Routine helical computed tomographic evaluation of the mediastinum in high-risk blunt trauma patients

Diagnosis of blunt thoracic aortic injury with electrocardiogram-gated computed tomography in pediatric patient: A case report

Computed tomography (CT) is a sensitive and specific test for thoracic aortic injury, and is the choice of diagnostic test for adult patients. However, the diagnostic accuracy of conventional CT in pediatric patients has not been elucidated, and the diagnostic strategy has not been clarified. We present the case of an eight-year-old patient who had a thoracic injury, with left open pneumothorax, pulmonary contusion, and multiple left-sided rib fractures. Although the findings on conventional CT were insufficient either to diagnose or deny as having thoracic aortic injury, additional examination using electrocardiogram-gated CT angiography and three-dimensional reconstruction revealed a localized enlarged aortic diameter with an intimal flap. Electrocardiogram-gated CT may be useful for diagnosing thoracic aortic injury in pediatric patients.

Chest x-ray vs. computed tomography of the chest in pediatric blunt trauma

INTRODUCTION

Chest x-ray (CXR) has been shown to be an effective detection tool for clinically significant trauma. We evaluated differences in findings between CXR and computed tomography of the chest (CCT), their impact on clinical management and the performance of the CXR.

METHODS

This retrospective study examined children (less than 18 years) who received a CXR and CCT between 2009 and 2015. We compared characteristics of children by conducting univariate analysis, reporting the proportion of additional diagnoses captured by CCT, and using it to evaluate the sensitivity and specificity of the CXR. Outcome variables were diagnoses made by CCT as well as the ensuing changes in the clinical management attributable to the diagnoses reported by the CCT and not observed by the CXR.

RESULTS

In 1235 children, CCT was associated with diagnosing higher proportions of contusion or atelectasis (60% vs 31%; p < .0001), pneumothorax (23% vs 9%; p < .0001), rib fracture (18% vs 7%; p < .0001), other fracture (20% vs 10%; p < .0001), diaphragm rupture (0.2% vs 0.1%; p = .002), and incidental findings (7% vs 2%; p < .0001) as compared to CXR. CCT findings changed the management of 107 children (8.7%) with 32 (2.6%) of the changes being surgical procedures. The overall sensitivity and specificity of the CXR were 57.9% (95% CI: 54.5-61.2) and 90.2% (95% CI: 86.8-93.1), respectively. The positive predictive value and negative predictive value were 93.1% and 48.6%, respectively.

CONCLUSION

CXR is a useful initial screening tool to evaluate pediatric trauma patients along with clinical presentation in the Emergency Department in children.

LEVEL OF EVIDENCE

Level III, diagnostic test.

Blunt chest trauma: a clinical chameleon

The incidence of blunt chest trauma (BCT) is greater than 15% of all trauma admissions to the emergency departments worldwide and is the second leading cause of death after head injury in motor vehicle accidents. The mortality due to BCT is inhomogeneously described ranging from 9% to 60%. BCT is commonly caused by a sudden high-speed deceleration trauma to the anterior chest, leading to a compression of the thorax. All thoracic structures might be injured as a result of the trauma. Complex cardiac arrhythmia, heart murmurs, hypotension, angina-like chest pain, respiratory insufficiency or distention of the jugular veins may indicate potential cardiac injury. However, on admission to emergency departments symptoms might be missing or may not be clearly associated with the injury. Accurate diagnostics and early management in order to prevent serious complications and death are essential for patients suffering a BCT. Optimal initial diagnostics includes echocardiography or CT, Holter-monitor recordings, serial 12-lead electrocardiography and measurements of cardiac enzymes. Immediate diagnostics leading to the appropriate therapy is essential for saving a patient’s life. The key aspect of the entire management, including diagnostics and treatment of patients with BCT, remains an interdisciplinary team involving cardiologists, cardiothoracic surgeons, imaging radiologists and trauma specialists working in tandem.

Emergency Computed Tomography Angiogram of the Chest, Abdomen, and Pelvis

In the setting of blunt trauma, the rapid assessment of internal injuries is essential to prevent potentially fatal outcomes. Computed tomography is a useful diagnostic tool for both screening and diagnosis. In addition to trauma, acute chest syndromes often warrant emergent computed tomographic angiography, looking for etiologies such as aortic aneurysms or complications of aortic aneurysms, or both, pulmonary emboli, as well as other acute vascular process like aortic dissection and Takayasu aortitis. With continued improvements in diagnostic imaging, computed tomographic angiography of the chest, abdominal and pelvis proves to be an effective modality to image the aorta and other major vascular structures.

Trends in nonoperative management of traumatic injuries - A synopsis

Nonoperative management of both blunt and penetrating injuries can be challenging. During the past three decades, there has been a major shift from operative to increasingly nonoperative management of traumatic injuries. Greater reliance on nonoperative, or "conservative" management of abdominal solid organ injuries is facilitated by the various sophisticated and highly accurate noninvasive imaging modalities at the trauma surgeon's disposal. This review discusses selected topics in nonoperative management of both blunt and penetrating trauma. Potential complications and pitfalls of nonoperative management are discussed. Adjunctive interventional therapies used in treatment of nonoperative management-related complications are also discussed.

REPUBLISHED WITH PERMISSION FROM

Stawicki SPA. Trends in nonoperative management of traumatic injuries - A synopsis. OPUS 12 Scientist 2007;1(1):19-35.

Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma

BACKGROUND

Blunt traumatic aortic injury (BTAI) is the second most common cause of death in trauma patients. Eighty percent of patients with BTAI will die before reaching a trauma center. The issues of how to diagnose, treat, and manage BTAI were &filig;rst addressed by the Eastern Association for the Surgery of Trauma (EAST) in the practice management guidelines on this topic published in 2000. Since that time, there have been advances in the management of BTAI. As a result, the EAST guidelines committee decided to develop updated guidelines for this topic using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) framework recently adopted by EAST.

METHODS

A systematic review of the MEDLINE database using PubMed was performed. The search retrieved English language articles regarding BTAI from 1998 to 2013. Letters to the editor, case reports, book chapters, and review articles were excluded. Topics of investigation included imaging to diagnose BTAI, type of operative repair, and timing of operative repair.

RESULTS

Sixty articles were identi&filig;ed. Of these, 51 articles were selected to construct the guidelines.

CONCLUSION

There have been changes in practice since the publication of the previous guidelines in 2000. Computed tomography of the chest with intravenous contrast is strongly recommended to diagnose clinically signi&filig;cant BTAI. Endovascular repair is strongly recommended for patients without contraindications. Delayed repair of BTAI is suggested, with the stipulation that effective blood pressure control must be used in these patients.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET: Is CT thorax necessary to exclude significant injury in paediatric patients with blunt chest trauma?

A shortcut review was carried out to establish if CXR had sufficient sensitivity to rule out significant thoracic injury in haemodynamically stable, paediatric patients with a significant mechanism of trauma. No studies were found that directly answered the three-part question, but 13 studies were found which were considered relevant. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that important thoracic injuries may not be clinically apparent and that CT scans have a significantly higher sensitivity than CXR in detecting such injuries.

CT Chest with IV Contrast Compared with CT Angiography after Blunt Trauma

Blunt aortic injury (BAI) after chest trauma is a potentially lethal condition. Rapid diagnosis is important to appropriately treat patients. The purpose of this study was to compare CT with intravenous contrast (CTI) to CT with angiography (CTA) in the initial evaluation of blunt chest trauma patients. This was a retrospective review of all blunt trauma patients who received a CTI or CTA during the initial evaluation at an urban Level I trauma center from January 1, 2010 to December 31, 2013. Two-hundred and eighty-one trauma patients met inclusion criteria. Most, 167/281 (59%) received CTI and 114/281 (41%) received CTA. There were no differences between cohorts in age, gender, initial heart rate, systolic blood pressure, and Glasgow Coma Scale in emergency department. Mortality rates were similar for CTI and CTA (4% vs 8%, P = 0.20). CTI identified an injury in 54 per cent compared with 46 per cent in CTA ( P = 0.05). Overall, 2 per cent of patients had BAI with similar rates in CTI and CTA (2% vs 2%, P = 0.80). BAI was not missed using either CTI or CTA. Trauma patients studied with CTI had similar diagnostic findings as CTA. CTI may be preferable to CTA during the initial assessment for possible BAI because of a single contrast injection for whole body CT.

The utility of chest X-ray as a screening tool for blunt thoracic aortic injury

BACKGROUND

The early and accurate identification of patients with blunt thoracic aortic injury (BTAI) remains a challenge. Traditionally, a portable AP chest X-ray (CXR) is utilized as the initial screening modality for BTAI, however, there is controversy surrounding its sensitivity. The purpose of this study was to assess the sensitivity of CXR as a screening modality for BTAI.

METHODS

After IRB approval, all adult (≥18 yo) blunt trauma patients admitted to LAC+USC (01/2011-12/2013) who underwent CXR and chest CT were retrospectively reviewed. Final radiology attending CXR readings were reviewed for mediastinal abnormalities (widened mediastinum, mediastinal to chest width ratio greater than 0.25, irregular aortic arch, blurred aortic contour, opacification of the aortopulmonary window, and apical pleural haematoma) suggestive of aortic injury. Chest CT final attending radiologist readings were utilized as the gold standard for diagnosis of BTAI. The primary outcome analyzed was CXR sensitivity.

RESULTS

A total of 3728 patients were included in the study. The majority of patients were male (72.6%); mean age was 43 (SD 20). Median ISS was 9 (IQR 4-17) and median GCS was 15 (IQR 14-15). The most common mechanism of injury was MVC (48.0%), followed by fall (20.6%), and AVP (16.9%). The total number of CXRs demonstrating a mediastinal abnormality was 200 (5.4%). Widened mediastinum was present on 191 (5.1%) of CXRs, blurred aortic contour on 10 (0.3%), and irregular aortic arch on 4 (0.1%). An acute aortic injury confirmed by chest CT was present in 17 (0.5%) patients. Only 7 of these with CT-confirmed BTAI had a mediastinal abnormality identified on CXR, for a sensitivity of 41% (95% CI: 19-67%).

CONCLUSION

The results from this study suggest that CXR alone is not a reliable screening modality for BTAI. A combination of screening CXR and careful consideration of other factors, such as mechanism of injury, will be required to effectively discriminate between those who should and should not undergo chest CT.

Variation in Computed Tomography Imaging for Pediatric Injury-Related Emergency Visits

OBJECTIVE

To assess variation in the use of computed tomography (CT) for pediatric injury-related emergency department (ED) visits.

STUDY DESIGN

This was a retrospective cohort study of visits to 14 network-affiliated EDs from November 2010 through February 2013. Visits were identified by International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes. Primary outcome was CT use. We used descriptive statistics and performed multivariable logistic regression to evaluate the association of patient and ED covariates on any and body region-specific CT use.

RESULTS

Of the 80 868 injury-related visits, 11.4% included CT, and 28.4% of those involved more than 1 CT. Across EDs, CT use ranged from 7.6% to 25.5% of visits and did not correlate with institutional Injury Severity Score (P = .33) or admission/transfer rates (P = .07). In multivariable analysis of nonpediatric EDs, trauma centers and nonacademic EDs were associated with CT use. Higher pediatric volume was associated with any CT use; however, there was an inverse relationship between volume and nonhead CT use. When the pediatric ED was included in multivariable modeling, the effect of level 1-3 trauma center designation remained, and the pediatric level 1 trauma center was less likely to use most body region-specific CTs.

CONCLUSION

There is wide variation in CT imaging for pediatric injury-related visits not attributable solely to case mix. Future work to optimize CT utilization should focus on additional factors contributing to imaging practices and interventions.

CT Chest with IV Contrast Compared with CT Angiography after Blunt Trauma

Blunt aortic injury (BAI) after chest trauma is a potentially lethal condition that requires rapid diagnosis for appropriate treatment. We compared CT with IV contrast (CTI) with CT with angiography (CTA) during the initial phase of care at an urban Level I trauma center from January 1, 2010 to December 31, 2013. Overall, 281 patients met inclusion criteria with 167 (59%) CTI and 114 (41%) CTA. There were no differences between cohorts in age, gender, initial heart rate, systolic blood pressure, and Glasgow Coma Scale. Mortality rates were similar for CTI and CTA (4% vs 8%, P = 0.20). CTI identified any chest injury in 54 per cent of patients compared with 46 per cent with CTA ( P = 0.05). The rate of BAI was similar with CTI and CTA (2% vs 2%, P = 0.80), and neither modality was falsely negative. We conclude that CTI and CTA are similar at evaluating trauma patients for BAI, although CTI may be preferable during the initial assessment phase because the contrast injection may be combined with abdominal scanning and image time is reduced when whole-body CT is required.

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

PURPOSE

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

SUBJECTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Aortic dissection associated with blunt chest trauma diagnosed by elevated D-dimer

INTRODUCTION

Similar to spontaneous aortic dissection, traumatic aortic dissection is diagnosed with a careful history and physical exam, chest radiograph, and ultimately, dedicated aortic imaging. The diagnosis of spontaneous aortic dissection may be aided by using the serum D-dimer test. The use of D-dimer for diagnosing aortic injury in the setting of blunt trauma has not previously been reported.

PRESENTATION OF CASE

We present a case of aortic dissection in a 61-year-old male diagnosed when the patient presented with chest pain after blunt chest trauma.

DISCUSSION

The patient had no known history or risk factors for aortic disease. None of the classic findings were present by history, physical examination or chest radiograph and the diagnosis was made as the result of an elevated D-dimer. We discuss how the D-dimer test fortuitously led to the diagnosis in this case, and the implications.

CONCLUSION

D-dimer could be helpful in diagnosing aortic injuries in low-risk chest trauma patients.

Assessment and treatment of the trauma patient in shock

High-volume crystalloid resuscitation is associated with increased length of stay, ICU and ventilator days, and organ failure and infection rates. Rapid evaluation of a hemodynamically unstable trauma patient is vital to diagnosis and treatment of the cause of shock. CT scanning should be used liberally in trauma patients to effect decreased mortality. Nonoperative management and catheter-based interventions are becoming the standard of care in appropriately selected patients with solid organ injuries.

Penetrating cardiac injury and the significance of chest computed tomography findings

In rare circumstances, hemodynamically stable patients can harbor serious penetrating cardiac injuries. We hypothesized that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed. Those having an admission CCT were studied. The potential diagnostic value of hemopericardium (HPC) and pneumopericardium (PPC) on CCT was examined. Most of the 333 patients were male [293 (88.0 %)] with a roughly equal distribution of gunshot [189 (56.8 %)] and stab [144 (43.2 %)] wounds. Mean age was 28.7 ± 12.6 years. Thirteen (3.9 %) patients had cardiac injuries that were operatively managed. Eleven (3.3 %) CCT studies demonstrated HPC and/or PPC. Ten of these patients had an injury with one false positive. Retained hemothorax and proximity findings on the three false negative CCT studies led to video-assisted thoracoscopic surgery or subxiphoid exploration with diagnosis of the injury. HPC and/or PPC on CCT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, including all findings that changed management, CCT had a sensitivity and NPV of 100 %. CCT is a potentially useful modality for the evaluation of cardiac injuries in high-risk stable patients. The presence of HPC and/or PPC on CCT after penetrating thoracic trauma is highly indicative of a significant cardiac injury.

Ventilator-associated pneumonia in severe traumatic brain injury: the clinical significance of admission chest computed tomography findings

BACKGROUND

Ventilator-associated pneumonia (VAP) in severe traumatic brain injury (STBI) is a significant morbidity. Bilateral dependent consolidation (BDC) can be seen on admission chest computed tomography (CCT) in STBI. We hypothesize that this finding may be associated with VAP.

MATERIALS AND METHODS

We retrospectively studied patients who sustained STBI after blunt injury and survived >48 h, who were admitted over a 40-mo period. We defined STBI as an admission Glasgow Coma Scale Score ≤ 8. We identified VAP by an elevated white blood cell count, a new infiltrate on chest x-ray, and a positive respiratory culture in a ventilated patient. Variables included demographics, injury, admission CCT, and culture data. We compared BDC-positive and BDC-negative patients.

RESULTS

There were 33 cases of VAP in 94 study patients (35.1%), in whom the incidence of intracranial pressure (ICP) monitoring (66.7% versus 39.3%; P = 0.011) was significantly increased. Ventilator-associated pneumonia was significantly increased in the 28 patients (29.8%) in the BDC-positive group (16 [57.1%] versus 17 (25.6%); P = 0.004). Bilateral dependent consolidation independently predicted VAP. In the 33 VAP cases, gram-negative organisms were present in 27 patients (81.8%), with a predominance of Enterobacteriaceae (16 patients [48.5%]). Culture results did not significantly differ between the early (<4 d) versus late or BDC-positive versus BDC-negative VAP groups.

CONCLUSIONS

Ventilator-associated pneumonia is common after STBI, and BDC is independently associated; however, there is no predilection for specific organisms. Admission CCT findings may prove useful in identifying a group of STBI patients at higher risk for VAP.

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

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

Initial management and resuscitation of severe chest trauma

Severe chest trauma, blunt or penetrating, is responsible for up to 25% of traumatic deaths in North America. Respiratory compromise is the most frequent dramatic presentation in blunt trauma, while injuries to the heart and great vessels pose the greatest risk of immediate death following penetrating trauma. More than 80% of patients will be managed with interventions that can be performed in the emergency department. This article reviews the presentation, diagnosis, and management of the most important thoracic injuries. A structured approach to the acutely unstable patient is proposed to guide resuscitation decisions.

Shoulder girdle: patterns of trauma and associated injuries

OBJECTIVES

To develop a system of quantification of shoulder girdle injuries that stratifies their severity and to assess the association between shoulder girdle injuries and associated nonbony injuries to the head, thorax, and great vessels.

DESIGN

Retrospective review.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Trauma registry data from all patients who required admission to the hospital from October 1995 through January 2008, specifically patients with shoulder girdle injuries. Excluded were patients with isolated burns and late effects of injuries.

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

The patterns of shoulder girdle injury and their association with severe, nonorthopaedic injuries (head, thoracic, and great vessel). Also, the severity of all combinations of shoulder girdle injuries were observed using two systems (relative risk totals and injury severity score).

RESULTS

Of 52,924 patients recorded, 2971 had 3811 shoulder girdle injuries. High-energy mechanisms prevailed, causing over 91% of all shoulder girdle injuries. The rates of head, great vessel, and thoracic injury in patients with a shoulder girdle injury were 31.5%, 3.9%, and 36.8%, respectively, and were significant when compared with nonshoulder girdle injuries (P < 0.001). The two most severe injury combinations included a sternum injury with either a clavicle or scapula fracture.

CONCLUSIONS

Shoulder girdle injuries are strongly associated with great vessel, thoracic, and head injuries. In the presence of a sternum injury with a clavicle fracture or any open clavicle fracture, we recommend the routine use of a contrast-enhanced spiral thoracic computed tomography scan to aid in the diagnosis of a great vessel injury.

Blunt thoracic aortic injuries: an autopsy study

OBJECTIVE

The objective of this study was to identify the incidence and patterns of thoracic aortic injuries in a series of blunt traumatic deaths and describe their associated injuries.

METHODS

All autopsies performed by the Los Angeles County Department of Coroner for blunt traumatic deaths in 2005 were retrospectively reviewed. Patients who had a traumatic thoracic aortic (TTA) injury were compared with the victims who did not have this injury for differences in baseline characteristics and patterns of associated injuries.

RESULTS

During the study period, 304 (35%) of 881 fatal victims of blunt trauma received by the Los Angeles County Department of Coroner underwent a full autopsy and were included in the analysis. The patients were on average aged 43 years±21 years, 71% were men, and 39% had a positive blood alcohol screen. Motor vehicle collision was the most common mechanism of injury (50%), followed by pedestrian struck by auto (37%). A TTA injury was identified in 102 (34%) of the victims. The most common site of TTA injury was the isthmus and descending thoracic aorta, occurring in 67 fatalities (66% of the patients with TTA injuries). Patients with TTA injuries were significantly more likely to have other associated injuries: cardiac injury (44% vs. 25%, p=0.001), hemothorax (86% vs. 56%, p<0.001), rib fractures (86% vs. 72%, p=0.006), and intra-abdominal injury (74% vs. 49%, p<0.001) compared with patients without TTA injury. Patients with a TTA injury were significantly more likely to die at the scene (80% vs. 63%, p=0.002).

CONCLUSION

Thoracic aortic injuries occurred in fully one third of blunt traumatic fatalities, with the majority of deaths occurring at the scene. The risk for associated thoracic and intra-abdominal injuries is significantly increased in patients with thoracic aortic injuries.

The Clinical Significance of Occult Thoracic Injury in Blunt Trauma Patients

Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many injuries previously undetected on screening chest x-ray (CXR), termed “occult injury.” The optimal management of occult rib fractures, pneumothoraces (PTX), hemothoraces (HTX), and pulmonary contusions is uncertain. Our objective was to determine the current management and clinical outcome of these occult blunt thoracic injuries. A retrospective review identified patients with blunt thoracic trauma who underwent both CXR and TCT over a 2-year period at a Level I urban trauma center. Patients with acute rib fractures, PTX, HTX, or pulmonary contusion on TCT were included. Patient groups analyzed included: 1) no injury (normal CXR, normal TCT, n = 1337); 2) occult injury (normal CXR, abnormal TCT, n = 205); and 3) overt injury (abnormal CXR, abnormal TCT, n = 227). Patients with overt injury required significantly more mechanical ventilation and had greater mortality than either occult or no injury patients. Occult and no injury patients had similar ventilator needs and mortality, but occult injury patients remained hospitalized longer. No patient with isolated occult thoracic injury required intubation or tube thoracostomy. Occult injuries, diagnosed by TCT only, have minimal clinical consequences but attract increased hospital resources.

Traumatic aortic injury: computerized tomographic findings at presentation and after conservative therapy

OBJECTIVE

To determine the computerized tomographic (CT) findings in traumatic aortic injury (TAI) at presentation and after conservative management.

METHODS

Institutional review board-approved retrospective review of trauma registry during a 6-year period identified class 1 or 2 trauma patients with TAI. The CT findings were correlated with patient outcome.

RESULTS

Forty-eight of 3350 patients had TAI. Seven had TAI limited to the abdominal aorta. Twenty-nine of 48 had early (12) or delayed (17) aortic repair. Common abnormalities were pseudoaneurysms (69%) and intramural hematoma (IMH) (65%). Forty-one of 48 TAI were confirmed on endovascular imaging or surgery. Subsequent CT was available in those who had delayed repair (n = 9) or conservative management (10) and showed stable pseudoaneurysms with resolving IMH (n = 11), resolving IMH (n = 4), intimal flap (n = 2), aortic thrombus (n = 1), and dissection (n = 1).

CONCLUSIONS

Traumatic aortic injury is rare. It commonly involves thoracic aorta with pseudoaneurysm and IMH. Significant TAI in stable patients remains stable on follow-up imaging. Minor TAI may resolve with conservative therapy.

Criteria for the selective use of chest computed tomography in blunt trauma patients

PURPOSE

The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury.

METHODS

This observational study prospectively included consecutive patients (>or=16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre.

RESULTS

We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age >or=55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <-3 mmol/l and haemoglobin <6 mmol/l). Of 855 patients with >or=1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant.

CONCLUSION

Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.

Utility of Thoracic Computed Tomography after Blunt Trauma: When is Chest Radiograph Enough?

The purpose of this study was to identify the utility of thoracic computed tomography (TCT) in blunt trauma patients with a normal admission chest radiograph (CXR). A retrospective study was performed of 200 consecutive blunt trauma patients who received both CXR and TCT. One hundred and forty-three patients had a normal screening CXR; 36 of these patients (25%) had an abnormal TCT. TCT changed the management in only nine of these patients (6%): two required serial CXR for occult pneumothorax, four received additional imaging of the spine, and three were admitted to a monitored bed. Fifty-seven patients had an abnormal initial CXR. Of these, 41 (81%) had an abnormal TCT. TCT changed management in 21 (37%) of these patients: two aortic injuries identified, 12 aortic injuries excluded, two chest tubes placed, one patient taken to the Operating Room, and four patients required further diagnostic evaluation. TCT was significantly more likely to alter management in patients with an abnormal admission CXR (6% vs 37%, P < 0.001). TCT is of limited utility in patients with a normal admission CXR. A diagnostic strategy of obtaining TCT only in patients with abnormal CXR or high-risk mechanism of injury can result in significant cost savings without adversely affecting patient outcomes.

Concomitant aortic valve and internal mammary artery injuries in blunt chest trauma: report of a case

We report a case of concomitant injury to the aortic valve and internal mammary artery (IMA) from nonpenetrating chest trauma. To our knowledge, this is the first such case to be reported. Transcatheter arterial embolization (TAE) following diagnostic angiography offers an effective and minimally invasive treatment for traumatic IMA injuries. Because there might be an asymptomatic interval after traumatic aortic valve injuries, serial physical examinations and repeated echocardiography should be mandatory for patients with de novo heart failure after blunt chest trauma. Transesophageal echocardiography can provide a clearer image of cardiac injuries than transthoracic echocardiography, particularly if there is extensive anterior mediastinal hematoma resulting from IMA trauma.

Vascular injuries after blunt chest trauma: diagnosis and management

Background

Although relatively rare, blunt injury to thoracic great vessels is the second most common cause of trauma related death after head injury. Over the last twenty years, the paradigm for management of these devastating injuries has changed drastically. The goal of this review is to update the reader on current concepts of diagnosis and management of blunt thoracic vascular trauma.

Methods

A review of the medical literature was performed to obtain articles pertaining to both blunt injuries of the thoracic aorta and of the non-aortic great vessels in the chest. Articles were chosen based on authors' preference and clinical expertise.

Discussion

Blunt thoracic vascular injury remains highly lethal, with most victims dying prior to reaching a hospital. Those arriving in extremis require immediate intervention, which may include treatment of other associated life threatening injuries. More stable injuries can often be medically temporized in order to optimize definitive management. Endovascular techniques are being employed with increasing frequency and can often significantly simplify management in otherwise very complex patient scenarios.

Is chest x-ray an adequate screening tool for the diagnosis of blunt thoracic aortic injury?

BACKGROUND

Blunt thoracic aortic injuries (BTAI) have a high mortality rate. For survivors, chest X-ray (CXR) findings are used to determine the need for further diagnostic testing with chest computerized tomography with angiography (CTA) or conventional angiography. We set to determine the adequacy of utilizing CXR alone as a screening tool for BTAI.

METHODS

All patients diagnosed with BTAI at a level I trauma-center during a 7-year-period were identified. CXRs of these patients and those of a control group of blunt trauma patients with an injury severity score >15 were reviewed by four trauma surgeons blinded to the diagnosis. Based on each CXR viewed, the surgeons decided if they would have proceeded to chest CTA, angiography, or required no further studies to rule out BTAI.

RESULTS

In the 7-year-period, 83 patients had BTAI. CXRs were available in 45 patients. The four surgeons viewed 96 CXRs including those of 51 controls. Based on the CXR appearance in patients with BTAI, the surgeons chose to proceed to chest CTA in 38 patients (84.4%), conventional aortography in two patients (4.4%), and no further testing in five patients (11.2%). A widened mediastinum (75%) and loss of the aorto-pulmonary window (40%) were the most frequent CXR abnormalities. Patients with BTAI were more likely to have an abnormal CXR-40 of 45 (88.8%) patients when compared with the controls-25 of 51 (49%)patients-p < 0.001.

CONCLUSIONS

Although CXR is a sensitive screening modality, it failed to identify the possibility of BTAI in 11% of patients. The liberal use of chest CTA after high speed motor vehicle crashes is recommended to minimize the incidence of missed BTAI.

The role of chest computed tomography in trauma

Chest computed tomography (CCT) evaluation for trauma encompasses two main objectives: (1) The evaluation of the acutely injured in the search for diagnoses and (2) follow up assessment or diagnosis of pulmonary complications in the hospitalised patient. In the acute phase of evaluation, CCT has become particularly helpful for the diagnosis of blunt thoracic aortic injury (BAI), great vessel injury, extent of lung contusion, occult hemothorax, occult pneumothorax, spinal fractures and spinal cord injuries and to determine the tract of transmediastinal gun shot wounds. In the subacute phase, CCT has gained popularity for diagnosing pulmonary embolism and evaluation of retained hemothorax. Technological advances have lead to better diagnostic capabilities that can be obtained quickly but, particularly in the trauma patient, there is little consistent data supporting an outcome improvement in the majority of patients despite changes in clinical management. Further data is needed to support use of CCT in select trauma patient populations to increase useful diagnostic yield and cost effectiveness.