Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma

Comparison of whole body computed tomography findings with physician predictions in high-energy blunt trauma patients: prospective observational study

BACKGROUND

The whole-body computed tomography (WBCT) procedure is increasingly common in evaluating patients presenting with high-energy trauma. However, it remains unclear in which population WBCT provides benefit and whether its routine application is truly beneficial. In this study, we aimed to compare physician predictions with WBCT findings in patients with high-energy blunt trauma.

METHODS

The study was conducted as a single-center prospective observational study at a tertiary center. Patients presenting with high-energy blunt trauma between 01.03.2021-01.03.2023 were included. Both physician predictions and WBCT findings were recorded and compared in three categories: "no pathology," "no life-threatening pathology," and "life-threatening pathology." The predictive values of physician predictions for each category were calculated. The characteristics of patients evaluated as less severe than predicted by clinicians were examined.

RESULTS

The study included a total of 92 patients. The median age was 27 years (IQR 25-75; 20-54). Among the patients, 27 (%) had life-threatening injuries according to CT findings in any region. A total of 34 (37%) patients were predicted by physicians to have "no pathology" in all three regions. Among these patients, none had life-threatening pathology in all three regions. There were 10 (10.9%) patients with CT findings more severe than physician predictions in at least one region. The sensitivity of physician predictions for life-threatening injury to the head/cervical region was 94.1% (95% CI: 71.3-99.9). For life-threatening injury to the chest, the sensitivity was 85.7% (95% CI: 42.1-99.6). For the presence of life-threatening abdominal pathology, the sensitivity was 100% (95% CI: 63.1-100). CONCLUSıON: It appears reasonable to utilize WBCT in patients where physicians expect life-threatening injury in any system. However, in cases where no pathology is expected in any system according to clinical prediction, we believe that performing WBCT solely based on trauma mechanism will not provide sufficient benefit.

Automated Rib Fracture Detection on Chest X-Ray Using Contrastive Learning

To develop a deep learning-based model for detecting rib fractures on chest X-Ray and to evaluate its performance based on a multicenter study. Chest digital radiography (DR) images from 18,631 subjects were used for the training, testing, and validation of the deep learning fracture detection model. We first built a pretrained model, a simple framework for contrastive learning of visual representations (simCLR), using contrastive learning with the training set. Then, simCLR was used as the backbone for a fully convolutional one-stage (FCOS) objective detection network to identify rib fractures from chest X-ray images. The detection performance of the network for four different types of rib fractures was evaluated using the testing set. A total of 127 images from Data-CZ and 109 images from Data-CH with the annotations for four types of rib fractures were used for evaluation. The results showed that for Data-CZ, the sensitivities of the detection model with no pretraining, pretrained ImageNet, and pretrained DR were 0.465, 0.735, and 0.822, respectively, and the average number of false positives per scan was five in all cases. For the Data-CH test set, the sensitivities of three different pretraining methods were 0.403, 0.655, and 0.748. In the identification of four fracture types, the detection model achieved the highest performance for displaced fractures, with sensitivities of 0.873 and 0.774 for the Data-CZ and Data-CH test sets, respectively, with 5 false positives per scan, followed by nondisplaced fractures, buckle fractures, and old fractures. A pretrained model can significantly improve the performance of the deep learning-based rib fracture detection based on X-ray images, which can reduce missed diagnoses and improve the diagnostic efficacy.

Accuracy of physician gestalt in prediction of significant abdominal and pelvic injury in adult blunt trauma patients

OBJECTIVE

Focusing on potential missed injury rates and sensitivity of low-risk of injury predictions, we sought to evaluate the accuracy of physician gestalt in predicting clinically significant injury (CSI) in the abdomen and pelvis among blunt trauma patients presenting to the emergency department (ED).

METHODS

We collected gestalt data on physicians caring for adult blunt trauma patients who received abdominal/pelvic computed tomography (CT) at three Level I and one Level II trauma centers. The primary outcome of CSI was defined as injury on abdominal/pelvic CT requiring hospitalization or intervention. Physicians evaluating trauma patients estimated the likelihood of CSI prior to abdominal/pelvic CT review (response choices: <2%, 2%-10%, 11%-20%, 21%-40%, >40%). We evaluated potential missed injury rates (prevalence of CSI) and sensitivity for prediction categories, as well as calibration and area under the receiver operating characteristic (AUROC) curve for overall physician gestalt.

RESULTS

Of 2030 patients, 402 (20%) had an injury on abdominal/pelvic CT and 270 (13%) had CSI. The <2% risk of CSI gestalt cutoff had a potential missed injury rate of 5.6% and a sensitivity of 95.2% (95% confidence interval [CI] 91.7%-97.3%). The 0%-10% cutoff of CSI gestalt had a potential missed injury rate of 6.3% (95% CI, 5.0%-7.9%) and a sensitivity of 75.2% (95% CI 69.5%-80.1%). With an overall AUROC of 0.699 (95% CI 0.679-0.719), physician gestalt was moderately accurate and calibrated for the midranges of predicted risk but poorly calibrated at the extremes.

CONCLUSIONS

Physician gestalt for the prediction of adult abdominal and pelvic CSI is moderately accurate and calibrated. However, the potential missed CSI rate and low sensitivity of the low perceived risk of injury cutoffs indicate that gestalt by itself is insufficient to direct selective abdominal/pelvic CT use in adult blunt trauma patient evaluation.

Comparison of severity scales for acute bronchiolitis in real clinical practice

Several clinical scales have been developed to assess the severity of bronchiolitis as well as the probability of needing in-hospital care. A recent systematic review of 32 validated clinical scores for bronchiolitis concluded that 6 of them (Wood-Downes, M-WCAS, Respiratory Severity Score, Respiratory Clinical Score, Respiratory Score and Bronchiolitis risk of admission score) were the best ones regarding reliability, sensitivity, validity, and usability. However, to the best of our knowledge, no study has compared all of them in a clinical scenario. Also, after this review, three more scales were published: BROSJOD, Tal modified, and one score developed by PERN. Our main aim was to compare the ability of different clinical scales for bronchiolitis to predict any relevant outcome. A prospective observational study was conducted that included patients of up to 12 months old attended to, due to bronchiolitis, in the paediatric Emergency Department of a secondary university hospital from October 2019 to January 2022. For each patient, the attending clinician filled in a form with the items of the scales, decomposed, in order to prevent the clinician from knowing the score of each scale. Then, the patient was managed according to the protocol of our Emergency Department. A phone call was made to each patient in order to check whether the patient ended up being admitted in the next 48 h. In the case of those that were impossible to contact by phone, the clinical history was reviewed. For the purpose of the study, any of the following were considered to be a relevant outcome: admission to ward and need for supplementary oxygen, non-invasive ventilation (NIV) or intravenous fluids, and admission to the paediatric intensive care unit (PICU) within the next 48 h or death. For the aim of the study, the area under the curve (AUC) and the odds ratio (OR) for a relevant outcome were calculated in each scale. Also, the best cut-off point was estimated according to the Youden index, and its sensitivity (Sn) and specificity (Sp) for a relevant outcome were calculated. We included 265 patients (52.1% male) with a median age of 5.3 months (P₂₅-P₇₅ 2.6-7.4). Among them, 46 (17.4%) had some kind of relevant outcome. AUC for prediction of a relevant outcome ranged from 0.705 (Respiratory Score) to 0.786 (BRAS), although no scale performed significantly better than others. A score ≤ 2 in the PERN scale showed a sensitivity of 91.3% (CI95% 79.7-96.6) for a relevant outcome, with only 4 misdiagnosed patients (only 2 of them needed NIV).   Conclusions: There were no differences in the performance of the nine scales to predict relevant outcomes in patients with bronchiolitis. However, the PERN scale might be more useful to select patients at low risk of a severe outcome. What is Known: • Several clinical scales are used to assess the severity of bronchiolitis. Nevertheless, none of them seems to be better than others. What is New: • This is the first study comparing different bronchiolitis scales in a real clinical scenario. None of the nine scales compared performed better than the other. However, the PERN scale might be more useful to select patients at low risk of relevant outcomes.

Treatment outcomes of penetrating abdominal injury requiring laparotomy at Hiwot Fana Specialized University Hospital, Harar, Ethiopia

Background

Penetrating abdominal injury (PAI) is a public health problem and accounts for significant mortality and disability in both developing and developed countries. It often causes damage to internal organs, resulting in shock and infection. In this study, we assessed the outcomes of PAI and factors associated with post-surgical outcomes including surgical site infection (SSI) and in-hospital death.

Methods

An institution-based cross-sectional study was conducted from 15 January to January 30, 2020, using a standard checklist to review the clinical charts of patients who presented to Hiwot Fana Specialized University Hospital (HFSUH) with PAI and underwent laparotomy between January 2015 and September 2019. Descriptive statistics were used to describe the characteristics of patients, and odds ratios (ORs) with a 95% confidence interval (CI) were reported for factors included in binary logistic regression. The statistical significance was declared at a P-value <0.05.

Results

A total of 352 charts of patients with PAI were reviewed. A majority of them (84.9%) were males and the mean age was 26.5 years. The anterior abdomen was the most common site of injury, accounting for 285 patients (81%), 329 patients (93.5%) suffered organ injury, 204 (62%) had a single organ injury, and 125 (38%) had more than one organ injury. The leading injured organs were small intestines 194 (55.1%), followed by the colon 88 (25%) and liver 40 (11.4%). The magnitude of SSI and hospital death was 84 (23.9%) and 12 (3.4%), respectively. Patients above 45 years of age (AOR = 2.9, 95% CI: 1.2, 9.2), with fluid collection (AOR = 2.7, 95% CI: 1.2, 5.9), colostomy (AOR = 3.9, 95% CI: 1.9, 7.8), body temperature >37.5 °C (AOR = 3.8,95% CI:1.9,7.6), and Hgb < 10 mg/dl (AOR = 7.4, 95% CI: 3.4,16.1) had a higher likelihood of SSI. Those patients admitted to the intensive care unit (AOR = 21.3, 95% CI: 1.1, 412.3) and who underwent damage control surgery (AOR = 9.6, 95% CI: 1.3, 73.3) had a higher likelihood of mortality.

Conclusions

SSI and death among patients with PAI were high. Age, fluid collection, colostomy, body temperature, and hemoglobin level were statistically associated with SSI, and intensive care unit and damage control surgery were statistically associated with death. Therefore, health professionals working in surgical wards should consider these factors to alleviate SSI and prevent death. Broadly speaking, the guidelines of the World Society of Emergency Surgery (WSES) should consider these factors in their recommendations.

Developing a decision instrument to guide abdominal-pelvic imaging of blunt trauma patients: Methodology and protocol of the NEXUS abdominal-pelvic imaging study

Although computed tomography (CT) of the abdomen and pelvis (A/P) can provide crucial information for managing blunt trauma patients, liberal and indiscriminant imaging is expensive, can delay critical interventions, and unnecessarily exposes patients to ionizing radiation. Currently no definitive recommendations exist detailing which adult blunt trauma patients should receive A/P CT imaging and which patients may safely forego CT. Considerable benefit could be realized by identifying clinical criteria that reliably classify the risk of abdominal and pelvic injuries in blunt trauma patients. Patients identified as “very low risk” by such criteria would be free of significant injury, receive no benefit from imaging and therefore could be safely spared the expense and radiation exposure associated with A/P CT. The goal of this two-phase nationwide multicenter observational study is to derive and validate the use of clinical criteria to stratify the risk of injuries to the abdomen and pelvis among adult blunt trauma patients. We estimate that nation-wide implementation of a rigorously developed decision instrument could safely reduce CT imaging of adult blunt trauma patients by more than 20%, and reduce annual radiographic charges by $180 million, while simultaneously expediting trauma care and decreasing radiation exposure with its attendant risk of radiation-induced malignancy. Prior to enrollment we convened an expert panel of trauma surgeons, radiologists and emergency medicine physicians to develop a consensus definition for clinically significant abdominal and pelvic injury. In the first derivation phase of the study, we will document the presence or absence of preselected candidate criteria, as well as the presence or absence of significant abdominal or pelvic injuries in a cohort of blunt trauma victims. Using recursive partitioning, we will examine combinations of these criteria to identify an optimal “very low risk” subset that identifies injuries with a sensitivity exceeding 98%, excludes injury with a negative predictive value (NPV) greater than 98%, and retains the highest possible specificity and potential to decrease imaging. In Phase 2 of the study we will validate the performance of a decision rule based on these criteria among a new cohort of patients to ensure that the criteria retain high sensitivity, NPV and optimal specificity. Validating the sensitivity of the decision instrument with high statistical precision requires evaluations on 317 blunt trauma patients who have significant abdominal-pelvic injuries, which will in turn require evaluations on approximately 6,340 blunt trauma patients. We will estimate potential reductions in CT imaging by counting the number of abdominal-pelvic CT scans performed on “very low risk” patients. Reductions in charges and radiation exposure will be determined by respectively summing radiographic charges and lifetime decreases in radiation morbidity and mortality for all “very low risk” cases.

Trial registration: Clinicaltrials.gov trial registration number: NCT04937868.

Occult Abdominal Trauma

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.

Efficacy of new scoring system for diagnosis of abdominal injury after blunt abdominal trauma in patients referred to emergency department

PURPOSE

The blunt abdominal trauma (BAT) is a common emergency and is significantly associated with morbidity and mortality. Our study was conducted to achieve the goal that a new scoring system could be used for the BAT patients.

METHODS

The statistical population of this study was 1000 patients with BAT referred to emergency department of Imam Hossein Hospital, Tehran, Iran. Sampling was carried out in a convenience non-random manner and continued to reach the required sample size. All the patients with BAT due to road traffic accidents, falls, and other direct blunt traumas such as punctures and kickbacks were included in the study. Exclusion criteria were after 3 months of pregnancy, under the age of 18, warfarin taking, no reliable medical history providing and penetrating trauma. The study questionnaire was based on BAT scoring system. The data were analyzed by SPSS V20 software. The receiver operating characteristic curve was used to analyze the effectiveness of the new scoring system in predicting the BAT patients' outcome.

RESULTS

The mean age of the patients (n = 1000) was (35.79 ± 13.09) years. The mean score of patients was (6.29 ± 5.80). Based on this scoring system, the patients were divided into three categories. The first group was patients at low risk with score of less than 8, the second group was patients at moderate risk with score of 8-12 and the third group was patients at high risk with score of 12-24. The score of 661 (66.1%) patients were low, 109 (10.9%) were moderate and 230 (23%) had a high score. The association between hip fracture and abdominal tenderness with abdominal injury was significant (p < 0.001). Cronbach's alpha was 0.76 showing the reliability of this questionnaire to predict the future of patients.

CONCLUSIONS

The study tool has a sensitivity to predict the BAT patients' outcome, and has a proper specificity that can be used to reduce the use of harmful modalities such as computed tomography scan.

How useful are clinical details in blunt trauma referrals for computed tomography of the abdomen?

Background

The relevance of clinical data included in blunt trauma referrals for abdominal computed tomography (CT) is not known.

Objectives

To analyse the clinical details provided on free-text request forms for abdominal CT following blunt trauma and assess their association with imaging evidence of intra-abdominal injury.

Method

A single-institution, retrospective study of abdominal CT scans was performed for blunt trauma between 01 January and 31 March 2018. Computed tomography request forms were reviewed with their corresponding CT images. Clinical details provided and scan findings were captured systematically. The relationship between individual clinical features and CT evidence of abdominal injury was tested using one-way cross tabulation and Fisher’s exact test.

Results

One hundred thirty-nine studies met inclusion criteria. A wide range of clinical details was communicated. Only clinical abdominal examination findings (p = 0.05), macroscopic haematuria (p < 0.01), pelvic fracture or hip dislocation (p = 0.04) and positive focused assessment with sonography in trauma (p < 0.01) demonstrated an associated trend with abdominal injury.

Conclusion

Key abdominal examination and basic imaging findings remain essential clinical details for the appropriate evaluation of CT abdomen requests in the setting of blunt trauma. Methods to improve consistent communication of relevant clinical details are likely to be of value.

Characteristics of knowledge content in a curated online evidence library

Objective

To describe types of recommendations represented in a curated online evidence library, report on the quality of evidence-based recommendations pertaining to diagnostic imaging exams, and assess underlying knowledge representation.

Materials and Methods

The evidence library is populated with clinical decision rules, professional society guidelines, and locally developed best practice guidelines. Individual recommendations were graded based on a standard methodology and compared using chi-square test. Strength of evidence ranged from grade 1 (systematic review) through grade 5 (recommendations based on expert opinion). Finally, variations in the underlying representation of these recommendations were identified.

Results

The library contains 546 individual imaging-related recommendations. Only 15% (16/106) of recommendations from clinical decision rules were grade 5 vs 83% (526/636) from professional society practice guidelines and local best practice guidelines that cited grade 5 studies (P < .0001). Minor head trauma, pulmonary embolism, and appendicitis were topic areas supported by the highest quality of evidence. Three main variations in underlying representations of recommendations were "single-decision," "branching," and "score-based."

Discussion

Most recommendations were grade 5, largely because studies to test and validate many recommendations were absent. Recommendation types vary in amount and complexity and, accordingly, the structure and syntax of statements they generate. However, they can be represented in single-decision, branching, and score-based representations.

Conclusion

In a curated evidence library with graded imaging-based recommendations, evidence quality varied widely, with decision rules providing the highest-quality recommendations. The library may be helpful in highlighting evidence gaps, comparing recommendations from varied sources on similar clinical topics, and prioritizing imaging recommendations to inform clinical decision support implementation.

Laparotomy for Abdominal Injury Indication & Outcome of patients at a Teaching Hospital in Addis Ababa, Ethiopia

Background

Abdominal injury is among the major causes of trauma admissions. The aim was to determine etiology, commonly injured organs, indication and outcome of patients with abdominal injuries requiring laparotomy.

Methods

A retrospective study of all adult patients who underwent laparotomy for abdominal injury at St. Paul's Hospital Millennium Medical College was conducted from January 2014 to December 2016. The factors associated with outcome were identified with bivariate and multivariate logistic regressions.

Results

Laparotomy for abdominal injury was performed for 145 patients. Of these, 129 (89%) case records were retrieved. The male to female ratio was 6.2:1. The mean age was 29 years, and most of them were unemployed. Penetrating trauma was the commonest injury, stab (46, 35.7%) and Road Traffic Accidents (RTA) (27, 20.9%) being the leading causes. Extra-abdominal injuries were seen in 33.3% (46) of the cases. Hollow organs were commonly injured than solid organs. Small intestine (35, 43.8%) and Spleen (17, 34.7%) were the leading injured organs in penetrating and blunt respectively. The main procedure performed was repair of hollow and solid organ laceration/perforation (70,54.3%). The negative laparotomy rate was 4.6% (6). Complications were seen in 23(17.8%) patients, the commonest being irreversible shock (7,30.4%). The mortality rate was 8.5 % (11), and it was significantly associated with blunt abdominal injury (AOR=7.25; 95% CI 1.09–48.37; p=0.041) and systolic blood pressure<90mmHg (AOR=8.66; 95% CI 1.1–68.41; p=0.041).

Conclusion

Stab and RTA were the commonest indications of laparotomy. The mortality was significantly associated with blunt abdominal injury and hypotension (SBP<90mmHg).

Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation

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.

Occult bowel injury after blunt abdominal trauma

BACKGROUND

Following blunt abdominal trauma, bowel injuries are often missed on admission computed tomography (CT) scan.

METHODS

Multicenter retrospective analysis of 176 adults with moderate-critical blunt abdominal trauma and admission CT scan who underwent operative exploration. Patients with a bowel injury missed on CT (n = 36, 20%) were compared to all other patients (n = 140, 80%).

RESULTS

The missed injury group had greater incidence free fluid without solid organ injury on CT scan (44% vs. 25%, p = 0.038) and visceral adhesions (28% vs. 6%, p = 0.001). Independent predictors of missed bowel injury included prior abdominal inflammation (OR 3.74, 95% CI 1.37-10.18), CT evidence of free fluid in the absence of solid organ injury (OR 2.31, 95% CI 1.03-5.19) and intraoperative identification of visceral adhesions (OR 4.46, 95% CI 1.52-13.13).

CONCLUSIONS

Patients with visceral adhesive disease and indirect evidence of bowel injury on CT scan were more likely to have occult bowel injury.

The Impact of Prior Laparotomy and Intra-abdominal Adhesions on Bowel and Mesenteric Injury Following Blunt Abdominal Trauma

BACKGROUND

Early recognition of bowel and mesenteric injury following blunt abdominal trauma remains difficult. We hypothesized that patients with intra-abdominal adhesions from prior laparotomy would be subjected to visceral sheering deceleration forces and increased risk for bowel and mesenteric injury following blunt abdominal trauma.

METHODS

We performed a multicenter retrospective cohort analysis of 267 consecutive adult trauma patients who underwent operative exploration following moderate-critical (abdominal injury score 2-5) blunt abdominal trauma, comparing patients with prior laparotomy (n = 31) to patients with no prior laparotomy (n = 236). Multivariable regression was performed to identify predictors of bowel or mesenteric injury.

RESULTS

There were no significant differences between groups for injury severity scores or findings on abdominal ultrasound, diagnostic peritoneal aspirate/lavage, pelvic radiography, or preoperative CT scan. The prior laparotomy cohort had greater incidence of full thickness bowel injury (26 vs. 9%, p = 0.010) and mesenteric injury (61 vs. 31%, p = 0.001). The proportion of bowel and mesenteric injuries occurring at the ligament of Treitz or ileocecal region was greater in the no prior laparotomy group (52 vs. 25%, p = 0.003). Prior laparotomy was an independent predictor of bowel or mesenteric injury (OR 5.1, 95% CI 1.6-16.8) along with prior abdominal inflammation and free fluid without solid organ injury (model AUC: 0.81, 95% CI 0.74-0.88).

CONCLUSIONS

Patients with a prior laparotomy are at increased risk for bowel and mesenteric injury following blunt abdominal trauma. The distribution of bowel and mesenteric injuries among patients with no prior laparotomy favors embryologic transition points tethering free intraperitoneal structures to the retroperitoneum.

Blunt Trauma Abdominal and Pelvic Computed Tomography Has Low Yield for Injuries in More Than One Anatomic Region

Introduction

Most trauma centers order abdominal and pelvic computed tomography (CT) as an automatically paired CT for adult blunt trauma evaluation. However, excessive CT utilization adds risks of excessive exposure to ionizing radiation, the need to work up incidental findings (leading to unnecessary and invasive tests), and greater costs. Examining a cohort of adult blunt trauma patients that received paired abdominal and pelvic (A/P) CT, we sought to determine the diagnostic yield of clinically significant injuries (CSI) in the following: 1) the abdomen alone; 2) the pelvis alone; 3) the lumbosacral spine alone; and 4) more than one of these anatomic regions concomitantly.

Methods

In this retrospective study, we reviewed the imaging and hospital course of a consecutive sample of blunt trauma activation patients older than 14 years of age who received paired A/P CT during their blunt trauma assessments at an urban Level I trauma center from April through October 2014. Categorization of CSI was determined according to an a priori, expert panel-derived classification scheme.

Results

The median age of the 689 patients who had A/P CT was 48 years old; 68.1% were male; 64.0% were admitted, and hospital mortality was 3.6%. CSI yields were as follows: abdomen 2.2% (95% confidence interval [CI] [1.3–3.6%]); pelvis 2.9% (95% CI [1.9–4.4%]); lumbosacral spine 0.6% (95% CI [0.2–1.5%]); both abdomen and pelvis 0.3% (95% CI [0.1–1.1%]); both the abdomen and lumbosacral spine 0.6% (0.2–1.5%); both the pelvis and lumbosacral spine 0.1% (0.0–0.8%); all three regions – abdomen, pelvis and lumbosacral spine – 0.1% (0.0–0.8%).

Conclusion

Automatic pairing of A/P CT has very low diagnostic yield for CSI in both the abdomen and pelvis. These data suggest a role for selective CT imaging protocols that image these regions individually instead of automatically as a pair.

Costal Margin Tenderness and the Risk for Intraabdominal Injuries in Children With Blunt Abdominal Trauma

BACKGROUND

The risk of radiation exposure from computed tomography (CT) imaging in children is well recognized. Patient history and physical examination findings, including costal margin tenderness (CMT), influence a physician's decision to image a child with blunt torso trauma. The objective of this study was to determine the importance of CMT for identifying children with intraabdominal injuries (IAI) found on CT and IAI undergoing acute intervention.

METHODS

We conducted an analysis of the Pediatric Emergency Care Applied Research Network (PECARN) IAI public use data set, representing a large prospective multicenter cohort study from May 2007 to January 2010. Isolated CMT was defined as CMT without other identified PECARN risk factors for IAI (i.e., abdominal or thoracic wall trauma, abdominal tenderness or pain, decreased breath sounds, or vomiting). Logistic regression was used to calculate adjusted odds of IAI in children presenting with isolated and nonisolated CMT. Risk differences were calculated to estimate the risk of IAI independently attributable to CMT in the setting of isolated PECARN risk factors. Finally, CT use among exposure groups was estimated to quantify potentially avoidable imaging.

RESULTS

Among 9,174 children with Glasgow Coma Scale scores of 14 or 15 who sustained blunt torso trauma, 1,267 (13.8%) had CMT. Among those with CMT, 177 (14.0%) had isolated CMT and 1,090 (86.0%) had nonisolated CMT. No children (0/177; 0%, 95% confidence interval [CI] = 0.0%-2.1%) with isolated CMT had IAI, compared to 17.2% (187/1,090; 95% CI = 15.0%-19.5%) of those with nonisolated CMT. The risk differences were not statistically significant. 36/177 (20.3%; 95% CI = 14.7%-27.0%) children with isolated CMT underwent abdominal CT scans.

CONCLUSIONS

The risk of IAI associated with isolated CMT is minimal. For children with blunt abdominal trauma and isolated CMT, abdominal CT scan is of low yield.

Ruling out intra-abdominal injuries in blunt trauma patients using clinical criteria and abdominal ultrasound

OBJECTIVE

to identify victims of blunt abdominal trauma in which intra-abdominal injuries can be excluded by clinical criteria and by complete abdominal ultrasonography.

METHODS

retrospective analysis of victims of blunt trauma in which the following clinical variables were analyzed: hemodynamic stability, normal neurologic exam at admission, normal physical exam of the chest at admission, normal abdomen and pelvis physical exam at admission and absence of distracting lesions (Abbreviated Injury Scale >2 at skull, thorax and/or extremities). The ultrasound results were then studied in the group of patients with all clinical variables evaluated.

RESULTS

we studied 5536 victims of blunt trauma. Intra-abdominal lesions with AIS>1 were identified in 144 (2.6%); in patients with hemodynamic stability they were present in 86 (2%); in those with hemodynamic stability and normal neurological exam at admission in 50 (1.8%); in patients with hemodynamic stability and normal neurological and chest physical exam at admission, in 39 (1.5%); in those with hemodynamic stability, normal neurological, chest, abdominal and pelvic physical exam at admission, in 12 (0.5%); in patients with hemodynamic stability, normal neurological, chest, abdominal and pelvic physical exam at admission, and absence of distracting lesions, only two (0.1%) had intra-abdominal lesions. Among those with all clinical variables, 693 had normal total abdominal ultrasound, and, within this group, there were no identified intra-abdominal lesions.

CONCLUSION

when all clinical criteria and total abdominal ultrasound are associated, it is possible to identify a group of victims of blunt trauma with low chance of significant intra-abdominal lesions.

A nomogram predicting the need for abdominal and pelvic computed tomography in blunt trauma patients: A retrospective cohort study

BACKGROUND

Abdominal and pelvic computed tomography (APCT) has become the preferred means for the initial evaluation of blunt trauma patients. However, computed tomography examination has some disadvantages, such as radiation exposure, the requirement for intravenous iodinated contrast medium, high cost, and time. We aimed to develop a nomogram to predict the need for APCT scanning after the primary survey of blunt trauma patients.

MATERIALS AND METHODS

We conducted a retrospective observational cohort study at a single-center and reviewed medical records of 972 trauma patients admitted between January 2013 and June 2016. We enrolled 786 blunt trauma patients who had undergone APCT and were 16 years of age or older. A multivariate logistic regression model was used to determine independent predictors for trauma-related findings on APCT scans. A nomogram was constructed to predict injury on APCT scans based on each predictive factor.

RESULTS

Of 786 patients, 355 (45%) patients had at least 1 injury on APCT scans. Results of multivariate logistic regression analysis showed that independent predictive factors of injuries on APCT scans were as follows: falls (≥3 m high); pain (abdominal, back, flank, or pelvic); positive peritoneal signs; abnormal findings on chest radiographs; abnormal findings on pelvic radiographs; and positive findings on focused assessment with ultrasonography for trauma. The nomogram was developed using these parameters. The area under a receiver operating characteristic curve of the multivariate model for discrimination was 0.865 (95% confidence interval, 0.840-0.892). The calibration plot showed good agreement between predicted and observed outcomes. The maximal Youden index was 0.59, corresponding to a cutoff value > 59 points, which was considered the optimal cutoff value for the probability that the injury would be detected on APCT scans.

CONCLUSION

The nomogram, based on initial clinical findings in blunt trauma patients, will help clinicians be more selective in their use of APCT evaluations.

Correlating abdominal pain and intra-abdominal injury in patients with blunt abdominal trauma

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.

The predictive value of biochemical parameters in evaluating patients with abdominal trauma: The new scoring system

Aim

The aim of this study was to investigate the contribution of non-invasively and rapidly obtained biochemical parameter results to the diagnosis and follow-up of intraabdominal injuries in multitrauma patients.

Material and Methods

A total of 2604 multitrauma patients who were treated following their referral to our emergency department between January 2009 and January 2012 were retrospectively reviewed. A logistic regression analysis was used in the risk assessment.

Results

Statistically significant associations between intraabdominal injury and certain biochemical variables measured at the time of the referral were determined. These variables were hemoglobin ≤9.99 g/dL [odds ratio (OR): 6.25, 95% CI: 2.86–13.52, p < 0.0001], serum alanine amino transferase (ALT) ≥ 100 IU/L (OR: 34.45, 95% CI: 21.76–54.54, p < 0.0001), and serum lipase ≥ 61 U/L (OR: 10.44, 95% CI: 6.56–16.49, p < 0.0001). The pretest probability score was determined for each patient by adding the scores that were obtained from each factor. ROC curve analysis was performed to determine the diagnostic value of the pretest probability score for detecting intra-abdominal injury (area = 0.88; p < 0.0001).

Conclusion

The results of our study demonstrated that biochemical parameters may contribute to the diagnosis and follow-up of intraabdominal injuries in multitrauma patients. In particular, ALT, AST, CK and myoglobin were found to have higher ORs than low hemoglobin. After these parameters are tested in larger scale studies in conjunction with the gold standard multislice abdominal CT, they may be used for establishing scores to evaluate the severity of abdominal injuries.

Minimizing Attrition for Multisite Emergency Care Research

Loss to follow-up of enrolled patients (a.k.a. attrition) is a major threat to study validity and power. Minimizing attrition can be challenging even under ideal research conditions, including the presence of adequate funding, experienced study personnel, and a refined research infrastructure. Emergency care research is shifting toward enrollment through multisite networks, but there have been limited descriptions of approaches to minimize attrition for these multicenter emergency care studies. This concept paper describes a stepwise approach to minimize attrition, using a case example of a multisite emergency department prospective cohort of over 3,000 patients that has achieved a 30-day direct phone follow-up attrition rate of <3%. The seven areas of approach to minimize attrition in this study focused on patient selection, baseline contact data collection, patient incentives, patient tracking, central phone banks, local enrollment site assistance, and continuous performance monitoring. Appropriate study design, including consideration of these methods to reduce attrition, will be time well spent and may improve study validity.

Assessment of urinary dipstick in patients admitted to an ED for blunt abdominal trauma

INTRODUCTION

Clinicians still face significant challenge in predicting intra-abdominal injuries in patients admitted to an emergency department for blunt abdominal trauma. This study was thus designed to investigate the value of dipstick urinalysis in patients with blunt abdominal trauma.

METHODS

We performed a retrospective, multicenter, cohort study involving patients admitted to the emergency department for abdominal traumas, examined by means of urinary dipstick and abdominal CT scan. The primary endpoint was the correlation between microscopic hematuria detected via dipstick urinalysis (defined by the presence of blood on the dipstick urinalysis but without gross hematuria) and abdominal injury, as evidenced on CT scan.

RESULTS

Of the 100 included patients, 56 experienced microscopic hematuria, 17 gross hematuria, and 44 no hematuria. Patients with abdominal injury were more likely to present with hypovolemic shock (odds ratio [OR]: 8.4; 95% confidence interval [CI]: 2.7-26), abdominal wall hematoma (OR: 3.1; 95% CI: 1.2-7.9), abdominal defense (OR: 5.2; 95% CI: 1.8-14.5), or anemia (OR: 3.6; 95% CI: 1.2-10.3). Moreover, dipstick urinalysis was less likely to predict injury, with just 72.2% sensitivity (95% CI: 54.8-85.8), 53.1% specificity (95% CI: 40.2-65.7), and positive and negative predictive values of 46.4% (95% CI: 33.0-60.3) and 77.3% (95% CI: 62.2-88.5), respectively.

CONCLUSION

Dipstick urinalysis was neither adequately specific nor sensitive for predicting abdominal injury and should thus not be used as a key assessment component in patients suffering from blunt abdominal trauma, with physical exam and vital sign assessment the preferred choice.

Prediction of blunt traumatic injuries and hospital admission based on history and physical exam

BACKGROUND

We evaluated the ability of experienced trauma surgeons to accurately predict specific blunt injuries, as well as patient disposition from the emergency department (ED), based only on the initial clinical evaluation and prior to any imaging studies. It would be hypothesized that experienced trauma surgeons' initial clinical evaluation is accurate for excluding life-threatening blunt injuries and for appropriate admission triage decisions.

METHODS

Using only their history and physical exam, and prior to any imaging studies, three (3) experienced trauma surgeons, with a combined Level 1 trauma experience of over 50 years, predicted injuries in patients with an initial GCS (Glasgow Coma Score) of 14-15. Additionally, ED disposition (ICU, floor, discharge to home) was also predicted. These predictions were compared to actual patient dispositions and to blunt injuries documented at discharge.

RESULTS

A total of 101 patients with 92 blunt injuries were studied. 43/92 (46.7 %) injuries would have been missed by only performing an initial history and physical exam ("Missed injury"). A change in treatment, though often minor, was required in 19/43 (44.2 %) of the missed injuries. Only 1/43 (2.3 %) of these "missed injuries" (blunt aortic injury) required surgery. Sensitivity, specificity, and accuracy for injury prediction were 53.2, 95.9, and 92.3 % respectively. Positive and negative predictive values were 53.8 and 95.8 % respectively. Prediction of disposition from the ED was 77.8 % accurate. In 7/34 (20.6 %) patients, missed injuries led to changes in disposition. "Undertriage" occurred in 9/99 (9.1 %) patients (Predicted for floor but admitted to ICU). Additionally, 8/84 (9.5 %) patients predicted for floor admission were sent home from the ED; and 5/13 (38.5 %) patients predicted for ICU admission were actually sent to the floor after complete evaluations, giving an "overtriage" rate of 13/99 (13.1 %) patients.

CONCLUSIONS

In a neurologically-intact group of trauma patients, experienced trauma surgeons would have missed 46.7 % of the actual injuries, based only on their history and physical exam. Once accurate diagnoses of injuries were completed, usually with the help of CT scans, admission dispositions changed in 20.6 % of patients. Treatment changes occurred in 44.2 % of the missed injuries, though usually minimal. Broad elimination of early imaging studies in alert, blunt trauma patients cannot be advocated.

Can clinical prediction tools predict the need for computed tomography in blunt abdominal? A systematic review

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.

A negative urinalysis is associated with a low likelihood of intra-abdominal injury after blunt abdominal trauma

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.

JOURNAL CLUB: Quantification of Fetal Dose Reduction if Abdominal CT Is Limited to the Top of the Iliac Crests in Pregnant Patients With Trauma

OBJECTIVE

The purposes of this study were to correlate fetal z-axis location within the maternal abdomen on CT with gestational age and estimate fetal dose reduction of a study limited to the abdomen only, with its lower aspect at the top of the iliac crests, compared with full abdominopelvic CT in pregnant trauma patients.

MATERIALS AND METHODS

We performed a study of pregnant patients who underwent CT of the abdomen and pelvis for trauma at a single institution over a 10-year period. The inferior aspect of maternal liver, spleen, gallbladder, pancreas, adrenals, and kidneys was recorded as above or below the iliac crests. The distance from the iliac crest to the top of the fetus or gestational sac was determined. The CT images of the limited and full scanning studies were independently reviewed by two blinded radiologists to identify traumatic injuries. Fetal dose profiles, including both scatter and primary radiation, were computed analytically along the central axis of the patient to estimate fetal dose reduction. Linear regression analysis was performed between gestational age and distance of the fetus to the iliac crests.

RESULTS

Thirty-five patients were included (mean age, 26.2 years). Gestational age ranged from 5 to 38 weeks, with 5, 19, and 11 gestations in the first, second, and third trimesters, respectively. All solid organs were above the iliac crests in all patients. In three of six patients, traumatic findings in the pelvis would have been missed with the limited study. There was high correlation between gestational age and distance of the fetus to the iliac crests (R(2) = 0.84). The mean gestational age at which the top of the fetus was at the iliac crest was 17.3 weeks. Using the limited scanning study, fetuses at 5, 20, and 40 weeks of gestation would receive an estimated 4.3%, 26.2%, and 59.9% of the dose, respectively, compared with the dose for the full scanning study.

CONCLUSION

In pregnant patients in our series with a history of trauma, CT of the abdomen only was an effective technique to reduce fetal radiation exposure compared with full abdomen and pelvis CT.

Severity and treatment of "occult" intra-abdominal injuries in blunt trauma victims

BACKGROUND

to assess the severity and treatment of "occult" intra-abdominal injuries in blunt trauma victims.

METHOD

Retrospective analysis of charts and trauma register data of adult blunt trauma victims, admitted without abdominal pain or alterations in the abdominal physical examination, but were subsequently diagnosed with intra-abdominal injuries, in a period of 2 years. The severity was stratified according to RTS, AIS, OIS and ISS. The specific treatment for abdominal injuries and the complications related to them were assessed.

RESULTS

Intra-abdominal injuries were diagnosed in 220 (3.8%) out of the 5785 blunt trauma victims and 76 (34.5%) met the inclusion criteria. The RTS and ISS median (lower quartile, upper quartile) were 7.84 (6.05, 7.84) and 25 (16, 34). Sixty seven percent had a GCS≥13 on admission. Injuries were identified in the spleen (34), liver (33), kidneys (9), intestines (4), diaphragm (3), bladder (3) and iliac vessels (1). Abdominal injuries scored AIS≥3 in 67% of patients. Twenty-one patients (28%) underwent laparotomy, 5 of which were nontherapeutic. The surgical procedures performed were splenectomy (8), suturing of the diaphragm (3), intestines (3), bladder (2), kidneys (1), enterectomy/anastomosis (1), ligation of the common iliac vein (1), and revascularization of the common iliac artery (1). Angiography and embolization of liver and/or spleen injuries were performed in 3 cases. Three patients developed abdominal complications, all of which were operatively treated. There were no deaths directly related to the abdominal injuries.

CONCLUSION

Severe "occult" intra-abdominal injuries, requiring specific treatment, may be present in adult blunt trauma patients.

Predictors of "occult" intra-abdominal injuries in blunt trauma patients

OBJECTIVE

to assess predictors of intra-abdominal injuries in blunt trauma patients admitted without abdominal pain or abnormalities on the abdomen physical examination.

METHODS

We conducted a retrospective analysis of trauma registry data, including adult blunt trauma patients admitted from 2008 to 2010 who sustained no abdominal pain or abnormalities on physical examination of the abdomen at admission and were submitted to computed tomography of the abdomen and/or exploratory laparotomy. Patients were assigned into: Group 1 (with intra-abdominal injuries) or Group 2 (without intra-abdominal injuries). Variables were compared between groups to identify those significantly associated with the presence of intra-abdominal injuries, adopting p<0.05 as significant. Subsequently, the variables with p<0.20 on bivariate analysis were selected to create a logistic regression model using the forward stepwise method.

RESULTS

A total of 268 cases met the inclusion criteria. Patients in Group I were characterized as having significantly (p<0.05) lower mean AIS score for the head segment (1.0 ± 1.4 vs. 1.8 ± 1.9), as well as higher mean AIS thorax score (1.6 ± 1.7 vs. 0.9 ± 1.5) and ISS (25.7 ± 14.5 vs. 17,1 ± 13,1). The rate of abdominal injuries was significantly higher in run-over pedestrians (37.3%) and in motorcyclists (36.0%) (p<0.001). The resultant logistic regression model provided 73.5% accuracy for identifying abdominal injuries. The variables included were: motorcyclist accident as trauma mechanism (p<0.001 - OR 5.51; 95%CI 2.40-12.64), presence of rib fractures (p<0.003 - OR 3.00; 95%CI 1.47-6.14), run-over pedestrian as trauma mechanism (p=0.008 - OR 2.85; 95%CI 1.13-6.22) and abnormal neurological physical exam at admission (p=0.015 - OR 0.44; 95%CI 0.22-0.85).

CONCLUSION

Intra-abdominal injuries were predominantly associated with trauma mechanism and presence of chest injuries.

Comparison of Clinician Suspicion Versus a Clinical Prediction Rule in Identifying Children at Risk for Intra-abdominal Injuries After Blunt Torso Trauma

OBJECTIVES

Emergency department (ED) identification and radiographic evaluation of children with intra-abdominal injuries who need acute intervention can be challenging. To date, it is unclear if a clinical prediction rule is superior to unstructured clinician judgment in identifying these children. The objective of this study was to compare the test characteristics of clinician suspicion with a derived clinical prediction rule to identify children at risk of intra-abdominal injuries undergoing acute intervention following blunt torso trauma.

METHODS

This was a planned subanalysis of a prospective, multicenter observational study of children (<18 years old) with blunt torso trauma conducted in 20 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). Clinicians documented their suspicion for the presence of intra-abdominal injuries needing acute intervention as <1, 1 to 5, 6 to 10, 11 to 50, or >50% prior to knowledge of abdominal computed tomography (CT) scanning (if performed). Intra-abdominal injuries undergoing acute intervention were defined by a therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid administration for 2 or more days in those with pancreatic or gastrointestinal injuries. Patients were considered to be positive for clinician suspicion if suspicion was documented as ≥1%. Suspicion ≥ 1% was compared to the presence of any variable in the prediction rule for identifying children with intra-abdominal injuries undergoing acute intervention.

RESULTS

Clinicians recorded their suspicion in 11,919 (99%) of 12,044 patients enrolled in the parent study. Intra-abdominal injuries undergoing acute intervention were diagnosed in 203 (2%) patients. Abdominal CT scans were obtained in the ED in 2,302 of the 2,667 (86%, 95% confidence interval [CI] = 85% to 88%) enrolled patients with clinician suspicion ≥1% and in 3,016 of the 9,252 (33%, 95% CI = 32% to 34%) patients with clinician suspicion < 1%. Sensitivity of the prediction rule for intra-abdominal injuries undergoing acute intervention (197 of 203; 97.0%, 95% CI = 93.7% to 98.9%) was higher than that of clinician suspicion ≥1% (168 of 203; 82.8%, 95% CI = 76.9% to 87.7%; difference = 14.2%, 95% CI = 8.6% to 20.0%). Specificity of the prediction rule (4,979 of the 11,716; 42.5%, 95% CI = 41.6% to 43.4%), however, was lower than that of clinician suspicion (9,217 of the 11,716, 78.7%, 95% CI = 77.9% to 79.4%; difference = -36.2%, 95% CI = -37.3% to -35.0%). Thirty-five (0.4%, 95% CI = 0.3% to 0.5%) patients with clinician suspicion < 1% had intra-abdominal injuries that underwent acute intervention.

CONCLUSIONS

The derived clinical prediction rule had a significantly higher sensitivity, but lower specificity, than clinician suspicion for identifying children with intra-abdominal injuries undergoing acute intervention. The higher specificity of clinician suspicion, however, did not translate into clinical practice, as clinicians frequently obtained abdominal CT scans in patients they considered very low risk. If validated, this prediction rule can assist in clinical decision-making around abdominal CT use in children with blunt torso trauma.

"Occult" rib fractures diagnosed on computed tomography scan only are still a risk factor for solid organ injury

Introduction:

Prior to the widespread use of computed tomography (CT) scan imaging, lower rib fractures diagnosed on chest X-rays (CXRs) were considered a risk factor for abdominal solid organ injury (ASOI). However, CXRs miss about 50% of the rib fractures that are detected on CT scans. We hypothesized that these “occult” rib fractures would not be predictive for ASOI.

Materials and Methods:

Retrospective review of a level I trauma center's database identified all adult blunt trauma patients (n = 11,170) over a 5-year period. Data were abstracted for demographics, injury severity score, presence of ASOI, extremity, pelvic and spine fractures as well as presence and location of rib fractures.

Results:

Rib fractures correlated with the presence of ASOI, regardless of whether they were diagnosed by CXR or CT scan alone (P < 0.01). Middle (3-7) and lower (8-12) rib fractures, especially, correlated with the presence of ipsilateral ASOI (P < 0.0001).

Discussion:

Although CT scan detects more rib fractures than CXR, rib fractures remain a marker for increased likelihood of ASOI regardless of the modality by which they are diagnosed. Patients with rib fractures also have a greater incidence of spine and pelvic fractures. As the trauma community debates moving away from routine whole-body CT imaging towards a more selective approach, these results suggest that any clinical suspicion of rib fractures, despite a negative CXR, may warrant further investigation.

Abdominal Injuries in the "Found Down": Is Imaging Indicated?

BACKGROUND

We sought to investigate the incidence of abdominal injuries in "found down" trauma patients to better understand the value of emergency department (ED) imaging. Found down patients are at high risk for injuries to the head or neck and low risk to the abdomen or pelvis, so imaging with CT of the abdomen/pelvis (AP) or Focused Assessment with Sonography for Trauma (FAST) is of questionable value.

STUDY DESIGN

The trauma registry was queried over a 10-year period ending December 2013 for found down patients. Demographics, CT AP, FAST scans, and injuries were abstracted from the trauma registry and then through a confirmatory chart review. The primary outcome was significant abdominal or pelvis injury, defined as abdomen/pelvis Abbreviated Injury Scale (AIS) ≥ 3 or an abdominal injury that required operative intervention. The secondary outcome was mortality due to abdominal injury.

RESULTS

Of the 342 patients who met inclusion criteria, mean Glasgow Coma Scale (GCS) was 11.0, and 189 (60%) of those tested for alcohol were intoxicated. Abdominal imaging included: CT AP only, 88 (57%); FAST only, 37 (24%); and CT AP and FAST, 29 (19%). Neither CT AP nor FAST scan led to a change in treatment and no patient had abdomen/pelvis AIS ≥ 3. Overall mortality was 33 (10%).The 24 trauma deaths were attributed to serious head trauma (n = 16) or traumatic arrest in the ED (n = 8); the 9 medical deaths were due to cerebral vascular accident (n = 5) or sepsis (n = 4).

CONCLUSIONS

Although patients found down have a high mortality, abdominal injuries identified by imaging are highly unlikely. Efforts should focus on rapidly identifying and treating other causes of mortality, especially trauma to the head and neck, or medical diagnoses such as cerebral vascular accident or sepsis.

Pan-body computed tomographic scanning for patients with intracranial hemorrhage after low-energy falls

BACKGROUND

We sought to determine if a liberal policy of pan-body computerized tomography (CT) scanning was useful in patients with intracranial hemorrhage after low falls.

METHODS

Patients with intracranial hemorrhage after low falls, with a Glasgow Coma Score of greater than or equal to 14 and systolic blood pressure of greater than 100 mm Hg, were included. The primary outcome was any torso or spine injury requiring surgical or radiologic intervention. The secondary outcome was any torso or spine injury.

RESULTS

Of 365 patients, 71% underwent pan-body CT. Eight (2%) patients had a primary outcome and 66 (18%) a secondary outcome. Only signs and symptoms of cervical injury were associated with a cervical-related outcome (4/23 vs 3/316, P = .005). Only signs and symptoms of torso injury were associated with a torso-related outcome.

CONCLUSIONS

A liberal policy of pan-body CT in these patients is of low yield. Signs and symptoms of trauma should dictate the judicious use of CT.

Accuracy of the abdominal examination for identifying children with blunt intra-abdominal injuries

OBJECTIVE

To determine the accuracy of complaints of abdominal pain and findings of abdominal tenderness for identifying children with intra-abdominal injury (IAI) stratified by Glasgow Coma Scale (GCS) score.

STUDY DESIGN

This was a prospective, multicenter observational study of children with blunt torso trauma and a GCS score ≥13. We calculated the sensitivity of abdominal findings for IAI with 95% CI stratified by GCS score. We examined the association of isolated abdominal pain or tenderness with IAI and that undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion, or ≥2 nights of intravenous fluid therapy).

RESULTS

Among the 12 044 patients evaluated, 11 277 (94%) had a GCS score of ≥13 and were included in this analysis. Sensitivity of abdominal pain for IAI was 79% (95% CI, 76%-83%) for patients with a GCS score of 15, 51% (95% CI, 37%-65%) for patients with a GCS score of 14, and 32% (95% CI, 14%-55%) for patients with a GCS score of 13. Sensitivity of abdominal tenderness for IAI also decreased with decreasing GCS score: 79% (95% CI, 75%-82%) for a GCS score of 15, 57% (95% CI, 42%-70%) for a GCS score of 14, and 37% (95% CI, 19%-58%) for a GCS score of 13. Among patients with isolated abdominal pain and/or tenderness, the rate of IAI was 8% (95% CI, 6%-9%) and the rate of IAI undergoing acute intervention was 1% (95% CI, 1%-2%).

CONCLUSION

The sensitivity of abdominal findings for IAI decreases as GCS score decreases. Although abdominal computed tomography is not mandatory, the risk of IAI is sufficiently high that diagnostic evaluation is warranted in children with isolated abdominal pain or tenderness.

Assessment and treatment of the trauma patient in shock

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

Utilization of a clinical prediction rule for abdominal-pelvic CT scans in patients with blunt abdominal trauma

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.

Extremity Injuries as Predictors of Emergency Care Resource Needs among Blunt Trauma Patients in Japan

This study aimed to exhaustively examine associations between prehospital variables and emergency care resource needs among blunt trauma patients. The study included blunt trauma patients aged 15 years or older who were admitted to a tertiary care medical center in Osaka, Japan, from January 2005 to December 2009. The primary end point was a composite measure of overall emergency care resource needs. Predictive variables were easily detectable upper and lower extremity injuries. A multivariate logistic regression model was used to identify associations between the predictive variables and the end point; this model included other covariates known to be associated with emergency care resource needs (demographic characteristics, mechanism of injury, and physiological parameters). Of 982 blunt trauma patients, 81 died, and 573 required overall emergency care resources. Upper extremity injury (odds ratio [OR], 2.60) and lower extremity injury (OR, 4.50) were significantly associated with overall emergency care resource needs after controlling for other covariates. The results of this study suggest that easily detectable extremity injuries may be useful predictors of the emergency care resource needs of trauma patients. Further studies are needed to validate the predictive values of these injuries and to determine ways to use information about extremity injuries to improve triage decisions.

Use of health information technology to reduce diagnostic errors

BACKGROUND

Health information technology (HIT) systems have the potential to reduce delayed, missed or incorrect diagnoses. We describe and classify the current state of diagnostic HIT and identify future research directions.

METHODS

A multi-pronged literature search was conducted using PubMed, Web of Science, backwards and forwards reference searches and contributions from domain experts. We included HIT systems evaluated in clinical and experimental settings as well as previous reviews, and excluded radiology computer-aided diagnosis, monitor alerts and alarms, and studies focused on disease staging and prognosis. Articles were organised within a conceptual framework of the diagnostic process and areas requiring further investigation were identified.

RESULTS

HIT approaches, tools and algorithms were identified and organised into 10 categories related to those assisting: (1) information gathering; (2) information organisation and display; (3) differential diagnosis generation; (4) weighing of diagnoses; (5) generation of diagnostic plan; (6) access to diagnostic reference information; (7) facilitating follow-up; (8) screening for early detection in asymptomatic patients; (9) collaborative diagnosis; and (10) facilitating diagnostic feedback to clinicians. We found many studies characterising potential interventions, but relatively few evaluating the interventions in actual clinical settings and even fewer demonstrating clinical impact.

CONCLUSIONS

Diagnostic HIT research is still in its early stages with few demonstrations of measurable clinical impact. Future efforts need to focus on: (1) improving methods and criteria for measurement of the diagnostic process using electronic data; (2) better usability and interfaces in electronic health records; (3) more meaningful incorporation of evidence-based diagnostic protocols within clinical workflows; and (4) systematic feedback of diagnostic performance.

Survival benefit of helicopter emergency medical services compared to ground emergency medical services in traumatized patients

INTRODUCTION

Physician-staffed helicopter emergency medical services (HEMS) are a well-established component of prehospital trauma care in Germany. Reduced rescue times and increased catchment area represent presumable specific advantages of HEMS. In contrast, the availability of HEMS is connected to a high financial burden and depends on the weather, day time and controlled visual flight rules. To date, clear evidence regarding the beneficial effects of HEMS in terms of improved clinical outcome has remained elusive.

METHODS

Traumatized patients (Injury Severity Score; ISS≥9) primarily treated by HEMS or ground emergency medical services (GEMS) between 2007 and 2009 were analyzed using the TraumaRegister DGU® of the German Society for Trauma Surgery. Only patients treated in German level I and II trauma centers with complete data referring to the transportation mode were included. Complications during hospital treatment included sepsis and organ failure according to the criteria of the American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus conference committee and the Sequential Organ Failure Assessment (SOFA) score.

RESULTS

A total of 13,220 patients with traumatic injuries were included in the present study. Of these, 62.3% (n=8,231) were transported by GEMS and 37.7% (n=4,989) by HEMS. Patients treated by HEMS were more seriously injured compared to GEMS (ISS 26.0 vs. 23.7, P<0.001) with more severe chest and abdominal injuries. The extent of medical treatment on-scene, which involved intubation, chest and treatment with vasopressors, was more extensive in HEMS (P<0.001) resulting in prolonged on-scene time (39.5 vs. 28.9 minutes, P<0.001). During their clinical course, HEMS patients more frequently developed multiple organ dysfunction syndrome (MODS) (HEMS: 33.4% vs. GEMS: 25.0%; P<0.001) and sepsis (HEMS: 8.9% vs. GEMS: 6.6%, P<0.001) resulting in an increased length of ICU treatment and in-hospital time (P<0.001). Multivariate logistic regression analysis found that after adjustment by 11 other variables the odds ratio for mortality in HEMS was 0.75 (95% CI: 0.636 to 862).

CONCLUSIONS

Although HEMS patients were more seriously injured and had a significantly higher incidence of MODS and sepsis, these patients demonstrated a survival benefit compared to GEMS.

Interobserver agreement in the clinical assessment of children with blunt abdominal trauma

OBJECTIVES

The objective was to determine the interobserver agreement of historical and physical examination findings assessed during the emergency department (ED) evaluation of children with blunt abdominal trauma.

METHODS

This was a planned substudy of a multicenter, prospective cohort study of children younger than 18 years of age evaluated for blunt abdominal trauma. Patients were excluded if injury occurred more than 24 hours prior to evaluation or if computed tomography (CT) imaging was obtained at another hospital prior to transfer to a study site. Two clinicians independently recorded their clinical assessments of a convenience sample of patients onto data collection forms within 60 minutes of each other and prior to CT imaging (if obtained) or knowledge of laboratory results. The authors categorized variables as either subjective symptoms (i.e., patient history) or objective findings (i.e., physical examination). For each variable recorded by the two observers, the agreement beyond that expected by chance was estimated, using the kappa (κ) statistic for categorical variables and weighted κ for ordinal variables. Variables with 95% lower confidence limits (LCLs) κ ≥ 0.4 (moderate agreement or better) were considered to have acceptable agreement.

RESULTS

A total of 632 pairs of physician observations were obtained on 23 candidate variables. Acceptable agreement was achieved in 16 (70%) of the 23 variables tested. For six subjective symptoms, κ ranged from 0.48 (complaint of shortness of breath) to 0.90 (mechanism of injury), and only the complaint of shortness of breath had a 95% LCL κ < 0.4. For the 17 objective findings, κ ranged from -0.01 (pelvis instability) to 0.82 (seat belt sign present). The 95% LCL for κ was <0.4 for flank tenderness, abnormal chest auscultation, suspicion of alcohol or drug intoxication, pelvis instability, absence of bowel sounds, and peritoneal irritation.

CONCLUSIONS

Observers can achieve at least acceptable agreement on the majority of historical and physical examination variables in children with blunt abdominal trauma evaluated in the ED. Those variables are candidates for consideration for development of a clinical prediction rule for intra-abdominal injury in children with blunt trauma.

Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults with blunt trauma

OBJECTIVE

The objective of this study is to determine the rate of intra-abdominal injury (IAI) in adults with blunt abdominal trauma after a normal abdominal computed tomographic (CT) scan. We hypothesize that the risk of subsequent IAI is so low that hospital admission and observation for possible IAI are unnecessary.

METHODS

We conducted a prospective, observational cohort study of adults (>18 years) with blunt trauma who underwent abdominal CT scanning in the emergency department. Computed tomographic scans were obtained with intravenous contrast but no oral contrast. Abnormalities on abdominal CT included all visualized IAIs or any finding suggestive of possible IAI. Patients were followed up to determine the presence or absence of IAI and the need for therapeutic intervention if IAI was identified.

RESULTS

Of the 3103 patients undergoing abdominal CT, 2734 (88%) had normal CT scans. The median age was 39 years (interquartile range, 26-51 years); and 2141 (78%) were admitted to the hospital. Eight (0.3%; 95% confidence interval, 0.1%-0.6%) were identified with IAIs after normal abdominal CT scans including the following injuries: pancreas (5), liver (4), gastrointestinal (2), and spleen (2). Five underwent therapy at laparotomy. Abdominal CT had a likelihood ratio (+) of 20.9 (95% confidence interval, 17.7-24.8) and likelihood ratio (-) of 0.034 (0.017-0.068).

CONCLUSION

Adult patients with blunt torso trauma and normal abdominal CT scans are at low risk for subsequently identified IAI. Thus, hospitalization for evaluation of possible IAI after a normal abdominal CT scan is unnecessary in most cases.

Does this adult patient have a blunt intra-abdominal injury?

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.