Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

Massive Trauma and Resuscitation Strategies

Massive trauma remains the leading cause of mortality among people aged younger than 45 years. In this review, we discuss the initial care and diagnosis of trauma patients followed by a comparison of resuscitation strategies. We discuss various strategies including use of whole blood and component therapy, examine viscoelastic techniques for management of coagulopathy, and consider the benefits and limitations of the resuscitation strategies and consider a series of questions that will be important for researchers to answer to provide the best and most cost-effective therapy for severely injured patients.

The Use of Computerized Tomography Scans in Elective Knee and Hip Arthroplasty—What Do They Tell Us and at What Risk?

The average background radiation exposure in the United States has nearly doubled over the previous quarter century, with almost all the increase derived from medical imaging. Nearly 2% of all cancers in the United States may be attributable to radiation from computerized tomography (CT) scans. Given the nondiagnostic nature of CT scans that are used in elective knee and hip arthroplasty today, special consideration should be given to the inherent risk of radiation exposure with routine use of this technology. Methods to decrease radiation exposure including modulating the settings of the CT machine and using alternative non-CT-based systems can decrease patient exposure to radiation from CT scans. The rapid evolution of CT technology in arthroplasty has allowed for expanded clinical applications, the benefits of which remain controversial.

Optimising whole body computed tomography doses for paediatric trauma patients: a Swiss retrospective analysis

We aimed to evaluate the impact of a low-dose whole-body computed tomography (WBCT) protocol on radiation doses in paediatric major trauma patients. Retrospective cohort study of paediatric trauma patients (<16 years) at a national level 1 paediatric trauma centre (PTC) over a 6 year period prior and post introduction of a low-dose WBCT protocol (2014-2019). Demographic data, patient characteristics, CT device, and exposure information including scan range, dose-length product, and volume CT dose index were collected. Effective dose (ED) and exposure parameters were compared before and after protocol introduction. Forty-eight patients underwent WBCT during the study period. Prior to introduction of the low-dose protocol (n= 18), the ED was 20.6 mSv (median 20.1 ± 5.3 mSv [range 12.5-30.7]). After introduction of the low-dose WBCT protocol (n= 30), mean ED was 4.8 mSv (median 2.6 ± 5.0 [range: 0.8-19.1]). This resulted in a reduction of 77% in mean ED (pvalue <0.001). Significant radiation dose reduction of 77% can be achieved with low-dose WBCT protocols in PTCs.

Full-body MR imaging: a retrospective study on a novel diagnostic approach for children sustaining high-energy trauma

Purpose

Severe accidents are the leading cause of long-term impairment and death in children. A common diagnostic procedure for children exposed to high-injury trauma is full-body contrast-enhanced CT (fbCT). However, the number of fbCT without detected injuries is relevant. In 2007, full-body MRI (fbMRI) was implemented as a diagnostic approach for children sustaining high-energy trauma.

The aim of this cross-sectional retrospective study was to analyze fbMRI as a diagnostic tool for children after high-energy trauma focusing on feasibility, radiological findings, and limitations.

Methods

Diagnostics using fbMRI (from apex of the head to the pelvis) was performed if a child was stable and suffered a high-energy trauma in a Level I Trauma Center in Germany. 105 fbMRIs in patients exposed to high-energy trauma aged ≤ 16 years were performed between January 2007 and December 2018. Four fbMRIs were excluded as conducted for reasons other than trauma. Time between arrival in the emergency department and fbMRI, additional diagnostic procedures, injuries, and non-trauma related pathologies were analyzed.

Results

Mean time between arrival in the emergency department and fbMRI was 71 min (± SD 132 min). Two scans were discontinued and changed to a faster diagnostic procedure. 45% of children had additional X-rays and 11% CT scans. The MRIs showed intracranial abnormalities in 27%, extremities injuries in 26%, spinal injuries in 18%, pelvic, and thoracic injuries in 7% of the cases.

Conclusion

Overall fbMRI is a diagnostic alternative for hemodynamically stable, conscious children after high-energy trauma with the advantages of a radiation-free technique. However, MRI diagnostics take longer than CT scans. Prospective studies will be needed to identify the limiting factors of fbMRIs as primary diagnostic procedure compared to CT scans.

Trial registration

German Clinical Trials Register (DRKS; DRKS00017015).

Level of evidence

Case series, level of evidence V.

Prospective observational cohort study on epidemiology, treatment and outcome of patients with traumatic brain injury (TBI) in German BG hospitals

OBJECTIVES

Since 2000/2001, no large-scale prospective studies addressing traumatic brain injury (TBI) epidemiology in Germany have been published. Our aim was to look for a possible shift in TBI epidemiology described in other European countries, to look for possible changes in TBI management and to identify predictors of 1-year outcome especially in patients with mild TBI.

DESIGN

Observational cohort study.

SETTING

All patients suffering from a TBI of any degree between 1 October 2014 and 30 September 2015, and who arrived in one of the seven participating BG hospitals within 24 hours after trauma, were included.

PARTICIPANTS

In total, 3514 patients were included.

OUTCOME MEASURES

Initial care, acute hospital care and rehabilitation were documented using standardised documentation forms. A standardised telephone interview was conducted 3 and 12 months after TBI in order to obtain information on outcome.

RESULTS

Peaks were identified in males in the early 20s and mid-50s, and in both sexes in the late 70s, with 25% of all patients aged 75 or older. A fall was the most frequent cause of TBI, followed by traffic accidents (especially bicyclists). The number of head CT scans increased, and the number of conventional X-rays of the skull decreased compared with 2000/2001. Besides, more patients were offered rehabilitation than before. Though most TBI were classified as mild, one-third of the patients participating in the telephone interview after 12 months still reported troubles attributed to TBI. Negative predictors in mild TBI were female gender, intracranial bleeding and Glasgow Coma Scale (GCS) 13/14.

CONCLUSION

The observed epidemiologic shift in TBI (ie, elderly patients, more falls, more bicyclists) calls for targeted preventive measures. The heterogeneity behind the diagnosis 'mild TBI' emphasises the need for defining subgroups not only based on GCS.

Utility of enteric contrast material in abdominal penetrating trauma: A narrative review

Penetrating trauma is an important cause of morbidity and mortality. With the possibility of conservative management for hemodynamically stable trauma patient, computed tomography (CT) has become an important tool in diagnosis and management of penetrating trauma. There have been multiple studies examining the utility and lack of perceived benefit of using enteric contrast material in the initial CT evaluation. We provide a narrative review of the surgical and radiological literature, offer our own protocol for how to approach the imaging of patients with suspected bowel injury following penetrating traumatic injury and discuss the potential of using enteric contrast material.

Relationship between End-Tidal CO2 (ETCO2) and Lactate and their Role in Predicting Hospital Mortality in Critically Ill Trauma Patients; A Cohort Study

OBJECTIVE

To investigate the relationship between end-tidal CO₂ (ETCO₂) and serum lactate and their predictive role in hospital mortality of intubated multiple trauma patients.

METHODS

In a cohort study, intubated multiple trauma patients who referred to the emergency department for two years were enrolled. After orotracheal intubation using Rapid Sequence Intubation (RSI) method, ETCO2 was immediately measured by capnography. Blood samples for serum lactate measurements were sent to the laboratory, immediately after intubation. Data collection was done using the questionnaire, and the patients were followed using their medical records.

RESULTS

Totally, 250 patients were included with hospital mortality of 14.8% (n=37). Using Pearson correlation, an inverse relationship was noticed between serum lactate and ETCO2, immediately (p<0.0001, r=-0.65). In adjusted multivariate analysis, three variables including heart rate (HR), serum lactate and ETCO2 showed a significant relationship with hospital mortality, respectively (p=0.007, p=0.009, p=0.023, respectively). Receiver operating characteristic curve illustrated an area under the curve (AUC) of 0.93, 0.96, and 0.97 for HR, lactate, and ETCO2, respectively.

CONCLUSION

ETCO₂ post-intubation and serum lactate may be considered as prognostic factors for intubated multiple trauma patients referring to the emergency department, which can give the clinician an important clue in early prediction of the hospital mortality.