Accuracy of physical and ultrasonographic examinations by emergency physicians for the early diagnosis of intraabdominal haemorrhage in blunt abdominal trauma

Computed tomography in initially unstable thoracoabdominal trauma can safely enhance triage

Introduction

Computed tomography (CT) imaging of hemodynamically abnormal trauma patients undergoing aggressive resuscitation is controversial. Our study investigated outcomes for hemodynamically abnormal thoracoabdominal trauma undergoing CT prior to definitive therapy.

Methods

Hemodynamically abnormal (HR≥120 bpm, SBP<90 mmHg) patients arriving to our Level I trauma center between 2015 and 2022 were reviewed. Patients with thoracoabdominal trauma achieving hemodynamic improvement (SBP≥90 mmHg) were included. Pediatric patients, pregnant patients, and traumatic arrests were excluded. After matching for baseline characteristics, CT findings, and operative details, clinical outcomes were tabulated. Primary outcomes included hospital length of stay (HLOS), intensive care unit length of stay (ICU LOS), ventilator days and mortality. Secondary outcomes included intraoperative data, transfusions, additional procedures, and complications.

Results

A total of 235 patients met inclusion criteria. Thirty-six (15 %) were triaged directly to the OR while 199 (85 %) went to CT. The CT and OR groups were matched for injury burden (mean ISS OR group=21±2.6 vs. CT group=18.4 ± 0.8, p = 0.24). Overall, no difference in HLOS (p = 0.3), ICU LOS (p = 0.9), time on ventilator (p = 0.4) or mortality (p = 0.5) was observed. Patients undergoing CT needed less PRBCs (9.0 ± 2.6 vs. 3.4 ± 0.7 units) and FFP (5.1 ± 1.9 vs. 1.6 ± 0.4 units). The OR group patients had a higher probability of needing to undergo additional procedures (36 % vs. 12 %).

Conclusion

Hemodynamically abnormal thoracoabdominal trauma patients who are resuscitated to a SBP≥90 mmHg can safely undergo CT prior to definitive therapy.

Competencies for proficiency in basic point-of-care ultrasound in anesthesiology: national expert recommendations using Delphi methodology

PURPOSE

Point-of-care ultrasound (POCUS) allows for rapid bedside assessment and guidance of patient care. Recently, POCUS was included as a mandatory component of Canadian anesthesiology training; however, there is no national consensus regarding the competencies to guide curriculum development. We therefore aimed to define national residency competencies for basic perioperative POCUS proficiency.

METHODS

We adopted a Delphi process to delineate relevant POCUS competencies whereby we circulated an online survey to academic anesthesiologists identified as POCUS leads/experts (n = 25) at all 17 Canadian anesthesiology residency programs. After reviewing a list of competencies derived from the Royal College of Physicians and Surgeons of Canada's National Curriculum, we asked participants to accept, refine, delete, or add competencies. Three rounds were completed between 2022 and 2023. We discarded items with < 50% agreement, revised those with 50-79% agreement based upon feedback provided, and maintained unrevised those items with ≥ 80% agreement.

RESULTS

We initially identified and circulated (Round 1) 74 competencies across 19 clinical domains (e.g., basics of ultrasound [equipment, nomenclature, clinical governance, physics]; cardiac [left ventricle, right ventricle, valve assessment, pericardial effusion, intravascular volume status] and lung ultrasound anatomy, image acquisition, and image interpretation; and clinical applications [monitoring and serial assessments, persistent hypotension, respiratory distress, cardiac arrest]). After three Delphi rounds (and 100% response rate maintained), panellists ultimately agreed upon 75 competencies.

CONCLUSION

Through national expert consensus, this study identified POCUS competencies suitable for curriculum development and assessment in perioperative anesthesiology. Next steps include designing and piloting a POCUS curriculum and assessment tool(s) based upon these nationally defined competencies.

Deep learning for emergency ascites diagnosis using ultrasonography images

PURPOSE

The detection of abdominal free fluid or hemoperitoneum can provide critical information for clinical diagnosis and treatment, particularly in emergencies. This study investigates the use of deep learning (DL) for identifying peritoneal free fluid in ultrasonography (US) images of the abdominal cavity, which can help inexperienced physicians or non-professional people in diagnosis. It focuses specifically on first-response scenarios involving focused assessment with sonography for trauma (FAST) technique.

METHODS

A total of 2985 US images were collected from ascites patients treated from 1 January 2016 to 31 December 2017 at the Shenzhen Second People's Hospital. The data were categorized as Ascites-1, Ascites-2, or Ascites-3, based on the surrounding anatomy. A uniform standard for regions of interest (ROIs) and the lack of obstruction from acoustic shadow was used to classify positive samples. These images were then divided into training (90%) and test (10%) datasets to evaluate the performance of a U-net model, utilizing an encoder-decoder architecture and contracting and expansive paths, developed as part of the study.

RESULTS

Test results produced sensitivity and specificity values of 94.38% and 68.13%, respectively, in the diagnosis of Ascites-1 US images, with an average Dice coefficient of 0.65 (standard deviation [SD] = 0.21). Similarly, the sensitivity and specificity for Ascites-2 were 97.12% and 86.33%, respectively, with an average Dice coefficient of 0.79 (SD = 0.14). The accuracy and area under the curve (AUC) were 81.25% and 0.76 for Ascites-1 and 91.73% and 0.91 for Ascites-2.

CONCLUSION

The results produced by the U-net demonstrate the viability of DL for automated ascites diagnosis. This suggests the proposed technique could be highly valuable for improving FAST-based preliminary diagnoses, particularly in emergency scenarios.

Accuracy of Bedside Lung Ultrasound as a Rapid Triage Tool for Suspected Covid-19 Cases

OBJECTIVES

The novel coronavirus disease 2019 (Covid-19) outbreak began in China. The characteristic of the disease is development of pneumonia. We aimed to investigate the accuracy of bedside lung ultrasound (BLUS) for diagnosing Covid-19 pneumonia, and its effectiveness for the correct triage of patients with suspected Covid-19 in the emergency department (ED).

METHODS

This study was a prospective, cross-sectional cohort study. During their shifts, 3 accredited and certificated emergency physicians performed BLUS using BLUE protocol at the triage area of the ED on patients with suspected Covid-19. All of the patients underwent chest computed tomography. The BLUS findings were statistically compared with formal radiology reports of computed tomographies as the criterion standard for the diagnosis of Covid-19 pneumonia. Kolmogorov-Smirnov analysis, Shapiro-Wilk test, and Q-Q plots were performed with 95% confidence intervals (CIs) for statistical analysis.

RESULTS

A total of 72 patients were included in the study. The sensitivity, specificity, positive predictive value, negative predictive value, and overall accuracy of BLUS were 96.9% (95% CI, 84.2%-99.9%), 92.3% (95% CI, 79.1%-98.3%), 84.3% (95% CI, 64.5%-94.1%), 98.6% (95% CI, 91.1%-99.8%), and 93.7% (95% CI, 85.3%-98.0%), respectively. The positive and negative predictive values were 84.3% (95% CI, 64.5%-94.1%) and 98.6% (95% CI, 91.1%-99.8%), respectively. The area under curve was found to be 0.946 (95% CI, 0.866-0.986; P < 0.0001).

CONCLUSIONS

Bedside lung ultrasound can be used to detect the presence of pulmonary involvement in suspected cases of Covid-19 for the effective triage of patients in the ED.

Diagnostic options for blunt abdominal trauma

PURPOSE

Physical examination, laboratory tests, ultrasound, conventional radiography, multislice computed tomography (MSCT), and diagnostic laparoscopy are used for diagnosing blunt abdominal trauma. In this article, we investigate and evaluate the usefulness and limitations of various diagnostic modalities on the basis of a comprehensive review of the literature.

METHODS

We searched commonly used databases in order to obtain information about the aforementioned diagnostic modalities. Relevant articles were included in the literature review. On the basis of the results of our comprehensive analysis of the literature and a current case, we offer a diagnostic algorithm.

RESULTS

A total of 86 studies were included in the review. Ecchymosis of the abdominal wall (seat belt sign) is a clinical sign that has a high predictive value. Laboratory values such as those for haematocrit, haemoglobin, base excess or deficit, and international normalised ratio (INR) are prognostic parameters that are useful in guiding therapy. Extended focused assessment with sonography for trauma (eFAST) has become a well established component of the trauma room algorithm but is of limited usefulness in the diagnosis of blunt abdominal trauma. Compared with all other diagnostic modalities, MSCT has the highest sensitivity and specificity. Diagnostic laparoscopy is an invasive technique that may also serve as a therapeutic tool and is particularly suited for haemodynamically stable patients with suspected hollow viscus injuries.

CONCLUSIONS

MSCT is the gold standard diagnostic modality for blunt abdominal trauma because of its high sensitivity and specificity in detecting relevant intra-abdominal injuries. In many cases, however, clinical, laboratory and imaging findings must be interpreted jointly for an adequate evaluation of a patient's injuries and for treatment planning since these data supplement and complement one another. Patients with blunt abdominal trauma should be admitted for clinical observation over a minimum period of 24 h since there is no investigation that can reliably rule out intra-abdominal injuries.

Recommendations on the Use of Ultrasound Guidance for Adult Abdominal Paracentesis: A Position Statement of the Society of Hospital Medicine

1. We recommend that ultrasound guidance should be used for paracentesis to reduce the risk of serious complications, the most common being bleeding. 2. We recommend that ultrasound guidance should be used to avoid attempting paracentesis in patients with an insufficient volume of intraperitoneal free fluid to drain. 3. We recommend that ultrasound guidance should be used with paracentesis to improve the success rates of the overall procedure. 4. We recommend that ultrasound should be used to assess the volume and location of intraperitoneal free fluid to guide clinical decision making of where paracentesis can be safely performed. 5. We recommend that ultrasound should be used to identify a needle insertion site based on size of the fluid collection, thickness of the abdominal wall, and proximity to abdominal organs. 6. We recommend that the needle insertion site should be evaluated using color flow Doppler ultrasound to identify and avoid abdominal wall blood vessels along the anticipated needle trajectory. 7. We recommend that a needle insertion site should be evaluated in multiple planes to ensure clearance from underlying abdominal organs and detect any abdominal wall blood vessels along the anticipated needle trajectory. 8. We recommend that a needle insertion site should be marked with ultrasound immediately before performing the procedure, and the patient should remain in the same position between marking the site and performing the procedure. 9. We recommend that using real-time ultrasound guidance for paracentesis should be considered when the fluid collection is small or difficult to access. 10. We recommend that dedicated training sessions, including didactics, supervised practice on patients, and simulation-based practice, should be used to teach novices how to perform ultrasound-guided paracentesis. 11. We recommend that simulation-based practice should be used, when available, to facilitate acquisition of the required knowledge and skills to perform ultrasoundguided paracentesis. 12. We recommend that competence in performing ultrasound-guided paracentesis should be demonstrated prior to independently performing the procedure on patients.

Early scaphoid fractures are better diagnosed with ultrasonography than X-rays: A prospective study over 114 patients

PURPOSE

Wrist has a complex anatomy and undergoes complex injuries. Scaphoid fracture is one of such injuries. It is the most common fracture in carpal bone. Most of the scaphoid fractures are missed on initial X-rays. Magnetic resonance imaging (MRI) is considered as a gold standard for diagnosing scaphoid fractures. Ultrasonography (USG) is emerging as a good alternative to make an early diagnosis of scaphoid fractures. Our aim is to throw light upon the role of USG in detection of scaphoid fractures.

METHODS

The study was centered upon 114 patients in the age range 10-65 years, with traumatic wrist injury and were clinically suspected to have scaphoid fractures. Patient with non-traumatic history, bilateral wrist injury and late presentation were excluded. X-rays, USG using high frequency probe and MRI were done for all patients. MRI was considered to be the gold standard test. Patients were followed up at 6 weeks.

RESULTS

Of the 114 patients, X-ray could diagnose scaphoid fractures in 48 patients, 30 of which were confirmed by MRI. USG results were positive in 74 patients, of which MRI was positive in 67 patients. The accuracy of scaphoid fracture detection with USG was 98.04% in comparison to X-ray (20.58%), which was statistically significant.

CONCLUSION

USG provides a more accurate and reliable method of making an early diagnosis of scaphoid fracture than X-rays. It is non-invasive, non-expensive and allows better visualisation of cortical disruption.

Thoracoabdominal Injuries

Trauma to the thorax and abdomen can occur during participation in sports. This chapter reviews some of the more common presentations of such injuries and how such injuries should be best managed. Thoracic injuries reviewed include internal injuries such as pneumothorax, pulmonary contusion, hemothorax, commotio cordis, and cardiac contusion. Chest wall injuries are also reviewed such as rib fractures, costochondritis, and slipping rib syndrome plus sternal and scapular fractures. Abdominal injuries reviewed are focused on internal organ trauma to the spleen and liver, kidney, pancreas, and bowel. There is attention to the effect of Epstein-Barr virus and infectious mononucleosis, seen very frequently in high school and collegiate athletes. Finally, groin pain and athletic pubalgia are described.

In addition to anatomy and clinical presentation, imaging modalities that characterize such trauma are reviewed for each diagnosis. Prevention of thoracoabdominal injuries and return-to-play decisions are described at the chapter conclusion.

The Effect of the Emergency Physicians' Clinical Decision of Targeted Ultrasonography Application in Non-Traumatic Shock Patients

Introduction

Clinical evaluation of non-traumatic shock patients with high risk of mortality and morbidity is problematic for emergency physicians. In this study, changes in the investigations, diagnosis and treatment decision of the physicians using the Abdominal and Cardiac Evaluation with Sonography in Shock (ACES) protocol were examined.

Methods

In this clinical prospective study, the patients were ultrasonographically examined within the scope of the ACES protocol at 6 quadrants including cardiac, pleural, peritoneal, inferior vena cava and aorta. Pre- and post-US investigations, diagnoses and treatments were compared.

Results

A total of 141 patients were included in this study. Of these, 92 (65.2%) of the patients were males and 49 (34.8%) were females. The average age of the patients was 62.9±16.8 years (18-97). After the ultrasonographic evaluation, request for new investigations was needed in 25 (17%), and modification of the treatment was needed in 57 (40.4%) of the patients. It was seen that with a targeted ultrasonography (US), the number of the considered pre-diagnoses decreased in 51 (36.2%) of the patients, and the physicians made a new pre-diagnosis in 6 (4.3%) of the patients. When the pre-diagnoses made by the physicians after the US and the final diagnoses clinically made at the end of the follow-up process were compared, there were no changes in the diagnoses in 124 (87.9%) patients.

Conclusion

Ultrasonographic examination is considered useful for rapid evaluation, early diagnosis and treatment planning in non-traumatic shock patients in emergency department. (Hong Kong j.emerg.med. 2015;22:364-370)

Bedside lung ultrasonography for diagnosis of pneumonia

Objective

The aim of this study was to investigate the accuracy of bedside lung ultrasound (BUS) in the diagnosis of community-acquired pneumonia (CAP) in patients with dyspnoea presenting to the emergency department (ED) and to analyse the characteristic sonographic findings of CAP.

Methods

After a six-hour training program, BUS procedures were performed between October 2011 and February 2012 to prospectively evaluate patients presenting to the ED with dyspnoea. Chest X-ray (CXR) or computerised tomography (CT) were ordered, depending on the presence of consolidation signs on CXR. The outcome was determined by consolidation findings on CXR or CT. BUS results were compared using Chi-squared testing.

Results

Of the 112 enrolled patients with dyspnoea, 40 patients were excluded and 72 were included in the study. Thirty-four patients were BUS positive. Of these, CXR or CT findings agreed with the BUS findings in 27 patients. In 38 cases, BUS was negative, and one patient was diagnosed with pneumonia based on the CT report. The sensitivity, specificity, PPV, NPV, and the positive and negative likelihood ratios for BUS were 96.4%, 84.1%, 79.4%, 97.4%, 6.1 and 0.042, respectively. The diagnostic accuracy of BUS was 89%. The presence of consolidation signs, either shred or hepatisation, were the most frequent sonographic findings in our study.

Conclusions

Acute alveolar consolidation can be diagnosed easily by performing BUS with high degree of accuracy in EDs.

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.

Diagnostic Accuracy of Focused Assessment With Sonography for Trauma in the Emergency Department

Background

Trauma is currently the fourth leading cause of death in developed countries. One of the main objectives in abdominal trauma patients is to develop a rapid and accurate diagnosis. There is a tendency to use emergency abdominal ultrasound with abdominal trauma, therefore, it is recommended in some centers as a diagnostic tool and as a primary choice in abdominal trauma.

Objectives

The aim of this study was to determine the diagnostic accuracy of sonography for trauma by emergency medicine residents and radiology residents

Patients and Methods

This was a descriptive and analytical study performed on patients with abdominal blunt trauma who referred to the emergency ward. The diagnostic accuracy of sonography for trauma by emergency medicine residents and radiology residents was evaluated.

Results

Of the 380 patients, 296 were males and 84 were females. The mean ages of male and female patients were 34.52 ± 16.38 years and 41.19 ± 21.38 years, respectively (P = 0.009). The sonographies performed by emergency residents were positive in 46 patients, with 22 of these confirmed by CT scans. The sensitivity and specificity of the sonography by emergency residents, as confirmed by CT scans, were 78.5% and 93.2%, respectively. The sonographies performed by radiology residents were positive in 38 patients, with 24 being confirmed by CT scans.

Conclusions

The sensitivity and specificity of the sonography by radiology residents, as confirmed by CT scans, were 85.7% and 96%, respectively. Sonographies performed by emergency residents were positive in 46 patients with 34 of these being confirmed by sonographies by radiology residents. The sensitivity and specificity of the sonographies by emergency residents, as confirmed by sonographies by radiology residents, were 89.5% and 96.5%, respectively

Cell salvage in emergency trauma surgery

BACKGROUND

Trauma is the leading cause of death in people under the age of 45 years. Over the past 20 years, intraoperative autologous transfusions (obtained by cell salvage, also known as intraoperative blood salvage (IBS)) have been used as an alternative to blood products from other individuals during surgery because of the risk of transfusion-related infections such as hepatitis and human immunodeficiency virus (HIV). In this review, we sought to assess the effects and cost of cell salvage in individuals undergoing abdominal or thoracic surgery.

OBJECTIVES

To compare the effect and cost of cell salvage with those of standard care in individuals undergoing abdominal or thoracic trauma surgery.

SEARCH METHODS

We ran the search on 25 November 2014. We searched the Cochrane Injuries Group's Specialised Register, Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library), Ovid MEDLINE, Ovid MEDLINE In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily and Ovid OLDMEDLINE, EMBASE Classic + EMBASE (OvidSP), PubMed, and ISI Web of Science (SCI-Expanded & CPSI-SSH). We also screened reference lists and contacted principal investigators.

SELECTION CRITERIA

Randomised controlled trials comparing cell salvage with no cell salvage (standard care) in individuals undergoing abdominal or thoracic trauma surgery.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data from the trial reports. We used the standard methodological procedures expected by The Cochrane Collaboration.

MAIN RESULTS

Only one small study (n = 44) fulfilled the inclusion criteria. Results suggested that cell salvage did not affect mortality overall (death rates were 67% (14/21 participants) in the cell salvage group and 65% (15/23) in the control group) (odds ratio (OR) 1.07, 95% confidence interval (CI) 0.31 to 3.72). For individuals with abdominal injury, mortality was also similar in both groups (OR 0.48, 95% CI 0.11 to 2.10).Less donor blood was needed for transfusion within the first 24 hours postinjury in the cell salvage group compared with the control group (mean difference (MD) -4.70 units, 95% CI -8.09 to -1.31). Adverse events, notably postoperative sepsis, did not differ between groups (OR 0.54, 95% CI 0.11 to 2.55). Cost did not notably differ between groups (MD -177.81, 95% CI -452.85 to 97.23, measured in GBP in 2002).

AUTHORS' CONCLUSIONS

Evidence for the use of cell salvage in individuals undergoing abdominal or thoracic trauma surgery remains equivocal. Large, multicentre, methodologically rigorous trials are needed to assess the relative efficacy, safety and cost-effectiveness of cell salvage in different surgical procedures in the emergency context.

Sports medicine ultrasound (US) beyond the musculoskeletal system: use in the abdomen, solid organs, lung, heart and eye

The use of point-of-care ultrasound (US) by non-radiologists is not new and the expansion into sports medicine practice is relatively young. US has been used extensively to evaluate the musculoskeletal system including the diagnosis of muscle, tendon and bone injuries. However, as sports medicine practitioners we are responsible for the care of the entire athlete. There are many other non-musculoskeletal applications of US in the evaluation and treatment of the athlete. This paper highlights the use of US in the athlete to diagnose pulmonary, cardiac, solid organ, intra-abdominal and eye injuries.

Bedside ultrasonography by emergency physicians for anterior talofibular ligament injury

Objective:

Our objective was to study the accuracy of emergency physician (EP) performed bedside ultrasonography (BUS) in patients with suspected anterior talofibular ligament (ATFL) injury.

Materials and Methods:

After a 6-h training program, from January to December 2011, an EP used BUS to prospectively evaluate patients presenting to the emergency department (ED) with suspected ATFL injury. Then, patients underwent ankle X-ray and Magnetic Resonance (MR) imaging. Outcome was determined by official radiology reports of the MR imaging. BUS and MR imaging results were compared using Chi-square testing.

Results:

Of the 65 enrolled patients, 30 patients were BUS positive. Of these, MR imaging results agreed with the BUS findings in 30 patients. In 35 cases, BUS was negative, and 33 of these were corroborated by MR imaging. The sensitivity, specificity, positive predictive value, negative predictive value, and negative likelihood ratio for BUS were 93.8%, 100%, 100%, 94.3%, and 0.06%, respectively. The diagnostic accuracy of BUS was not statistically different from MR imaging (K = 0.938, P = 0.001).

Conclusion:

BUS for the diagnosis of ATFL injury is another application of BUS in the ED. EPs can diagnose ATFL injury using BUS with a high degree of accuracy.

Duration and predictors of emergency surgical operations--basis for medical management of mass casualty incidents

BACKGROUND

Hospitals have a critically important role in the management of mass causality incidents (MCI), yet there is little information to assist emergency planners. A significantly limiting factor of a hospital's capability to treat those affected is its surgical capacity. We therefore intended to provide data about the duration and predictors of life saving operations.

METHODS

The data of 20,815 predominantly blunt trauma patients recorded in the Trauma Registry of the German-Trauma-Society was retrospectively analyzed to calculate the duration of life-saving operations as well as their predictors. Inclusion criteria were an ISS≥16 and the performance of relevant ICPM-coded procedures within 6h of admission.

RESULTS

From 1,228 patients fulfilling the inclusion criteria 1,793 operations could be identified as life-saving operations. Acute injuries to the abdomen accounted for 54.1% followed by head injuries (26.3%), pelvic injuries (11.5%), thoracic injuries (5.0%) and major amputations (3.1%). The mean cut to suture time was 130min (IQR 65-165min). Logistic regression revealed 8 variables associated with an emergency operation: AIS of abdomen ≥3 (OR 4,00), ISS ≥35 (OR 2,94), hemoglobin level ≤8 mg/dL (OR 1,40), pulse rate on hospital admission <40 or >120/min (OR 1,39), blood pressure on hospital admission <90 mmHg (OR 1,35), prehospital infusion volume ≥2000 ml (OR 1,34), GCS ≤8 (OR 1,32) and anisocoria (OR 1,28) on-scene.

CONCLUSIONS

The mean operation time of 130min calculated for emergency life-saving surgical operations provides a realistic guideline for the prospective treatment capacity which can be estimated and projected into an actual incident admission capacity. Knowledge of predictive factors for life-saving emergency operations helps to identify those patients that need most urgent operative treatment in case of blunt MCI.

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.

Field testing of a remote controlled robotic tele-echo system in an ambulance using broadband mobile communication technology

We report the testing of a mobile Robotic Tele-echo system that was placed in an ambulance and successfully transmitted clear real time echo imaging of a patient's abdomen to the destination hospital from where this device was being remotely operated. Two-way communication between the paramedics in this vehicle and a doctor standing by at the hospital was undertaken. The robot was equipped with an ultrasound probe which was remotely controlled by the clinician at the hospital and ultrasound images of the patient were transmitted wirelessly. The quality of the ultrasound images that were transmitted over the public mobile telephone networks and those transmitted over the Multimedia Wireless Access Network (a private networks) were compared. The transmission rate over the public networks and the private networks was approximately 256 Kbps, 3 Mbps respectively. Our results indicate that ultrasound images of far higher definition could be obtained through the private networks.