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Tran J, Park J, Nguyen J, Ruiz A, Marty M, Singleton A, Obaid-Schmid A. Comparison and Utility of Intravenous Iodinated Contrast in Chest, Abdomen, Pelvis Computerized Tomography for Trauma Patients With Blunt Mechanism of Injury Before and After the May 9, 2022 Global Contrast Shortage at a Level II Trauma Center. Am Surg 2024; 90:2494-2500. [PMID: 38655835 DOI: 10.1177/00031348241248806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
Background: Intravenous (IV) contrast improves the sensitivity and specificity of injury detection in computerized tomography (CT). Its use is recommended in the workup of trauma patients by the American College of Surgeons and American College of Radiology. On May 9, 2022, the Food and Drug Administration declared a shortage of iodinated contrast due to the COVID-19 pandemic. Although the shortage has ended, the temporary lack of IV contrast forced physicians to be prudent in ordering CT scans with IV contrast. We sought to determine if there was a change in the percentage of CT contrast studies performed during the contrast shortage and if this change affected patient outcomes.Methods: Retrospective chart review was performed on all adult tier 2 trauma patients at a 619-bed community-based level II trauma center who received CT chest, abdomen, and pelvis imaging as initial workup for blunt trauma from 5/9/2021-6/30/2021 (pre-shortage) and 5/9/2022-6/30/2022 (during shortage).Results: Patients were predominantly male with median age of 31-52 and of White or Hispanic ethnicity. Before the contrast shortage, all 110 trauma patients were scanned with contrast. During the shortage, 29 of 114 patients were scanned with contrast (P < 0.001). Injuries were identified in 59% of patients scanned with contrast (P < 0.001). There were no significant differences in blood transfusion needs, repeat CT, disposition, or mortality when comparing pre-shortage to during shortage or when comparing between non-contrast and contrast studies during the shortage.Discussion: There was a decrease in the percentage of CT contrast studies performed during the shortage. A higher percentage of injuries were identified in the patients scanned with contrast. However, there were no significant differences in patient outcomes. Certain trauma patients may be safely scanned without contrast.
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Affiliation(s)
- James Tran
- Department of Surgery, Huntington Health, Pasadena, CA, USA
| | - Jasmine Park
- Department of Surgery, Huntington Health, Pasadena, CA, USA
| | - Jade Nguyen
- Department of Surgery, Huntington Health, Pasadena, CA, USA
| | - Andres Ruiz
- Department of Surgery, Huntington Health, Pasadena, CA, USA
| | - Makenna Marty
- Department of Surgery, Huntington Health, Pasadena, CA, USA
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Rossaint R, Afshari A, Bouillon B, Cerny V, Cimpoesu D, Curry N, Duranteau J, Filipescu D, Grottke O, Grønlykke L, Harrois A, Hunt BJ, Kaserer A, Komadina R, Madsen MH, Maegele M, Mora L, Riddez L, Romero CS, Samama CM, Vincent JL, Wiberg S, Spahn DR. The European guideline on management of major bleeding and coagulopathy following trauma: sixth edition. Crit Care 2023; 27:80. [PMID: 36859355 PMCID: PMC9977110 DOI: 10.1186/s13054-023-04327-7] [Citation(s) in RCA: 122] [Impact Index Per Article: 122.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 01/20/2023] [Indexed: 03/03/2023] Open
Abstract
BACKGROUND Severe trauma represents a major global public health burden and the management of post-traumatic bleeding continues to challenge healthcare systems around the world. Post-traumatic bleeding and associated traumatic coagulopathy remain leading causes of potentially preventable multiorgan failure and death if not diagnosed and managed in an appropriate and timely manner. This sixth edition of the European guideline on the management of major bleeding and coagulopathy following traumatic injury aims to advise clinicians who care for the bleeding trauma patient during the initial diagnostic and therapeutic phases of patient management. METHODS The pan-European, multidisciplinary Task Force for Advanced Bleeding Care in Trauma included representatives from six European professional societies and convened to assess and update the previous version of this guideline using a structured, evidence-based consensus approach. Structured literature searches covered the period since the last edition of the guideline, but considered evidence cited previously. The format of this edition has been adjusted to reflect the trend towards concise guideline documents that cite only the highest-quality studies and most relevant literature rather than attempting to provide a comprehensive literature review to accompany each recommendation. RESULTS This guideline comprises 39 clinical practice recommendations that follow an approximate temporal path for management of the bleeding trauma patient, with recommendations grouped behind key decision points. While approximately one-third of patients who have experienced severe trauma arrive in hospital in a coagulopathic state, a systematic diagnostic and therapeutic approach has been shown to reduce the number of preventable deaths attributable to traumatic injury. CONCLUSION A multidisciplinary approach and adherence to evidence-based guidelines are pillars of best practice in the management of severely injured trauma patients. Further improvement in outcomes will be achieved by optimising and standardising trauma care in line with the available evidence across Europe and beyond.
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Affiliation(s)
- Rolf Rossaint
- Department of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074, Aachen, Germany.
| | - Arash Afshari
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Bertil Bouillon
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Vladimir Cerny
- grid.424917.d0000 0001 1379 0994Department of Anaesthesiology, Perioperative Medicine and Intensive Care, Masaryk Hospital, J.E. Purkinje University, Socialni pece 3316/12A, CZ-40113 Usti nad Labem, Czech Republic ,grid.4491.80000 0004 1937 116XDepartment of Anaesthesiology and Intensive Care Medicine, Charles University Faculty of Medicine, Simkova 870, CZ-50003 Hradec Králové, Czech Republic
| | - Diana Cimpoesu
- grid.411038.f0000 0001 0685 1605Department of Emergency Medicine, Emergency County Hospital “Sf. Spiridon” Iasi, University of Medicine and Pharmacy ”Grigore T. Popa” Iasi, Blvd. Independentei 1, RO-700111 Iasi, Romania
| | - Nicola Curry
- grid.410556.30000 0001 0440 1440Oxford Haemophilia and Thrombosis Centre, Nuffield Orthopaedic Centre, Oxford University Hospitals NHS Trust, Windmill Road, Oxford, OX3 7HE UK ,grid.4991.50000 0004 1936 8948Radcliffe Department of Medicine, Oxford University, Oxford, UK
| | - Jacques Duranteau
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Daniela Filipescu
- grid.8194.40000 0000 9828 7548Department of Cardiac Anaesthesia and Intensive Care, “Prof. Dr. C. C. Iliescu” Emergency Institute of Cardiovascular Diseases, Carol Davila University of Medicine and Pharmacy, Sos Fundeni 256-258, RO-022328 Bucharest, Romania
| | - Oliver Grottke
- grid.1957.a0000 0001 0728 696XDepartment of Anaesthesiology, University Hospital Aachen, RWTH, Aachen University, Pauwelsstrasse 30, D-52074 Aachen, Germany
| | - Lars Grønlykke
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Anatole Harrois
- grid.460789.40000 0004 4910 6535Department of Anesthesiology, Intensive Care and Perioperative Medicine, Assistance Publique Hôpitaux de Paris, Paris Saclay University, 78 rue du Général Leclerc, F-94275 Le Kremlin-Bicêtre Cedex, France
| | - Beverley J. Hunt
- grid.420545.20000 0004 0489 3985Thrombosis and Haemophilia Centre, Guy’s and St Thomas’ NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH UK
| | - Alexander Kaserer
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
| | - Radko Komadina
- grid.8954.00000 0001 0721 6013Department of Traumatology, General and Teaching Hospital Celje, Medical Faculty, Ljubljana University, Oblakova ulica 5, SI-3000 Celje, Slovenia
| | - Mikkel Herold Madsen
- grid.5254.60000 0001 0674 042XDepartment of Paediatric and Obstetric Anaesthesia, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Marc Maegele
- grid.412581.b0000 0000 9024 6397Department of Trauma and Orthopaedic Surgery, Cologne-Merheim Medical Centre (CMMC), Institute for Research in Operative Medicine (IFOM), University of Witten/Herdecke, Ostmerheimer Strasse 200, D-51109 Cologne, Germany
| | - Lidia Mora
- grid.7080.f0000 0001 2296 0625Department of Anaesthesiology, Intensive Care and Pain Clinic, Vall d’Hebron Trauma, Rehabilitation and Burns Hospital, Autonomous University of Barcelona, Passeig de la Vall d’Hebron 119-129, ES-08035 Barcelona, Spain
| | - Louis Riddez
- grid.24381.3c0000 0000 9241 5705Department of Surgery and Trauma, Karolinska University Hospital, S-171 76 Solna, Sweden
| | - Carolina S. Romero
- grid.106023.60000 0004 1770 977XDepartment of Anaesthesia, Intensive Care and Pain Therapy, Consorcio Hospital General Universitario de Valencia, Universidad Europea of Valencia Methodology Research Department, Avenida Tres Cruces 2, ES-46014 Valencia, Spain
| | - Charles-Marc Samama
- Department of Anaesthesia, Intensive Care and Perioperative Medicine, GHU AP-HP Centre - Université Paris Cité - Cochin Hospital, 27 rue du Faubourg St. Jacques, F-75014 Paris, France
| | - Jean-Louis Vincent
- grid.4989.c0000 0001 2348 0746Department of Intensive Care, Erasme University Hospital, Université Libre de Bruxelles, Route de Lennik 808, B-1070 Brussels, Belgium
| | - Sebastian Wiberg
- grid.5254.60000 0001 0674 042XDepartment of Thoracic Anaesthesiology, The Heart Centre, Rigshospitalet, University of Copenhagen, Blegdamsvej 9, DK-2100 Copenhagen, Denmark
| | - Donat R. Spahn
- grid.412004.30000 0004 0478 9977Institute of Anaesthesiology, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland
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Whole body CT for trauma reduces emergency department time for patients with lower extremity fractures. Emerg Radiol 2022; 29:449-454. [DOI: 10.1007/s10140-022-02030-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/03/2022] [Indexed: 11/26/2022]
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Studer S, van Veelen NM, van de Wall BJM, Kuner V, Schrading S, Link BC, Knobe M, Babst R, Beeres FJP. Improving the protocol for whole-body CT scans in trauma patients. Eur J Trauma Emerg Surg 2022; 48:3149-3156. [PMID: 35088109 DOI: 10.1007/s00068-021-01862-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2021] [Accepted: 12/11/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE While whole-body computed tomography is an established diagnostic method for the work up of polytraumatized patients, the protocols used differ between trauma centers. This study aimed to compare scan duration and estimated radiation of two protocols. Secondary aim was to assess if using the revised CT protocol reduced the number of additional images of the upper extremities. METHODS Two groups of consecutive trauma patients, which both received a whole-body CT, were analyzed. Patients, who received a three-phased CT during which their arms needed to be repositioned from their side to above the head, were assigned to group A. Those, who received a CT with their arms placed on a pillow ventral to the abdomen throughout the entire scan were assigned to group B. Estimated radiation dose, scan duration, number of upper limb injuries and number of additional images of the upper limbs within 24 h after initial CT were assessed. RESULTS Group A consisted of 182 patients, group B of 218. The scan duration was 3 min shorter (p < 0.001) and the estimated radiation dose lower (15.0 vs 22.9 mSv, p < 0.001) in group B. There was no difference in the number of upper limb injuries detected or the number of upper limb additional images required within 24 h. CONCLUSION Using a whole-body CT scan protocol in which the arms remain on a pillow ventral to the torso instead of one which requires a repositioning of the arms, both scan duration and estimated radiation dose can be reduced. Despite the arms being within the scanned area in the revised protocol, the number of additional imaging of the upper extremities could not be reduced.
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Affiliation(s)
- Stephanie Studer
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Nicole Maria van Veelen
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland.
| | | | - Valerie Kuner
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Simone Schrading
- Department of Radiology and Nuclear Medicine, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Björn-Christian Link
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Matthias Knobe
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
| | - Reto Babst
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
- Department of Health Science and Medicine, University of Lucerne, Lucerne, Switzerland
| | - Frank Joseph Paulus Beeres
- Department of Orthopedic and Trauma Surgery, Lucerne Cantonal Hospital, Spitalstrasse, 6000, Lucerne 16, Switzerland
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Almusayliem HA, Kommosani LA, Malebary RM, Althagafi MA, Alghanmi RA, Nematallah QS, Bakhsh A, Bakhsh AA. Yield of whole-body computed tomography at a low-volume emergency department: A 5-year experience. Saudi Med J 2021; 42:428-432. [PMID: 33795499 PMCID: PMC8128644 DOI: 10.15537/smj.2021.42.4.20200722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 03/10/2021] [Indexed: 11/25/2022] Open
Abstract
Objectives: To share our experience with immediate whole-body computed tomography (WBCT) imaging for trauma patients and to determine its association with surgical intervention and hospital admission. Methods: This retrospective observational study included 208 trauma patients who presented to the emergency department and underwent WBCT at the King Abdulaziz University Hospital, Jeddah, Saudi Arabia between January 2014 and November 2018. We excluded pregnant patients and those who went into traumatic cardiac arrest or died before imaging. Results: Of all included patients, 48.6% were adults and 72.1% had positive findings; of these, 36.7% of patients were admitted for observation and 27.3% underwent operative interventions. Conclusion: Whole-body computed tomography is a useful tool to detect significant traumatic injuries in patients presenting to the emergency department. Moreover, it may assist physicians in determining the disposition of these patients. A clear set of criteria should be established to determine which trauma patients require WBCT imaging during initial resuscitation.
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Affiliation(s)
- Hamidh A. Almusayliem
- From the Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
- Address correspondence and reprint request to: Dr. Hamidh A. Almusayliem, Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia. E-mail: ORCID ID: http://orcid.org/0000-0001-8347-0144
| | - Layan A. Kommosani
- From the Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Raghdaa M. Malebary
- From the Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Miral A. Althagafi
- From the Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Reem A. Alghanmi
- From the Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Qusai S. Nematallah
- From the Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Amal Bakhsh
- From the Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
| | - Abdullah A. Bakhsh
- From the Faculty of Medicine, King Abdulaziz University, Jeddah, Kingdom of Saudi Arabia.
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Hussain K, Verma D, Firoz A, Namiq KS, Raza M, Haris M, Bouchama M, Khan S. Radiology and A Radiologist: A Keystone in the Turmoil of Trauma Setting. Cureus 2021; 13:e14267. [PMID: 33959449 PMCID: PMC8093107 DOI: 10.7759/cureus.14267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Traumatic injuries are one of the leading causes of morbidity and mortality. Precise diagnosis and management in the golden hour are key to decrease morbidity and mortality. History and physical examination alone are insufficient to avoid misdiagnosis. In this article, we tried to determine the role of a radiologist and an appropriate imaging modality in a trauma setting. We conducted a literature review of published research articles. We used the keywords imaging, trauma, imaging and trauma, and trauma imaging essentials were used on PubMed and Google Scholar. The articles published in the English language from 2015 to 2020 with full free text available were included. Using the medical subject heading (MeSH) strategy, "diagnostic imaging" (Major {Majr}) and "multiple trauma/diagnostic imaging" (Mesh) on PubMed, we identified 34 papers after applying the inclusion and exclusion criteria. Twenty articles were finally selected which included studies from 2015 to 2020 with articles focusing on the adult population and acute cases. A radiologist and imaging modalities are the essential parts of a trauma setting to lower morbidity and mortality. X-rays and Extended Focussed Assessment with Sonography for Trauma (eFAST) are the first-line imaging modality in the acute trauma setting. However, the CT scan is the most sensitive modality that should be done to avoid misdiagnosis depending upon the patient's history and physical examination.
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Affiliation(s)
- Khadija Hussain
- Radiology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Deepak Verma
- Internal Medicine/Family Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Amena Firoz
- Pediatrics, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Karez S Namiq
- Oncology, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Maham Raza
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Muhammad Haris
- Internal Medicine, Royal Lancaster Infirmary, Health Education England North West, Lancaster, GBR.,Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Manel Bouchama
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
| | - Safeera Khan
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
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Weger K, Hammer P, McKinley T, Steenburg S. Incidence and clinical impact of lower extremity vascular injuries in the setting of whole body computed tomography for trauma. Emerg Radiol 2020; 28:265-272. [PMID: 32857232 DOI: 10.1007/s10140-020-01847-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Accepted: 08/20/2020] [Indexed: 12/19/2022]
Abstract
PURPOSE The aims of this study are to determine the incidence of lower extremity fractures and/or vascular injuries in the setting of whole body computed tomography (WBCT) for trauma and to determine lower extremity injury outcomes in this patient population. METHODS This is a retrospective observational study performed at a large urban Level 1 trauma center. Our institutional trauma registry was queried for patients who were evaluated with WBCT and lower extremity CT angiography (CTA) as a part of their initial imaging evaluation over a 43-month period. Patients with lower extremity fractures and/or vascular injuries were identified. Those patients with both lower extremity vascular injury and fracture were then analyzed to determine the physical relationship of the fracture to the vascular injury. Physical exam findings were extracted from the medical record. Interventions and long-term outcomes were determined from the medical record. RESULTS A total of 370 patients met the inclusion criteria, with 98% experiencing blunt trauma. Of these, 290 (78.4%) were positive for lower extremity injury, including 266 (71.9%) with isolated fractures, 2 (0.6%) with isolated vascular injury, and 22 (5.9%) with vascular injury associated with long bone fracture. Of the 22 patients with combined fracture and vascular injury, 8 received vascular intervention and 10 had long-term complications as a result of their injuries. Physical exam findings were insufficient to diagnose 57% of the vascular injuries. CONCLUSIONS The inclusion of lower extremity CTA as part of a WBCT imaging exam for trauma allows for the identification of vascular injuries that otherwise may have gone undetected or resulted in delayed diagnosis. Clinically occult lower extremity vascular injuries may be associated with poor outcomes.
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Affiliation(s)
- Kendal Weger
- Indiana University School of Medicine and Indiana University Health, Indianapolis, IN, USA.
| | - Peter Hammer
- Indiana University School of Medicine and Indiana University Health, Indianapolis, IN, USA
| | - Todd McKinley
- Indiana University School of Medicine and Indiana University Health, Indianapolis, IN, USA
| | - Scott Steenburg
- Indiana University School of Medicine and Indiana University Health, Indianapolis, IN, USA
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Bieler D, Paffrath T, Schmidt A, Völlmecke M, Lefering R, Kulla M, Kollig E, Franke A. Why do some trauma patients die while others survive? A matched-pair analysis based on data from Trauma Register DGU®. Chin J Traumatol 2020; 23:224-232. [PMID: 32576425 PMCID: PMC7451614 DOI: 10.1016/j.cjtee.2020.05.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Revised: 11/21/2019] [Accepted: 01/02/2020] [Indexed: 02/04/2023] Open
Abstract
PURPOSE The mortality rate for severely injured patients with the injury severity score (ISS) ≥16 has decreased in Germany. There is robust evidence that mortality is influenced not only by the acute trauma itself but also by physical health, age and sex. The aim of this study was to identify other possible influences on the mortality of severely injured patients. METHODS In a matched-pair analysis of data from Trauma Register DGU®, non-surviving patients from Germany between 2009 and 2014 with an ISS≥16 were compared with surviving matching partners. Matching was performed on the basis of age, sex, physical health, injury pattern, trauma mechanism, conscious state at the scene of the accident based on the Glasgow coma scale, and the presence of shock on arrival at the emergency room. RESULTS We matched two homogeneous groups, each of which consisted of 657 patients (535 male, average age 37 years). There was no significant difference in the vital parameters at the scene of the accident, the length of the pre-hospital phase, the type of transport (ground or air), pre-hospital fluid management and amounts, ISS, initial care level, the length of the emergency room stay, the care received at night or from on-call personnel during the weekend, the use of abdominal sonographic imaging, the type of X-ray imaging used, and the percentage of patients who developed sepsis. We found a significant difference in the new injury severity score, the frequency of multi-organ failure, hemoglobine at admission, base excess and international normalized ratio in the emergency room, the type of accident (fall or road traffic accident), the pre-hospital intubation rate, reanimation, in-hospital fluid management, the frequency of transfusion, tomography (whole-body computed tomography), and the necessity of emergency intervention. CONCLUSION Previously postulated factors such as the level of care and the length of the emergency room stay did not appear to have a significant influence in this study. Further studies should be conducted to analyse the identified factors with a view to optimising the treatment of severely injured patients. Our study shows that there are significant factors that can predict or influence the mortality of severely injured patients.
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Affiliation(s)
- Dan Bieler
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany; Department of Orthopaedics and Trauma Surgery, Heinrich Heine University Hospital, Düsseldorf, 40225, Germany.
| | - Thomas Paffrath
- Department of Trauma and Orthopaedic Surgery, Witten/Herdecke University, Faculty of Health - School of Medicine, Cologne, 51109, Germany
| | - Annelie Schmidt
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
| | - Maximilian Völlmecke
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, 51109, Germany
| | - Martin Kulla
- Department of Anaesthesiology and Intensive Care, German Armed Forces Hospital Ulm, Ulm, 89081, Germany
| | - Erwin Kollig
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
| | - Axel Franke
- Department of Trauma Surgery and Orthopaedics, Reconstructive and Hand Surgery, Burn Medicine, German Armed Forces Central Hospital Koblenz, Koblenz 56072, Germany
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Mortani Barbosa EJ, Osuntokun O. Incidental findings in thoracic CTs performed in trauma patients: an underestimated problem. Eur Radiol 2019; 29:6772-6779. [PMID: 31264016 DOI: 10.1007/s00330-019-06313-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Revised: 04/30/2019] [Accepted: 06/07/2019] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Whole-body CT scans are commonly performed to assess trauma patients, and often reveal incidental findings (IFs) the patient may be unaware of. We assessed the prevalence, associations, and adequacy of follow-up of IFs. METHODS We retrospectively identified 1113 patients who had a chest CT to assess for traumatic injuries (6-year interval). We coded the radiology reports for IFs and queried our EMR regarding clinical history and adherence to follow-up recommendations for IFs mentioned in the reports. RESULTS IFs are much more likely (62.2%) to be found in a chest CT scan than acute traumatic injuries (ATI, 32.4%), in patients being evaluated for potential traumatic injuries. A total of 86.4% of patients who had IFs also had another relevant ICD-10 diagnosis (RD). Lung nodules were the most common IF (45.7%). A multivariate logistic regression model (MLR) demonstrated an accuracy of 89% to predict IFs; the 3 statistically significant predictors (p < 0.05) were any RD (FDR logworth 68.6), followed by smoking history (29.8) and age (4.1). Radiologists recommended follow-up for IF 53.5% of the time, but only 13.9% of patients ever received a follow-up imaging exam or invasive procedure. CONCLUSIONS IFs are much more common than ATI and can be accurately predicted based on MLR utilizing only 3 clinical variables. While radiologists often recommend follow-up for IFs in trauma patients, most are never effectively followed up or addressed, leading to increased risk of poor outcomes. Clinicians should be aware of the high prevalence of IFs and develop systems for appropriate, evidence-based recommendations, and effective management. KEY POINTS • Incidental findings (IFs) are much more common (2×) than acute traumatic injuries (ATI) in chest CTs performed in trauma patients. • IFs can be accurately predicted via logistic regression modeling with only 3 variables (any relevant ICD-10 diagnosis; positive smoking history; age), which may help radiologist to focus their attention on higher risk patients. • Radiologists recommend follow-up for IFs more than half of the time; however, IFs are seldom followed up appropriately (less than 14%), leading to missed opportunities and potentially poor patient outcomes.
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Affiliation(s)
- Eduardo J Mortani Barbosa
- Division of Cardiothoracic Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Ground Floor Founders Bldg., Philadelphia, PA, 19104, USA.
| | - Oladayo Osuntokun
- Division of Cardiothoracic Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, Ground Floor Founders Bldg., Philadelphia, PA, 19104, USA
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Routine versus selective chest and abdominopelvic CT-scan in conscious blunt trauma patients: a randomized controlled study. Eur J Trauma Emerg Surg 2017; 44:9-14. [PMID: 28948295 DOI: 10.1007/s00068-017-0842-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Accepted: 09/14/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE CT-scan is increasingly used in blunt trauma, but the real impact on patient outcome is still unclear. This study was conducted to assess the effect of performing routine (versus selective) chest and abdominopelvic CT-scan on patient admission time and outcome in blunt trauma. METHODS Conscious and hemodynamically stable high-energy trauma patients were included (n = 140). Routine chest and abdominopelvic CT-scan was requested in addition to the conventional radiography and ultrasound for the intervention group and selective CT-scan according to clinical presentation was done for the control group. Patient admission times in the emergency room and surgery ward, complications, and performed surgical procedures were assessed. "Unsuspected injuries" defined as additional findings on CT-scan, which were not expected before CT-scan, were evaluated. RESULTS Admission time in the emergency ward and admission time in hospital were significantly shorter in the intervention group. Complications were similar in both groups. Abdominopelvic CT-scan in the intervention group revealed nine (7.8%) unsuspected injuries. All of these nine patients had also a positive clinical examination and injuries in other body regions. Chest CT-scan in the intervention group led to additional diagnoses in 17 patients (24.28%) leading to tube thoracostomy in 13 patients (18.57%). CONCLUSION Routine chest and abdominopelvic CT-scan in conscious blunt trauma patients decreases the hospitalization time, but has no impact on patient outcome and probably might lead to overtreatment of occult injuries. The option of using a selective approach should be further evaluated to decrease radiation exposure and facility overuse.
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Alagic Z, Eriksson A, Drageryd E, Motamed SR, Wick MC. A new low-dose multi-phase trauma CT protocol and its impact on diagnostic assessment and radiation dose in multi-trauma patients. Emerg Radiol 2017; 24:509-518. [PMID: 28378236 PMCID: PMC5596047 DOI: 10.1007/s10140-017-1496-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 03/27/2017] [Indexed: 11/30/2022]
Abstract
Purpose Computed tomography (CT) examinations, often using high-radiation dosages, are increasingly used in the acute management of polytrauma patients. This study compares a low-dose polytrauma multi-phase whole-body CT (WBCT) protocol on a latest generation of 16-cm detector 258-slice multi-detector CT (MDCT) scanner with advanced dose reduction techniques to a single-phase polytrauma WBCT protocol on a 64-slice MDCT scanner. Methods Between March and September 2015, 109 polytrauma patients (group A) underwent acute WBCT with a low-dose multi-phase WBCT protocol on a 258-slice MDCT whereas 110 polytrauma patients (group B) underwent single-phase trauma CT on a 64-slice MDCT. The diagnostic accuracy to trauma-related injuries, radiation dose, quantitative and semiquantitative image quality parameters, subjective image quality scorings, and workflow time parameters were compared. Results In group A, statistically significantly more arterial injuries (p = 0.04) and arterial dissections (p = 0.002) were detected. In group A, the mean (±SD) dose length product value was 1681 ± 183 mGy*cm and markedly lower when compared to group B (p < 0.001). The SDs of the mean Houndsfield unit values of the brain, liver, and abdominal aorta were lower in group A (p < 0.001). Mean signal-to-noise ratios (SNRs) for the brain, liver, and abdominal aorta were significantly higher in group A (p < 0.001). Group A had significantly higher image quality scores for all analyzed anatomical locations (p < 0.02). However, the mean time from patient registration until completion of examination was significantly longer for group A (p < 0.001). Conclusions The low-dose multi-phase CT protocol improves diagnostic accuracy and image quality at markedly reduced radiation. However, due to technical complexities and surplus electronic data provided by the newer low-dose technique, examination time increases, which reduces workflow in acute emergency situations.
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Affiliation(s)
- Zlatan Alagic
- Functional Unit for Musculoskeletal Radiology, Function Imaging and Physiology, Karolinska University Hospital, Karolinska Vägen Solna, SE-17176, Stockholm, Sweden
| | - Andreas Eriksson
- Functional Unit for Musculoskeletal Radiology, Function Imaging and Physiology, Karolinska University Hospital, Karolinska Vägen Solna, SE-17176, Stockholm, Sweden
| | - Erika Drageryd
- General Electrics Healthcare Sverige AB, Danderyd, Sweden
| | - Sara Rezaei Motamed
- Functional Unit for Musculoskeletal Radiology, Function Imaging and Physiology, Karolinska University Hospital, Karolinska Vägen Solna, SE-17176, Stockholm, Sweden
| | - Marius C Wick
- Functional Unit for Musculoskeletal Radiology, Function Imaging and Physiology, Karolinska University Hospital, Karolinska Vägen Solna, SE-17176, Stockholm, Sweden. .,Diagnostic Radiology, Institute for Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden.
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Crönlein M, Holzapfel K, Beirer M, Postl L, Kanz KG, Pförringer D, Huber-Wagner S, Biberthaler P, Kirchhoff C. Evaluation of a new imaging tool for use with major trauma cases in the emergency department. BMC Musculoskelet Disord 2016; 17:482. [PMID: 27855665 PMCID: PMC5114770 DOI: 10.1186/s12891-016-1337-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 11/10/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The aim of this study was to evaluate potential benefits of a new diagnostic software prototype (Trauma Viewer, TV) automatically reformatting computed tomography (CT) data on diagnostic speed and quality, compared to CT-image data evaluation using a conventional CT console. METHODS Multiple trauma CT data sets were analysed by one expert radiology and one expert traumatology fellow independently twice, once using the TV and once using the secondary conventional CT console placed in the CT control room. Actual analysis time and precision of diagnoses assessment were evaluated. The TV and CT-console results were compared respectively, but also a comparison to the initial multiple trauma CT reports assessed by emergency radiology fellows considered as the gold standard was performed. Finally, design and function of the Trauma Viewer were evaluated in a descriptive manner. RESULTS CT data sets of 30 multiple trauma patients were enrolled. Mean time needed for analysis of one CT dataset was 2.43 min using the CT console and 3.58 min using the TV respectively. Thus, secondary conventional CT console analysis was on average 1.15 min shorter compared to the TV analysis. Both readers missed a total of 11 diagnoses using the secondary conventional CT console compared to 12 missed diagnoses using the TV. However, none of these overlooked diagnoses resulted in an Abbreviated Injury Scale (AIS) > 2 corresponding to life threatening injuries. CONCLUSIONS Even though it took the two expert fellows a little longer to analyse the CT scans on the prototype TV compared to the CT console, which can be explained by the new user interface of the TV, our preliminary results demonstrate that, after further development, the TV might serve as a new diagnostic feature in the trauma room management. Its high potential to improve time and quality of CT-based diagnoses might help in fast decision making regarding treatment of severely injured patients.
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Affiliation(s)
- Moritz Crönlein
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany, Ismaninger Strasse 22, 81675, Munich, Germany.
| | - Konstantin Holzapfel
- Department of Diagnostic and Interventional Radiology, Klinikum rechts der Isar, Technical University of Munich, Germany, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Marc Beirer
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Lukas Postl
- Department of Oral and Maxillofacial Surgery, Kepler University Hospital, Johannes Kepler University, Krankenhausstraße 9, 4021, Linz, Austria
| | - Karl-Georg Kanz
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Dominik Pförringer
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Stefan Huber-Wagner
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Peter Biberthaler
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany, Ismaninger Strasse 22, 81675, Munich, Germany
| | - Chlodwig Kirchhoff
- Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Germany, Ismaninger Strasse 22, 81675, Munich, Germany
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