Ultrasound in the diagnosis of injury

Trauma to a horseshoe kidney

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Hemoperitoneum as the sole indicator of abdominal visceral injuries: a potential limitation of screening abdominal US for trauma

PURPOSE

To determine, at screening ultrasonography, the prevalence, severity, and clinical outcome of clinically important abdominal visceral injuries, without associated hemoperitoneum, that result from blunt abdominal trauma.

MATERIALS AND METHODS

Computed tomography (CT) was performed at admission in 466 patients with visceral injury. A retrospective review was performed of findings from surgery and contrast material-enhanced spiral and conventional CT performed to verify abdominal visceral injuries in 467 (4%) of 11,188 patients with blunt trauma. These patients were admitted to a level 1 trauma center over 33 months to determine the presence of hemoperitoneum and to identify the grade of injury. Medical records of patients with abdominal visceral injury without hemoperitoneum were reviewed for the management required and for results of focused abdominal sonography for trauma (FAST).

RESULTS

A total of 575 abdominal visceral injuries were identified at CT and/or surgery. Findings of CT at admission (n = 156) and of surgery (n = 1) revealed no evidence of hemoperitoneum in 157 (34%) patients with abdominal visceral injury; 26 (17%) of whom also had negative FAST studies. Abdominal visceral injuries diagnosed in patients without hemoperitoneum included 57 (27%) of 210 splenic injuries, 71 (34%) of 206 hepatic injuries, 30 (48%) of 63 renal injuries, four (11%) of 35 mesenteric injuries, and two (29%) of seven pancreatic injuries. Surgical and/or angiographic intervention was required in 26 (17%) patients without hemoperitoneum.

CONCLUSION

Reliance on the presence of hemoperitoneum as the sole indicator of abdominal visceral injury limits the value of FAST as a screening diagnostic modality for patients who sustain blunt abdominal trauma.

Survey of abdominal ultrasound and diagnostic peritoneal lavage for suspected intra-abdominal injury following blunt trauma

Over a 3 year period all severely injured blunt trauma patients who were investigated with abdominal ultrasound examinations (AUS) or diagnostic peritoneal lavage (DPL) to exclude intra-abdominal injury were evaluated. The ultrasound examinations were performed by radiologists in 220 severely injured patients (20 of whom also had DPL). The overall sensitivity and specificity of abdominal ultrasound were 82.7% and 99.5%, respectively. The sensitivity increased to 89.1% by repeat scanning. In comparison, 72 DPLs were performed in severely injured patients; the overall sensitivity and specificity of DPL were 82.8% and 97.2%, respectively. DPL resulted in more non-therapeutic laparotomies, 9/25 (36%) compared with 3/23 (13%) with AUS. Abdominal ultrasound is now the first line investigation at this centre for evaluation of possible intra-abdominal injury in injured patients.

The value of current developments in radiology to the accident and emergency department--a pictorial review

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The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study

Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrast-enhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with 'isolated' abdominal trauma (N = 23) or with fractures of lower ribs 7-12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected 'isolated' head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with 'isolated' head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7-12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with 'isolated' head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7-12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.