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van den Wittenboer GJ, van der Kolk BYM, Nijholt IM, Langius-Wiffen E, van Dijk RA, van Hasselt BAAM, Podlogar M, van den Brink WA, Bouma GJ, Schep NWL, Maas M, Boomsma MF. Diagnostic accuracy of an artificial intelligence algorithm versus radiologists for fracture detection on cervical spine CT. Eur Radiol 2024; 34:5041-5048. [PMID: 38206401 DOI: 10.1007/s00330-023-10559-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 11/07/2023] [Accepted: 12/08/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVES To compare diagnostic accuracy of a deep learning artificial intelligence (AI) for cervical spine (C-spine) fracture detection on CT to attending radiologists and assess which undetected fractures were injuries in need of stabilising therapy (IST). METHODS This single-centre, retrospective diagnostic accuracy study included consecutive patients (age ≥18 years; 2007-2014) screened for C-spine fractures with CT. To validate ground truth, one radiologist and three neurosurgeons independently examined scans positive for fracture. Negative scans were followed up until 2022 through patient files and two radiologists reviewed negative scans that were flagged positive by AI. The neurosurgeons determined which fractures were ISTs. Diagnostic accuracy of AI and attending radiologists (index tests) were compared using McNemar. RESULTS Of the 2368 scans (median age, 48, interquartile range 30-65; 1441 men) analysed, 221 (9.3%) scans contained C-spine fractures with 133 IST. AI detected 158/221 scans with fractures (sensitivity 71.5%, 95% CI 65.5-77.4%) and 2118/2147 scans without fractures (specificity 98.6%, 95% CI 98.2-99.1). In comparison, attending radiologists detected 195/221 scans with fractures (sensitivity 88.2%, 95% CI 84.0-92.5%, p < 0.001) and 2130/2147 scans without fracture (specificity 99.2%, 95% CI 98.8-99.6, p = 0.07). Of the fractures undetected by AI 30/63 were ISTs versus 4/26 for radiologists. AI detected 22/26 fractures undetected by the radiologists, including 3/4 undetected ISTs. CONCLUSION Compared to attending radiologists, the artificial intelligence has a lower sensitivity and a higher miss rate of fractures in need of stabilising therapy; however, it detected most fractures undetected by the radiologists, including fractures in need of stabilising therapy. Clinical relevance statement The artificial intelligence algorithm missed more cervical spine fractures on CT than attending radiologists, but detected 84.6% of fractures undetected by radiologists, including fractures in need of stabilising therapy. KEY POINTS The impact of artificial intelligence for cervical spine fracture detection on CT on fracture management is unknown. The algorithm detected less fractures than attending radiologists, but detected most fractures undetected by the radiologists including almost all in need of stabilising therapy. The artificial intelligence algorithm shows potential as a concurrent reader.
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Affiliation(s)
- Gaby J van den Wittenboer
- Department of Radiology and Nuclear Medicine, Isala, Dr. van Heesweg 2, Zwolle, The Netherlands.
- Department of Emergency Medicine, Isala, Dr. van Heesweg 2, Zwolle, The Netherlands.
| | - Brigitta Y M van der Kolk
- Department of Radiology and Nuclear Medicine, Isala, Dr. van Heesweg 2, Zwolle, The Netherlands
- Department of Emergency Medicine, Isala, Dr. van Heesweg 2, Zwolle, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Ingrid M Nijholt
- Department of Radiology and Nuclear Medicine, Isala, Dr. van Heesweg 2, Zwolle, The Netherlands
| | - Eline Langius-Wiffen
- Department of Radiology and Nuclear Medicine, Isala, Dr. van Heesweg 2, Zwolle, The Netherlands
| | - Rogier A van Dijk
- Department of Radiology and Nuclear Medicine, Isala, Dr. van Heesweg 2, Zwolle, The Netherlands
| | | | - Martin Podlogar
- Department of Neurosurgery, Isala, Dr. van Heesweg 2, Zwolle, The Netherlands
| | | | - Gert Joan Bouma
- Department of Neurosurgery, Amsterdam University Medical Centers, Location Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
| | - Niels W L Schep
- Department of Trauma surgery, Maasstad Hospital, Maasstadweg 21, Rotterdam, The Netherlands
| | - Mario Maas
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location Academic Medical Center, Meibergdreef 9, Amsterdam, The Netherlands
- Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Martijn F Boomsma
- Department of Radiology and Nuclear Medicine, Isala, Dr. van Heesweg 2, Zwolle, The Netherlands
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Reichel K, Hahlbohm P, Kromrey ML, Nebelung H, Schön F, Kamin K, Goronzy J, Kühn JP, Hoffmann RT, Blum SFU. Feasibility and diagnostic accuracy of fast whole-body MRI in slightly to moderately injured trauma patients. Eur Radiol 2024:10.1007/s00330-024-10933-y. [PMID: 38995385 DOI: 10.1007/s00330-024-10933-y] [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: 03/18/2024] [Revised: 04/29/2024] [Accepted: 05/29/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVES To determine the feasibility and diagnostic accuracy of fast whole-body magnetic resonance imaging (WB-MRI) compared to whole-body computed tomography (WB-CT) in detecting injuries of slightly to moderately injured trauma patients. MATERIALS AND METHODS In a prospective single-center approach, trauma patients from convenience sampling with an expected Abbreviated Injury Scale (AIS) score ≤ 3 at admission, received an indicated contrast-enhanced WB-CT (reference standard) and a plain WB-MRI (index test) voluntarily up to five days after trauma. Two radiologists, blinded to the WB-CT findings, evaluated the absence or presence of injuries with WB-MRI in four body regions: head, torso, axial skeleton, and upper extremity. Diagnostic accuracy was determined using sensitivity, specificity, positive predictive value, and negative predictive value by body region. RESULTS Between June 2019 and July 2021, 40 patients were assessed for eligibility of whom 35 (median age (interquartile range): 50 (32.5) years; 26 men) received WB-MRI. Of 140 body regions (35 patients × 4 regions), 31 true positive, 6 false positive, 94 true negative, and 9 false negative findings were documented with WB-MRI. Thus, plain WB-MRI achieved a total sensitivity of 77.5% (95%-confidence interval (CI): (61.6-89.2%)), specificity of 94% (95%-CI: (87.4-97.8%)), and diagnostic accuracy of 89.3% (95%-CI: (82.9-93.9%)). Across the four regions sensitivity and specificity varied: head (66.7%/93.1%), torso (62.5%/96.3%), axial skeleton (91.3%/75%), upper extremity (33.3%/100%). Both radiologists showed substantial agreement on the WB-MRI reading (Cohen's Kappa: 0.66, 95%-CI: (0.51-0.81)). CONCLUSION Regarding injury detection, WB-MRI is feasible in slightly to moderately injured trauma patients, especially in the axial skeleton. CLINICAL RELEVANCE STATEMENT Besides offering a radiation-free approach, whole-body MRI detects injuries almost identically to whole-body CT in slightly to moderately injured trauma patients, who comprise a relevant share of all trauma patients. KEY POINTS Whole-body MRI could offer radiation-free injury detection in slightly to moderately injured trauma patients. Whole-body MRI detected injuries almost identically compared to whole-body CT in this population. Whole-body MRI could be a radiation-free approach for slightly to moderately injured young trauma patients.
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Affiliation(s)
- Katrin Reichel
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany.
| | - Patricia Hahlbohm
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Marie-Luise Kromrey
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Heiner Nebelung
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Felix Schön
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Konrad Kamin
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Jens Goronzy
- University Center of Orthopaedic, Trauma and Plastic Surgery, University Hospital, TU Dresden, Fetscherstr. 74, 01307, Dresden, Germany
| | - Jens-Peter Kühn
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Ralf-Thorsten Hoffmann
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
| | - Sophia Freya Ulrike Blum
- Institute and Polyclinic for Diagnostic and Interventional Radiology, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstraße 74, 01307, Dresden, Germany
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Gümbel D, Matthes G, Ekkernkamp A, Laue F, Lefering R. Influencing factors for delayed diagnosed injuries in multiple trauma patients - introducing the 'Risk for Delayed Diagnoses Score' (RIDD-Score). Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02571-2. [PMID: 38926171 DOI: 10.1007/s00068-024-02571-2] [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: 11/26/2023] [Accepted: 06/01/2024] [Indexed: 06/28/2024]
Abstract
PURPOSE Delayed diagnosed injuries (DDI) in severely injured patients are an essential problem faced by emergency staff. Aim of the current study was to analyse incidence and type of DDI in a large trauma cohort. Furthermore, factors predicting DDI were investigated to create a score to identify patients at risk for DDI. METHODS Multiply injured patients admitted between 2011 and 2020 and documented in the TraumaRegister DGU® were analysed. Primary admitted patients with severe injuries and/or intensive care who survived at least 24 h were included. The prevalence, type and severity of DDI were described. Through multivariate logistic regression analysis, risk factors for DDI were identified. Results were used to create a 'Risk for Delayed Diagnoses' (RIDD) score. RESULTS Of 99,754 multiply injured patients, 9,175 (9.2%) had 13,226 injuries first diagnosed on ICU. Most common DDI were head injuries (35.8%), extremity injuries (33.3%) and thoracic injuries (19.7%). Patients with DDI had a higher ISS, were more frequently unconscious, in shock, required more blood transfusions, and stayed longer on ICU and in hospital. Multivariate analysis identified seven factors indicating a higher risk for DDI (OR from 1.2 to 1.9). The sum of these factors gives the RIDD score, which expresses the individual risk for a DDI ranging from 3.6% (0 points) to 24.8% (6 + points). CONCLUSION DDI are present in a sounding number of trauma patients. The reported results highlight the importance of a highly suspicious and thorough physical examination in the trauma room. The introduced RIDD score might help to identify patients at high risk for DDI. A tertiary survey should be implemented to minimise delayed diagnosed or even missed injuries.
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Affiliation(s)
- Denis Gümbel
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany.
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Straße 7, 12683, Berlin, Germany.
| | - Gerrit Matthes
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
- Department of Trauma and Orthopaedic Surgery, Klinikum Ernst von Bergmann gGmbH, Charlottenstrasse 72, 14467, Potsdam, Germany
| | - Axel Ekkernkamp
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Straße, 17475, Greifswald, Germany
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Warener Straße 7, 12683, Berlin, Germany
| | - Fabian Laue
- Department of Trauma and Orthopaedic Surgery, Klinikum Ernst von Bergmann gGmbH, Charlottenstrasse 72, 14467, Potsdam, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, University Witten/Herdecke, Cologne, Germany
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Strahl A, Willemsen JF, Schoof B, Reinshagen K, Frosch KH, Wintges K. The paediatric polytrauma CT-indication (PePCI)-score-Development of a prognostic model to reduce unnecessary CT scans in paediatric trauma patients. Injury 2024; 55:111494. [PMID: 38521635 DOI: 10.1016/j.injury.2024.111494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2023] [Revised: 02/03/2024] [Accepted: 03/07/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Whole-Body CT (WBCT) is frequently used in emergency situations for promptly diagnosing paediatric polytrauma patients, given the challenges associated with obtaining precise details about the mechanism and progression of trauma. However, WBCT does not lead to reduced mortality in paediatric patients, but is associated with high radiation exposure. We therefore wanted to develop a screening tool for CT demand-driven emergency room (ER)-trauma diagnostic to reduce radiation exposure in paediatric patients. METHODS A retrospective study in a Level I trauma centre in Germany was performed. Data from 344 paediatric emergency patients with critical mechanism of injury who were pre-announced by the ambulance for the trauma room were collected. Patients' symptoms, clinical examination, extended Focused Assessment with Sonography for Trauma (eFAST), routinely, laboratory tests and blood gas and - when obtained - WBCT images were analysed. To identify potential predictors of severe injuries (ISS > 23), 300 of the 344 cases with complete data were subjected to regression analyses model. RESULTS Multiple regression analysis identified cGCS, base excess (BE), medically abnormal results from eFAST screening, initial unconsciousness, and injuries involving three or more body regions as significant predictors for a screening tool for decision-making to perform WBCT or selective CT. The developed Paediatric polytrauma CT-Indication (PePCI)-Score was divided into three risk categories and achieved a sensitivity of 87 % and a specificity of 71 % when comparing the low and medium risk groups with the high risk group. Comparing only the low-risk group with the high-risk group for the decision to perform WBCT, 32/35 (91 %) of patients with an ISS >23 were correctly identified, as were 124/137 (91 %) with lower ISS scores. CONCLUSION With the newly developed PePCI-Score, the frequency of WBCT in a paediatric emergency patients collective can be significantly reduced according to our data. After prospective validation, the initial assessment of paediatric trauma patients in the future could be made not only by the mechanism of injury, but also by the new PePCI-Score, deriving on clinical findings after thorough clinical assessment and the discretion of the trauma team.
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Affiliation(s)
- André Strahl
- Department of Trauma and Orthopaedic Surgery, Division of Orthopeadics, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Jan Fritjof Willemsen
- Department of Paediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Benjamin Schoof
- Department of Paediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany; Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Konrad Reinshagen
- Department of Paediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany
| | - Karl-Heinz Frosch
- Department of Trauma and Orthopaedic Surgery, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; Department of Trauma Surgery, Orthopedics and Sportstraumatology, BG Hospital Hamburg, 21033 Hamburg, Germany
| | - Kristofer Wintges
- Department of Paediatric Surgery, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246 Hamburg, Germany.
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Martínez Chamorro E, Ibáñez Sanz L, Blanco Barrio A, Chico Fernández M, Borruel Nacenta S. Patients with severe polytrauma: management and imaging protocols. RADIOLOGÍA (ENGLISH EDITION) 2023; 65 Suppl 1:S11-S20. [PMID: 37024226 DOI: 10.1016/j.rxeng.2022.09.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 09/17/2022] [Indexed: 04/08/2023]
Abstract
Traumatic injuries can be severe and complex, requiring the coordinated efforts of a multidisciplinary team. Imaging tests play a fundamental role in rapid and accurate diagnosis. In particular, whole-body computed tomography (CT) has become a key tool. There are different CT protocols depending on the patient's condition; whereas dose-optimized protocols can be used in stable patients, time/precision protocols prioritizing speed at the cost of delivering higher doses of radiation should be used in more severe patients. In unstable patients who cannot be examined by CT, X-rays of the chest and pelvis and FAST or e-FAST ultrasound studies, although less sensitive than CT, enable the detection of situations that require immediate treatment. This article reviews the imaging techniques and CT protocols for the initial hospital workup for patients with multiple trauma.
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Martínez Chamorro E, Ibáñez Sanz L, Blanco Barrio A, Chico Fernández M, Borruel Nacenta S. Manejo y protocolos de imagen en el paciente politraumatizado grave. RADIOLOGIA 2022. [DOI: 10.1016/j.rx.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Cisneros R, Nair A, Kashyap R, Pineda-Solis K. Page phenomenon in a transplanted kidney: is it salvageable? BMJ Case Rep 2022; 15:e249625. [PMID: 36162963 PMCID: PMC9516073 DOI: 10.1136/bcr-2022-249625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2022] [Indexed: 11/03/2022] Open
Abstract
A male in his late 70s with a history of an uncomplicated kidney transplantation 20 years prior was brought to the Emergency Department after experiencing blunt abdominal trauma following a motor vehicle collision. Imaging revealed a large perinephric haematoma, a retroperitoneal haematoma and multiple fractures. He was admitted to the intensive care unit where a renal haematoma was found to be expanding with ultrasonography (US) and developed renal dysfunction including anuria and hyperkalemia. His creatinine rose to twice his baseline and Doppler US showed elevated resistive indices, confirming extrinsic compression and causing a Page phenomenon. An open surgical exploration through the upper aspect of his Gibson incisional scar was performed followed by evacuation of the haematoma. An intraoperative US was done demonstrating good flow in the renal vessels. His postoperative course was uncomplicated and was discharged home with renal function back to baseline. On follow-up, he continued to have a good renal function.
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Affiliation(s)
- Rafael Cisneros
- School of Medicine and Dentistry, University of Rochester, Rochester, New York, USA
| | - Amit Nair
- Transplant Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Randeep Kashyap
- Transplant Surgery, University of Rochester Medical Center, Rochester, New York, USA
| | - Karen Pineda-Solis
- Transplant Surgery, University of Rochester Medical Center, Rochester, New York, USA
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Harntaweesup S, Krutsri C, Sumritpradit P, Singhatas P, Thampongsa T, Jenjitranant P, Wongwaisayawan S, Saksobhavivat N, Kaewlai R. Usefulness and outcome of whole-body computed tomography (pan-scan) in trauma patients: A prospective study. Ann Med Surg (Lond) 2022; 76:103506. [PMID: 35495401 PMCID: PMC9052170 DOI: 10.1016/j.amsu.2022.103506] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/14/2022] [Accepted: 03/26/2022] [Indexed: 12/05/2022] Open
Abstract
Background Severe trauma can cause multi-organ injuries, and the mortality rate may increase if significant organ injuries are missed. This study was performed to determine whether whole-body computed tomography scan (pan-scan) can detect significant injury and leads to proper management, including alteration the priority of management. Methods This prospective study was conducted from January 2019 to March 2021 and involved trauma patients level 1, level 2, and dangerous mechanism of trauma. Additionally, the data of trauma patients who had selective computed tomography scan were retrospectively reviewed to compared the clinical benefits. Results Twenty-two patients were enrolled in the prospective study. The pan-scan detected significant organ injury in 86% of the patients. Prioritization of organ injury management changed after performance of the pan-scan in 64% (major change in 64.29% and minor change in 35.71%). Skull base fracture, small bowel injury, retroperitoneal injury, kidney and bladder injury, and occult pneumothorax were the majority of injuries which was not consider before underwent pan-scan (p < 0.05). The door-to-scan time tended to be shorter in the pan-scan group than in the selective scan group without a significant difference [mean (SD), 59.5 (34) and 72.0 (86) min, respectively; p = 0.13]. Pan-scan contribute 100% confidence for trauma surgeon in diagnosis of specific organ injuries in severe injured patients. Conclusions The pan-scan facilitates timely detection of significant unexpected organ injuries such as the skull base, occult pneumothorax, small bowel, and retroperitoneum. It also helps to prioritize management and increases the diagnostic confidence of trauma surgeons, leading to better outcomes without delay. The pan-scan facilitates timely detection of significant unexpected organ injuries. Pan-scan helps to prioritize management and increases the diagnostic confidence leading to better outcomes without delay. Pan-scan contribute 100% confidence for trauma surgeon in diagnosis of specific organ injuries in severe injured patients. Contrast-induced nephropathy from pan-scan is lower than that in selective CT scan accumulated on the same admission.
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van der Kolk B(BY, van den Wittenboer G(GJ, Warringa N, Nijholt IM, van Hasselt BA, Buijteweg LN, Schep NW, Maas M, Boomsma MF. Assessment of cervical spine CT scans by emergency physicians: A comparative diagnostic accuracy study in a non-clinical setting. J Am Coll Emerg Physicians Open 2022; 3:e12609. [PMID: 35079729 PMCID: PMC8776040 DOI: 10.1002/emp2.12609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/04/2021] [Accepted: 10/28/2021] [Indexed: 11/11/2022] Open
Abstract
OBJECTIVES To determine and compare the diagnostic accuracy of assessing injuries on cervical spine computed tomography (CT) scans by trained emergency physicians and radiologists, both in a non-clinical setting. METHODS In this comparative diagnostic accuracy study, 411 cervical spine CT scans, of which 120 contained injuries (fractures and/or dislocations), were divided into 8 subsets. Eight emergency physicians received focused training and assessed 1 subset each before and after training. Four radiologists assessed 2 subsets each. Diagnostic accuracy between both groups was compared. The reference standard used was a multiverified data set, assessed by radiologists, neurosurgeons, and emergency physicians. The neurosurgeons also classified whether an "injury in need of stabilizing therapy" (IST) was present. RESULTS Posttraining, the emergency physicians demonstrated increased sensitivity and specificity for identifying cervical spine injuries compared to pretraining: sensitivity 88% (95% confidence interval [CI] 80% to 93%) versus 80% (95% CI 72% to 87%) and specificity 89% (95% CI 85% to 93%) versus 86% (95% CI 81% to 89%). When comparing the trained emergency physicians to the group of radiologists, no difference in sensitivity was found, 88% (95% CI 80% to 83%); however, the radiologists showed a significantly higher specificity (P < 0.01): 99% (95% CI 96% to 100%). In the 12% (15 scans) with missed injuries, emergency physicians missed more ISTs than radiologists, 6 versus 4 scans; however, this difference was not significant (P = 0.45). CONCLUSION After focused training and in a non-clinical setting, no significant difference was found between emergency physicians and radiologists in ruling out cervical spine injuries; however, the radiologists achieved a significantly higher specificity.
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Affiliation(s)
- Brigitta (Britt) Y.M. van der Kolk
- Department of Emergency MedicineIsalaZwolleThe Netherlands
- Department of Radiology and Nuclear MedicineIsalaZwolleThe Netherlands
- Department of Radiology and Nuclear MedicineAmsterdam University Medical Centers, location Academic Medical CenterAmsterdamThe Netherlands
| | | | - Niek Warringa
- Department of Radiology and Nuclear MedicineIsalaZwolleThe Netherlands
| | - Ingrid M. Nijholt
- Department of Radiology and Nuclear MedicineIsalaZwolleThe Netherlands
| | | | | | - Niels W.L. Schep
- Department of Trauma SurgeryMaasstad HospitalRotterdamThe Netherlands
| | - Mario Maas
- Department of Radiology and Nuclear MedicineAmsterdam University Medical Centers, location Academic Medical CenterAmsterdamThe Netherlands
- Amsterdam Movement SciencesAmsterdamThe Netherlands
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Nam JG, Hong JH, Kim DS, Oh J, Goo JM. Deep learning reconstruction for contrast-enhanced CT of the upper abdomen: similar image quality with lower radiation dose in direct comparison with iterative reconstruction. Eur Radiol 2021; 31:5533-5543. [PMID: 33555354 DOI: 10.1007/s00330-021-07712-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Revised: 12/23/2020] [Accepted: 01/21/2021] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To evaluate the effect of a commercial deep learning algorithm on the image quality of chest CT, focusing on the upper abdomen. METHODS One hundred consecutive patients who simultaneously underwent contrast-enhanced chest and abdominal CT were collected. The radiation dose was optimized for each scan (mean CTDIvol: chest CT, 3.19 ± 1.53 mGy; abdominal CT, 7.10 ± 1.88 mGy). Three image sets were collected: chest CT reconstructed with an adaptive statistical iterative reconstruction (ASiR-CHT; 50% blending), chest CT with a deep learning algorithm (DLIR-CHT), and abdominal CT with ASiR (ASiR-ABD; 40% blending). Afterwards, the images covering the upper abdomen were extracted, and image noise, the signal-to-noise ratio (SNR), and the contrast-to-noise ratio (CNR) were measured. For subjective evaluation, three radiologists independently assessed noise, spatial resolution, presence of artifacts, and overall image quality. Additionally, readers selected the most preferable reconstruction technique among three image sets for each case. RESULTS The average measured noise for DLIR-CHT, ASiR-CHT, and ASiR-ABD was 8.01 ± 2.81, 14.8 ± 2.56, and 12.3 ± 2.28, respectively (p < .001). Deep learning-based image reconstruction (DLIR) also showed the best SNR and CNR (p < .001). However, in the subjective analysis, ASiR-ABD showed less subjective noise than DLIR (2.94 ± 0.23 vs. 2.87 ± 0.26; p < .001), while DLIR showed better spatial resolution (2.60 ± 0.34 vs. 2.44 ± 0.31; p = .02). ASiR-ABD showed a better overall image quality (p = .001), but two of the three readers preferred DLIR more frequently. CONCLUSION With < 50% of the radiation dose, DLIR chest CT showed comparable image quality in the upper abdomen to that of dedicated abdominal CT and was preferred by most readers. KEY POINTS • With < 50% radiation dose, a deep learning algorithm applied to contrast-enhanced chest CT exhibited better image noise and signal-to-noise ratio than standard abdominal CT with the ASiR technique. • Pooled readers mostly preferred deep learning algorithm-reconstructed contrast-enhanced chest CT reconstructed using a standard ASiR-reconstructed abdominal CT. • Reconstruction algorithm-induced distortion artifacts were more frequently observed on deep learning algorithm-reconstructed images, but diagnostic difficulty was reported in only 0.3% of cases.
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Affiliation(s)
- Ju Gang Nam
- Department of Radiology, Seoul National University Hospital and College of Medicine, and Institute of Radiation Medicine, Seoul National University Medical Research Center, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea
| | - Jung Hee Hong
- Department of Radiology, Seoul National University Hospital and College of Medicine, and Institute of Radiation Medicine, Seoul National University Medical Research Center, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea
| | - Da Som Kim
- Department of Radiology, Busan Paik Hospital, Inje University College of Medicine, Busan, 47392, Republic of Korea
| | - Jiseon Oh
- Department of Radiology, Seoul National University Hospital and College of Medicine, and Institute of Radiation Medicine, Seoul National University Medical Research Center, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea
| | - Jin Mo Goo
- Department of Radiology, Seoul National University Hospital and College of Medicine, and Institute of Radiation Medicine, Seoul National University Medical Research Center, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Republic of Korea. .,Cancer Research Institute, Seoul National University College of Medicine, 03080, Seoul, Republic of Korea.
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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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12
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Stengel D, Mutze S, Güthoff C, Weigeldt M, von Kottwitz K, Runge D, Razny F, Lücke A, Müller D, Ekkernkamp A, Kahl T. Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma. JAMA Surg 2020; 155:224-232. [PMID: 31940019 PMCID: PMC6990738 DOI: 10.1001/jamasurg.2019.5468] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Question Is low-dose whole-body computed tomography with statistical image reconstruction associated with similar rates of missed injuries and accuracy but reduced radiation exposure compared with standard-dose whole-body computed tomography in the primary diagnostic workup of blunt multiple trauma? Findings In this quasi-experimental cohort study of 971 patients with suspected blunt multiple trauma, participants in the standard-dose and low-dose whole-body computed tomography groups had the same risk of missed injury diagnoses. Low-dose scanning markedly reduced exposure to radiation, improved the contrast-to-noise ratio, and showed similar diagnostic accuracy among the investigated anatomical areas and organs when compared with standard-dose scanning. Meaning These findings suggest that low-dose whole-body computed tomography may safely replace standard-dose scanning in the primary diagnostic workup of blunt multiple trauma. Importance Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure. Objective To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure. Design, Setting, and Participants This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019. Interventions Standard- or low-dose WBCT. Main Outcomes and Measures The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy. Results Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, −2.0% [95% CI, −7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001). Conclusions and Relevance Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.
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Affiliation(s)
- Dirk Stengel
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany.,Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany.,BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
| | - Sven Mutze
- Institute of Radiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany.,Institute for Diagnostic Radiology and Neuroradiology, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Claas Güthoff
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Moritz Weigeldt
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Konrad von Kottwitz
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Domenique Runge
- Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Filip Razny
- Institute of Radiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Anna Lücke
- Institute of Radiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
| | - Dirk Müller
- Consultant in radiation physics, Hamburg, Germany
| | - Axel Ekkernkamp
- Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany.,BG Kliniken-Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany.,Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
| | - Thomas Kahl
- Institute of Radiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
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Azuma M, Nakada H, Kitatani K, Shinkawa N, Khant ZA, Ochiai H, Hirai T. Conditional unnecessity of head CT for whole-body CT of traffic accident victims: a pilot study. Emerg Radiol 2020; 28:273-278. [PMID: 32918636 DOI: 10.1007/s10140-020-01851-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 09/04/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE To investigate whether head CT should be included in whole-body CT in road traffic accident victims. METHODS A review of electronic medical records identified 124 patients (81 males, 43 females; age 4 to 92 years, mean 47.7 years) involved in a road traffic accident in a 12-month period. All had undergone whole-body CT and physical and neurologic examinations. We recorded their age, sex, Glasgow Coma Scale (GCS), systolic blood pressure (SBP), the type of traffic accident, and the presence/absence of visible trauma above the clavicles (VTCs) and of acute traumatic brain injury (TBI) on CT. Statistical analyses were performed to evaluate predictors of acute TBI. RESULTS Of 124 patients, 34 (27%) manifested acute TBI on CT. Univariate analysis identified their age, GCS, SBP, VTCs, and the accident type as statistically significant factors for acute TBI (p < 0.05). Multivariate analysis demonstrated VTCs, GCS score < 15, and SBP ≤ 90 mmHg were significant independent predictors of acute TBI (p = 0.001, p = 0.001, and p = 0.004, respectively); the odds ratio was 16.07 for VTCs, 14.85 for GCS score < 15, and 13.78 for SBP ≤ 90 mmHg. No patients without both decrease in GCS score and VTCs manifested acute TBI. CONCLUSION Our pilot study showed that visible trauma above the clavicles and decrease in GCS score were highly associated with the presence of acute TBI in road traffic accident victims. In whole-body CT, a head CT may not be indicated in patients without these factors.
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Affiliation(s)
- Minako Azuma
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan.
| | - Hiroshi Nakada
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Keiji Kitatani
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Norihiro Shinkawa
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Zaw Aung Khant
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Hidenobu Ochiai
- Center for Emergency and Critical Care Medicine, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
| | - Toshinori Hirai
- Department of Radiology, Faculty of Medicine, University of Miyazaki, Miyazaki, Japan
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CT Protocol Optimization in Trauma Imaging: A Review of Current Evidence. CURRENT RADIOLOGY REPORTS 2020. [DOI: 10.1007/s40134-020-00351-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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15
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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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[The TraumaRegister DGU® dataset, its development over 25 years and advances in the care of severely injured patients]. Unfallchirurg 2019; 121:794-801. [PMID: 30225633 DOI: 10.1007/s00113-018-0555-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Since the publication in 1993, the dataset and documentation form of the TraumaRegister DGU® (TR-DGU) have continuously evolved. On the occasion of the 25th anniversary the authors have analyzed this evolution in order to reflect it in the light of medical progress in the treatment of the severely injured. MATERIAL AND METHODS Enrolled in the study were 5 reference data entry sheets from the years 1993, 1996, 2002, 2009 and 2016. Every piece of information (item) queried therein was entered into the study database, was categorized by topic and counted for further analysis. RESULTS The arrangement of the 4‑page data entry form has remained practically unchanged since 1993 and includes an average of 212 items. A total of 491 items were identified of which 64 were present throughout every dataset. Based on the average extent of the form this equals a proportion of approximately 30%. The dataset actually shows much more consistency than this number suggests because many changes can be traced back to a smarter design of the data entry form. Most items fell into the categories "results/diagnosis" (143 items/29.1%), "coagulation" (104/21.2%) and "surgical approach" (40/8.1%). Many items serve as raw data for the calculation of prognostic risk scores, such as the trauma and injury severity score (TRISS), the revised injury severity classification II (RISC II) and the trauma associated severe hemorrhage (TASH) score. Currently, nine scores can be calculated from the dataset. CONCLUSION The members of the working group TraumaRegister all actively participate in the treatment of severely injured patients. For 25 years this group has managed to unify the latest medical developments and well-established parameters within the TR-DGU dataset at a relatively constant degree of effort for documentation. Practice in place of theory is the driving force behind this development that serves quality assurance and research in the treatment of severely injured patients.
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Vogl TJ, Eichler K, Marzi I, Wutzler S, Zacharowski K, Frellessen C. [Imaging techniques in modern trauma diagnostics]. Med Klin Intensivmed Notfmed 2019; 112:643-657. [PMID: 28936574 DOI: 10.1007/s00063-017-0359-9] [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] [Indexed: 10/18/2022]
Abstract
Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.
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Affiliation(s)
- T J Vogl
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland.
| | - K Eichler
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | - I Marzi
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - S Wutzler
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - K Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - C Frellessen
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
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18
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Laue F, Ramadanov N, Matthes G. Schockraummanagement beim Schwerverletzten. Notf Rett Med 2019. [DOI: 10.1007/s10049-018-0552-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Stengel D, Leisterer J, Ferrada P, Ekkernkamp A, Mutze S, Hoenning A. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Cochrane Database Syst Rev 2018; 12:CD012669. [PMID: 30548249 PMCID: PMC6517180 DOI: 10.1002/14651858.cd012669.pub2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Point-of-care sonography (POCS) has emerged as the screening modality of choice for suspected body trauma in many emergency departments worldwide. Its best known application is FAST (focused abdominal sonography for trauma). The technology is almost ubiquitously available, can be performed during resuscitation, and does not expose patients or staff to radiation. While many authors have stressed the high specificity of POCS, its sensitivity varied markedly across studies. This review aimed to compile the current best evidence about the diagnostic accuracy of POCS imaging protocols in the setting of blunt thoracoabdominal trauma. OBJECTIVES To determine the diagnostic accuracy of POCS for detecting and excluding free fluid, organ injuries, vascular lesions, and other injuries (e.g. pneumothorax) compared to a diagnostic reference standard (i.e. computed tomography (CT), magnetic resonance imaging (MRI), thoracoscopy or thoracotomy, laparoscopy or laparotomy, autopsy, or any combination of these) in patients with blunt trauma. SEARCH METHODS We searched Ovid MEDLINE (1946 to July 2017) and Ovid Embase (1974 to July 2017), as well as PubMed (1947 to July 2017), employing a prospectively defined literature and data retrieval strategy. We also screened the Cochrane Library, Google Scholar, and BIOSIS for potentially relevant citations, and scanned the reference lists of full-text papers for articles missed by the electronic search. We performed a top-up search on 6 December 2018, and identified eight new studies which may be incorporated into the first update of this review. SELECTION CRITERIA We assessed studies for eligibility using predefined inclusion and exclusion criteria. We included either prospective or retrospective diagnostic cohort studies that enrolled patients of any age and gender who sustained any type of blunt injury in a civilian scenario. Eligible studies had to provide sufficient information to construct a 2 x 2 table of diagnostic accuracy to allow for calculating sensitivity, specificity, and other indices of diagnostic test accuracy. DATA COLLECTION AND ANALYSIS Two review authors independently screened titles, abstracts, and full texts of reports using a prespecified data extraction form. Methodological quality of individual studies was rated by the QUADAS-2 instrument (the revised and updated version of the original Quality Assessment of Diagnostic Accuracy Studies list of items). We calculated sensitivity and specificity with 95% confidence intervals (CI), tabulated the pairs of sensitivity and specificity with CI, and depicted these estimates by coupled forest plots using Review Manager 5 (RevMan 5). For pooling summary estimates of sensitivity and specificity, and investigating heterogeneity across studies, we fitted a bivariate model using Stata 14.0. MAIN RESULTS We included 34 studies with 8635 participants in this review. Summary estimates of sensitivity and specificity were 0.74 (95% CI 0.65 to 0.81) and 0.96 (95% CI 0.94 to 0.98). Pooled positive and negative likelihood ratios were estimated at 18.5 (95% CI 10.8 to 40.5) and 0.27 (95% CI 0.19 to 0.37), respectively. There was substantial heterogeneity across studies, and the reported accuracy of POCS strongly depended on the population and affected body area. In children, pooled sensitivity of POCS was 0.63 (95% CI 0.46 to 0.77), as compared to 0.78 (95% CI 0.69 to 0.84) in an adult or mixed population. Associated specificity in children was 0.91 (95% CI 0.81 to 0.96) and in an adult or mixed population 0.97 (95% CI 0.96 to 0.99). For abdominal trauma, POCS had a sensitivity of 0.68 (95% CI 0.59 to 0.75) and a specificity of 0.95 (95% CI 0.92 to 0.97). For chest injuries, sensitivity and specificity were calculated at 0.96 (95% CI 0.88 to 0.99) and 0.99 (95% CI 0.97 to 1.00). If we consider the results of all 34 included studies in a virtual population of 1000 patients, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 28%, POCS would miss 73 patients with injuries and falsely suggest the presence of injuries in another 29 patients. Furthermore, in a virtual population of 1000 children, based on the observed median prevalence (pretest probability) of thoracoabdominal trauma of 31%, POCS would miss 118 children with injuries and falsely suggest the presence of injuries in another 62 children. AUTHORS' CONCLUSIONS In patients with suspected blunt thoracoabdominal trauma, positive POCS findings are helpful for guiding treatment decisions. However, with regard to abdominal trauma, a negative POCS exam does not rule out injuries and must be verified by a reference test such as CT. This is of particular importance in paediatric trauma, where the sensitivity of POCS is poor. Based on a small number of studies in a mixed population, POCS may have a higher sensitivity in chest injuries. This warrants larger, confirmatory trials to affirm the accuracy of POCS for diagnosing thoracic trauma.
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Affiliation(s)
- Dirk Stengel
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryBerlinGermany12683
| | | | - Paula Ferrada
- Virginia Commonwealth UniversityDepartment of SurgeryRichmondVAUSA
| | - Axel Ekkernkamp
- University HospitalDepartment of Trauma and Reconstructive SurgeryGreifswaldGermany17475
| | - Sven Mutze
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
| | - Alexander Hoenning
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryBerlinGermany12683
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Waheed KB, Baig AA, Raza A, Ul Hassan MZ, Khattab MA, Raza U. Diagnostic accuracy of Focused Assessment with Sonography for Trauma for blunt abdominal trauma in the Eastern Region of Saudi Arabia. Saudi Med J 2018; 39:598-602. [PMID: 29915855 PMCID: PMC6058749 DOI: 10.15537/smj.2018.6.22031] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives: To determine the diagnostic accuracy of Focused Assessment with Sonography for Trauma (FAST) in blunt abdominal trauma caused by motor vehicle accidents at our Hospital in Dhahran city. Methods: This descriptive, observational study was conducted in the Radiology Department at King Fahad Military Medical Complex Dhahran, Saudi Arabia between September 2016 and September 2017. All adult patients (n=105) involved in motor vehicle accidents with blunt abdominal injury on presentation were retrospectively reviewed for FAST and CT scans for detection of free fluid. Focused assessment with sonography for trauma studies were conducted or supervised by senior registrar of general surgery (trauma team leader). Computed tomography findings were reviewed by 2 experienced radiologists. High and low-grade solid abdominal visceral (liver, spleen, kidney) injuries were identified on CT scans. Focused assessment with sonography for trauma and CT scan findings were identified as ‘positive’ and ‘negative’ for presence and absence of free fluid respectively. Outcomes of FAST were presented on a 2x2 contingency table. Results: Sensitivity of FAST in detecting intraperitoneal free fluid was calculated as 76.1% (95% confidence interval [CI], 64.14-85.69%), specificity 84.2% (95% CI, 68.75-93.98%) and accuracy 79% (95% CI, 70.01-86.38%). Focused assessment with sonography for trauma detected free fluid in most cases of high-grade solid visceral injuries. Nearly half of true-negative cases were having low grade visceral or other injuries. Conclusion: Focused assessment with sonography for trauma is an important tool in initial assessment of suspected blunt abdominal injury patients with high sensitivity and specificity. A negative FAST does not exclude low grade solid visceral or other injuries.
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Affiliation(s)
- Khawaja B Waheed
- Radiology Department, King Fahad Military Medical Complex, Dhahran, Kingdom of Saudi Arabia. E-mail.
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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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Godt JC, Eken T, Schulz A, Johansen CK, Aarsnes A, Dormagen JB. Triple-split-bolus versus single-bolus CT in abdominal trauma patients: a comparative study. Acta Radiol 2018; 59:1038-1044. [PMID: 29350048 DOI: 10.1177/0284185117752522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Split-bolus computed tomography (CT) is a recent development in trauma imaging. Instead of multiple scans in different contrast phases after a single contrast bolus, split-bolus protocols consist of one single scan of the thorax and abdomen after two or three contrast injections at different points of time. Purpose To evaluate and compare image quality and injury findings of a new triple-split-bolus CT (TS-CT) protocol of thorax and abdomen with those of a portal venous phase CT (PV-CT) in the same patient group. Material and Methods Trauma patients in 2009-2012 who underwent both the TS-CT initially and a PV-CT during the next six weeks were included. The TS-CT examination was performed as one CT run after application of three contrast boluses (total 175 mL) to enhance renal pelvis and urinary tract, the abdominal organs, and the large arterial vessels. The PV-CT had a fixed delay of 85 s. We measured attenuation in Hounsfield units (HU), evaluated possible organ injury and assessed image quality on a 5-point scale. Results Thirty-five patients were included. Attenuation measurements of major abdominal vessels, organs, and renal pelvis were significantly higher with the TS-CT protocol. Performance in organ injury diagnosis and image quality was equal in both protocols. Conclusion The overall performance of the TS-CT protocol is similar to the standard PV-CT. Excellent visualization of the arterial tree and the collecting system may eliminate the need for separate scans.
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Affiliation(s)
- Johannes Clemens Godt
- Department of Radiology and Nuclear Medicine, Oslo University Hospital Ullevål, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Torsten Eken
- Department of Anesthesiology, Oslo University Hospital Ullevål, Oslo, Norway
| | - Anselm Schulz
- Department of Radiology and Nuclear Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Cathrine K Johansen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital Ullevål, Oslo, Norway
| | - Anette Aarsnes
- Department of Diagnostic Physics, The Intervention Centre, Oslo University Hospital Rikshospitalet, Oslo, Norway
| | - Johann Baptist Dormagen
- Department of Radiology and Nuclear Medicine, Oslo University Hospital Ullevål, Oslo, Norway
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Orf AA, Waheed KB, Baig AA, Mohammad KS, El Sirafy MN, Amin MS, Arulanatham ZJ. Patterns of injury detected by pan-computed tomography after road traffic accidents: retrospective review from a trauma center in Saudi Arabia. Ann Saudi Med 2018; 38:245-250. [PMID: 30078022 PMCID: PMC6086669 DOI: 10.5144/0256-4947.2018.245] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Pan-scan (whole-body) computed tomography (CT) has a paramount role in the diagnosis of injuries in road traffic accidents (RTA). OBJECTIVE Identify patterns of injuries on pan-CT scans. DESIGN Retrospective medical record review. SETTING Tertiary care center. PATIENTS AND METHODS The records of all RTA patients who presented to the radiology department at King Fahad Military Medical Complex (KFMMC) in Dhahran for the 3-year period from July 2014 to July 2017 and underwent pan-CT were retrospectively reviewed. Drivers and front-seat passengers with complete clinical information on seating, safety and mechanism of injury were selected. Children under 5 years of age, pregnant women and back-seat passengers were excluded. Patterns of injuries were categorized as 'no abnormality detected' (NAD), isolated or combined head, face and neck (H), isolated or combined chest, abdomen and pelvis (C) or both regions of the body (B). MAIN OUTCOME MEASURES Injury patterns on pan-CT scans. SAMPLE SIZE 305 RESULTS: Most patients were males (n=287, 94.1%). The median age was 26 years for males (IQR, 22-33 years) and 30 years for females (IQR, 28-39). More than two-thirds were drivers (all males); the remainder were front-seat passengers. Young males were most often involved. The most common type of accident was a roll-over. Of those who sustained injuries, 273 (89.5%) were not wearing a seat belt (unrestrained). The patterns of injuries were NAD (87, 28%), H (27, 9%), C (93, 30.5%), B (98, 32%). CONCLUSION When abnormalities were detected, most high-speed vehicular injuries affected the torso. Unrestrained young male drivers are most often involved in RTAs in Saudi Arabia. LIMITATIONS Retrospective study with a small sample size. Types and severity of injuries on pan-CT were not documented. CONFLICT OF INTEREST None.
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Affiliation(s)
| | - Khawaja Bilal Waheed
- Dr. Khawaja Bilal Waheed, Department of Radiology,, King Fahad Military Medical Complex,, Dhahran, Saudi Arabia, T: +966138440000 ext: 3222, F:+96613844000-3207, , ORCID: http://orcid.org/0000-0001-6340-3139
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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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Abstract
INTRODUCTION Whole body computed tomography has become standard practice in many centres in the management of severely injured trauma patients, however, the evidence for it's diagnostic accuracy is limited. AIM To assess the sensitivity of whole body CT in major trauma. METHOD Retrospective review of all patients with injury severity score (ISS) > 15 presenting with blunt trauma to a UK Major Trauma Centre between May 2012 and April 2014. Injuries were classified as per ISS score-1 = head and neck 2 = face 3 = chest 4 = abdomen. The authors reviewed patient's electronic charts, radiological results; interventional procedure records, discharge letters and outpatient follow up documentation and referenced this with Trauma Audit and Research Network data. RESULTS 407 patients with ISS > 15 presented to the Trauma centre during May 2012 and April 2014. Of these, 337 (82.8%) had a whole body CT scan. 246 pts were male, 91 were female. 74 (21.9%) were due to a fall from > 2 m, 41 (12.2%) due to a fall from < 2 m, 208 (61.7%) were due to motor vehicle crashes, 1 (0.3%) due to a blast injury, 5 (1.5%) due to blows, and 8 (2.4%) due to crush injuries. Sensitivity for Region 1 was 0.98, Region 2 = 0.98, Region 3 = 0.98 and Region 4 was 0.95. Overall sensitivity was 0.98. 15 injuries (2.4%) were not identified on initial CT (false -ve). These injuries were: colonic perforation = 1, splenic contusion = 1, pneumothorax = 1, liver laceration = 1, intracranial haemorrhage = 1, cerebral contusions = 1, spinal injuries = 7, canal haemorrhage = 1, maxilla fracture = 1. CONCLUSION These results show that whole body CT in trauma has a high sensitivity and a low rate of missed injuries (2.4%). However, our study only evaluated a subgroup of patients with ISS > 15 and further work is required to assess the use of this investigation for all major trauma patients.
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Affiliation(s)
- Susan Yoong
- Queen's Medical Centre, Derby Rd, Nottingham, NG7 2UH, UK.
| | - Ravi Kothari
- Queen's Medical Centre, Derby Rd, Nottingham, NG7 2UH, UK
| | - Adam Brooks
- Queen's Medical Centre, Derby Rd, Nottingham, NG7 2UH, UK
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Vogl TJ, Eichler K, Marzi I, Wutzler S, Zacharowski K, Frellessen C. [Imaging techniques in modern trauma diagnostics]. Unfallchirurg 2018; 120:417-431. [PMID: 28455618 DOI: 10.1007/s00113-017-0352-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.
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Affiliation(s)
- T J Vogl
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland.
| | - K Eichler
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
| | - I Marzi
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - S Wutzler
- Zentrum der Chirurgie, Klinik für Unfall-, Hand- und Wiederherstellungschirurgie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - K Zacharowski
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Frankfurt, Deutschland
| | - C Frellessen
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Frankfurt, Johann Wolfgang Goethe-Universität, Theodor-Stern-Kai 7, 60590, Frankfurt, Deutschland
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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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McKechnie PS, Kerslake DA, Parks RW. Time to CT and Surgery for HPB Trauma in Scotland Prior to the Introduction of Major Trauma Centres. World J Surg 2018; 41:1796-1800. [PMID: 28258447 DOI: 10.1007/s00268-017-3934-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS To assess the time taken to CT and emergency surgery for trauma patients with an injury to liver, spleen or pancreas prior to the introduction of major trauma centres (MTCs) in Scotland. METHODS A search was performed of the Scottish Trauma Audit Group database for any patient with relevant injuries over a 2-year period. Primary outcome measures were time to CT and emergency surgery. Patient demographics were also recorded. RESULTS A total of 211 patients were identified of whom 23 had more than one organ affected. There were a total of 234 injuries (123 liver, 99 splenic and 12 pancreatic) in these patients. A total of 160 injuries (75.8%) suffered blunt trauma. Of 211 patients, 157 underwent emergency CT with a median time to scan of 73 min (range 4-474). Hospitals provisionally designated as MTCs were 9 min faster than non-MTCs in time to CT. There was no difference in time of day. Ninety-nine patients had surgery within 24 h at a median time of 200 min. Twenty-five patients with hypotension on presentation took a median time of 130 min. Only 44 patients (27%) had a CT or emergency surgery within the expected MTC target of 1 h. Thirty-nine patients required transfer to another centre. CONCLUSIONS Current management of patients with abdominal trauma and haemodynamic instability remains sub-optimal in Scotland when compared to recognized performance indicators of CT and emergency surgery within 1 h. Implementation of a major trauma network in Scotland should improve access to emergency radiology and surgery and efforts to shorten current timelines should improve patient outcomes.
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Affiliation(s)
- P S McKechnie
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK.
| | - D A Kerslake
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
| | - R W Parks
- Department of Clinical Surgery, University of Edinburgh, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh, EH16 4SA, UK
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The value of 'binder-off' imaging to identify occult and unexpected pelvic ring injuries. Injury 2018; 49:284-289. [PMID: 29198375 DOI: 10.1016/j.injury.2017.11.023] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Revised: 10/24/2017] [Accepted: 11/18/2017] [Indexed: 02/02/2023]
Abstract
AIMS To determine the effectiveness of 'binder-off' plain pelvic radiographs in the assessment of pelvic ring injuries. PATIENTS AND METHODS All patients requiring operative intervention at our tertiary referral pelvic unit/major trauma centre for high-energy pelvic injuries between April 2012 and December 2014 were retrospectively identified. Pre-operative pelvic imaging with and without pelvic binder was reviewed with respect to fracture pattern and pelvic stability. The frequency with which the imaging without pelvic binder changed the opinion of the pelvic stability and need for operative intervention, when compared with the computed tomography (CT) scans and anteroposterior (AP) radiographs with the binder on, was assessed. RESULTS Seventy-three percent (71 of 97) of patients had initial imaging with a pelvic binder in situ. Of these, 76% (54 of 71) went on to have 'binder-off' imaging. Seven percent (4 of 54) of patients had unexpected unstable pelvic ring injuries identified on 'binder-off' imaging that were not identified on CT imaging in binder. CONCLUSIONS Trauma CT imaging of the pelvis with a pelvic binder in place is inadequate at excluding unstable pelvic ring injuries, and, based on the original findings in this paper, we recommend additional plain film 'binder-off' radiographs, when there is any clinical concern.
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Gümbel D, Schneidler F, Frank M, Bockholdt B, Hinz P, Napp M, Spitzmüller R, Ekkernkamp A, Langner S. Urinary bladder volume measured in whole-body CT scans is a useful marker for alcohol intoxication. Alcohol 2017; 65:45-50. [PMID: 29084629 DOI: 10.1016/j.alcohol.2017.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 06/06/2017] [Accepted: 07/10/2017] [Indexed: 11/16/2022]
Abstract
PURPOSE The aim of this study was to investigate whether urinary bladder volume (UBV) and blood alcohol concentration (BAC) correlate in a cohort of emergency trauma patients. Furthermore, the feasibility of semi-automated 3D-CT volumetry for urinary bladder volumetry calculations in whole-body CT examinations was elucidated. MATERIAL AND METHODS Whole-body CT scans of 831 individuals treated in the emergency department with suspected multiple injuries were included. Manual 3D-CT volumetry of the urinary bladder was performed and the mechanism of injury, patient demographics, BAC, serum creatinine, and hematocrit were retrospectively analyzed. Semi-automated calculation of UBV was performed in 30 patients. Statistical analysis included ROC analysis to calculate cut-off values, sensitivity, and specificity. The Mann-Whitney test and Spearman's correlation coefficient were used to detect significant correlations between UBV and BAC. RESULTS Manual 3D-CT volumetry showed maximum sensitivity and specificity with a cut-off value for urinary bladder volume of 416.3 mL (sensitivity 50.9%; specificity 76.3%; AUC 0.678). With a cut-off value of 4.2 mL/μmol for the creatinine quotient (quotient of serum creatinine and UBV), the sensitivity was 64.2% (specificity 67.0%; AUC 0.681). Semi-automated 3D-CT volumetry resulted in lower UBV values compared to those obtained with manual 3D-CT volumetry. CONCLUSION Semi-automated 3D-CT volumetry is a reliable method to quantify UBV. UBV correlates with positive BAC results. A UBV above 416 mL seen on an initial whole-body CT must raise suspicion of alcohol intoxication. The creatinine quotient is an even more sensitive and specific parameter for the detection of alcohol intoxication.
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Affiliation(s)
- Denis Gümbel
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany; Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH (ukb), Warener Str. 7, 12683 Berlin, Germany.
| | - Frank Schneidler
- Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany.
| | - Matthias Frank
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany; Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH (ukb), Warener Str. 7, 12683 Berlin, Germany.
| | - Britta Bockholdt
- Department of Forensic Medicine, University Medicine Greifswald, Kuhstraße 30, 17489 Greifswald, Germany.
| | - Peter Hinz
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany.
| | - Matthias Napp
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany.
| | - Romy Spitzmüller
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany.
| | - Axel Ekkernkamp
- Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany; Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH (ukb), Warener Str. 7, 12683 Berlin, Germany.
| | - Sönke Langner
- Institute for Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Ferdinand-Sauerbruch-Str., 17475 Greifswald, Germany.
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Bildgebende Verfahren der modernen Schockraumdiagnostik. Notf Rett Med 2017. [DOI: 10.1007/s10049-017-0376-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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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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Early computed tomography or focused assessment with sonography in abdominal trauma: what are the leading opinions? Eur J Trauma Emerg Surg 2017; 44:3-8. [PMID: 28730296 DOI: 10.1007/s00068-017-0816-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Accepted: 07/11/2017] [Indexed: 10/19/2022]
Abstract
PURPOSE The initial assessment of severely injured patients in the resuscitation room requires a systematic and quickly performed survey. Whereas the Advanced Trauma Life Support (ATLS®)-based algorithm recommends focused assessment with sonography in trauma (FAST) among others, recent studies report a survival advantage of early whole-body computed tomography (WBCT) in haemodynamically stable as well as unstable patients. This study assessed the opinions of trauma surgeons about the early use of WBCT in severely injured patients with abdominal trauma, and abdominal CT in patients with isolated abdominal trauma, during resuscitation room treatment. METHODS An online cross-sectional survey was performed over 8 months. Members of the Swiss Society for Surgery and the Austrian and German associations for trauma surgery were invited to answer nine online questions. RESULTS Overall, 175 trauma surgeons from 155 departments participated. For haemodynamically stable patients, most considered FAST (77.6%) and early CT (82.3%) to be the ideal diagnostic tools. For haemodynamically unstable patients, 93.4% considered FAST to be mandatory. For CT imaging in unstable patients, 47.5% agreed with the use of CT, whereas 52.5% rated early CT as not essential. For unstable patients with pathological FAST and clinical signs, 86.8% agreed to proceed with immediate laparotomy. CONCLUSIONS Most surgeons rely on early CT for haemodynamically stable patients with abdominal trauma, whereas FAST is performed with similar frequency and is prioritized in unstable patients. It seems that the results of recent studies supporting early WBCT have not yet found broad acceptance in the surgical community.
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Stengel D, Hoenning A, Leisterer J. Point-of-care ultrasonography for diagnosing thoracoabdominal injuries in patients with blunt trauma. Hippokratia 2017. [DOI: 10.1002/14651858.cd012669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Dirk Stengel
- Unfallkrankenhaus Berlin; Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery; Berlin Germany 12683
| | - Alexander Hoenning
- Unfallkrankenhaus Berlin; Centre for Clinical Research, Department of Trauma and Orthopaedic Surgery; Berlin Germany 12683
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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: 46] [Impact Index Per Article: 6.6] [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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Imaging Techniques in Emergency Surgeries. Int Anesthesiol Clin 2016; 54:22-38. [PMID: 26655507 DOI: 10.1097/aia.0000000000000086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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: 22] [Impact Index Per Article: 2.8] [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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Van Zyl HP, Bilbey J, Vukusic A, Ring T, Oakes J, Williamson LD, Mitchell IV. Can emergency physicians accurately rule out clinically important cervical spine injuries by using computed tomography? CAN J EMERG MED 2016; 16:131-5. [PMID: 24626117 DOI: 10.2310/8000.2013.130978] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Emergency physicians are expected to rule out clinically important cervical spine injuries using clinical skills and imaging. Our objective was to determine whether emergency physicians could accurately rule out clinically important cervical spine injuries using computed tomographic (CT) imaging of the cervical spine. METHOD Fifteen emergency physicians were enrolled to interpret a sample of 50 cervical spine CT scans in a nonclinical setting. The sample contained a 30% incidence of cervical spine injury. After a 2-hour review session, the participants interpreted the CT scans and categorized them into either a suspected cervical spine injury or no cervical spine injury. Participants were asked to specify the location and type of injury. The gold standard interpretation was the combined opinion of two staff radiologists. RESULTS Emergency physicians correctly identified 182 of the 210 abnormal cases with cervical spine injury. The sensitivity of emergency physicians was 87% (95% confidence interval [CI] 82-91), and the specificity was 76% (95% CI 74-77). The negative likelihood ratio was 0.18 (95% CI 0.12-0.25). CONCLUSION Experienced emergency physicians successfully identified a large proportion of cervical spine injuries on CT; however, they were not sufficiently sensitive to accurately exclude clinically important injuries. Emergency physicians should rely on a radiologist review of cervical spine CT scans prior to discontinuing cervical spine precautions.
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Stengel D, Rademacher G, Ekkernkamp A, Güthoff C, Mutze S. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Cochrane Database Syst Rev 2015; 2015:CD004446. [PMID: 26368505 PMCID: PMC6464800 DOI: 10.1002/14651858.cd004446.pub4] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Ultrasonography (performed by means of a four-quadrant, focused assessment of sonography for trauma (FAST)) is regarded as a key instrument for the initial assessment of patients with suspected blunt abdominal and thoraco-abdominal trauma in the emergency department setting. FAST has a high specificity but low sensitivity in detecting and excluding visceral injuries. Proponents of FAST argue that ultrasound-based clinical pathways enhance the speed of primary trauma assessment, reduce the number of unnecessary multi-detector computed tomography (MDCT) scans, and enable quicker triage to surgical and non-surgical care. Given the proven accuracy, increasing availability of, and indication for, MDCT among patients with blunt abdominal and multiple injuries, we aimed to compile the best available evidence of the use of FAST-based assessment compared with other primary trauma assessment protocols. OBJECTIVES To assess the effects of diagnostic algorithms using ultrasonography including in FAST examinations in the emergency department in relation to the early, late, and overall mortality of patients with suspected blunt abdominal trauma. SEARCH METHODS The most recent search was run on 30th June 2015. We searched the Cochrane Injuries Group Specialised Register, The Cochrane Library, MEDLINE (OvidSP), EMBASE (OvidSP), ISI Web of Science (SCI-EXPANDED, SSCI, CPCI-S, and CPSI-SSH), clinical trials registers, and screened reference lists. Trial authors were contacted for further information and individual patient data. SELECTION CRITERIA We included randomised controlled trials (RCTs). Participants were patients with blunt torso, abdominal, or multiple trauma undergoing diagnostic investigations for abdominal organ injury. The intervention was diagnostic algorithms comprising emergency ultrasonography (US). The control was diagnostic algorithms without US examinations (for example, primary computed tomography (CT) or diagnostic peritoneal lavage (DPL)). Outcomes were mortality, use of CT or invasive procedures (DPL, laparoscopy, laparotomy), and cost-effectiveness. DATA COLLECTION AND ANALYSIS Two authors (DS and CG) independently selected trials for inclusion, assessed methodological quality, and extracted data. Methodological quality was assessed using the Cochrane Collaboration risk of bias tool. Where possible, data were pooled and relative risks (RRs), risk differences (RDs), and weighted mean differences, each with 95% confidence intervals (CIs), were calculated by fixed-effect or random-effects models as appropriate. MAIN RESULTS We identified four studies meeting our inclusion criteria. Overall, trials were of poor to moderate methodological quality. Few trial authors responded to our written inquiries seeking to resolve controversial issues and to obtain individual patient data. Strong heterogeneity amongst the trials prompted discussion between the review authors as to whether the data should or should not be pooled; we decided in favour of a quantitative synthesis to provide a rough impression about the effect sizes achievable with US-based triage algorithms. We pooled mortality data from three trials involving 1254 patients; the RR in favour of the FAST arm was 1.00 (95% CI 0.50 to 2.00). FAST-based pathways reduced the number of CT scans (random-effects model RD -0.52, 95% CI -0.83 to -0.21), but the meaning of this result was unclear. AUTHORS' CONCLUSIONS The experimental evidence justifying FAST-based clinical pathways in diagnosing patients with suspected abdominal or multiple blunt trauma remains poor. Because of strong heterogeneity between the trial results, the quantitative information provided by this review may only be used in an exploratory fashion. It is unlikely that FAST will ever be investigated by means of a confirmatory, large-scale RCT in the future. Thus, this Cochrane Review may be regarded as a review which provides the best available evidence for clinical practice guidelines and management recommendations. It can only be concluded from the few head-to-head studies that negative US scans are likely to reduce the incidence of MDCT scans which, given the low sensitivity of FAST (or reliability of negative results), may adversely affect the diagnostic yield of the trauma survey. At best, US has no negative impact on mortality or morbidity. Assuming that major blunt abdominal or multiple trauma is associated with 15% mortality and a CT-based diagnostic work-up is considered the current standard of care, 874, 3495, or 21,838 patients are needed per intervention group to demonstrate non-inferiority of FAST to CT-based algorithms with non-inferiority margins of 5%, 2.5%, and 1%, power of 90%, and a type-I error alpha of 5%.
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Affiliation(s)
- Dirk Stengel
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Grit Rademacher
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
| | - Axel Ekkernkamp
- University HospitalDepartment of Trauma and Reconstructive SurgeryFerdinand‐Sauerbruch‐StraßeGreifswaldGermany17475
| | - Claas Güthoff
- Unfallkrankenhaus BerlinCentre for Clinical Research, Department of Trauma and Orthopaedic SurgeryWarener Str 7BerlinGermany12683
| | - Sven Mutze
- Unfallkrankenhaus BerlinDepartment of Diagnostic and Interventional RadiologyWarener Str 7BerlinGermany12683
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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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Beenen LFM, Sierink JC, Kolkman S, Nio CY, Saltzherr TP, Dijkgraaf MGW, Goslings JC. Split bolus technique in polytrauma: a prospective study on scan protocols for trauma analysis. Acta Radiol 2015; 56:873-80. [PMID: 25033993 DOI: 10.1177/0284185114539319] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2013] [Accepted: 05/19/2014] [Indexed: 11/17/2022]
Abstract
BACKGROUND For the evaluation of severely injured trauma patients a variety of total body computed tomography (CT) scanning protocols exist. Frequently multiple pass protocols are used. A split bolus contrast protocol can reduce the number of passes through the body, and thereby radiation exposure, in this relatively young and vitally threatened population. PURPOSE To evaluate three protocols for single pass total body scanning in 64-slice multidetector CT (MDCT) on optimal image quality. MATERIAL AND METHODS Three total body CT protocols were prospectively evaluated in three series of 10 consecutive trauma patients. In Group A unenhanced brain and cervical spine CT was followed by chest-abdomen-pelvis CT in portovenous phase after repositioning of the arms. Group B underwent brain CT followed without arm repositioning by a one-volume contrast CT from skull base to the pubic symphysis. Group C was identical to Group A, but the torso was scanned with a split bolus technique. Three radiologists independently evaluated protocol quality scores (5-point Likert scale), parenchymal and vascular enhancement and artifacts. RESULTS Overall image quality was good (4.10) in Group A, more than satisfactory (3.38) in Group B, and nearly excellent (4.75) in Group C (P < 0.001). Interfering artifacts were mostly reported in Group B in the liver and spleen. CONCLUSION In single pass total body CT scanning a split bolus technique reached the highest overall image quality compared to conventional total body CT and one-volume contrast CT.
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Affiliation(s)
- Ludo FM Beenen
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Joanne C Sierink
- Trauma Unit Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Saskia Kolkman
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - C Yung Nio
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands
| | - Teun Peter Saltzherr
- Trauma Unit Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | | | - J Carel Goslings
- Trauma Unit Department of Surgery, Academic Medical Center, Amsterdam, The Netherlands
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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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Khokhlov VD. Trauma to the hyoid bone and laryngeal cartilages in hanging: Review of forensic research series since 1856. Leg Med (Tokyo) 2015; 17:17-23. [DOI: 10.1016/j.legalmed.2014.09.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2014] [Revised: 09/22/2014] [Accepted: 09/25/2014] [Indexed: 10/24/2022]
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Kirkpatrick AW, Vis C, Dubé M, Biesbroek S, Ball CG, Laberge J, Shultz J, Rea K, Sadler D, Holcomb JB, Kortbeek J. The evolution of a purpose designed hybrid trauma operating room from the trauma service perspective: the RAPTOR (Resuscitation with Angiography Percutaneous Treatments and Operative Resuscitations). Injury 2014; 45:1413-21. [PMID: 24560091 DOI: 10.1016/j.injury.2014.01.021] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Revised: 12/25/2013] [Accepted: 01/18/2014] [Indexed: 02/02/2023]
Abstract
Traumatic injury is the leading cause of potentially preventable lost years of life in the Western world and exsanguination is the most potentially preventable cause of post-traumatic death. With mature trauma systems and experienced trauma centres, extra-abdominal sites, such as the pelvis, constitute the most frequent anatomic site of exsanguination. Haemorrhage control for such bleeding often requires surgical adjuncts most notably interventional radiology (IR). With the usual paradigm of surgery conducted within an operating room and IR procedures within distant angiography suites, responsible clinicians are faced with making difficult decisions regarding where to transport the most physiologically unstable patients for haemorrhage control. If such a critical patient is transported to the wrong suite, they may die unnecessarily despite having potentially salvageable injuries. Thus, it seems only logical that the resuscitative operating room of the future would have IR capabilities making it the obvious geographic destination for critically unstable patients, especially those who are exsanguinating. Our trauma programme recently had the opportunity to conceive, design, build, and operationalise a purpose-designed hybrid trauma operating room, designated as the resuscitation with angiographic percutaneous techniques and operative resuscitation (RAPTOR) suite, which we believe to be the first such resource designed primarily to serve the exsanguinating trauma patient. The project was initiated after consultations between the trauma programme and private philanthropists regarding the greatest potential impacts on regional trauma care. The initial capital construction costs were thus privately generated but coincided with a new hospital wing construction allowing the RAPTOR to be purpose-designed for the exsanguinating patient. Many trauma programmes around the world are now starting to navigate the complex process of building new facilities, or else retrofitting existing ones, to address the need for single-site flexible haemorrhage control. This manuscript therefore describes the many considerations in the design and refinement of the physical build, equipment selection, human factors evaluation of new combined treatment paradigms, and the final introduction of a RAPTOR protocol in order that others may learn from our initial efforts.
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Affiliation(s)
- Andrew W Kirkpatrick
- Department of Surgery, Calgary, Alberta, Canada; Department of Regional Trauma Services, Calgary, Alberta, Canada; Department of Foothills Medical Centre and the University of Calgary Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada.
| | | | | | | | - Chad G Ball
- Department of Surgery, Calgary, Alberta, Canada; Department of Regional Trauma Services, Calgary, Alberta, Canada; Department of Foothills Medical Centre and the University of Calgary Calgary, Alberta, Canada
| | | | | | - Ken Rea
- Dialog Corporation, Calgary, Alberta, Canada
| | - David Sadler
- Department of Radiology, Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada
| | - John B Holcomb
- The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - John Kortbeek
- Department of Surgery, Calgary, Alberta, Canada; Department of Critical Care Medicine, Calgary, Alberta, Canada; Department of Regional Trauma Services, Calgary, Alberta, Canada; Department of Foothills Medical Centre and the University of Calgary Calgary, Alberta, Canada; Alberta Health Services, Alberta, Canada
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Dose reduction in whole-body computed tomography of multiple injuries (DoReMI): protocol for a prospective cohort study. Scand J Trauma Resusc Emerg Med 2014; 22:15. [PMID: 24589310 PMCID: PMC3973884 DOI: 10.1186/1757-7241-22-15] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2013] [Accepted: 02/22/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Single-pass, contrast-enhanced whole body multidetector computed tomography (MDCT) emerged as the diagnostic standard for evaluating patients with major trauma. Modern iterative image algorithms showed high image quality at a much lower radiation dose in the non-trauma setting. This study aims at investigating whether the radiation dose can safely be reduced in trauma patients without compromising the diagnostic accuracy and image quality. METHODS/DESIGN Prospective observational study with two consecutive cohorts of patients. SETTING A high-volume, academic, supra-regional trauma centre in Germany. STUDY POPULATION Consecutive male and female patients who 1. had been exposed to a high-velocity trauma mechanism, 2. present with clinical evidence or high suspicion of multiple trauma (predicted Injury Severity Score [ISS] ≥16) and 3. are scheduled for primary MDCT based on the decision of the trauma leader on call.Imaging protocols: In a before/after design, a consecutive series of 500 patients will undergo single-pass, whole-body 128-row multi-detector computed tomography (MDCT) with a standard, as low as possible radiation dose. This will be followed by a consecutive series of 500 patients undergoing an approved ultra-low dose MDCT protocol using an image processing algorithm. DATA Routine administrative data and electronic patient records, as well as digital images stored in a picture archiving and communications system will serve as the primary data source. The protocol was approved by the institutional review board. MAIN OUTCOMES (1) incidence of delayed diagnoses, (2) diagnostic accuracy, as correlated to the reference standard of a synopsis of all subsequent clinical, imaging, surgical and autopsy findings, (3) patients' safety, (4) radiation exposure (e.g. effective dose), (5) subjective image quality (assessed independently radiologists and trauma surgeons on a 100-mm visual analogue scale), (6) objective image quality (e.g., contrast-to-noise ratio). ANALYSIS Multivariate regression will be employed to adjust and correct the findings for time and cohort effects. An exploratory interim analysis halfway after introduction of low-dose MDCT will be conducted to assess whether this protocol is clearly inferior or superior to the current standard. DISCUSSION Although non-experimental, this study will generate first large-scale data on the utility of imaging-enhancing algorithms in whole-body MDCT for major blunt trauma. TRIAL REGISTRATION Current Controlled Trials ISRCTN74557102.
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The incidence and outcomes of acute kidney injury amongst patients admitted to a level I trauma unit. Injury 2014; 45:259-64. [PMID: 23921194 DOI: 10.1016/j.injury.2013.07.013] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Revised: 07/07/2013] [Accepted: 07/11/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE This study aimed to identify the incidence and outcomes of patients with trauma related acute kidney injury (AKI), as defined by RIFLE criteria, at a single level I trauma centre and trauma ICU. METHODS We performed a retrospective observational study of 666 patients admitted to a trauma ICU from a level I trauma unit from March 2008 to March 2011. We conducted multivariable logistic regression to identify independent predictors for AKI and mortality. RESULTS The overall incidence of AKI was 15% (n=102). Median injury severity score (ISS) was 25 (inter quartile range [IQR] 16-34) and mean age was 39 (SD 16.3) in the AKI group. Thirteen patients (13%) were referred with rhabdomyolysis associated renal Failure. Overall mortality in the AKI group was 57% (n=58) but was significantly lower in the rhabdomyolysis Failure group (23% versus 64%; p=0.012). AKI was independently associated with older age, base excess (BE)<-12 (odd ratio [OR] 22.9, 95% confidence interval [CI] 1.89-276.16), IV contrast administration (OR 2.7 95% CI 1.39-5.11) and blunt trauma (OR 2.2 95% CI 1.04-4.71). AKI was an independent predictor of mortality (OR 8.5, 95% CI 4.51-15.95). Thirty-nine (38%) patients required renal replacement therapy. CONCLUSIONS AKI in critically ill trauma patients is an independent risk factor for mortality and is independently associated with increasing age and low BE. Renal replacement therapy utilisation is high in this group and represents a significant health care cost burden.
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Harvey J, West A. The right scan, for the right patient, at the right time: The reorganization of major trauma service provision in England and its implications for radiologists. Clin Radiol 2013; 68:871-86. [DOI: 10.1016/j.crad.2013.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Revised: 01/02/2013] [Accepted: 01/08/2013] [Indexed: 12/30/2022]
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Huber-Wagner S, Biberthaler P, Häberle S, Wierer M, Dobritz M, Rummeny E, van Griensven M, Kanz KG, Lefering R. Whole-body CT in haemodynamically unstable severely injured patients--a retrospective, multicentre study. PLoS One 2013; 8:e68880. [PMID: 23894365 PMCID: PMC3722202 DOI: 10.1371/journal.pone.0068880] [Citation(s) in RCA: 164] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 05/31/2013] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The current common and dogmatic opinion is that whole-body computed tomography (WBCT) should not be performed in major trauma patients in shock. We aimed to assess whether WBCT during trauma-room treatment has any effect on the mortality of severely injured patients in shock. METHODS In a retrospective multicenter cohort study involving 16719 adult blunt major trauma patients we compared the survival of patients who were in moderate, severe or no shock (systolic blood pressure 90-110,<90 or >110 mmHg) at hospital admission and who received WBCT during resuscitation to those who did not. Using data derived from the 2002-2009 version of TraumaRegister®, we determined the observed and predicted mortality and calculated the standardized mortality ratio (SMR) as well as logistic regressions. FINDINGS 9233 (55.2%) of the 16719 patients received WBCT. The mean injury severity score was 28.8±12.1. The overall mortality rate was 17.4% (SMR = 0.85, 95%CI 0.81-0.89) for patients with WBCT and 21.4% (SMR = 0.98, 95%CI 0.94-1.02) for those without WBCT (p<0.001). 4280 (25.6%) patients were in moderate shock and 1821 (10.9%) in severe shock. The mortality rate for patients in moderate shock with WBCT was 18.1% (SMR 0.85, CI95% 0.78-0.93) compared to 22.6% (SMR 1.03, CI95% 0.94-1.12) to those without WBCT (p<0.001, p = 0.002 for the SMRs). The mortality rate for patients in severe shock with WBCT was 42.1% (SMR 0.99, CI95% 0.92-1.06) compared to 54.9% (SMR 1.10, CI95% 1.02-1.16) to those without WBCT (p<0.001, p = 0.049 for the SMRs). Adjusted logistic regression analyses showed that WBCT is an independent predictor for survival that significantly increases the chance of survival in patients in moderate shock (OR = 0.73; 95%CI 0.60-0.90, p = 0.002) as well as in severe shock (OR = 0.67; 95%CI 0.52-0.88, p = 0.004). The number needed to scan related to survival was 35 for all patients, 26 for those in moderate shock and 20 for those in severe shock. CONCLUSIONS WBCT during trauma resuscitation significantly increased the survival in haemodynamically stable as well as in haemodynamically unstable major trauma patients. Thus, the application of WBCT in haemodynamically unstable severely injured patients seems to be safe, feasible and justified if performed quickly within a well-structured environment and by a well-organized trauma team.
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Affiliation(s)
- Stefan Huber-Wagner
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University Munich, Munich, Germany.
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