Garcia , Cali, Colombia.,Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Carlos García
- Fundación Valle del Lili, Radiology Department, Cali, Colombia
| | - Michael W Parra
- Broward General Level I Trauma Center, Department of Trauma Critical Care. Fort Lauderdale, FL. EEUU
| | - Edison Angamarca
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y EmergenciasCali, Colombia.,Hospital Universitario del Valle Evaristo Garcia , Cali, Colombia
| | | | - Claudia P Orlas
- Harvard Medical School & Harvard T.H. Chan School of Public Health, Brigham & Women's Hospital, Department of Surgery, Center for Surgery and Public Health Boston, MA, EEUU
| | - Juan Pablo Herrera-Escobar
- Harvard Medical School & Harvard T.H. Chan School of Public Health, Brigham & Women's Hospital, Department of Surgery, Center for Surgery and Public Health Boston, MA, EEUU
| | - Erika Rincón
- Fundación Valle del Lili, Radiology Department, Cali, Colombia
| | - Juan José Meléndez
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y EmergenciasCali, Colombia.,Hospital Universitario del Valle Evaristo Garcia , Cali, Colombia
| | - Jose Julián Serna
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | | | - Ana Milena Del Valle
- Universidad del Valle, Facultad de Salud, Escuela de Medicina, Sección de Cirugía de Trauma y EmergenciasCali, Colombia.,Hospital Universitario del Valle Evaristo Garcia , Cali, Colombia
| | - Alberto F García
- Fundación Valle del Lili, Division of Trauma and Acute Care Surgery, Cali, Colombia
| | - Alfonso Holguín
- Fundación Valle del Lili, Radiology Department, Cali, Colombia
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14
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Angamarca E, Orlas CP, Herrera-Escobar JP, Rincón É, Guzmán-Rodríguez M, Meléndez JJ, Carlos Andrés Serna CAS, Franco MJ, Padilla N, De las Salas A, Diego Beltrán DB, Ortiz L, Ordoñez Mosquera JM, Munévar E, Del Valle AM, García Marín AF, García7 CA, Holguín A, Parra MW, Ordóñez CA. Uso de la tomografía corporal total en pacientes con trauma grave. REVISTA COLOMBIANA DE CIRUGÍA 2020. [DOI: 10.30944/20117582.591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Introducción. La tomografía corporal (TC) total en la evaluación de pacientes con trauma grave, puede ser una herramienta eficaz y segura para decidir entre un tratamiento quirúrgico y uno no quirúrgico, pero aún no son claras las implicaciones diagnósticas y los riesgos asociados con esta técnica.
Métodos. Se incluyeron pacientes mayores de 15 años con trauma grave que fueron sometidos a TC total. Se evaluaron la seguridad, la efectividad y la eficiencia por medio de los parámetros de incidencia de nefropatía inducida por los medios de contraste, dosis total de radiación por paciente, proporción de casos en los que la TC total cambió el manejo, y el retraso en el diagnóstico.
Resultados. Se incluyeron 263 pacientes, 83 % sufrieron trauma cerrado y 17 % sufrieron trauma penetrante. La gravedad de la lesión fue mayor en estos últimos y, sin embargo, el trauma cerrado con inestabilidad hemodinámica se presentó con mayores grados de choque. El 65 % de los pacientes recibió tratamiento selectivo no operatorio. Entre los subgrupos, no hubo diferencias significativas en el tiempo entre el ingreso a la sala de urgencias y la toma de la TC total (p=0,96) y, en la mayoría de los casos, el tiempo entre la práctica de la TC total y el diagnóstico de presencia o ausencia de heridas fue menor de 25 minutos. La mediana de radiación total estuvo por debajo de 20 mSv en todos los grupos. No hubo diferencias significativas en la mortalidad (p=0,17).
Conclusión. La TC total es una herramienta segura y eficiente para decidir entre un tratamiento quirúrgico y uno no quirúrgico en los casos de trauma grave, independientemente del mecanismo de la lesión o la estabilidad hemodinámica al ingreso.
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Abstract
OBJECTIVE To develop French guidelines on the management of patients with severe abdominal trauma. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU), the French Society of Urology (Société française d'urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded. METHODS The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a "damage control surgery" strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology. RESULTS The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question. CONCLUSIONS Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.
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16
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George MR, Carroll M, Strayer RJ. Prevalence of serious injuries in low risk trauma patients. Am J Emerg Med 2019; 38:1572-1575. [PMID: 31500924 DOI: 10.1016/j.ajem.2019.158422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Revised: 08/10/2019] [Accepted: 09/02/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVES Computed tomography (CT) utilization is widespread in contemporary Emergency Departments (EDs). CT overuse leads to radiation exposure, contrast toxicity, overdiagnosis, and incidental findings. This study explores the prevalence of clinically significant injuries in patients identified as low-risk trauma patients (LRTPs) using newly created criteria that account for the patient's age, trauma mechanism, assessability (which relies on level of consciousness, intoxication, and neurologic deficits), vital signs and other evidence of hypoperfusion, bleeding risk, and past medical history. METHODS This was a 6-month retrospective chart review of all LRTPs presenting to a level 1 trauma center in Queens, New York. Data abstraction was performed independently by two abstractors and discrepancies adjudicated by the senior author. Patients were identified using the hospital trauma registry and two reports, created by the researchers, identifying selected chief complaints and discharge diagnoses. RESULTS 750 patients were identified of which 352 (46.93%) received one or more CT scans. There were a total of 790 CT scans ordered, of which 731 (92.53%) were negative for acute injury. There were 13 clinically significant injuries of which only one (0.13%) required immediate intervention. There were no mortalities in this LRTP group. CONCLUSION The prevalence of clinically significant injuries in this population is very low and injuries requiring immediate intervention are even lower. CT utilization in LRTPs should be guided by an explicit consideration of benefit and harm for each patient.
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Affiliation(s)
- Megha R George
- Emergency Department, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.
| | - Moira Carroll
- Emergency Department, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America
| | - Reuben J Strayer
- Emergency Department, Maimonides Medical Center, Brooklyn, New York, United States of America
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17
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Belabbas D, Auger M, Lederlin M, Bonenfant J, Gandon Y, Aubé C, Paisant A. Whole-Body CT after Motor Vehicle Crash: No Benefit after High-Energy Impact and with Normal Physical Examination. Radiology 2019; 292:94-100. [PMID: 31135296 DOI: 10.1148/radiol.2019182806] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Background Debate continues about the risks and benefits of systematic whole-body CT when no injury is clinically suspected. Risks of whole-body CT include high radiation exposure and iodine contrast agent, but its effectiveness in reducing mortality in low-risk motor vehicle crashes is unclear. Purpose To assess unsuspected injuries revealed at whole-body CT in patients following motor vehicle crash (MVC) meeting only kinetic elements of the Vittel criteria for the severity of trauma, with no evidence of trunk injury and a Glasgow Coma Scale score of 15. Materials and Methods This retrospective study included all consecutive adult patients who consulted an emergency department of a level 1 trauma center between August 2016 and July 2017 if they underwent whole-body CT for one or more kinetic elements of the Vittel criteria, had a normal examination of the trunk, and had a Glasgow Coma Scale score of 15. Data of the MVC mechanism and physical and biologic examinations were collected, as well as patient treatment data after whole-body CT. Whole-body CT examinations were read by two double-blinded readers to help detect unsuspected injuries. Results Ninety-three patients were included; 72 were men with a mean age of 30.8 years ± 12.0 (standard deviation). Sixty-nine patients were occupants of a car. Seventeen patients were hit by a car while on motorbikes, three while on bicycles, and four as pedestrians. Unsuspected injuries were depicted at 11 whole-body CT examinations: eight lung contusions, one acetabular fracture, one sternal fracture, and one adrenal hematoma. None of these injuries required a specific treatment. One patient with lung contusion of more than 30% of lung volume was followed without requiring further treatment. Conclusion In this population, whole-body CT did not lead to any change in patient treatment. These results suggest whole-body CT should not be systematically performed when no evidence of trunk injury is observed in patients following motor vehicle crash meeting only kinetic elements of Vittel criteria. © RSNA, 2019 See also the editorial by Munera and Durso in this issue.
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Affiliation(s)
- Dihia Belabbas
- From the Departments of Radiology (D.B., M.A., M.L., Y.G., A.P.) and Emergency (J.B.), University Hospital of Rennes, 2 Rue Henri le Guilloux, 35000 Rennes, France; and Department of Radiology, University Hospital of Angers, Angers, France (C.A., A.P.)
| | - Magali Auger
- From the Departments of Radiology (D.B., M.A., M.L., Y.G., A.P.) and Emergency (J.B.), University Hospital of Rennes, 2 Rue Henri le Guilloux, 35000 Rennes, France; and Department of Radiology, University Hospital of Angers, Angers, France (C.A., A.P.)
| | - Mathieu Lederlin
- From the Departments of Radiology (D.B., M.A., M.L., Y.G., A.P.) and Emergency (J.B.), University Hospital of Rennes, 2 Rue Henri le Guilloux, 35000 Rennes, France; and Department of Radiology, University Hospital of Angers, Angers, France (C.A., A.P.)
| | - Jérémie Bonenfant
- From the Departments of Radiology (D.B., M.A., M.L., Y.G., A.P.) and Emergency (J.B.), University Hospital of Rennes, 2 Rue Henri le Guilloux, 35000 Rennes, France; and Department of Radiology, University Hospital of Angers, Angers, France (C.A., A.P.)
| | - Yves Gandon
- From the Departments of Radiology (D.B., M.A., M.L., Y.G., A.P.) and Emergency (J.B.), University Hospital of Rennes, 2 Rue Henri le Guilloux, 35000 Rennes, France; and Department of Radiology, University Hospital of Angers, Angers, France (C.A., A.P.)
| | - Cristophe Aubé
- From the Departments of Radiology (D.B., M.A., M.L., Y.G., A.P.) and Emergency (J.B.), University Hospital of Rennes, 2 Rue Henri le Guilloux, 35000 Rennes, France; and Department of Radiology, University Hospital of Angers, Angers, France (C.A., A.P.)
| | - Anita Paisant
- From the Departments of Radiology (D.B., M.A., M.L., Y.G., A.P.) and Emergency (J.B.), University Hospital of Rennes, 2 Rue Henri le Guilloux, 35000 Rennes, France; and Department of Radiology, University Hospital of Angers, Angers, France (C.A., A.P.)
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18
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Tsutsumi Y, Fukuma S, Tsuchiya A, Yamamoto Y, Fukuhara S. Whole-Body Computed Tomography During Initial Management and Mortality Among Adult Severe Blunt Trauma Patients: A Nationwide Cohort Study. World J Surg 2019; 42:3939-3946. [PMID: 29959493 DOI: 10.1007/s00268-018-4732-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Whole-body computed tomography (WBCT) is increasingly being incorporated into the initial management of blunt trauma patients. Several observational studies have suggested that, compared to selective CT, WBCT is associated with lower mortality. In contrast, a randomized controlled trial found no significant difference in survival between patients undergoing WBCT compared to selective CT. Our objective was to confirm the association between WBCT and in-hospital mortality among adult severe blunt trauma patients. METHODS This was a retrospective cohort study based on Japan Trauma Data Bank 2004-2015 registry data. The study population comprised adult severe blunt trauma patients with at least one abnormal vital sign: systolic blood pressure ≤100 mmHg, heart rate ≥120, respiratory rate ≥30 or ≤10, or Glasgow Coma Score ≤13. The primary outcome was in-hospital mortality. To adjust for both measured and unmeasured confounders, we performed instrumental variable (IV) analysis to compare the in-hospital mortality of patients undergoing WBCT with those undergoing selective CT. RESULTS Of 40,435 patients who were eligible for this study, 19,766 (48.9%) patients underwent WBCT. The proportion of patients undergoing WBCT significantly increased during the study period, from 10.7% in 2004 to 59.6% in 2015. Primary IV analysis showed a significant association between WBCT and lower in-hospital mortality (odds ratio 0.84, 95% confidence interval 0.72-0.98). CONCLUSIONS WBCT can be beneficial in patients with blunt trauma which has compromised vital signs. These findings from a nationwide study suggest that physicians should consider WBCT for blunt trauma patients when warranted by vital signs.
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Affiliation(s)
- Yusuke Tsutsumi
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan.,Department of Emergency Medicine, National Hospital Organization Mito Medical Center, 280 Sakuranosato Ibaraki-machi, Higashiibaraki-gun, Ibaraki, 311-3117, Japan
| | - Shingo Fukuma
- Human Health Sciences, Graduate School of Medicine, Kyoto University, 53 Yoshida-Kawahara-machi, Sakyo-ku, Kyoto, 606-8507, Japan.
| | - Asuka Tsuchiya
- Department of Clinical Epidemiology and Health Economics, School of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan.,Department of Emergency Medicine, National Hospital Organization Mito Medical Center, 280 Sakuranosato Ibaraki-machi, Higashiibaraki-gun, Ibaraki, 311-3117, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
| | - Shunichi Fukuhara
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Yoshida-Konoe-cho, Sakyo-ku, Kyoto, 606-8501, Japan
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Kim JH, Ha SO, Park YS, Yi JH, Hur SB, Lee KH. Central Venous Catheterization before Versus after Computed Tomography in Hemodynamically Unstable Patients with Major Blunt Trauma: Clinical Characteristics and Factors for Decision Making. JOURNAL OF TRAUMA AND INJURY 2018. [DOI: 10.20408/jti.2018.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Affiliation(s)
- Ji Hun Kim
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
| | - Young Sun Park
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
| | - Jeong Hyeon Yi
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
| | - Sun Beom Hur
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
| | - Ki Ho Lee
- Department of Emergency Medicine, Hallym University Sacred Heart Hospital, Hallym University Medical Center, Anyang, Korea
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Hartka T, Glass G, Kao C, McMurry T. Development of injury risk models to guide CT evaluation in the emergency department after motor vehicle collisions. TRAFFIC INJURY PREVENTION 2018; 19:S114-S120. [PMID: 30543473 DOI: 10.1080/15389588.2018.1543872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 10/26/2018] [Accepted: 10/30/2018] [Indexed: 06/09/2023]
Abstract
OBJECTIVE The clinical evaluation of motor vehicle collision (MVC) victims is challenging and commonly relies on computed tomography (CT) to detect internal injuries. CT scans are financially expensive and each scan exposes the patient to additional ionizing radiation with an associated, albeit low, risk of cancer. Injury risk prediction based on regression modeling has been to be shown to be successful in estimating Injury Severity Scores (ISSs). The objective of this study was to (1) create risk models for internal injuries of occupants involved in MVCs based on CT body regions (head, neck, chest, abdomen/pelvis, cervical spine, thoracic spine, and lumbar spine) and (2) evaluate the performance of these risk prediction models to predict internal injury. METHODS All Abbreviated Injury Scale (AIS) 2008 injury codes were classified based on which CT body region would be necessary to scan in order to make the diagnosis. Cases were identified from the NASS-CDS. The NASS-CDS data set was queried for cases of adult occupants who sought medical care and for which key crash characteristics were all present. Forward stepwise logistic regression was performed on data from 2010-2014 to create models predicting risk of internal injury for each CT body region. Injury risk for each region was grouped into 5 levels: very low (<2%), low (2-5%), medium (5-10%), high (10-20%), and very high (20%). The models were then tested using weighted data from 2015 in order to determine whether injury rates fell within the predicted risk level. RESULTS The inclusion and exclusion criteria identified 5,477 cases in the NASS-CDS database. Cases from 2010-2014 were used for risk modeling (n = 4,826). Seven internal injury risk models were created based on the CT body regions using data from 2010-2014. These models were tested against data from 2015 (n = 651). In all CT body regions, the majority of occupants fell in the very low or low predicted injury rate groups, except for the head. On average, 57% of patients were classified as very low risk and 15% as low risk for each body region. In most cases the actual rate of injury was within the predicted injury risk range. The 95% confidence interval overlapped with predicting injury risk range in all cases. CONCLUSION This study successfully demonstrated the ability for internal injury risk models to accurately identify occupants at low risk for internal injury in individual body regions. This represents a step towards incorporating telemetry data into a clinical tool to guide physicians in the use of CT for the evaluation of MVC victims.
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Affiliation(s)
- Thomas Hartka
- a Department of Emergency Medicine , University of Virginia , Charlottesville , Virigina
| | - George Glass
- a Department of Emergency Medicine , University of Virginia , Charlottesville , Virigina
| | - Christopher Kao
- b School of Medicine , University of Virginia , Charlottesville , Virigina
| | - Timothy McMurry
- c Department of Public Health , University of Virginia , Charlottesville , Virigina
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Whole body computed tomography in multi trauma patients: Review of the current literature. Turk J Emerg Med 2018; 18:142-147. [PMID: 30533556 PMCID: PMC6261098 DOI: 10.1016/j.tjem.2018.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Revised: 09/26/2018] [Accepted: 09/26/2018] [Indexed: 01/29/2023] Open
Abstract
Many authors adopt the Selected Computed Tomography (SCT) approach of the Advanced Trauma Life Support (ATLS) for the management of multiple trauma patients. In the SCT approach, the initial physical examination is followed by conventional radiography (cervical X-ray, chest X-ray, pelvic X-ray and Focused Abdominal Sonography in Trauma (FAST)), and the computed tomography (CT) of the specific body regions if indicated. An alternative to this traditional approach is the Whole-body Computed Tomography (WBCT) protocol, which became widespread all over the world in the last two decades to minimize the rate of missed injuries and decrease the mortality rate. According to the literature, the WBCT approach is superior to the traditional SCT approach in the time of imaging, diagnostic accuracy, and mortality rates. Conversely, WBCT increases the cancer risk due to additional irradiation. Therefore, it is recommended that the WBCT protocol should be reserved for only severe multi-trauma patients. However, further studies to define severe patients, and clinical decision criteria for WBCT are needed.
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22
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Abstract
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.
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Katayama Y, Kitamura T, Hirose T, Kiguchi T, Matsuyama T, Sado J, Kiyohara K, Izawa J, Tachino J, Ebihara T, Yoshiya K, Nakagawa Y, Shimazu T. Delay of computed tomography is associated with poor outcome in patients with blunt traumatic aortic injury: A nationwide observational study in Japan. Medicine (Baltimore) 2018; 97:e12112. [PMID: 30170440 PMCID: PMC6392548 DOI: 10.1097/md.0000000000012112] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
According to guidelines from the Eastern Association for the Surgery of Trauma, computed tomography (CT) with intravenous contrast is strongly recommended to diagnose clinically significant blunt traumatic aortic injury (BTAI). However, it remains unclear whether the timing of CT scanning is associated with the prognosis of BTAI patients.We extracted data on emergency patients who suffered a BTAI in the chest and/or the abdomen from 2004 to 2015 from the Japanese Trauma Data Bank, a nationwide trauma registry. The primary outcome was death in the emergency department (ED) and secondary outcome was discharge to death. In addition, we assessed the relationship between death in the ED and the timing of CT scanning by shock status in subgroup analysis. We divided these patients into the tertile groups of early (≤26 minutes), middle (27-40 minutes), and late (≥41 minutes) phases based on the time interval from hospital arrival to start of first CT scanning, and assessed death of BTAI patients in the ED by CT scanning time with the use of a multivariable logistic regression model.In total, 421 patients who suffered BTAI in the chest and/or the abdomen were eligible for our analysis. The proportion of patients dying at hospital admission was 7.7% (11/142) in the early group, 11.1% (15/135) in the middle group, and 17.6% (25/144) in the late group. In a multivariable logistic regression adjusted for confounding factors, the adjusted odds ratio (AOR) of death in the ED was 1.833 (95% confidence interval [CI]: 0.601-5.590, P = .287) in the middle group and 2.832 (95% CI: 1.007-7.960, P = .048) in the late group compared with the early group. Compared with the early group, the late group tended to have a higher rate of discharge to death (AOR: 1.438, 95% CI: 0.735-2.813). In the patients with shock, the AOR was 3.292 (95% CI: 0.495-21.902) in the middle group and 6.039 (95% CI: 0.990-36.837) in the late group compared with the early group.This study revealed that a longer time interval from hospital arrival to CT scanning was associated with higher mortality in the ED in patients with BTAI.
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Affiliation(s)
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita
| | - Tomoya Hirose
- Department of Traumatology and Acute Critical Medicine
- Emergency and Critical Care Center, Osaka Police Hospital, Osaka
| | | | - Tasuku Matsuyama
- Department of Emergency Medicine, Kyoto Prefectural University of Medicine, Kyoto
| | - Junya Sado
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, Suita
| | - Kosuke Kiyohara
- Department of Public Health, Tokyo Women's Medical University
| | - Junichi Izawa
- Intensive Care Unit, Department of Anesthesiology, The Jikei University School of Medicine, Tokyo, Japan
| | | | | | | | - Yuko Nakagawa
- Department of Traumatology and Acute Critical Medicine
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Özçete E, Kiyan S, Uz İ, Songür Kodik M, Altuncı YA. The role of whole-body computed tomography in determining risky patient group with regard to polytrauma patients in the emergency department. HONG KONG J EMERG ME 2018. [DOI: 10.1177/1024907918755174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Backround: High rates in trauma-related mortality pose a major health problem and increase every day. Early diagnosis and treatment can be lifesavers for this patient group in the emergency departments, which serve as the first place to admit trauma patients in a hospital. Objectives: We aim to determine high-risk criteria to indicate trauma patients getting the most use from whole-body tomography in patients with multiple traumas and reduce unnecessary computed tomography. Methods: We examined retrospectively all electronic files and computed tomography results of patients, who had been admitted to emergency department due to trauma, and who had undergone whole-body computed tomography. Results: We found that possibility of multiple injuries increased by 5.9 times in patients requiring mechanical ventilation. Possibility of multiple injuries in patients with free fluid in the Focused Assessment with Sonography for Trauma increased by 5.6 times. We also observed that possibility of multiple injuries in patients with Glasgow Coma Score < 13 increased by 4.3 times. Possibility of multiple injuries in hypoxic patients increased by 3.2 times. Possibility of multiple injuries in patients with a pulse ≥ 120/min increased by 1.8 times. Possibility of multiple injuries in patients with shock index ≥ 0.9 increased by 1.7 times. Conclusion: High-risk group in terms of multiple traumas involves mechanical ventilation need in trauma patients, positive Focused Assessment with Sonography for Trauma, Glasgow Coma Score being under 13, hypoxia, tachycardia, positive shock index, and extravehicular traffic accidents. Whole-body computed tomography should be performed in this patient group.
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Affiliation(s)
- Enver Özçete
- Department of Emergency Medicine, Ege University School of Medicine, Izmir, Turkey
| | - Selahattin Kiyan
- Department of Emergency Medicine, Ege University School of Medicine, Izmir, Turkey
| | - İlhan Uz
- Department of Emergency Medicine, Ege University School of Medicine, Izmir, Turkey
| | - Meltem Songür Kodik
- Department of Emergency Medicine, Ege University School of Medicine, Izmir, Turkey
| | - Yusuf Ali Altuncı
- Department of Emergency Medicine, Ege University School of Medicine, Izmir, Turkey
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Furugori S, Kato M, Abe T, Iwashita M, Morimura N. Treating patients in a trauma room equipped with computed tomography and patients' mortality: a non-controlled comparison study. World J Emerg Surg 2018; 13:16. [PMID: 29599816 PMCID: PMC5870518 DOI: 10.1186/s13017-018-0176-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Accepted: 03/12/2018] [Indexed: 11/16/2022] Open
Abstract
Background To improve acute trauma care workflow, the number of trauma centers equipped with a computed tomography (CT) machine in the trauma resuscitation room has increased. The effect of the presence of a CT machine in the trauma room on a patient’s outcome is still unclear. This study evaluated the association between a CT machine in the trauma room and a patient’s outcome. Methods Our study included all trauma patients admitted to a trauma center in Yokohama, Japan, between April 2014 and March 2016. We compared 140 patients treated using a conventional resuscitation room with 106 patients treated in new trauma rooms equipped with a CT machine. Results For the group treated in a trauma room with a CT machine, the Injury Severity Score (13.0 vs. 9.0; p = 0.002), CT scans of the head (78.3 vs. 66.4%; p = 0.046), CT scans of the body trunk (75.5 vs. 58.6%; p = 0.007), intubation in the emergency department (48.1 vs. 30.7%; p = 0.008), and multiple trauma patients (47.2 vs. 30.0%; p = 0.008) were significantly higher and Trauma and Injury Severity Score probability of survival (96.75 vs. 97.80; p = 0.009) was significantly lower than the group treated in a conventional resuscitation room. In multivariate analysis and propensity score matched analysis, being treated in a trauma room with a CT machine was an independent predictor for fewer hospital deaths (odds ratio 0.002; 95% CI 0.00–0.75; p = 0.04, and 0.07; 0.00–0.98, respectively). Conclusions Equipping a trauma room with a CT machine reduced the time in decision-making for treating a trauma patient and subsequently lowered the mortality of trauma patients.
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Affiliation(s)
- Shintaro Furugori
- 1Department of Emergency Medicine, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Makoto Kato
- 2Department of Surgery, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Takeru Abe
- 1Department of Emergency Medicine, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Masayuki Iwashita
- 1Department of Emergency Medicine, Yokohama City University, 4-57 Urafunecho, Minamiku, Yokohama City, Kanagawa Prefecture 232-0024 Japan
| | - Naoto Morimura
- 3Department of Acute Medicine, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033 Japan
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A review of split-bolus single-pass CT in the assessment of trauma patients. Emerg Radiol 2018; 25:367-374. [DOI: 10.1007/s10140-018-1591-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2017] [Accepted: 02/14/2018] [Indexed: 11/25/2022]
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Garcia CM, Cunningham SJ. Role of clinical suspicion in pediatric blunt trauma patients with severe mechanisms of injury. Am J Emerg Med 2018; 36:105-109. [DOI: 10.1016/j.ajem.2017.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 06/19/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022] Open
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Botelho Filho FM, de Oliveira e Silva RC, Starling SV, Zille DP, Drumond DAF. Complementary exams in blunt torso trauma. Perform only radiographs and fast: is it safe? Rev Col Bras Cir 2017; 42:220-3. [PMID: 26517796 DOI: 10.1590/0100-69912015004005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 04/02/2015] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE to evaluate effectiveness of using chest X-ray (CXR), pelvis X-ray (RXP) and FAST (Focused Abdominal Sonography on Trauma) to exclude significant lesions of the body in blunt trauma. METHODS a prospective study involving 74 patients whom made the three tests (CXR, RXP and FAST) during the initial evaluation between October 2013 and February 2014. The results were compared to the tomography of the same patients or clinical outcome. If the patient did not have alterations on the CT scans or during the observation time, the initial workup was considered safe. All patients were evaluated at the Hospital João XXIII, Belo Horizonte, Brazil. RESULTS of the 74 patients studied the average age was 33 years, RTS: 6.98, ECG: 12. From 44 (59.45%) patients with exams (radiographs and FAST) unchanged, three had significant injuries (two splenic injuries and one liver injury) diagnosed by clinical monitoring. The remaining patients - 30 (40.55%) - had at least one alteration in conventional tests. Of these group 27 (90%) had significant injuries and three (10%) minor injuries. The sensitivity of all three tests for screening considerable lesions was 90% and the specificity was 93%. The negative predictive value was 93% and the positive predictive value 89%. CONCLUSION this research showed that all the three exams - chest X-ray, pelvis and FAST - are safe to lead with the blunt trauma if well used and associated with clinical examination.
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Lang P, Kulla M, Kerwagen F, Lefering R, Friemert B, Palm HG. The role of whole-body computed tomography in the diagnosis of thoracic injuries in severely injured patients - a retrospective multi-centre study based on the trauma registry of the German trauma society (TraumaRegister DGU ®). Scand J Trauma Resusc Emerg Med 2017; 25:82. [PMID: 28810921 PMCID: PMC5558663 DOI: 10.1186/s13049-017-0427-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 08/07/2017] [Indexed: 12/14/2022] Open
Abstract
Background Thoracic injuries are a leading cause of death in polytrauma patients. Early diagnosis and treatment are of paramount importance. Whole-body computed tomography (WBCT) has largely replaced traditional imaging techniques such as conventional radiographs and focused computed tomography (CT) as diagnostic tools in severely injured patients. It is still unclear whether WBCT has led to higher rates of diagnosis of thoracic injuries and thus to a change in outcomes. Methods In a retrospective study based on the trauma registry of the German Trauma Society (TraumaRegister DGU®), we analysed data from 16,545 patients who underwent treatment in 59 hospitals between 2002 and 2012 (ISS ≥ 9). The 3 years preceding and the 3 years following the introduction of WBCT as a standard imaging modality for the investigation of severely injured patients were assessed for every hospital. Accordingly, patients were assigned to either the pre-WBCT or the WBCT group. We compared the numbers of thoracic injuries and the outcomes of patients before and after the routine use of WBCT. Results A total of 13,564 patients (pre-WBCT: n = 5005, WBCT: n = 8559) were included. Relevant thoracic injuries were detected in 47.8%. There were no major differences between the patient groups in injury severity (pre-WBCT: median ISS 21; WBCT: median ISS 22), injury patterns and demographics. After the introduction of WBCT, only minor changes were observed regarding the rates of most thoracic injuries. Clinically relevant injuries were pulmonary contusions (pre-WBCT: 18.5%; WBCT: 28.7%), injuries to the lung parenchyma (pre-WBCT: 12.6%; WBCT: 5.9%), multiple rib fractures (pre-WBCT: 10.6%; WBCT: 21.6%), and pneumothoraces (pre-WBCT: 17.3%; WBCT: 21.6%). The length of stay in the intensive care unit (pre-WBCT: 10.8 days; WBCT: 9.7 days) and in hospital (pre-WBCT: 26.2 days; WBCT: 23.3 days) decreased. There was no difference in overall mortality (pre-WBCT: 15.5%; WBCT: 15.6%). Conclusions The routine use of WBCT in the trauma room setting has led to changes in patient management that are not reflected in the rates of diagnosis of severe thoracic injuries (e.g. tension pneumothoraces, cardiac injuries, arterial injuries). By contrast, there was a relevant increase in the rates of diagnosis of minor thoracic injuries, which, however, did not result in an improvement in survival prognosis.
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Affiliation(s)
- Patricia Lang
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Martin Kulla
- Department of Anaesthesiology and Intensive Care Medicine, German Armed Forces Hospital of Ulm, Oberer Eselsberg 40, 89081, Ulm, Germany.
| | - Fabian Kerwagen
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), Witten/Herdecke University, Ostmerheimer Str. 200, 51109, Cologne, Germany
| | - Benedikt Friemert
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
| | - Hans-Georg Palm
- Trauma Research Group, Department of Orthopaedics and Trauma Surgery, Reconstructive and Septic Surgery, and Sports Traumatology, German Armed Forces Hospital of Ulm, Ulm, Germany
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Chidambaram S, Goh EL, Khan MA. A meta-analysis of the efficacy of whole-body computed tomography imaging in the management of trauma and injury. Injury 2017; 48:1784-1793. [PMID: 28610777 DOI: 10.1016/j.injury.2017.06.003] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 06/05/2017] [Accepted: 06/06/2017] [Indexed: 02/02/2023]
Abstract
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.
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Affiliation(s)
- Swathikan Chidambaram
- Department of Surgery and Trauma, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, United Kingdom.
| | - En Lin Goh
- Department of Surgery and Trauma, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, United Kingdom
| | - Mansoor A Khan
- Department of Surgery and Trauma, Faculty of Medicine, Imperial College London, St Mary's Hospital, London, United Kingdom
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Whole body CT versus selective radiological imaging strategy in trauma: an evidence-based clinical review. Am J Emerg Med 2017; 35:1356-1362. [PMID: 28366287 DOI: 10.1016/j.ajem.2017.03.048] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 03/19/2017] [Accepted: 03/21/2017] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Trauma patients often present with injuries requiring resuscitation and further evaluation. Many providers advocate for whole body computed tomography (WBCT) for rapid and comprehensive diagnosis of life-threatening injuries. OBJECTIVE Evaluate the literature concerning mortality effect, emergency department (ED) length of stay, radiation, and incidental findings associated with WBCT. DISCUSSION Physicians have historically relied upon history and physical examination to diagnose life-threatening injuries in trauma. Diagnostic imaging modalities including radiographs, ultrasound, and computed tomography have demonstrated utility in injury detection. Many centers routinely utilize WBCT based on the premise this test will improve mortality. However, WBCT may increase radiation and incidental findings when used without considering pre-test probability of actionable traumatic injuries. Studies supporting WBCT are predominantly retrospective and incorporate trauma scoring systems, which have significant design weaknesses. The recent REACT-2 trial randomized trauma patients with high index of suspicion for actionable injuries to WBCT versus selective imaging and found no mortality difference. Additional prospective trials evaluating WBCT in specific trauma subgroups (e.g. polytrauma) are needed to evaluate benefit. In the interim, the available data suggests clinicians should adopt a selective imaging strategy driven by history and physical examination. CONCLUSIONS While observational data suggests an association between WBCT and a benefit in mortality and ED length of stay, randomized controlled data suggests no mortality benefit to this diagnostic tool. The literature would benefit from confirmatory studies of the use of WBCT in trauma sub-groups to clarify its impact on mortality for patients with specific injury patterns.
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Ong AW, Moyer J, Wordofa FD, Sigal A, Sandel K, Fernandez FB. Trauma surgeon utilization of computerized tomography scanning: Room for improvement? Am J Surg 2017; 213:579-582. [DOI: 10.1016/j.amjsurg.2016.11.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 11/24/2016] [Accepted: 11/26/2016] [Indexed: 11/28/2022]
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Sammy IA, Chatha H, Bouamra O, Fragoso-Iñiguez M, Lecky F, Edwards A. The use of whole-body computed tomography in major trauma: variations in practice in UK trauma hospitals. Emerg Med J 2017; 34:647-652. [PMID: 28130346 DOI: 10.1136/emermed-2016-206167] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 12/09/2016] [Accepted: 12/17/2016] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBCT in trauma can reduce time to definitive care, thereby increasing survival. However, its use varies significantly worldwide. METHODS We performed a retrospective observational study of Trauma Audit and Research Network (TARN) data from 2012 to 2014. The proportion of adult patients receiving WBCT during initial resuscitation at major trauma centres (MTCs) and trauma units/non-designated hospitals (TUs/NDHs) was compared. A model was developed that included factors associated with WBCT use, and centre effects within the model were explored to determine variation in usage beyond that expected from the model. RESULTS Of the 115 664 study participants, 16.5% had WBCT. WBCT was performed five times more frequently in MTCs than in TUs/NDHs (31% vs 6.6%). In the multivariate model, increased injury severity, low GCS, shock, comorbidities and triage category increased the chances of having a WBCT, but there was no consistent relation with age. High falls and motor vehicle collisions also increased WBCT usage. Adjusting for casemix, there was a 13-fold intrahospital variation in the use of WBCT between MTCs and a 30-fold variation between TUs/NDHs. The amount of variability between individual hospitals that could not be accounted for by the factors shown to impact on WBCT use was 26% (95% CI 17% to 39%) for MTCs and 17% (95% CI 13% to 21%) for TUs/NDHs. CONCLUSION There are significant variations in WBCT use between different hospitals in England and Wales, which require further investigation.
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Affiliation(s)
- Ian Ayenga Sammy
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hridesh Chatha
- Emergency Department, Salford Royal Hospitals NHS Foundation Trust, Salford, UK
| | - Omar Bouamra
- Trauma Audit and Research Network, University of Manchester, Manchester, UK
| | | | - Fiona Lecky
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Antoinette Edwards
- Trauma Audit and Research Network, University of Manchester, Manchester, UK
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Introduction of a pan-scan protocol for blunt trauma activations: what are the consequences? Am J Emerg Med 2017; 35:13-19. [DOI: 10.1016/j.ajem.2016.09.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/13/2016] [Accepted: 09/14/2016] [Indexed: 11/18/2022] Open
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Sierink JC, Treskes K, Edwards MJR, Beuker BJA, den Hartog D, Hohmann J, Dijkgraaf MGW, Luitse JSK, Beenen LFM, Hollmann MW, Goslings JC. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet 2016; 388:673-83. [PMID: 27371185 DOI: 10.1016/s0140-6736(16)30932-1] [Citation(s) in RCA: 157] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma. METHODS We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ(2) test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626. FINDINGS Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0.92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0.46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0.31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died. INTERPRETATION Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT. FUNDING ZonMw, the Netherlands Organisation for Health Research and Development.
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Affiliation(s)
- Joanne C Sierink
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Kaij Treskes
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Michael J R Edwards
- Trauma Unit, Department of Surgery, Radboud University Medical Center, Nijmegen, Netherlands
| | - Benn J A Beuker
- Trauma Unit, Department of Surgery, University Medical Center Groningen, Groningen, Netherlands
| | - Dennis den Hartog
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Joachim Hohmann
- Department of Radiology and Nuclear Medicine, University of Basel Hospital, Basel, Switzerland
| | | | - Jan S K Luitse
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands
| | - Ludo F M Beenen
- Department of Radiology, Academic Medical Center, Amsterdam, Netherlands
| | - Markus W Hollmann
- Department of Anaesthesiology, Academic Medical Center, Amsterdam, Netherlands
| | - J Carel Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Amsterdam, Netherlands.
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Sharples A, Brohi K. Can clinical prediction tools predict the need for computed tomography in blunt abdominal? A systematic review. Injury 2016; 47:1811-8. [PMID: 27319389 DOI: 10.1016/j.injury.2016.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/22/2016] [Accepted: 05/23/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Blunt abdominal trauma is a common reason for admission to the Emergency Department. Early detection of injuries is an important goal but is often not straightforward as physical examination alone is not a good predictor of serious injury. Computed tomography (CT) has become the primary method for assessing the stable trauma patient. It has high sensitivity and specificity but there remains concern regarding the long term consequences of high doses of radiation. Therefore an accurate and reliable method of assessing which patients are at higher risk of injury and hence require a CT would be clinically useful. We perform a systematic review to investigate the use of clinical prediction tools (CPTs) for the identification of abdominal injuries in patients suffering blunt trauma. MATERIALS AND METHODS A literature search was performed using Medline, Embase, The Cochrane Library and NHS Evidence up to August 2014. English language, prospective and retrospective studies were included if they derived, validated or assessed a CPT, aimed at identifying intra-abdominal injuries or the need for intervention to treat an intra-abdominal after blunt trauma. Methodological quality was assessed using a 14 point scale. Performance was assessed predominantly by sensitivity. RESULTS Seven relevant studies were identified. All studies were derivative studies and no CPT was validated in a separate study. There were large differences in the study design, composition of the CPTs, the outcomes analysed and the methodological quality of the included studies. Sensitivities ranged from 86 to 100%. The highest performing CPT had a lower limit of the 95% CI of 95.8% and was of high methodological quality (11 of 14). Had this rule been applied to the population then 25.1% of patients would have avoided a CT scan. CONCLUSIONS Seven CPTs were identified of varying designs and methodological quality. All demonstrate relatively high sensitivity with some achieving very high sensitivity whilst still managing to reduce the number of CTs performed by a significant amount. Further studies are required to validate the results obtained by the highest performing CPTs before any firm recommendation can be used regarding their use in routine clinical practice.
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Affiliation(s)
- Alistair Sharples
- University Hospital of North Midlands, UK; Queen Mary University of London and Barts and The London School of Medicine and Dentistry, London, UK.
| | - Karim Brohi
- Queen Mary University of London and Barts and The London School of Medicine and Dentistry, London, UK
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Treskes K, Saltzherr TP, Luitse JSK, Beenen LFM, Goslings JC. Indications for total-body computed tomography in blunt trauma patients: a systematic review. Eur J Trauma Emerg Surg 2016; 43:35-42. [PMID: 27435196 PMCID: PMC5306321 DOI: 10.1007/s00068-016-0711-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2015] [Accepted: 07/12/2016] [Indexed: 11/29/2022]
Abstract
PURPOSE Total-body CT scanning (TBCT) could improve the initial in-hospital evaluation of severe trauma patients. Indications for TBCT, however, differ between trauma centers, so more insight in how to select patients that could benefit from TBCT is required. The aim of this review was to give an overview of currently used indications for total-body CT in trauma patients and to describe mortality and Injury Severity Scores of patient groups selected for TBCT. METHODS A systematic review was performed by searching MEDLINE and Embase databases. Studies evaluating or describing criteria for selection of patients with potentially severe injuries for TBCT during initial trauma care were included. Also, studies comparing total-body CT during the initial assessment of injured patients with conventional imaging and selective CT in specific patient groups were included. RESULTS Thirty eligible studies were identified. Three studies evaluated indications for TBCT in trauma with divergent methods. Combinations of compromised vital parameters, severe trauma mechanisms and clinical suspicion on severe injuries are often used indications; however, clinical judgement is used as well. Studies describing TBCT indications selected patients in different ways and were difficult to compare regarding mortality and injury severity. CONCLUSIONS Indications for TBCT in trauma show a wide variety in structure and cut-off values for vital parameters and trauma mechanism dimensions. Consensus on indications for TBCT in trauma is lacking.
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Affiliation(s)
- K Treskes
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
| | - T P Saltzherr
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J S K Luitse
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - L F M Beenen
- Department of Radiology, Academic Medical Center, Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - J C Goslings
- Trauma Unit, Department of Surgery, Academic Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
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O׳Keeffe M, Clark S, Khosa F, Mohammed MF, McLaughlin PD, Nicolaou S. Imaging Protocols for Trauma Patients: Trauma Series, Extended Focused Assessment With Sonography for Trauma, and Selective and Whole-body Computed Tomography. Semin Roentgenol 2016; 51:130-42. [DOI: 10.1053/j.ro.2016.02.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Bingol O, Ayrık C, Kose A, Bozkurt S, Narcı H, Ovla D, Duce MN. Retrospective analysis of whole-body multislice computed tomography findings taken in trauma patients. Turk J Emerg Med 2016; 15:116-21. [PMID: 27239608 PMCID: PMC4878127 DOI: 10.1016/j.tjem.2015.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2014] [Revised: 12/10/2014] [Accepted: 12/26/2014] [Indexed: 11/23/2022] Open
Abstract
Objectives Using whole-body multislice computed tomography (MSCT) excessively or with irrelevant indications can be seen in many centers. The aim of this study was to analyze retrospectively the MSCT findings in trauma patients admitted to the emergency department. Methods Records of the patients who have applied to the emergency department due to blunt trauma in a 12 month period and whose whole body MSCT images have been taken, were evaluated using the “Nucleus Medical Information System”. Results The most frequent type of trauma was traffic accidents in 61.4%, falling down from the height in 22.4%, and motorcycle accidents in 11.4% of patients. Of the patients, 25.2% were discharged from the emergency, while 73.8% were hospitalized. At least one CT findings associated with trauma was present in 61.4% of our patients. Pathological findings in MSCT were most frequently detected in the head and face (35.3%) and thoracic (28.6%) regions, respectively. The most common finding in the head and face region was fractures. The most common pathological findings in the thoracic region were pulmonary contusion and rib fractures. A significant relationship was detected between trauma type and spinal MSCT result (p < 0.001). In a large percentage of the patients, MSCT findings were normal in the abdominal region and genitourinary system. Vertebral fractures were most frequently detected in the thoracolumbar region. Conclusions In our study, our rate of negative CT was found to be 38.6%, which is a higher ratio compared to other studies conducte on this topic.
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Affiliation(s)
- Ozlem Bingol
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Cuneyt Ayrık
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Ataman Kose
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
- Corresponding Author.
| | - Seyran Bozkurt
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Huseyin Narcı
- Department of Emergency Medicine, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Didem Ovla
- Department of Biostatistics, Mersin University, Faculty of Medicine, Mersin, Turkey
| | - Meltem Nass Duce
- Department of Radiology, Mersin University, Faculty of Medicine, Mersin, Turkey
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Gupta M, Gertz M, Schriger DL. Injury Severity Score Inflation Resulting From Pan–Computed Tomography in Patients With Blunt Trauma. Ann Emerg Med 2016; 67:71-75.e3. [DOI: 10.1016/j.annemergmed.2015.03.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Revised: 03/12/2015] [Accepted: 03/27/2015] [Indexed: 10/23/2022]
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Shannon L, Peachey T, Skipper N, Adiotomre E, Chopra A, Marappan B, Kotnis N. Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims. Clin Radiol 2015. [DOI: 10.1016/j.crad.2015.06.084] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Stephan K, Huber S, Häberle S, Kanz KG, Bühren V, van Griensven M, Meyer B, Biberthaler P, Lefering R, Huber-Wagner S. Spinal cord injury--incidence, prognosis, and outcome: an analysis of the TraumaRegister DGU. Spine J 2015; 15:1994-2001. [PMID: 25939671 DOI: 10.1016/j.spinee.2015.04.041] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2014] [Revised: 03/31/2015] [Accepted: 04/21/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Little is known about the incidence of spinal cord injury (SCI) in polytrauma patients. PURPOSE The purpose of this study was to analyze incidence, prognosis, and outcome of SCI in polytrauma patients. STUDY DESIGN/SETTING This is a retrospective multicenter cohort study. PATIENT SAMPLE A total of 57,310 patients of TraumaRegister DGU (2002-2012) of the German Trauma Society were included. Aim of this large multicentre database is a standardized documentation of severely injured patients. OUTCOME MEASURES Outcome measures were mortality and Glasgow Outcome 4Scale. METHODS Inclusion criteria were adult blunt trauma patients (age greater than 16 years) and injury severity score (ISS) greater than 16. The severity of SCI was based on the Abbreviated Injury Scale (AIS), and the outcome of patients was assessed with the Glasgow Outcome Scale (GOS). Factors with an impact on the outcome were analyzed with a logistic regression model. RESULTS Four thousand two hundred eighty five (7.5%) of 57,310 patients sustained SCI. Mean age was 48.9±20.7 years, ISS 28.0±12, and 72.7% were men. Two thousand two hundred twenty two (3.9%) SCIs involved the cervical, 1,388 (2.4%) the thoracic, and 791 (1.4%) the lumbar spine. One hundred fifty-nine (7.2%) cervical spine injuries were associated with transient neurologic deficit (TND) (AIS 3), 612 (27.5%) with an incomplete paraplegia (AIS 4), 1,101 (49.6%) with a complete paraplegia (AIS 5), and 350 (15.8%) with a complete lesion above C3 (AIS 6). Lesions of the thoracic spine showed in 93 (6.7%) of the 1,388 lesions a TND (AIS 3), in 332 (23.9%) an incomplete paraplegia (AIS 4), and in 963 (69.4%) a complete lesion (AIS 5). In the lumbar region, lesions were distributed as follows: TND (AIS 3) 145 (18.3%), incomplete paraplegia (AIS 4) 305 (38.6%), and complete lesion 341 (43.1%). Sepsis and multiorgan failure were found more often in patients with AIS 5/6 lesions (p<.001). The hospital length of stay in SCIs was significantly longer. Most of the patients (85.8%) with SCI were treated in Level I trauma centers. Spinal cord injuries had a minor impact in the mortality. Only AIS 6 injuries resulted in a significantly higher mortality (64.6%). Adjusted logistic regression analysis (target variable: GOS 4 or 5, good outcome) showed that the following factors were significantly associated with an unfavorable outcome (p≤.02): AIS greater than or equal to 4, age greater than or equal to 60 years, resuscitation, severe head injury, shock on scene, and severity of injury (ISS per point). CONCLUSIONS Spinal cord injury with a neurologic deficit could be found in every 13th patient with polytrauma. Over half of the patients with SCI suffer from complete cord lesion. In polytrauma patients, SCI only has a limited influence on the mortality, with exception of AIS 6 lesions. Complications such as multiorgan failure or sepsis and extended hospital length of stay are more frequent in SCI.
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Affiliation(s)
- Katharina Stephan
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Stephan Huber
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Sandra Häberle
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Karl-Georg Kanz
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Volker Bühren
- Berufsgenossenschaftliche Unfallklinik Murnau, Murnau Trauma Center, Prof.-Küntscher-Str. 8, 82418 Murnau, Germany
| | - Martijn van Griensven
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Bernhard Meyer
- Department of Neurosurgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany
| | - Rolf Lefering
- Faculty of Health, IFOM-Institute for Research in Operative Medicine, University Witten/Herdecke, Ostmerheimerstr. 200, 51109 Cologne, Germany
| | - Stefan Huber-Wagner
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675 Munich, Germany.
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Facial Fracture in the Setting of Whole-Body CT for Trauma: Incidence and Clinical Predictors. AJR Am J Roentgenol 2015; 205:W4-10. [PMID: 26102417 DOI: 10.2214/ajr.14.13589] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE The objective of our study was to identify the incidence and clinical predictors of facial fracture in the setting of whole-body MDCT for trauma. MATERIALS AND METHODS The clinical data from the electronic medical records, including the final radiology reports, of 486 consecutive patients who underwent MDCT for trauma (head, cervical spine, chest, abdomen, and pelvis examinations) with dedicated maxillofacial reconstructions from October 1, 2011, to July 31, 2013, were studied. The clinical variables were compared between cohorts of patients with and those without facial fracture. The two-sample t test was used to compare continuous variables, and the Fisher exact test was used to compare categoric variables. RESULTS Two hundred sixteen (44.4%) patients had at least one fracture on the dedicated maxillofacial CT examinations, 215 of whom had facial physical examination findings (sensitivity = 99.5%). Of the 28 patients without documented physical examination findings, 27 did not have a facial fracture (negative predictive value = 96.4%). Statistically significant differences were found between positive and negative cases of facial fracture in patients with a Glasgow coma scale (GCS) score of 8 or less (p < 0.0001), an injury severity score of 16 or greater (p < 0.0001), acute alcohol intoxication according to blood alcohol concentration (BAC) (p = 0.0387), intubation at presentation (p < 0.0001), positive physical examination findings (p < 0.0001), and loss of consciousness (p = 0.0364). Falls from a height greater than standing height and open-vehicle collisions had the highest fracture rates (80.0% and 58.3%, respectively). CONCLUSION A negative finding at facial physical examination reliably excluded fracture. Clinical variables positively associated with facial fracture included the following: GCS score of 8 or less, ISS of 16 or greater, alcohol intoxication according to BAC, intubation at presentation, loss of consciousness, and the presence of abnormal facial findings at physical examination.
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Gunn ML, Kool DR, Lehnert BE. Improving Outcomes in the Patient with Polytrauma: A Review of the Role of Whole-Body Computed Tomography. Radiol Clin North Am 2015; 53:639-56, vii. [PMID: 26046503 DOI: 10.1016/j.rcl.2015.02.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Whole-body computed tomography (WBCT) is used for the workup of the patient with blunt polytrauma. WBCT is associated with improved patient survival and reduces the emergency department length of stay. However, randomized studies are needed to determine whether early WBCT improves survival, to clarify which patients benefit the most, and to model the costs of this technique compared with traditional workup. Advancements in modern multidetector computed tomography technology and an improved understanding of optimal protocols have enabled one to scan the entire body and achieve adequate image quality for a comprehensive trauma assessment in a short period.
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Affiliation(s)
- Martin L Gunn
- Department of Radiology, University of Washington, Box 359728, 325 9th Ave, Seattle, WA 98104, USA.
| | | | - Bruce E Lehnert
- Department of Radiology, University of Washington, Box 359728, 325 9th Ave, Seattle, WA 98104, USA
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[Interdisciplinary management of trauma patients : Update 3 years after implementation of the S3 guidelines on treatment of patients with severe and multiple injuries]. Anaesthesist 2015; 63:852-64. [PMID: 25227879 DOI: 10.1007/s00101-014-2375-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The recommendations still have to be implemented 3 years after publication of the S3 guidelines on the treatment of patients with severe and multiple injuries. AIM This article reiterates some of the essential core statements of the S3 guidelines and also gives an overview of new scientific studies. MATERIAL AND METHODS In a selective literature search new studies on airway management, traumatic cardiac arrest, shock classification, coagulation therapy, whole-body computed tomography, air rescue and trauma centers were identified and are discussed in the light of the S3 guideline recommendations. RESULTS The recommendations on airway management are up to date; however, recommendations on difficult airway evaluation tools, e.g. the LEMON law, should be included. The first pass success (i.e. intubation success at the first attempt) must be considered as a quality marker in the future. Video laryngoscopy is identified as a leading airway procedure in order to reach this aim. Recently estimated learning curves for endotracheal intubation and supraglottic airway devices should be implemented in qualification statements. Life-saving emergency interventions have to be performed in the prehospital setting as they do not prolong the complete treatment period for severely injured patients up to discharge from the resuscitation room. The outcome of patients suffering from traumatic cardiac arrest is better than expected. Recently developed algorithms for trauma patients have to be implemented. The prehospital trauma life support (PHTLS) and advanced trauma life support (ATLS) shock classification does not reflect the clinical reality; therefore, lactate, lactate clearance and base deficit should be used for evaluating the shock state in the resuscitation room. Concerning coagulation therapy, tranexamic acid is easy to administer, safe and effective as an antifibrinolytic therapy and should not be restricted to the most severely injured patients. Numerous studies have shown the positive effect of whole-body computed tomography on treatment time and outcome; however, clear indications for the use of whole-body computed tomography are lacking. Further investigations supported the positive effects of air rescue on the treatment outcome of trauma patients. CONCLUSION The recommendations on interdisciplinary trauma management contained in the S3 guidelines on the treatment of patients with severe and multiple injuries should be implemented into the clinical routine. Additionally, the knowledge gained from more recent scientific studies is necessary for anesthetists and emergency physicians to be able to adequately implement the core statements of the S3 guidelines for the treatment of patients with severe and multiple injuries.
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Abstract
PURPOSE OF REVIEW To provide an update on the recent developments and controversies in the assessment of the traumatically injured patient. RECENT FINDINGS Recent literature suggests that: whole-body computed tomography (CT) is an effective strategy in more severely injured blunt trauma patients; 64-slice CT scanning now provides an effective noninvasive screening method for blunt cerebrovascular injury; the need for MRI imaging, in addition to CT, for the diagnosis of occult ligamentous injury of the cervical spine remains an unresolved controversy; point-of-care testing has made significant improvements in our ability to predict which patients will need a massive transfusion; and thromboelastography has enhanced our ability to tailor a hemostatic resuscitation more accurately. SUMMARY The recent advances in the assessment of the multiply injured patient allow clinicians to more efficiently diagnose a patient's injuries and implement treatment in a more timely manner.
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Hajibandeh S, Hajibandeh S. Systematic review: effect of whole-body computed tomography on mortality in trauma patients. J Inj Violence Res 2015; 7:64-74. [PMID: 26104319 PMCID: PMC4522317 DOI: 10.5249/jivr.v7i2.613] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 07/10/2014] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND The initial diagnostic evaluation and management of trauma patients is mainly based on Advanced Trauma Life Support (ATLS) guidelines worldwide. Based on ATLS principles, conventional diagnostics such as conventional radiography (CR) and focused abdominal sonography in trauma (FAST) should precede selective use of CT. Whole-body CT (WBCT) is highly accurate and allows detection of life threatening injuries with good sensitivity and specificity. WBCT is faster than conventional diagnostics and saves more time in management of trauma patients. This study aims to review studies investigating the effect of WBCT on mortality in trauma patients. METHODS Literatures were found by searching keywords in Medline, PubMed and Cochrane library. The relevant articles were selected by two independent reviewers based on title, abstract and introduction sections. Full-texts of selected articles were reviewed and those investigating effect of WBCT on mortality in trauma patients were included. RESULTS Searching the keywords in Medline and PubMed resulted in 178 and 167 articles, respectively. Nine studies met the inclusion criteria and were reviewed. These included 8 retrospective and 1 prospective cohort studies. Mortality was measured as mortality rate or standardised mortality ratio (SMR) in the included studies. CONCLUSIONS Unlike previous systematic reviews, this review indicates that use of WBCT in blunt trauma patients is associated with reduced overall mortality rate and that WBCT can potentially improve the probability of survival in haemodynamically stable and unstable blunt trauma patients. High quality RCTs are required to describe a causal relationship between WBCT and mortality in trauma patients.
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Affiliation(s)
- Shahab Hajibandeh
- School of Medicine, University of Liverpool, Liverpool, United Kingdom. E-mail:
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Gordic S, Alkadhi H, Hodel S, Simmen HP, Brueesch M, Frauenfelder T, Wanner G, Sprengel K. Whole-body CT-based imaging algorithm for multiple trauma patients: radiation dose and time to diagnosis. Br J Radiol 2015; 88:20140616. [PMID: 25594105 DOI: 10.1259/bjr.20140616] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To determine the number of imaging examinations, radiation dose and the time to complete trauma-related imaging in multiple trauma patients before and after introduction of whole-body CT (WBCT) into early trauma care. METHODS 120 consecutive patients before and 120 patients after introduction of WBCT into the trauma algorithm of the University Hospital Zurich were compared regarding the number and type of CT, radiography, focused assessment with sonography for trauma (FAST), additional CT examinations (defined as CT of the same body regions after radiography and/or FAST) and the time to complete trauma-related imaging. RESULTS In the WBCT cohort, significantly more patients underwent CT of the head, neck, chest and abdomen (p < 0.001) than in the non-WBCT cohort, whereas the number of radiographic examinations of the cervical spine, chest and pelvis and of FAST examinations were significantly lower (p < 0.001). There were no significant differences between cohorts regarding the number of radiographic examinations of the upper (p = 0.56) and lower extremities (p = 0.30). We found significantly higher effective doses in the WBCT (29.5 mSv) than in the non-WBCT cohort (15.9 mSv; p < 0.001), but fewer additional CT examinations for completing the work-up were needed in the WBCT cohort (p < 0.001). The time to complete trauma-related imaging was significantly shorter in the WBCT (12 min) than in the non-WBCT cohort (75 min; p < 0.001). CONCLUSION Including WBCT in the initial work-up of trauma patients results in higher radiation doses, but fewer additional CT examinations are needed, and the time for completing trauma-related imaging is shorter. ADVANCES IN KNOWLEDGE WBCT in trauma patients is associated with a high radiation dose of 29.5 mSv.
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Affiliation(s)
- S Gordic
- 1 Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland
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Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg 2015; 77:534-9. [PMID: 25250591 DOI: 10.1097/ta.0000000000000414] [Citation(s) in RCA: 98] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Traumatic injury in the United States is the Number 1 cause of mortality for patients 1 year to 44 years of age. Studies suggest that early identification of major injury leads to better outcomes for patients. Imaging, such as computed tomography (CT), is routinely used to help determine the presence of major underlying injuries. We review the literature to determine whether whole-body CT (WBCT), a protocol including a noncontrast scan of the brain and neck and a contrast-enhanced scan of the chest, abdomen, and pelvis, detects more clinically significant injuries as opposed to selective scanning as determined by mortality rates. METHODS Scientific publications from 1980 to 2013 involving the study of the difference between pan scan and selective scan after trauma were identified. The Preferred Reporting Items for Systematic Reviews and Meta-analyses was used. Publications were categorized by level of evidence. Injury Severity Score (ISS) and pooled odds for mortality rate of patients who received WBCT scan versus those who received selective scans were compared. RESULTS Of the 465 publications identified, 7 were included, composing of 25,782 trauma patients who received CT scan following trauma. Of the patients, 52% (n = 13,477) received pan scan and 48% (n = 12,305) received selective scanning. Overall ISS was significantly higher for patients receiving WBCT versus those receiving selective scan (29.7 vs. 26.4, p < 0.001, respectively). Overall mortality rate was significantly lower for WBCT versus selective scanning (16.9; 95% confidence interval [CI], 16.3-17.6 vs. 20.3; 95% CI, 19.6-21.1, p < 0.0002, respectively). Pooled odds ratio for mortality rate was 0.75 (95% CI, 0.7-0.79), favoring WBCT. CONCLUSION Despite the WBCT group having significantly higher ISS at baseline compared with the group who received selective scanning, the WBCT group had a lower overall mortality rate and a more favorable pooled odds ratio for trauma patients. This suggests that in terms of overall mortality, WBCT scan is preferable to selective scanning in trauma patients. LEVEL OF EVIDENCE Systematic review and meta-analysis, level III.
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Ong AW, Castor L, Figueredo R, Butler S, Fernandez F. Pan-body computed tomographic scanning for patients with intracranial hemorrhage after low-energy falls. Am J Surg 2014; 209:521-5. [PMID: 25556029 DOI: 10.1016/j.amjsurg.2014.12.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 11/25/2014] [Accepted: 12/06/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND We sought to determine if a liberal policy of pan-body computerized tomography (CT) scanning was useful in patients with intracranial hemorrhage after low falls. METHODS Patients with intracranial hemorrhage after low falls, with a Glasgow Coma Score of greater than or equal to 14 and systolic blood pressure of greater than 100 mm Hg, were included. The primary outcome was any torso or spine injury requiring surgical or radiologic intervention. The secondary outcome was any torso or spine injury. RESULTS Of 365 patients, 71% underwent pan-body CT. Eight (2%) patients had a primary outcome and 66 (18%) a secondary outcome. Only signs and symptoms of cervical injury were associated with a cervical-related outcome (4/23 vs 3/316, P = .005). Only signs and symptoms of torso injury were associated with a torso-related outcome. CONCLUSIONS A liberal policy of pan-body CT in these patients is of low yield. Signs and symptoms of trauma should dictate the judicious use of CT.
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Affiliation(s)
- Adrian W Ong
- Department of Surgery, Section of Trauma/Critical Care, Reading Hospital, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA.
| | - Laura Castor
- Department of Surgery, Section of Trauma/Critical Care, Reading Hospital, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA
| | - Ronald Figueredo
- Department of Surgery, Section of Trauma/Critical Care, Reading Hospital, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA
| | - Susan Butler
- Department of Surgery, Section of Trauma/Critical Care, Reading Hospital, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA
| | - Forrest Fernandez
- Department of Surgery, Section of Trauma/Critical Care, Reading Hospital, Sixth Avenue and Spruce Street, West Reading, PA 19611, USA
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