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Fabig S, Weigert N, Migliorini F, Kleeff J, Hofmann GO, Schenk P, Hilbert-Carius P, Kobbe P, Mendel T. Predictive parameters for early detection of clinically relevant abdominal trauma in multiple-injury or polytraumatised patients: a retrospective analysis. Eur J Med Res 2024; 29:394. [PMID: 39080791 PMCID: PMC11288090 DOI: 10.1186/s40001-024-01969-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 07/10/2024] [Indexed: 08/03/2024] Open
Abstract
Diagnosis of relevant organ injury after blunt abdominal injury (AI) in multiple-injury/polytraumatised patients is challenging. AI can be distinguished between injuries of parenchymatous organs (POI) of the upper abdomen (liver, spleen) and bowel and mesenteric injuries (BMI). Still, such injuries may be associated with delays in diagnosis and treatment. The present study aimed to verify laboratory parameters, imaging diagnostics, physical examination and related injuries to predict intraabdominal injuries. This retrospective, single-centre study includes data from multiple-injury/polytraumatised patients between 2005 and 2017. Two main groups were defined with relevant abdominal injury (AI+) and without abdominal injury (AI-). The AI+ group was divided into three subgroups: BMI+, BMI+/POI+, and POI+. Groups were compared in a univariate analysis for significant differences. Logistic regression analysis was used to determine predictors for AI+, BMI+ and POI+. 26.3% (271 of 1032) of the included patients had an abdominal injury. Subgroups were composed of 4.7% (49 of 1032) BMI+, 4.7% (48 of 1032) BMI+/POI+ and 16.8% (174 of 1032) POI+. Pathological abdominal signs had a sensitivity of 48.7% and a specificity of 92.4% for AI+. Transaminases were significantly higher in cases of AI+. Pathological computed tomography (CT) (free fluid, parenchymal damage, Bowel Injury Prediction Score (BIPS), CT Grade > 4) was summarised and had a sensitivity of 94.8%, a specificity of 98%, positive predictive value (PPV) of 94.5% and, negative predictive value (NPV) of 98.2% for AI+. The detected predictors for AI+ were pathological abdominal findings (odds ratio (OR) 3.93), pathological multi-slice computed tomography (MSCT) (OR 668.9), alanine (ALAT) ≥ 1.23 µmol/ls (OR 2.35) and associated long bone fractures (OR 3.82). Pathological abdominal signs, pathological MSCT and lactate (LAC) levels ≥ 1.94 mmol/l could be calculated as significant risk factors for BMI+. For POI+ pathological abdominal MSCT, ASAT ≥ 1.73 µmol/ls and concomitant thoracic injuries had significant relevance. The study presents reliable risk factors for abdominal injury and its sub-entities. The predictors can be explained by the anatomy of the trunk and existing studies. Elevated transaminases predicted abdominal injury (AI+) and, specifically, the POI+. The pathological MSCT was the most reliable predictive parameter. However, it was essential to include further relevant parameters.
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Affiliation(s)
- Stefan Fabig
- Department of General, Visceral and Vascular Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Nadja Weigert
- Department of General, Visceral and Vascular Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Filippo Migliorini
- Department of Orthopaedic and Trauma Surgery, Academic Hospital of Bolzano (SABES-ASDAA), 39100, Bolzano, Italy
- Department of Life Sciences, Health, and Health Professions, Link Campus University, 00165, Rome, Italy
| | - Jörg Kleeff
- Department of General, Visceral and Vascular Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
- Department of Visceral, Vascular and Endocrine Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
| | - Gunther Olaf Hofmann
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Jena, Am Klinikum 1, 74771, Jena, Germany
| | - Philipp Schenk
- Department of Science, Research and Education, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Peter Hilbert-Carius
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
| | - Philipp Kobbe
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany
| | - Thomas Mendel
- Department of Trauma and Reconstructive Surgery, BG Klinikum Bergmannstrost Halle, Merseburger Strasse 165, 06112, Halle (Saale), Germany.
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital Halle, Ernst-Grube-Strasse 40, 06120, Halle (Saale), Germany.
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Zarama V, Torres N, Duque E, Arango-Ibañez JP, Duran K, Azcárate V, Maya DA, Sánchez ÁI. Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department. BMC Emerg Med 2024; 24:103. [PMID: 38902603 PMCID: PMC11191214 DOI: 10.1186/s12873-024-01014-w] [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: 03/09/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
OBJECTIVES Blunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period. METHODS We performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death. RESULTS We included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01-1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported. CONCLUSION The incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.
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Affiliation(s)
- Virginia Zarama
- Facultad de Ciencias de la Salud, Universidad Icesi, Carrera 98 # 18-49, Cali, 760032, Colombia.
- Department of Emergency Medicine, Fundación Valle del Lili, Cali, Colombia.
| | - Nicolás Torres
- Department of Surgery, Fundación Valle del Lili, Cali, Colombia
| | - Esteban Duque
- Facultad de Ciencias de la Salud, Universidad Icesi, Carrera 98 # 18-49, Cali, 760032, Colombia
| | | | - Karina Duran
- Facultad de Ciencias de la Salud, Universidad Icesi, Carrera 98 # 18-49, Cali, 760032, Colombia
| | - Valeria Azcárate
- Facultad de Ciencias de la Salud, Universidad Icesi, Carrera 98 # 18-49, Cali, 760032, Colombia
| | - Duban A Maya
- Department of Emergency Medicine, Fundación Valle del Lili, Cali, Colombia
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Abdel Hamid MA, Abd-erRazik MA, Nagy M, El-Shinawi M, Hirshon JM, El-Setouhy M. Computed tomography benefits and cost in hemodynamically stable patients with blunt abdominal trauma at an Egyptian University Hospital. Afr J Emerg Med 2024; 14:96-99. [PMID: 38707935 PMCID: PMC11070236 DOI: 10.1016/j.afjem.2023.11.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 11/10/2023] [Accepted: 11/19/2023] [Indexed: 05/07/2024] Open
Abstract
Background Trauma is a significant cause of mortality, especially among individuals aged between 15 and 44 years, with a substantial burden falling on economically active populations. Low- and middle-income countries (LMICs) bear the burden of trauma-related deaths, accounting for over 90 % globally. In Egypt, trauma rates are increasing, primarily due to road traffic crashes (RTC), affecting males disproportionately. Blunt abdominal trauma, often caused by RTC, can lead to missed intra-abdominal injuries (IAIs) due to atypical symptoms. Computed Tomography (CT) offers high sensitivity and specificity in detecting IAIs, but concerns about cost and radiation exposure exist. Methodology This study investigates the roles of Focused Assessment with Sonography for Trauma (FAST) and CT in managing blunt abdominal trauma. A retrospective cohort study was conducted on hemodynamically stable patients. Data included patient demographics, trauma details, healthcare decisions, costs, and outcomes. Results Computed tomography significantly reduced unnecessary laparotomies (12.3% vs. 24.8 %, p = 0.001), shortened hospital stays (4.83±0.71 days vs. 6.15±1.28 days, p = 0.005), and reduced ICU admissions (8 vs. 32, p = 0.023) compared to FAST alone. Overall costs were lower in the CT & FAST Group ($2055.95 vs. $3488.7, p = 0.0001), with no significant difference in missed IAIs. Conclusion This study highlights the limitations of relying solely on FAST for IAIs and underscores the value of CT in guiding healthcare decisions. Incorporating CT led to reduced negative laparotomies, shorter hospital stays, and fewer ICU admissions. While CT incurs initial costs, its long-term benefits outweigh expenditures, particularly in LMICs. This study provides insights into optimizing diagnostic approaches for blunt abdominal trauma in low-resource settings.
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Affiliation(s)
| | | | - Mostafa Nagy
- Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Mohamed El-Shinawi
- Department of General Surgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
- Galala University, Suez, Egypt
| | - Jon M. Hirshon
- Department of Emergency Medicine, University of Maryland School of Medicine, Baltimore, MD, United States
- Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Maged El-Setouhy
- Department of Family and Community Medicine, Faculty of Medicine, Jazan University, Jazan, Saudi Arabia
- Department of Community, Environmental and Occupational Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Santos AT, Jagiella-Lodise O, Kim P, Freedberg ME, Smith RN, Nguyen J, Davis MA, Ayoung-Chee P, Todd SR, Benjamin ER, Sciarretta JD. Blunt Traumatic Abdominal Wall Hernias: An Indicator for Emergent Laparotomy? Am Surg 2023; 89:3829-3834. [PMID: 37141202 DOI: 10.1177/00031348231172453] [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: 05/05/2023]
Abstract
BACKGROUND Traumatic abdominal wall hernias (TAWH) are relatively uncommon; however, the shearing force that results in fascial disruption could indicate an increased risk of visceral injury. The aim of our study was to evaluate whether the presence of a TAWH was associated with intra-abdominal injury requiring emergent laparotomy. METHODS The trauma registry was queried over an 8-year period (7/2012-7/2020) for adult patients with blunt thoracoabdominal trauma diagnosed with a TAWH. Those patients who were identified with a TAWH and greater than 15 years of age were included in the study. Demographics, mechanism of injury, ISS, BMI, length of stay, TAWH size, type of TAWH repair, and outcomes were analyzed. RESULTS Overall, 38,749 trauma patients were admitted over the study period, of which 64 (.17%) had a TAWH. Patients were commonly male (n = 42, 65.6%); the median age was 39 years (range 16-79 years) and a mean ISS of 21. Twenty-eight percent had a clinical seatbelt sign. Twenty-seven (42.2%) went emergently to the operating room, the majority for perforated viscus requiring bowel resection (n = 16, 25.0%), and 6 patients (9.4%) who were initially managed nonoperatively underwent delayed laparotomy. Average ventilator days was 14 days, with a mean ICU LOS of 14 days and mean hospital LOS of 18 days. About half of the hernias were repaired at the index operation, 6 of which were repaired primarily and 10 with mesh. CONCLUSION The presence of a TAWH alone was an indication for immediate laparotomy to evaluate for intra-abdominal injury. In the absence of other indications for exploration, nonoperative management may be safe.
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Affiliation(s)
- Adora T Santos
- Emory University School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Olivia Jagiella-Lodise
- Emory University School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Phillip Kim
- Emory University School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Mari E Freedberg
- Emory University School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Randi N Smith
- Emory University School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Jonathan Nguyen
- Morehouse School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - M Andrew Davis
- Emory University School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Patricia Ayoung-Chee
- Morehouse School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - S Rob Todd
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Elizabeth R Benjamin
- Emory University School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
| | - Jason D Sciarretta
- Emory University School of Medicine, Atlanta, GA, USA
- Morehouse School of Medicine, Atlanta, GA, USA
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Bukowski J, Nowadly CD, Schauer SG, Koyfman A, Long B. High risk and low prevalence diseases: Blast injuries. Am J Emerg Med 2023; 70:46-56. [PMID: 37207597 DOI: 10.1016/j.ajem.2023.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 04/29/2023] [Accepted: 05/02/2023] [Indexed: 05/21/2023] Open
Abstract
INTRODUCTION Blast injury is a unique condition that carries a high rate of morbidity and mortality, often with mixed penetrating and blunt injuries. OBJECTIVE This review highlights the pearls and pitfalls of blast injuries, including presentation, diagnosis, and management in the emergency department (ED) based on current evidence. DISCUSSION Explosions may impact multiple organ systems through several mechanisms. Patients with suspected blast injury and multisystem trauma require a systematic evaluation and resuscitation, as well as investigation for injuries specific to blast injuries. Blast injuries most commonly affect air-filled organs but can also result in severe cardiac and brain injury. Understanding blast injury patterns and presentations is essential to avoid misdiagnosis and balance treatment of competing interests of patients with polytrauma. Management of blast victims can also be further complicated by burns, crush injury, resource limitation, and wound infection. Given the significant morbidity and mortality associated with blast injury, identification of various injury patterns and appropriate management are essential. CONCLUSIONS An understanding of blast injuries can assist emergency clinicians in diagnosing and managing this potentially deadly disease.
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Affiliation(s)
- Josh Bukowski
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Craig D Nowadly
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
| | - Steven G Schauer
- US Army Institute of Surgical Research, JBSA Fort Sam Houston, TX; Brooke Army Medical Center, JBSA Fort Sam Houston, TX, USA.
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, TX, USA
| | - Brit Long
- Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, TX, USA.
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Leenellett E, Rieves A. Occult Abdominal Trauma. Emerg Med Clin North Am 2021; 39:795-806. [PMID: 34600638 DOI: 10.1016/j.emc.2021.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Occult abdominal injuries are common and can be associated with increased risk of morbidity and mortality. Patients with a delayed presentation to care or who are multiply injured are at increased risk of this type of injury, and a high index of suspicion must be maintained. A careful combination of history, physical examination, laboratory, and imaging can be quite helpful in mitigating the risk of a missed occult abdominal injury.
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Affiliation(s)
- Elizabeth Leenellett
- Department of Emergency Medicine, University of Cincinnati, 231 Albert Sabin Way, Room 1505, Cincinnati, OH 45267-0769, USA.
| | - Adam Rieves
- Department of Emergency Medicine, Washington University in Saint Louis, 660 South Euclid Avenue, BC 8072, Saint Louis, MO 63110, USA
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Afzalimoghaddam M, Fattahi M, Pourghorban R, Eftekhari M, Abdollahi A. The accuracy of various types of urinalysis in terms of predicting intra-abdominal injury in emergency trauma patients: A diagnostic accuracy study. ARCHIVES OF TRAUMA RESEARCH 2021. [DOI: 10.4103/atr.atr_28_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Traumatic hollow viscus and mesenteric injury: role of CT and potential diagnostic-therapeutic algorithm. Updates Surg 2020; 73:703-710. [PMID: 33340338 PMCID: PMC8005390 DOI: 10.1007/s13304-020-00929-w] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Accepted: 11/11/2020] [Indexed: 11/23/2022]
Abstract
Despite its rarity, traumatic hollow viscus and mesenteric injury (HVMI) have high mortality and complication rates. There is no consensus regarding its best management. Our aim is to evaluate contrast enhanced CT (ceCT) in the screening of HVMI and its capability to assess the need for surgery. All trauma patients admitted to an urban Level 1 trauma center between 2010 and 2018 were retrospectively evaluated. Patients with ceCT scan prior to laparotomy were included. Patients requiring surgical repair of HVMI and a ceCT scan consistent with HVMI were considered true positives. Six ceCT scan criteria for HVMI were used; at least one criterion was considered positive for HVMI. Sensitivity (Sn), specificity (Sp), predictive values (PV), likelihood ratios (LR) and accuracy (Ac) of ceCT of single ceCT criteria and of the association of ceCT criteria were calculated using intraoperative findings as gold standard. Therapeutic time (TT), death probability (DP), and observed mortality (OM) were described. 114 of 4369 patients were selected for ceCT accuracy analysis; 47 were considered true positives. Sn of ceCT for HVMI was 97.9%, Sp 63.6%, PPV 66.2%, NPV 97.6%, + LR 2.69, −LR 0.03, Ac 78%; no single criterion stood out. The association of four or more criteria improved ceCT Sp to 98.5%, PPV to 95.6%, + LR to 30.5. Median TT was 2 h (IQR: 1–3 h). OM was 7.8%—not significantly higher than overall OM. CeCT in trauma has become a reliable screening test for HVMI and a valid exam to select HVMI patients for surgical exploration.
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Cohan CM, Beattie G, Tang A, Mazzolini K, Farzaneh N, Senekjian L, Victorino GP. Does Abdominal Seat Belt Sign Warrant Admission After a Negative CT Scan? A Cost-Utility Analysis. J Surg Res 2020; 255:619-626. [PMID: 32653694 DOI: 10.1016/j.jss.2020.05.093] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2020] [Revised: 05/05/2020] [Accepted: 05/24/2020] [Indexed: 12/24/2022]
Abstract
BACKGROUND Rapid deceleration against a seat belt during a motor vehicle collision (MVC) may result in an abdominal seat belt sign (ASBS), which is associated with a higher risk of hollow viscus injury (HVI). After a negative abdominal CT scan, management of patients with ASBS is variable, but recent evidence suggests emergency department (ED) discharge may be safe. Therefore, we hypothesized that discharge from the ED is cost-effective compared with 23-h observation or hospital admission for patients with ASBS and a negative CT. METHODS A cost-utility model was developed for an evaluable patient with ASBS and negative CT scan using TreeAge software. ED discharge was compared with 23-h observation and admission. Analysis was from a health care-based third-party payer perspective. Quality-adjusted life years (QALYs) were based on 3-y expected outcomes. Probability and costs were estimated from published literature and the Healthcare Cost and Utilization Project. RESULTS In our base case, ED discharge was the most cost-effective strategy, yielding a cost of $706 with 2.86 QALYs. The average costs of 23-h observation and hospital admission were $2600 and $8,827, respectively, with 2.87 QALYs gained each. The strategy of ED observation becomes cost-effective when the rate of HVI after ED discharge exceeds 2.3%. In a Monte Carlo simulation, ED discharge was the optimal strategy in 91% of 1000 trials of the model. CONCLUSIONS ED discharge is a cost-effective strategy for evaluable patients with ASBS and a negative abdominal CT and remains so when the risk of HVI after ED discharge is higher than currently assumed.
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Affiliation(s)
- Caitlin M Cohan
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California.
| | - Genna Beattie
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | - Annie Tang
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | - Kirea Mazzolini
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | | | - Lara Senekjian
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
| | - Gregory P Victorino
- Department of Surgery, University of California San Francisco, East Bay, Oakland, California
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Mitricof B, Brasoveanu V, Hrehoret D, Barcu A, Picu N, Flutur E, Tomescu D, Droc G, Lupescu I, Popescu I, Botea F. Surgical treatment for severe liver injuries: a single-center experience. MINERVA CHIR 2020; 75:92-103. [PMID: 32009332 DOI: 10.23736/s0026-4733.20.08193-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The liver is one of the most frequently injured organs in abdominal trauma. The advancements in diagnosis and interventional therapy shifted the management of liver trauma towards a non-operative management (NOM). Nevertheless, in severe liver injuries (LI), surgical treatment often involving liver resection (LR) and rarely liver transplantation (LT) remains the main option. The present paper analyses a single center experience in a referral HPB center on a series of patients with high-grade liver trauma. METHODS Forty-five patients with severe LI, that benefitted from NOM (6 pts), LRs (38 pts), and LT (1 pt) performed in our center between June 2000 and June 2019, were included in a combined prospective and retrospective study. The median age of the patients was 29 years (median 33, range 10-76), and the male/female ratio of 33/12. Almost all cases had blunt trauma, except 2 with stab wound (4.4%). RESULTS LIs classified according to the American Association for the Surgery of Trauma (AAST) system were 13.3% (grade III), 44.2% (grade IV), and 42.2% (grade V); none were grade I, II or VI. The rate of major LR was 56.4% (22 LRs). The median operative time was 200 minutes (mean 236; range 150-420). The median blood loss was 750 ml (mean 940; range 500-6500). Overall and major complication rates were 100% (45 pts) and 33.3% (15 pts), respectively. Overall mortality rate was 15.6% (7 pts). CONCLUSIONS Severe liver trauma, often involving complex liver resections, should be managed in a referral HPB center, thus obtaining the best results in terms of morbidity and mortality.
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Affiliation(s)
- Bianca Mitricof
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania
| | - Vladislav Brasoveanu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania.,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Doina Hrehoret
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Alexandru Barcu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Nausica Picu
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Elena Flutur
- Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Dana Tomescu
- Center of Anesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Gabriela Droc
- Center of Anesthesia and Intensive Care, Fundeni Clinical Institute, Bucharest, Romania
| | - Ioana Lupescu
- Center of Diagnostic and Interventional Radiology, Fundeni Clinical Institute, Bucharest, Romania
| | - Irinel Popescu
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania.,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
| | - Florin Botea
- Faculty of Medicine, Titu Maiorescu University, Bucharest, Romania - .,Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania
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Abstract
OBJECTIVE To develop French guidelines on the management of patients with severe abdominal trauma. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesiology and Critical Care Medicine (Société française d'anesthésie et de réanimation, SFAR), the French Society of Emergency Medicine (Société française de médecine d'urgence, SFMU), the French Society of Urology (Société française d'urologie, SFU) and from the French Association of Surgery (Association française de chirurgie, AFC), the Val-de-Grâce School (École du Val-De-Grâce, EVG) and the Federation for Interventional Radiology (Fédération de radiologie interventionnelle, FRI-SFR) was convened. Declaration of all conflicts of interest (COI) policy by all participants was mandatory throughout the development of the guidelines. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system for assessment of the available level of evidence with particular emphasis to avoid formulating strong recommendations in the absence of high level. Some recommendations were left ungraded. METHODS The guidelines are divided in diagnostic and, therapeutic strategy and early surveillance. All questions were formulated according to Population, Intervention, Comparison, and Outcomes (PICO) format. The panel focused on three questions for diagnostic strategy: (1) What is the diagnostic performance of clinical signs to suggest abdominal injury in trauma patients? (2) Suspecting abdominal trauma, what is the diagnostic performance of prehospital FAST (Focused Abdominal Sonography for Trauma) to rule in abdominal injury and guide the prehospital triage of the patient? and (3) When suspecting abdominal trauma, does carrying out a contrast enhanced thoraco-abdominal CT scan allow identification of abdominal injuries and reduction of mortality? Four questions dealt with therapeutic strategy: (1) After severe abdominal trauma, does immediate laparotomy reduce morbidity and mortality? (2) Does a "damage control surgery" strategy decrease morbidity and mortality in patients with a severe abdominal trauma? (3) Does a laparoscopic approach in patients with abdominal trauma decrease mortality or morbidity? and (4) Does non-operative management of patients with abdominal trauma without bleeding reduce mortality and morbidity? Finally, one question was formulated regarding the early monitoring of these patients: In case of severe abdominal trauma, which kind of initial monitoring does allow to reduce the morbi-mortality? The analysis of the literature and the recommendations were conducted following the GRADE® methodology. RESULTS The SFAR/SFMU Guideline panel provided 15 statements on early management of severe abdominal trauma. After three rounds of discussion and various amendments, a strong agreement was reached for 100% of recommendations. Of these recommendations, five have a high level of evidence (Grade 1±), six have a low level of evidence (Grade 2±) and four are expert judgments. Finally, no recommendation was provided for one question. CONCLUSIONS Substantial agreement exists among experts regarding many strong recommendations for the best early management of severe abdominal trauma.
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Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation. Emerg Radiol 2019; 26:655-661. [PMID: 31446523 DOI: 10.1007/s10140-019-01712-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Accepted: 07/31/2019] [Indexed: 12/27/2022]
Abstract
PURPOSE To determine whether torso CT can be avoided in patients who experience high-energy blunt trauma but have normal vital signs. METHODS High-energy blunt trauma patients with normal vital signs were retrieved retrospectively from our registry. We reviewed 1317 patients (1027 men and 290 women) and 761 (57.8%) fulfilled the inclusion criteria. All patients were initially evaluated at the emergency room (ER), with a set of tests, part of a specific protocol. Patients with at least one altered exam at initial examination or after six-hour observation received a torso CECT. Sensitivity, specificity, accuracy, positive (PPV) and negative predictive values (NPV), and likelihood ratio (LH) of the protocol were evaluated. RESULTS Of 761 patients, 354 (46.5%) received torso CECT because of the positive ER test, with 330 being true positive and 24 being false positive. The remaining 407 patients were negative at ER tests and did not receive torso CECT, showing a significantly (P < 0.001) lower Injury Severity Score (ISS). The positive and negative LH of the protocol to detect torso injuries were respectively 16.5 and 0.01 (overall accuracy of 0.96). CONCLUSIONS Torso CT can be avoided without adverse clinical outcomes in patients who experience high-energy blunt trauma, are hemodynamically stable, and have normal initial laboratory and imaging tests.
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13
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A negative computed tomography may be sufficient to safely discharge patients with abdominal seatbelt sign from the emergency department: A case series analysis. J Trauma Acute Care Surg 2019. [PMID: 29521798 DOI: 10.1097/ta.0000000000001872] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The presence of an abdominal seatbelt sign (ASBS) following a motor vehicle collision (MVC) is associated with a high risk for occult intra-abdominal injury, prompting imaging studies and a prolonged period of clinical observation. The aim of this study was to determine how a negative computed tomography (CT) of the abdomen/pelvis (A/P) can serve in the safe disposition of these patients. Our hypothesis was that in the setting of a negative CT, the presence of occult intra-abdominal injuries requiring a delayed intervention is extremely unlikely. METHODS The medical charts of patients admitted from January 2014 to December 2016 to a Level I trauma center following an MVC were reviewed for a documentation of an ASBS. Patients who did not have a CT A/P upon admission were excluded. The CT A/P of the remaining patients were then classified as negative if there were no findings of acute vascular, visceral or bony injury or positive if any of these findings was present. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of CT A/P for the presence of an intra-abdominal injury were calculated. RESULTS Over the 3-year study period, 1,108 patients were admitted after an MVC. Of those, 196 (17.7%) had an ASBS upon presentation and 183 (93.4%) of 196 underwent a CT A/P. A total of 114 (62.3%) of 183 had a negative CT A/P. These patients remained hospitalized for a median of 2 (1-35) days with none (0.0%) requiring a delayed laparotomy. The sensitivity of CT A/P in identifying patients requiring an exploratory laparotomy was 100.0%, specificity was 67.9%, NPV was 100.0%, and PPV was 21.7%. The negative likelihood ratio was 0.00. CONCLUSION For patients with an ASBS following an MVC, a negative CT A/P may be sufficient for safe discharge from the emergency department without any need for additional clinical observation. LEVEL OF EVIDENCE Therapuetic, level IV.
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Sun K, Xia H. Serum levels of NLRP3 and HMGB-1 are associated with the prognosis of patients with severe blunt abdominal trauma. Clinics (Sao Paulo) 2019; 74:e729. [PMID: 31411276 PMCID: PMC6683302 DOI: 10.6061/clinics/2019/e729] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 12/21/2018] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES To investigate the relationship between the serum levels of NLRP3 and HMGB-1 and the prognosis of patients with severe blunt abdominal trauma. METHODS In total, 299 patients were included in the current study from July 2014 to December 2015. All patients were divided into the mild/moderate blunt abdominal trauma group and the severe blunt abdominal trauma group according to their injury severity scores. Serum levels of NLRP3 and HMGB-1 were measured upon admission (0 h) and at 12 h, 24 h, 48 h, 72 h and 7 days after admission. RESULTS Compared with the healthy controls, both the mild/moderate and severe blunt abdominal trauma groups had higher serum levels of NLRP3 and HMGB-1 at admission. At all points, the serum levels of NLRP3 and HMGB-1 were significantly higher in the severe group than in the mild/moderate group. The serum levels of both NLRP3 and HMGB-1 were significantly higher in the deceased patients than in the living patients. The Kaplan-Meier curve showed that compared with patients with higher levels of NLRP3 or HMGB-1, those with lower levels had longer survival times. The serum levels of both NLRP3 and HMGB-1 were independent risk factors for 6-month mortality in severe blunt abdominal trauma patients. CONCLUSION The serum levels of NLRP3 and HMGB-1 were significantly elevated in severe blunt abdominal trauma patients, and the serum levels of both NLRP3 and HMGB-1 were correlated with 6-month mortality in severe blunt abdominal trauma patients.
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Affiliation(s)
- Kuanxue Sun
- Department of General Surgery, GongLi Hospital of Shanghai Pu Dong New District, Shanghai, 200135, China
- Department of Ultrasound, GongLi Hospital of Shanghai Pu Dong New District, Shanghai, 200135, China
| | - Hongwei Xia
- Department of Ultrasound, GongLi Hospital of Shanghai Pu Dong New District, Shanghai, 200135, China
- *Corresponding author. E-mail:
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Jeroukhimov I, Wiser I, Hershkovitz Y, Shapira Z, Peleg K, Alfici R, Givon A, Kessel B. Frequency of intra-abdominal organ injury is higher in patients with concomitant stab wounds to other anatomical areas. BMC Emerg Med 2018; 18:18. [PMID: 29945558 PMCID: PMC6020471 DOI: 10.1186/s12873-018-0167-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Accepted: 06/01/2018] [Indexed: 11/10/2022] Open
Abstract
Background Management of stable patients with abdominal stab wound remains controversial, particularly for those with no clear indications for explorative laparotomy. We evaluated the risk of intra-abdominal injury in stab wound victims concomitantly stabbed in other anatomical body areas. Methods We performed a retrospective cohort study of patients with abdominal stab wounds recorded in the Israeli National Trauma Registry from January 1st, 1997, to December 31st, 2013. Patients with an isolated abdominal stab wound were compared to those with concomitant stab wounds to other anatomical areas. Intra-abdominal organ injury was defined by imaging or surgery findings. Multivariate analysis using a logistic regression model was conducted to assess independent risk for intra-abdominal organ injury. Results The study included 3964 patients. After controlling for age, gender and hypotension on arrival, patients with multi-regional stab wounds had an increased risk of intra-abdominal injury (OR = 1.3, CI 95% 1.1–1.6, p < 0.001). These patients also had a higher rate of injury to the solid organs than patients with an isolated abdominal stab wound. Conclusions Patients with multi-regional stab wounds have an increased risk of intra-abdominal injury. Worldwide accepted “clinical follow up” protocol may not be appropriate in management of patients with multi-regional stab wounds.
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Affiliation(s)
- Igor Jeroukhimov
- Trauma Unit, Assaf Harofeh Medical Center, Zerifin 7030000, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Itay Wiser
- Trauma Unit, Assaf Harofeh Medical Center, Zerifin 7030000, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Yehuda Hershkovitz
- Trauma Unit, Assaf Harofeh Medical Center, Zerifin 7030000, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Zahar Shapira
- Trauma Unit, Assaf Harofeh Medical Center, Zerifin 7030000, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Kobi Peleg
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, 52621, Tel Hashomer, Israel
| | - Ricardo Alfici
- Surgical Division, Hillel Yaffe Medical Center, 38100, Hadera, Israel
| | - Adi Givon
- National Center for Trauma and Emergency Medicine Research, Gertner Institute for Epidemiology and Health Policy Research, Sheba Medical Center, 52621, Tel Hashomer, Israel
| | | | - Boris Kessel
- Trauma Unit, Hillel Yaffe Medical Center, 38100, Hadera, Israel
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16
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Negative computed tomography can safely rule out clinically significant intra-abdominal injury in the asymptomatic patient after blunt trauma: Prospective evaluation of 1193 patients. J Trauma Acute Care Surg 2018; 84:128-132. [PMID: 28930944 DOI: 10.1097/ta.0000000000001705] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Computed tomography of the abdomen and pelvis (CTAP) is highly specific for injury identification and commonly used in the evaluation of blunt trauma patients. Despite this, there is no consensus on the required clinical observation period after negative imaging, often impacting patient flow and hospital cost. The purpose of this study was to evaluate the use of CTAP after blunt trauma and the need for observation after negative imaging. METHODS A prospective analysis at a large Level I trauma center was conducted from November 2014 to May 2015. All blunt trauma patients, older than 14 years with CTAP on admission were included. Symptomatic patients were defined as having abdominal pain or external signs of trauma on admission. The main outcome was missed injury. RESULTS Over the study period, there were 1,468 blunt trauma admissions, of which 1,193 patients underwent CTAP. Eight hundred six (67.6%) patients were evaluable on admission (Glasgow Coma Scale score, 15), and of these, 327 (40.6%) were symptomatic, 479 (59.4%) asymptomatic. Among the evaluable asymptomatic patients, there were 65 (13.6%) positive computed tomography scans including 11 patients with grade III, IV, or V solid organ injury and three that required operation. In the 414 evaluable asymptomatic patients with negative imaging, median length of stay was 3 days, and there were zero missed injuries. All images were reviewed by an attending radiologist. CONCLUSION Abdominal imaging after trauma is justified in the appropriate clinical setting to evaluate for significant abdominal injury regardless of symptomatology. In asymptomatic, evaluable patients with a negative CTAP, clinically significant abdominal injury is unlikely, and these patients may be considered for early discharge or disposition to another treatment service. LEVEL OF EVIDENCE Diagnostic, level III; Therapy, level IV.
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17
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Neeki MM, Hendy D, Dong F, Toy J, Jones K, Kuhnen K, Yuen HW, Lux P, Sin A, Kwong E, Wong D. Correlating abdominal pain and intra-abdominal injury in patients with blunt abdominal trauma. Trauma Surg Acute Care Open 2017; 2:e000109. [PMID: 29766104 PMCID: PMC5877917 DOI: 10.1136/tsaco-2017-000109] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Revised: 08/27/2017] [Accepted: 09/05/2017] [Indexed: 11/18/2022] Open
Abstract
Background A thorough history and physical examination in patients with blunt abdominal trauma (BAT) is important to safely exclude clinically significant intra-abdominal injury (IAI). We seek to evaluate a correlation between self-reported abdominal pain, abdominal tenderness on examination and IAI discovered on CT or during exploratory laparotomy. Methods This retrospective analysis assessed patients with BAT ≥13 years old who arrived to the emergency department following BAT during the 23-month study period. Upon arrival, the trauma team examined all patients. Only those who underwent an abdominal and pelvic CT scan were included. Patients were excluded if they were unable to communicate or lacked documentation, had obvious evidence of extra-abdominal distracting injuries, had a positive drug or alcohol screen, had a Glasgow Coma Scale ≤13, or had a positive pregnancy screening. The primary objective was to assess the agreement between self-reported abdominal pain and abdominal tenderness on examination and IAI noted on CT or during exploratory laparotomy. Results Among the 594 patients included in the final analysis, 73.1% (n=434) had no self-reported abdominal pain, 64.0% (n=384) had no abdominal tenderness on examination, and 22.2% (n=132) had positive CT findings suggestive of IAI. Among the 352 patients who had no self-reported abdominal pain and no abdominal tenderness on examination, a significant number of positive CT scan results (14%, n=50) were still recorded. Furthermore, a small but clinically significant portion of these 50 patients underwent exploratory laparotomy (1.1%, n=4). All four of these patients ultimately underwent a splenectomy and all were completed on hospital day one. Conclusion Lack of abdominal pain and tenderness in patients with BAT with non-distracting injuries was associated with a small portion of patients who underwent a splenectomy. Patients with BAT without abdominal pain or tenderness may need a period of observation or CT scan to rule out IAI prior to discharge home. Level of evidence Level III, therapeutic/care management.
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Affiliation(s)
- Michael M Neeki
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA.,Department of Emergency Medicine, California University of Science and Medicine, Colton, California, USA
| | - Dylan Hendy
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - Fanglong Dong
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California, USA
| | - Jake Toy
- College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California, USA
| | - Kevin Jones
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - Keasha Kuhnen
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - Ho Wang Yuen
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA.,Department of Emergency Medicine, California University of Science and Medicine, Colton, California, USA
| | - Pamela Lux
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA.,Department of Emergency Medicine, California University of Science and Medicine, Colton, California, USA
| | - Arnold Sin
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA.,Department of Emergency Medicine, California University of Science and Medicine, Colton, California, USA
| | - Eugene Kwong
- Department of Emergency Medicine, Arrowhead Regional Medical Center, Colton, California, USA
| | - David Wong
- Department of General Surgery, Arrowhead Regional Medical Center, Colton, California, USA.,Department of Surgery, California University of Science and Medicine, Colton, California, USA
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Hammer MM, Raptis DA, Mellnick VM, Bhalla S, Raptis CA. Traumatic injuries of the diaphragm: overview of imaging findings and diagnosis. Abdom Radiol (NY) 2017; 42:1020-1027. [PMID: 27641159 DOI: 10.1007/s00261-016-0908-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Injuries to the diaphragm muscle occur in penetrating and severe blunt trauma and can lead to delayed hernia formation. Computed tomography is the mainstay in the diagnosis of these injuries, which may be subtle at presentation. Imaging findings differ between blunt and penetrating trauma. Key features in blunt trauma include diaphragm fragment distraction and organ herniation because of increased intra-abdominal pressure. In penetrating trauma, herniation is uncommon, and the trajectory of the object is critical in making the diagnosis of diaphragm injury in these patients. Radiologists must keep a high index of suspicion for injury to the diaphragm in cases of trauma to the chest or abdomen.
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Affiliation(s)
- Mark M Hammer
- Department of Radiology, Brigham & Women's Hospital, 75 Francis St., Boston, MA, 02115, USA.
| | - Demetrios A Raptis
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Vincent M Mellnick
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
| | - Sanjeev Bhalla
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO, USA
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Braungart S, Beattie T, Midgley P, Powis M. Implications of a negative abdominal CT in the management of pediatric blunt abdominal trauma. J Pediatr Surg 2017; 52:293-298. [PMID: 27912976 DOI: 10.1016/j.jpedsurg.2016.11.028] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 11/08/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND No consensus exists on management of children with a negative trauma CT following blunt abdominal trauma (BAT). Asymptomatic children are frequently "admitted for observation" following negative CT owing to concerns about missing an intraabdominal injury (IAI) without evidence for this practice. We aimed to investigate the feasibility of discharge following a negative CT scan in children sustaining blunt abdominal trauma. METHODS Retrospective audit at a UK paediatric major trauma center and review of the literature. RESULTS 108 patients were included (median age 11y; 60% male). Commonest mechanisms of injury: road traffic collisions (61 patients; 56%) and falls from a height (37; 34%). 40 (37%) had a normal CT scan, of whom 6 (15%) were discharged from ED. The remaining 34 patients were admitted, of whom 14 (41%) were discharged within 24h. The other 20 children were admitted for other specialty input. None of the 108 children had a missed IAI or reattended with suspicion of IAI. The NPV for CT to detect IAI was 100% (95% CI: 96%-100%). The literature search identified 3 observational cohort studies and 2 patient groups contained in a systematic review (total of 9149 patients with normal CT abdomen after BAT). Only 9 (<0.1%) patients required operative intervention for missed IAI. The NPV for CT to detect IAI was 99.6%-99.8% (95% CI 99%-100%). CONCLUSION Our study and literature review demonstrate that asymptomatic children with a normal abdominal CT scan in the ED are very unlikely to have IAI and that the NPV of CT is very high (96%-100%). Direct discharge from the ED is possible for asymptomatic children with a negative CT following blunt abdominal trauma, as long as no other reasons for admission exist and should be accompanied by safety-net advice. LEVEL OF EVIDENCE STATEMENT This is a level II evidence study. In itself it is a retrospective study, with the literature review including one large, high-quality prospective cohort study, and further prospective cohort studies of ordinary quality.
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Affiliation(s)
- Sarah Braungart
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, UK; Child Life and Health, University of Edinburgh, UK
| | | | | | - Mark Powis
- Department of Paediatric Surgery, Leeds Teaching Hospitals NHS Trust, UK.
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Abstract
The management of blunt abdominal trauma has evolved over time. While laparotomy is the standard of care in hemodynamically unstable patients, stable patients are usually treated by non-operative management (NOM), incorporating adjuncts such as interventional radiology. However, although NOM has shown good results in solid organ injuries, other lesions, namely those involving the hollow viscus, diaphragm, and mesentery, do not qualify for this approach and need surgical exploration. Laparoscopy can substantially reduce additional surgical aggression. It has both diagnostic and therapeutic potential and, when negative, may reduce the number of unnecessary laparotomies. Although some studies have shown promising results on the use of laparoscopy in blunt abdominal trauma, randomized controlled studies are lacking. Laparoscopy requires adequate training and experience as well as sufficient staffing and equipment.
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Affiliation(s)
- Viktor Justin
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - Abe Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
| | - Selman Uranues
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Auenbruggerplatz 29, 8036 Graz, Austria
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21
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22
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Zaboli R, Tofighi S, Aghighi A, Shokouh SJH, Naraghi N, Goodarzi H. Barriers Against Implementing Blunt Abdominal Trauma Guidelines in a Hospital: A Qualitative Study. Electron Physician 2016; 8:2793-2801. [PMID: 27757191 PMCID: PMC5053462 DOI: 10.19082/2793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 06/18/2016] [Indexed: 11/20/2022] Open
Abstract
Introduction Clinical practice guidelines are structured recommendations that help physicians and patients to make proper decisions when dealing with a specific clinical condition. Because blunt abdominal trauma causes a various range of mild, single-system, and multisystem injuries, early detection will help to reduce mortality and resulting disability. Emergency treatment should be initiated based on CPGs. This study aimed to determine the variables affecting implementing blunt abdominal trauma CPGs in an Iranian hospital. Methods This study was conducted as a qualitative and phenomenology study in the Family Hospital in Tehran (Iran) in 2015. The research population included eight experts and key people in the area of blunt abdominal trauma clinical practice guidelines. Sampling was based on purposive and nonrandom methods. A semistructured interview was done for the data collection. A framework method was applied for the data analysis by using Atlas.ti software. Results After framework analyzing and various reviewing and deleting and combining the codes from 251 codes obtained, 15 families and five super families were extracted, including technical knowledge barriers, economical barriers, barriers related to deployment and monitoring, political will barriers, and managing barriers. Conclusion Structural reform is needed for eliminating the defects available in the healthcare system. As with most of the codes, subconcepts and concepts are classified into the field of human resources; it seems that the education and knowledge will be more important than other resources such as capital and equipment.
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Affiliation(s)
- Rouhollah Zaboli
- Ph.D. of Health Services Administration, Assistant Professor, Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Shahram Tofighi
- Ph.D. of Health Services Administration, Assistant Professor, Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ali Aghighi
- Ph.D. of Health Services Administration, Health Management Research Center, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | | | - Nader Naraghi
- Assistant professor, AJA University of Medical Science, Tehran, Iran
| | - Hassan Goodarzi
- MD, Emergency Medicine Department, Baqiyatallah University of Medical Sciences, Tehran, Iran
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Sharples A, Brohi K. Can clinical prediction tools predict the need for computed tomography in blunt abdominal? A systematic review. Injury 2016; 47:1811-8. [PMID: 27319389 DOI: 10.1016/j.injury.2016.05.032] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Revised: 05/22/2016] [Accepted: 05/23/2016] [Indexed: 02/02/2023]
Abstract
INTRODUCTION Blunt abdominal trauma is a common reason for admission to the Emergency Department. Early detection of injuries is an important goal but is often not straightforward as physical examination alone is not a good predictor of serious injury. Computed tomography (CT) has become the primary method for assessing the stable trauma patient. It has high sensitivity and specificity but there remains concern regarding the long term consequences of high doses of radiation. Therefore an accurate and reliable method of assessing which patients are at higher risk of injury and hence require a CT would be clinically useful. We perform a systematic review to investigate the use of clinical prediction tools (CPTs) for the identification of abdominal injuries in patients suffering blunt trauma. MATERIALS AND METHODS A literature search was performed using Medline, Embase, The Cochrane Library and NHS Evidence up to August 2014. English language, prospective and retrospective studies were included if they derived, validated or assessed a CPT, aimed at identifying intra-abdominal injuries or the need for intervention to treat an intra-abdominal after blunt trauma. Methodological quality was assessed using a 14 point scale. Performance was assessed predominantly by sensitivity. RESULTS Seven relevant studies were identified. All studies were derivative studies and no CPT was validated in a separate study. There were large differences in the study design, composition of the CPTs, the outcomes analysed and the methodological quality of the included studies. Sensitivities ranged from 86 to 100%. The highest performing CPT had a lower limit of the 95% CI of 95.8% and was of high methodological quality (11 of 14). Had this rule been applied to the population then 25.1% of patients would have avoided a CT scan. CONCLUSIONS Seven CPTs were identified of varying designs and methodological quality. All demonstrate relatively high sensitivity with some achieving very high sensitivity whilst still managing to reduce the number of CTs performed by a significant amount. Further studies are required to validate the results obtained by the highest performing CPTs before any firm recommendation can be used regarding their use in routine clinical practice.
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Affiliation(s)
- Alistair Sharples
- University Hospital of North Midlands, UK; Queen Mary University of London and Barts and The London School of Medicine and Dentistry, London, UK.
| | - Karim Brohi
- Queen Mary University of London and Barts and The London School of Medicine and Dentistry, London, UK
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Jones TS, Stovall RT, Jones EL, Knepper B, Pieracci FM, Fox CJ, Moore EE, Cothren Burlew C. A negative urinalysis is associated with a low likelihood of intra-abdominal injury after blunt abdominal trauma. Am J Surg 2016; 213:69-72. [PMID: 27452187 DOI: 10.1016/j.amjsurg.2016.05.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Revised: 04/28/2016] [Accepted: 05/01/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The utility of urinalysis (UA) to diagnose intra-abdominal (IA) or genitourinary (GU) injury after blunt trauma remains controversial. The purpose of this study was to determine the significance of UA in the blunt trauma patient. METHODS A retrospective review of patients admitted for blunt abdominal trauma from 2011 to 2013. RESULTS A total of 1,795 patients sustained blunt abdominal trauma: mean age of 44 ± 21 years; mean Injury Severity Score of 13 ± 10. Overall 810 patients had a negative UA (45%). Two patients (2/810 and .2%) had a GU injury and neither required intervention. Thirty-two patients (32/810 and 4.0%) had an IA injury, and 2 (2/810 and .02%) required intervention. The sensitivity for predicting GU injury requiring intervention was 1, and IA injury requiring intervention was .96. Negative predictive values were 1 and .99. CONCLUSIONS A negative UA correlates with a low risk for GU and IA injury after blunt abdominal trauma. A negative UA should be evaluated prospectively as part of a clinical prediction score to rule out injury and avoid unnecessary radiation exposure from computed tomography imaging.
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Affiliation(s)
- Teresa S Jones
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Robert T Stovall
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Edward L Jones
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Bryan Knepper
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Fredric M Pieracci
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Charles J Fox
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Ernest E Moore
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA
| | - Clay Cothren Burlew
- Department of Surgery, Denver Health Medical Center, the University of Colorado School of Medicine, 777 Bannock Street, MC 0206, Denver, CO 80204, USA.
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25
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Abstract
Blunt abdominal trauma results in injury to the bowel and mesenteries in 3-5% of cases. The injuries are polymorphic including hematoma, seromuscular tear, perforation, and ischemia. They preferentially involve the small bowel and may result in bleeding and/or peritonitis. An urgent laparotomy is necessary if there is evidence of active bleeding or peritonitis at the initial examination, but these situations are uncommon. The main diagnostic challenge is to promptly and correctly identify lesions that require surgical repair. Diagnostic delay exceeding eight hours before surgical repair is associated with increased morbidity and probably with mortality. Because of this risk, the traditional therapeutic approach has been to operate on all patients with suspected bowel or mesenteric injury. However, this approach leads to a high rate of non-therapeutic laparotomy. A new approach of non-operative management (NOM) may be applicable to hemodynamically stable patients with no signs of perforation or peritonitis, and is being increasingly employed. This attitude has been described in several recent studies, and can be applied to nearly 40% of patients. However, there is no consensual agreement on which criteria or combination of clinical and radiological signs can insure the safety of NOM. When NOM is decided upon at the outset, very close monitoring is mandatory with repeated clinical examinations and interval computerized tomography (CT). Larger multicenter studies are needed to better define the selection criteria and modalities for NOM.
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Affiliation(s)
- T Bège
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
| | - C Brunet
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
| | - S V Berdah
- Université Aix-Marseille, Service de Chirurgie Générale et Digestive, Laboratoire de Biomécanique Appliquée (UMR 24), Hôpital Nord, AP-HM, Chemin des Bourrely, 13915 Marseille, France.
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Esposito A, Zilocchi M, Fasani P, Giannitto C, Maccagnoni S, Maniglio M, Campoleoni M, Brambilla R, Casiraghi E, Biondetti P. The value of precontrast thoraco-abdominopelvic CT in polytrauma patients. Eur J Radiol 2015; 84:1212-8. [DOI: 10.1016/j.ejrad.2015.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2014] [Revised: 02/15/2015] [Accepted: 02/20/2015] [Indexed: 10/24/2022]
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Review of the current management of upper urinary tract injuries by the EAU Trauma Guidelines Panel. Eur Urol 2015; 67:930-6. [PMID: 25578621 DOI: 10.1016/j.eururo.2014.12.034] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2014] [Accepted: 12/18/2014] [Indexed: 11/22/2022]
Abstract
CONTEXT The most recent European Association of Urology (EAU) guidelines on urological trauma were published in 2014. OBJECTIVE To present a summary of the 2014 version of the EAU guidelines on upper urinary tract injuries with the emphasis upon diagnosis and treatment. EVIDENCE ACQUISITION The EAU trauma guidelines panel reviewed literature by a Medline search on upper urinary tract injuries; publication dates up to December 2013 were accepted. The focus was on newer publications and reviews, although older key references could be included. EVIDENCE SYNTHESIS A full version of the guidelines is available in print and online. Blunt trauma is the main cause of renal injuries. The preferred diagnostic modality of renal trauma is computed tomography (CT) scan. Conservative management is the best approach in stable patients. Angiography and selective embolisation are the first-line treatments. Surgical exploration is primarily for the control of haemorrhage (which may necessitate nephrectomy) and renal salvage. Urinary extravasation is managed with endourologic or percutaneous techniques. Complications may require additional imaging or interventions. Follow-up is focused on renal function and blood pressure. Penetrating trauma is the main cause of noniatrogenic ureteral injuries. The diagnosis is often made by CT scanning or at laparotomy, and the mainstay of treatment is open repair. The type of repair depends upon the severity and location of the injury. CONCLUSIONS Renal injuries are best managed conservatively or with minimally invasive techniques. Preservation of renal units is feasible in most cases. This review, performed by the EAU trauma guidelines panel, summarises the current management of upper urinary tract injuries. PATIENT SUMMARY Patients with trauma benefit from being accurately diagnosed and treated appropriately, according to the nature and severity of their injury.
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Al Omran Y, Ahmed S. Re: A novel practical scoring for early diagnosis of traumatic bowel injury without obvious solid organ injury in hemodynamically stable patients. Int J Surg 2014; 12:923-4. [PMID: 25087973 DOI: 10.1016/j.ijsu.2014.07.268] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2014] [Accepted: 07/29/2014] [Indexed: 11/24/2022]
Affiliation(s)
- Yasser Al Omran
- Barts and the London School of Medicine and Dentistry, QMUL, Garrod Building, Turner Street, Whitechapel, London E1 2AD, UK.
| | - Shafi Ahmed
- Academic Surgical Unit, The Royal London Hospital, 80 Newark St, Whitechapel, London E1 2ES, UK
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Hershkovitz Y, Zoarets I, Stepansky A, Kozer E, Shapira Z, Klin B, Halevy A, Jeroukhimov I. Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury. Am J Emerg Med 2014; 32:697-9. [DOI: 10.1016/j.ajem.2014.04.024] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2014] [Accepted: 04/07/2014] [Indexed: 11/25/2022] Open
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Utilization of a clinical prediction rule for abdominal-pelvic CT scans in patients with blunt abdominal trauma. Emerg Radiol 2014; 21:571-6. [PMID: 24838812 DOI: 10.1007/s10140-014-1233-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 05/04/2014] [Indexed: 10/25/2022]
Abstract
This study aims to determine if a clinical prediction (CP) rule to identify patients at low risk for intra-abdominal injury (IAI) is being utilized in patients undergoing abdominal computed tomography (CT) following blunt abdominal trauma. A retrospective review of adult patients with blunt abdominal trauma undergoing abdominal CT scans was performed. The CP rule was positive if any of the following were present: systolic blood pressure <90 mmHg; urinalysis >25 red blood cells/high power field; Glasgow Coma Scale score <14; abdominal tenderness; costal margin tenderness; femur fracture; hematocrit <30 %; or pneumothorax or rib fracture on chest X-ray. The CP rule was negative if all variables were negative. Acute intervention was defined as therapeutic laparotomy or angiographic embolization. All variables in the CP rule were obtained in 218/262 (83 %; 95 % confidence interval (CI), 78, 88 %) patients. Of the 44 patients without complete CP rule assessment, 1 (2.3 %; 95 % CI, 0.1 %, 12.0 %) had an IAI but did not undergo therapeutic intervention. IAI was present in 11 (6.7 %; 95 % CI, 3.4, 11.6 %) of the 165 patients with at least one CP rule positive and 4 (36 %; 95 % CI, 11, 69 %) underwent therapeutic intervention. In the CP rule-negative patients, IAI was identified in 1/53 (1.9 %; 95 % CI, 0, 10.1 %) and no therapeutic intervention was required. An important percentage of patients undergoing abdominal CT are not assessed for or have a negative CP rule. Improved implementation of this CP rule may reduce unnecessary abdominal CT scans in patients presenting with blunt abdominal trauma.
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Emery M, Flannigan M. How useful are clinical findings in patients with blunt abdominal trauma? Ann Emerg Med 2014; 63:463-4. [PMID: 23706748 DOI: 10.1016/j.annemergmed.2013.03.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 03/19/2013] [Accepted: 03/25/2013] [Indexed: 10/26/2022]
Affiliation(s)
- Matt Emery
- Department of Emergency Medicine, Grand Rapids Medical Education Partners/Michigan State University College of Human Medicine, Grand Rapids, MI
| | - Matt Flannigan
- Department of Emergency Medicine, Grand Rapids Medical Education Partners/Michigan State University College of Human Medicine, Grand Rapids, MI
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Kerrey BT, Rogers AJ, Lee LK, Adelgais K, Tunik M, Blumberg SM, Quayle KS, Sokolove PE, Wisner DH, Miskin ML, Kuppermann N, Holmes JF. A Multicenter Study of the Risk of Intra-Abdominal Injury in Children After Normal Abdominal Computed Tomography Scan Results in the Emergency Department. Ann Emerg Med 2013; 62:319-26. [PMID: 23622949 DOI: 10.1016/j.annemergmed.2013.04.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 04/01/2013] [Accepted: 04/08/2013] [Indexed: 12/26/2022]
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Nicolle S, Noguer L, Palierne JF. Shear mechanical properties of the porcine pancreas: experiment and analytical modelling. J Mech Behav Biomed Mater 2013; 26:90-7. [PMID: 23820244 DOI: 10.1016/j.jmbbm.2013.05.029] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2012] [Revised: 05/16/2013] [Accepted: 05/27/2013] [Indexed: 12/31/2022]
Abstract
We provide the first account of the shear mechanical properties of porcine pancreas using a rheometer both in linear oscillatory tests and in constant strain-rate tests reaching the non-linear sub-failure regime. Our results show that pancreas has a low and weakly frequency-dependent dynamic modulus and experiences a noticeable strain-hardening beyond 20% strain. In both linear and non-linear regime, the viscoelastic behaviour of porcine pancreas follows a four-parameter bi-power model that has been validated on kidney, liver and spleen. Among the four solid organs of the abdomen, pancreas proves to be the most compliant and the most viscous one.
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Affiliation(s)
- S Nicolle
- Université de Lyon, F-69622, Lyon, France.
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Naulet P, Wassel J, Gervaise A, Blum A. Evaluation of the value of abdominopelvic acquisition without contrast injection when performing a whole body CT scan in a patient who may have multiple trauma. Diagn Interv Imaging 2013; 94:410-7. [DOI: 10.1016/j.diii.2013.01.018] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
CONTEXT Blunt abdominal trauma often presents a substantial diagnostic challenge. Well-informed clinical examination can identify patients who require further diagnostic evaluation for intra-abdominal injuries after blunt abdominal trauma. OBJECTIVE To systematically assess the precision and accuracy of symptoms, signs, laboratory tests, and bedside imaging studies to identify intra-abdominal injuries in patients with blunt abdominal trauma. DATA SOURCES We conducted a structured search of MEDLINE (1950-January 2012) and EMBASE (1980-January 2012) to identify English-language studies examining the identification of intra-abdominal injuries. A separate, structured search was conducted for studies evaluating bedside ultrasonography. STUDY SELECTION We included studies of diagnostic accuracy for intra-abdominal injury that compared at least 1 finding with a reference standard of abdominal computed tomography, diagnostic peritoneal lavage, laparotomy, autopsy, and/or clinical course for intra-abdominal injury. Twelve studies on clinical findings and 22 studies on bedside ultrasonography met inclusion criteria for data extraction. DATA EXTRACTION Critical appraisal and data extraction were independently performed by 2 authors. DATA SYNTHESIS The prevalence of intra-abdominal injury in adult emergency department patients with blunt abdominal trauma among all evidence level 1 and 2 studies was 13% (95% CI, 10%-17%), with 4.7% (95% CI, 2.5%-8.6%) requiring therapeutic surgery or angiographic embolization of injuries. The presence of a seat belt sign (likelihood ratio [LR] range, 5.6-9.9), rebound tenderness (LR, 6.5; 95% CI, 1.8-24), hypotension (LR, 5.2; 95% CI, 3.5-7.5), abdominal distention (LR, 3.8; 95% CI, 1.9-7.6), or guarding (LR, 3.7; 95% CI, 2.3-5.9) suggest an intra-abdominal injury. The absence of abdominal tenderness to palpation does not rule out an intra-abdominal injury (summary LR, 0.61; 95% CI, 0.46-0.80). The presence of intraperitoneal fluid or organ injury on bedside ultrasound assessment is more accurate than any history and physical examination findings (adjusted summary LR, 30; 95% CI, 20-46); conversely, a normal ultrasound result decreases the chance of injury detection (adjusted summary LR, 0.26; 95% CI, 0.19-0.34). Test results increasing the likelihood of intra-abdominal injury include a base deficit less than -6 mEq/L (LR, 18; 95% CI, 11-30), elevated liver transaminases (LR range, 2.5-5.2), hematuria (LR range, 3.7-4.1), anemia (LR range, 2.2-3.3), and abnormal chest radiograph (LR range, 2.5-3.8). Symptoms and signs may be most useful in combination, particularly in identification of patients who do not need further diagnostic workup. CONCLUSIONS Bedside ultrasonography has the highest accuracy of all individual findings, but a normal result does not rule out an intra-abdominal injury. Combinations of clinical findings may be most useful to determine which patients do not require further evaluation, but the ideal combination of variables for identifying patients without intra-abdominal injury requires further study.
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Affiliation(s)
- Daniel K Nishijima
- Department of Emergency Medicine, University of California Davis School of Medicine, Sacramento, USA.
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