Nicht traumaassozierte Nebenbefunde bei Ganzkörpercomputertomografien im Rahmen der Polytraumadiagnostik

Incidental Computed Tomography Findings Among Traumatized Adults: A One-Year Analysis at a Trauma Center

Background Computed tomography (CT) for patients with trauma represents a widely accepted diagnostic method. Non-trauma-related incidentalomas or incidental findings are commonly depicted based on CT examination. Our study aimed to assess the frequency of incidental findings on CT scans among traumatized adult patients during one year at a trauma center. Methods We performed a retrospective case review of all adult patients triaged at the King Abdullah Medical Complex trauma service in Jeddah, Saudi Arabia, between 31 May 2022 and 30 May 2023. Patients under the age of 18 were excluded from the study. Patients who could not complete radiographic studies due to deterioration in condition, patients with missing CT scan reports, and transfer patients who had CT scans done at outside facilities were excluded. Demographic data, including age, sex, type of trauma, and type of CT, were recorded. All CT studies were reviewed for incidental findings. Results A total of 106 incidental findings were discovered in 99 patients. The rate of incidental findings for one year was 1.87%. The average age was 41.19 ± 17.90 years, with 73 (73.7%) male and 26 (26.3%) female patients. In trauma classifications, road traffic accidents were the most common (59.60%), followed by falls (33.33%), penetrating trauma (3.03%), and others. A high number of scans for the whole body (56.57%); face, brain, and cervix (13.13%); chest and abdomen/pelvis (11%); and spine (5.05%) had incidental findings. Genitourinary-related incidental findings were observed in 27.36% of patients, followed by craniospinal (16.98%), pulmonary (12.26%), hepatobiliary (9.43%), endocrine (9.43%), and musculoskeletal (5.66%). Conclusion In trauma centers, incidental findings are frequently discovered during CT imaging. In contrast, our center has a lower incidental finding rate. A whole-body CT scan yielded more incident findings than a selective one. The incidental findings are prevalent in the genitourinary system and higher in young male patients. It is important to properly document, communicate, and follow up on these incidental discoveries.

Incidental CT Findings in the Elderly with Low-Energy Falls: Prevalence and Implications

Background: Computed tomography (CT) is commonly used in trauma care, with increasing implementation during the emergency work-up of elderly patients with low-energy falls (LEF). The prevalence of incidental findings (IFs) resulting from CT imaging and requiring down-stream actions in this patient cohort is unknown. We have investigated the prevalence and urgency of IFs from emergency CT examinations in these patients. Methods: A total of 2871 patients with LEF and emergency CT examinations were consecutively included in this retrospective cohort study. The primary endpoint was the prevalence of IFs; the secondary endpoint was their urgency. Results: The median age was 82 years (64.2% were women). IFs were identified in 73.9% of patients, with an average of 1.6 IFs per patient. Of all IFs, 16.4% were classified as urgent or relevant, predominantly in the abdomen, chest and neck. Increasing age was associated with the prevalence of an IF (odds ratio: 1.053, 95% confidence interval: 1.042–1.064). Significantly more IFs were found in female patients (75.2% vs. 71.5%). Conclusion: IFs resulting from CT examinations of the elderly are frequent, but in more than 8 out of 10, they are harmless or currently asymptomatic. For the benefit of an accurate diagnosis of traumatic lesions, concerns about IFs with respect to disease burden, further work-up and resource utilisation might be disregarded.

Incidental Findings on Whole-body Computed Tomography in Major Trauma Patients: Who and What?

PURPOSE

Whole-body computed tomography (WBCT) scans are frequently used for trauma patients, and sometimes, nontraumatic findings are observed. We aimed to investigate the characteristics of patients with nontraumatic findings on WBCT.

METHODS

From 2013 to 2016, adult trauma patients who underwent WBCT were enrolled. The proportions of nontraumatic findings in different anatomical regions were studied. Nontraumatic findings were classified and evaluated as clinically important findings and findings that needed no further follow-up or treatment. The characteristics of the patients with nontraumatic findings were analyzed and compared with those of patients without nontraumatic findings.

RESULTS

Two hundred seventeen patients were enrolled in this study during the 3-year study period, and 89 (41.0%) patients had nontraumatic findings. Nontraumatic findings were found more frequently in the abdomen (69.2%) than in the head/neck (17.3%) and chest regions (13.5%). In total, 31.3% of the findings needed further follow-up or treatment. Patients with nontraumatic findings that needed further management were significantly older than those without nontraumatic findings (57.3 vs. 38.9; P < .001), particularly those with abdominal nontraumatic findings (57.9 vs. 41.3; P < .001). A significantly higher proportion of women were observed in the group with head/neck nontraumatic findings that needed further management than in the group without nontraumatic findings (56.3% vs 24.9%; P = .015).

CONCLUSIONS

Whole-body computed tomography could provide alternative benefits for nontraumatic findings. Whole-body computed tomography images should be read carefully for nontraumatic findings, particularly for elderly patients or the head/neck region of female patients. A comprehensive program for the follow-up of nontraumatic findings is needed.

Detailed information gain and therapeutic impact of whole body computed tomography supplementary to conventional radiological diagnostics in blunt trauma emergency treatment: a consecutive trauma centre evaluation

Purpose

The indication of whole body computed tomography (WBCT) in the emergency treatment of trauma is still under debate. We were interested in the detailed information gain obtained from WBCT following standardized conventional imaging (CI).

Methods

Prospective study including all emergency trauma centre patients examined by CI (focused assessment of sonography in trauma, chest and pelvic X-ray) followed by WBCT from 2011 to 2017. Radiology reports were compared per patient for defined body regions for number and severity of injuries (Abbreviated Injury Scale, AIS; Injury Severity Score, ISS), incidental findings and treatment consequences (Wilcoxon signed rank test, Spearman rho, Chi-square).

Results

1271 trauma patients (ISS 11.3) were included in this study. WBCT detected more injury findings than CI in the equivalent body regions (1.8 vs. 0.6; p < 0.001). In 44.4% of cases at least one finding was missed by CI alone. Compared to WBCT, injury severity of specified body regions was underestimated by CI on average by an AIS of 1.9 (p < 0.001). In 22.0% of cases injury severity increased by an AIS ≥ 2 following WBCT. In 16.8% of patients additional injury findings resulted in a change of treatment (number needed to profit, NNP = 6 patients): NNP decreased from 25 for patients with an ISS < 7 up to nearly 2 for patients with an ISS > 25 at final evaluation, thereby demonstrating a significant improvement in the NNP with increasing ISS (rho = 0.33, p < 0.001). Moreover, WBCT in 88.4% of patients identified ≥ 1 incidental finding (mean 3.4) vs. 28.9% by CI only (p < 0.001). Overall, WBCT had treatment consequences in 31.9% of cases (NNP = 3.1).

Conclusions

The application of WBCT in addition to CI in the emergency treatment of trauma had therapy consequences for almost every third patient. On the other hand, WBCT appeared not to be indicated (ISS < 8) in at least 2/5 of patients.

Electronic supplementary material

The online version of this article (10.1007/s00068-020-01502-1) contains supplementary material, which is available to authorized users.

Implementation of a new Single-Pass Whole-Body Computed Tomography Protocol: Is it safe, effective and efficient in patients with severe trauma?

Purpose:

The objective of this study was to evaluate the implementation of a new single-pass whole-body computed tomography Protocol in the management of patients with severe trauma.

Methods:

This was a descriptive evaluation of polytrauma patients who underwent whole-body computed tomography. Patients were divided into three groups: 1. Blunt trauma hemodynamically stable 2. Blunt trauma hemodynamically unstable and 3. Penetrating trauma. Demographics, whole-body computed tomography parameters and outcome variables were evaluated.

Results:

Were included 263 patients. Median injury severity score was 22 (IQR: 16-22). Time between arrival to the emergency department and completing the whole-body computed tomography was under 30 minutes in most patients [Group 1: 28 minutes (IQR: 14-55), Group 2: 29 minutes (IQR: 16-57), and Group 3: 31 minutes (IQR: 13-50; p= 0.96)]. 172 patients (65.4%) underwent non-operative management. The calculated and the real survival rates did not vary among the groups either [Group 1: TRISS 86.4% vs. real survival rate 85% (p= 0.69); Group 2: TRISS 69% vs. real survival rate 74% (p= 0.25); Group 3: TRISS 93% vs. real survival rate 87% (p= 0.07)].

Conclusion:

This new single-pass whole-body computed tomography protocol was safe, effective and efficient to decide whether the patient with severe trauma requires a surgical intervention independently of the mechanism of injury or the hemodynamic stability of the patient. Its use could also potentially reduce the rate of unnecessary surgical interventions of patients with severe trauma including those with penetrating trauma.

Uso de la tomografía corporal total en pacientes con trauma grave

Introducción. La tomografía corporal (TC) total en la evaluación de pacientes con trauma grave, puede ser una herramienta eficaz y segura para decidir entre un tratamiento quirúrgico y uno no quirúrgico, pero aún no son claras las implicaciones diagnósticas y los riesgos asociados con esta técnica. Métodos. Se incluyeron pacientes mayores de 15 años con trauma grave que fueron sometidos a TC total. Se evaluaron la seguridad, la efectividad y la eficiencia por medio de los parámetros de incidencia de nefropatía inducida por los medios de contraste, dosis total de radiación por paciente, proporción de casos en los que la TC total cambió el manejo, y el retraso en el diagnóstico. Resultados. Se incluyeron 263 pacientes, 83 % sufrieron trauma cerrado y 17 % sufrieron trauma penetrante. La gravedad de la lesión fue mayor en estos últimos y, sin embargo, el trauma cerrado con inestabilidad hemodinámica se presentó con mayores grados de choque. El 65 % de los pacientes recibió tratamiento selectivo no operatorio. Entre los subgrupos, no hubo diferencias significativas en el tiempo entre el ingreso a la sala de urgencias y la toma de la TC total (p=0,96) y, en la mayoría de los casos, el tiempo entre la práctica de la TC total y el diagnóstico de presencia o ausencia de heridas fue menor de 25 minutos. La mediana de radiación total estuvo por debajo de 20 mSv en todos los grupos. No hubo diferencias significativas en la mortalidad (p=0,17). Conclusión. La TC total es una herramienta segura y eficiente para decidir entre un tratamiento quirúrgico y uno no quirúrgico en los casos de trauma grave, independientemente del mecanismo de la lesión o la estabilidad hemodinámica al ingreso.

Incidental findings in thoracic CTs performed in trauma patients: an underestimated problem

OBJECTIVES

Whole-body CT scans are commonly performed to assess trauma patients, and often reveal incidental findings (IFs) the patient may be unaware of. We assessed the prevalence, associations, and adequacy of follow-up of IFs.

METHODS

We retrospectively identified 1113 patients who had a chest CT to assess for traumatic injuries (6-year interval). We coded the radiology reports for IFs and queried our EMR regarding clinical history and adherence to follow-up recommendations for IFs mentioned in the reports.

RESULTS

IFs are much more likely (62.2%) to be found in a chest CT scan than acute traumatic injuries (ATI, 32.4%), in patients being evaluated for potential traumatic injuries. A total of 86.4% of patients who had IFs also had another relevant ICD-10 diagnosis (RD). Lung nodules were the most common IF (45.7%). A multivariate logistic regression model (MLR) demonstrated an accuracy of 89% to predict IFs; the 3 statistically significant predictors (p < 0.05) were any RD (FDR logworth 68.6), followed by smoking history (29.8) and age (4.1). Radiologists recommended follow-up for IF 53.5% of the time, but only 13.9% of patients ever received a follow-up imaging exam or invasive procedure.

CONCLUSIONS

IFs are much more common than ATI and can be accurately predicted based on MLR utilizing only 3 clinical variables. While radiologists often recommend follow-up for IFs in trauma patients, most are never effectively followed up or addressed, leading to increased risk of poor outcomes. Clinicians should be aware of the high prevalence of IFs and develop systems for appropriate, evidence-based recommendations, and effective management.

KEY POINTS

• Incidental findings (IFs) are much more common (2×) than acute traumatic injuries (ATI) in chest CTs performed in trauma patients. • IFs can be accurately predicted via logistic regression modeling with only 3 variables (any relevant ICD-10 diagnosis; positive smoking history; age), which may help radiologist to focus their attention on higher risk patients. • Radiologists recommend follow-up for IFs more than half of the time; however, IFs are seldom followed up appropriately (less than 14%), leading to missed opportunities and potentially poor patient outcomes.

[Relevant incidental findings and iatrogenic injuries : A retrospective analysis of 1165 resuscitation room patients]

BACKGROUND

Whole-body computed tomography (CT) is increasingly being used as the diagnostic modality of choice in patients admitted to the resuscitation room. Beyond findings related to the suspected diagnosis it often additionally reveals incidental findings. The aim of this investigation was the evaluation of these findings in patients admitted via the emergency room after suffering potential major trauma or life-threatening medical conditions. Furthermore, the number of iatrogenic injuries as well as misplaced catheters and endotracheal tubes was investigated.

METHODS

All patients admitted from 1 February 2012 to 31 January 2014 via the resuscitation area of the Mannheim University Medical Center, a tertiary care hospital and level 1 trauma center, were included in this study if they had undergone a whole-body CT scan at admission. Data from 1362 patients were collected retrospectively and 197 patients were excluded because of missing data so that the final cohort consisted of 1165 patients (1038 trauma and 127 internal neurological patients). Reports from the whole-body CT scans were screened for incidental findings. These findings were then classified as either clinically relevant or not. Furthermore, the reports were checked for iatrogenic injuries as well as misplaced catheters and endotracheal tubes.

RESULTS

A total of 465 incidental findings were reported in 293 patients (25.1%) of the final cohort. In the synopsis of the radiological and clinical findings, 72 were rated as clinically relevant. In one patient two relevant incidental findings were reported and one patient presented with three incidental findings. In total, relevant incidental findings could be detected in 5.8% of the study patients (68/1165). In the discharge letters and/or the radiological report 16.2% of the incidental findings rated as clinically relevant were reported to be previously known, 66.2% were reported to be unknown and 17.6% could not be unequivocally classified as known or unknown due to missing references in the discharge letters. The group of internal neurological patients were clearly older than the trauma patients (61.6 years vs. 45.5 years). The rate of relevant incidental findings in the internal neurological group was more than twice as high as in the trauma group (11.0% vs. 5.2%); however, in the relatively young trauma group 1 in 20 patients showed an incidental finding classified as clinically relevant. In 43 (3.7%) patients a total of 46 iatrogenic injuries or misplaced catheters were reported. The most common finding was a too deeply placed endotracheal tube and five transurethral catheters placed in the emergency room were found to be blocked within the urethra.

CONCLUSION

In addition to the main diagnosis, clinically relevant incidental findings were reported in nearly 25% of whole-body CT scans of patients admitted to the resuscitation room. Approximately 6% of patients had incidental findings rated as clinically relevant. In the internal neurological group of patients the rate of incidental findings was doubled compared to the trauma group; however, the latter were significantly younger. Whole-body CT was also useful for diagnosing iatrogenic injuries and misplaced catheters in approximately 4% of the study patients.

Cardiovascular findings on computed tomography in patients with unclear finding situation and trauma of unknown origin

Incidental cardiovascular findings are common and can be found in up to 70% of patients. Previously, several reports about incidental findings (IFs) on whole body computed tomography (CT) were published. However, no previous study investigated cardiovascular IFs in patients with unclear finding situation and trauma of unknown origin on whole body CT.The radiological database of 2 university hospitals was screened for patients with trauma of unknown origin and unclear finding situation investigated by whole body CT. The images were retrospectively analyzed by 2 radiologists in consensus. The findings were classified according to their clinical relevance. Clinically nonrelevant findings like valvular sclerosis, aortic sclerosis, or anatomic variants were excluded from this study. Moreover, the radiology reports were analyzed to assess initial reporting by the radiologist.Overall, we identified 60 patients with a mean age of 63 years. A total of 98 clinically relevant cardiovascular IFs (CRCIF) were identified in 60 (75%) patients (1.6 CRCIF per patient). The most prevalent finding was cardiomegaly in 23 patients, followed by coronary sclerosis in 21 patients and aortic ectasia in 11 patients; other findings were rarer. Sixty-one findings were reported (62.2%) and 37 were nonreported (37.8%). Thirty patients (50%) showed no traumatic event on whole body CT.CRCIFs are common in patients with unclear finding situation and trauma of unknown origin. Despite initial indication for trauma detection, the whole body CT should carefully be evaluated for CRCIF because of the high prevalence of clinically relevant findings. Notably, 37.76% of the findings were not reported by the radiologist.

Renal incidental findings on computed tomography: Frequency and distribution in a large non selected cohort

Renal incidental findings (IFs) are common. However, previous reports investigated renal IFs were limited to patient selection. The purpose of this study was to estimate the prevalence and distribution of all renal IFs on computed tomography (CT) in a large patient collective.All patients, who underwent CT investigations of the abdominal region at our institution in the time period between January 2006 and February 2014 were included in this study. Inclusion criteria were as follows: no previous history of renal diseases and well image quality. Patients with known kidney disorders were excluded from the study. Overall, 7365 patients meet the inclusion criteria were identified. There were 2924 (39.7%) women and 4441 men (60.3%) with a mean age of 59.8 ± 16.7 years. All CTs were retrospectively analyzed in consensus by 2 radiologists. Collected data were evaluated by means of descriptive statistics.Overall, 2756 patients (37.42% of all included patients) showed 3425 different renal IFs (1.24 findings per patient). Of all renal IFs, 123 (3.6%) findings were clinically relevant, 259 (7.6%) were categorized as possibly clinically relevant, and 3043 (88.8%) were clinically non relevant.Different renal IFs can be detected on CT. The present study provides a real prevalence and proportion of them in daily clinical routine. Kidneys should be thoroughly evaluated because of the fact that incidental renal findings occur frequently.

Non-traumatic incidental findings in patients undergoing whole-body computed tomography at initial emergency admission

OBJECTIVE

To evaluate the number, localisation and importance of non-traumatic incidental findings (IFs) in patients with suspected or obvious multiple trauma undergoing whole-body CT (WBCT) in a level-1 trauma centre.

METHODS

Between January 2009 and December 2013, a total of 2440 patients with trauma undergoing WBCT at admission to a level-1 trauma centre of a university hospital were retrospectively analysed, through imaging IFs unrelated to trauma with the radiological reports. All IFs were grouped into four categories according to their clinical relevance. Category 1: urgent treatment or further clarification needed; category 2: further examination and follow-up within 3-6 months required; category 3: findings with no immediate consequences for the treatment of the patient but of potential relevance in the future; category 4: harmless findings.

RESULTS

Altogether, 5440 IFs in 2440 patients (1735 male, 705 female; mean age 45.1 years) were documented. In 204 patients (8.4%) urgent category 1 findings were reported, 766 patients (31.4%) had category 2 findings, 1236 patients (50.7%) had category 3 findings and 1173 patients (48.1%) had category 4 findings. Most IFs were detected in the abdomen/pelvis (42.5%). 602 (24.7%) of the patients had no IFs.

CONCLUSIONS

WBCT scans of unrelated trauma patients demonstrate a high rate of IF. A substantial percentage (8.4%) of patients had urgent category 1IFs and a high percentage (31.4%) had category 2 IFs requiring a follow-up. This high number of patients with polytrauma undergoing WBCT, having IFs of high relevance, poses a major challenge for the level-1 trauma centre in the acute and postacute management of these patients.

High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients; results of the REACT-2 trial

Objectives

To determine whether there is a difference in frequency and clinical relevance of incidental findings detected by total-body computed tomography scanning (TBCT) compared to those by the standard work-up (STWU) with selective computed tomography (CT) scanning.

Methods

Trauma patients from five trauma centres were randomized between April 2011 and January 2014 to TBCT imaging or STWU consisting of conventional imaging with selective CT scanning. Incidental findings were divided into three categories: 1) major finding, may cause mortality; 2) moderate finding, may cause morbidity; and 3) minor finding, hardly relevant. Generalized estimating equations were applied to assess differences in incidental findings.

Results

In total, 1083 patients were enrolled, of which 541 patients (49.9 %) were randomized for TBCT and 542 patients (50.1 %) for STWU. Major findings were detected in 23 patients (4.3 %) in the TBCT group compared to 9 patients (1.7 %) in the STWU group (adjusted rate ratio 2.851; 95%CI 1.337–6.077; p < 0.007). Findings of moderate relevance were detected in 120 patients (22.2 %) in the TBCT group compared to 86 patients (15.9 %) in the STWU group (adjusted rate ratio 1.421; 95%CI 1.088–1.854; p < 0.010).

Conclusions

Compared to selective CT scanning, more patients with clinically relevant incidental findings can be expected by TBCT scanning.

Key points

• Total-body CT scanning in trauma results in 1.5 times more incidental findings.

• Evaluation by TBCT in trauma results in more patients with incidental findings.

• In every category of clinical relevance, TBCT detects more incidental findings.

Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial

BACKGROUND

Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma.

METHODS

We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with traumatic brain injury. The χ(2) test was used to assess differences in mortality. This trial is registered with ClinicalTrials.gov, number NCT01523626.

FINDINGS

Between April 22, 2011, and Jan 1, 2014, 5475 patients were assessed for eligibility, 1403 of whom were randomly assigned: 702 to immediate total-body CT scanning and 701 to the standard work-up. 541 patients in the immediate total-body CT scanning group and 542 in the standard work-up group were included in the primary analysis. In-hospital mortality did not differ between groups (total-body CT 86 [16%] of 541 vs standard work-up 85 [16%] of 542; p=0.92). In-hospital mortality also did not differ between groups in subgroup analyses in patients with polytrauma (total-body CT 81 [22%] of 362 vs standard work-up 82 [25%] of 331; p=0.46) and traumatic brain injury (68 [38%] of 178 vs 66 [44%] of 151; p=0.31). Three serious adverse events were reported in patients in the total-body CT group (1%), one in the standard work-up group (<1%), and one in a patient who was excluded after random allocation. All five patients died.

INTERPRETATION

Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT.

FUNDING

ZonMw, the Netherlands Organisation for Health Research and Development.

Extravascular incidental findings in run-off CT angiography in patients with acute limb ischaemia: incidence and clinical relevance

AIM

To evaluate the incidence and clinical relevance of extravascular incidental findings (EVIFs) in CT angiography of the abdominal aorta and lower extremities (run-off CTA) in patients presenting with acute limb ischaemia (ALI).

MATERIALS AND METHODS

In this institutional review board-approved, retrospective study, 141 run-off CTA examinations conducted between 2005 and 2013 of patients (67 women, mean age 80 years; 74 men, mean age 69 years) presenting with clinical symptoms of ALI were re-evaluated by two radiologists (2 and 7 years of experience in interpreting run-off CTA). Imaging was conducted using 16- and 64-section CT systems. Image acquisition ranged from the costodiaphragmatic recess to the forefoot. The medical history form of each patient served as the standard of reference for assessment of incidence of EVIFs. CT morphology was assessed to assign EVIFs to one of three categories of clinical relevance: (I) immediate, (II) potential, and (III) no clinical relevance.

RESULTS

Thirty-eight patients had category I findings, including four patients (2.8%) with previously unknown malignancy and 67 patients with category II EVIFs. In total 473 extravascular EVIFs were found in 141 patients: 52 category I, 163 category II and 258 category III.

CONCLUSION

EVIFs with immediate clinical relevance are very common in run-off CTA in patients presenting with acute peripheral artery disease. Therefore, it is important to evaluate all body regions included in a CT examination carefully, even if the clinical focus is on vascular evaluation. The adequate classification of these EVIFs is required to avoid possible unnecessary diagnostic work-up with associated risks and costs.

Retrospective analysis of incidental non-trauma associated findings in severely injured patients identified by whole-body spiral CT scans

BACKGROUND

Whole-body Computed Tomography (CT) scan today is considered a crucial imaging technique in the diagnostic work-up of polytrauma patients implicating a potential survival benefit. Apart from prompt identification of life threatening injuries this imaging technique provides an additional benefit by diagnosing incidental non-trauma associated medical diseases. These incidental findings might be also life threatening and warrant urgent therapy. The downside of whole-body CT is a relatively high radiation exposure that might result in an increased life time cancer risk. The aim of this study was to investigate the frequency and type of non trauma associated incidental medical findings in relation to patient age and potential clinical relevance.

METHODS

Between January 1(st) 2011 and December 15th 2012, a total of 704 trauma patients were referred to our hospital's emergency room that triggered trauma room alarm according to our trauma mechanism criteria. Of these 534 (75.8%) received a whole-body CT according to our dedicated multiple trauma protocol. Incidental Findings (IF) were assigned in three groups according to their clinical relevance. Category 1: IF with high medical relevance (urgent life threatening conditions, unless treated) needing early investigations and intervention prior to or shortly after hospital discharge. Category 2: IF with intermediate or low medical relevance, warranting further investigations. Category 3: IF without clinical relevance.

RESULTS

Overall 231 IFs (43.3%) were identified, 36 (6.7%) patients had IFs with a high clinical relevance, 48 (9.0%) with a moderate or minor clinical relevance and 147 (27.5%) with no clinical relevance. The distribution of incidental findings with high or moderate relevance according to age showed an incidence of 2.6%, 6.6% and 8.8% for patients younger than 40 years, 40 to 60 years and older than 60 years, respectively.

CONCLUSION

Whole-body CT scans of trauma patients demonstrate a high rate of incidental findings. Potentially life-threatening, medical findings were found in approximately every 15th patient, predominantly aged over 40 years and presenting with minor to moderate injuries and an Injury Severity Score (ISS) of 10 or less.

Diagnostic significance of rib series in minor thorax trauma compared to plain chest film and computed tomography

Background

Rib series (RS) are a special radiological technique to improve the visualization of the bony parts of the chest.

Objectives

The aim of this study was to evaluate the diagnostic accuracy of rib series in minor thorax trauma.

Methods

Retrospective study of 56 patients who received RS, 39 patients where additionally evaluated by plain chest film (PCF). All patients underwent a computed tomography (CT) of the chest. RS and PCF were re-read independently by three radiologists, the results were compared with the CT as goldstandard. Sensitivity, specificity, negative and positive predictive value were calculated. Significance in the differences of findings was determined by McNemar test, interobserver variability by Cohens kappa test.

Results

56 patients were evaluated (34 men, 22 women, mean age =61 y.). In 22 patients one or more rib fracture could be identified by CT. In 18 of these cases (82%) the correct diagnosis was made by RS, in 16 cases (73%) the correct number of involved ribs was detected. These differences were significant (p = 0.03). Specificity was 100%, negative and positive predictive value were 85% and 100%. Kappa values for the interobserver agreement was 0.92-0.96. Sensitivity of PCF was 46% and was significantly lower (p = 0.008) compared to CT.

Conclusions

Rib series does not seem to be an useful examination in evaluating minor thorax trauma. CT seems to be the method of choice to detect rib fractures, but the clinical value of the radiological proof has to be discussed and investigated in larger follow up studies.

Incidental findings on total-body CT scans in trauma patients

INTRODUCTION

Total-body Computed Tomography (CT) scans are increasingly used in trauma care. Herewith the observation of incidental findings, trauma unrelated findings, is also increased. The aim of this study was to evaluate the number of incidental findings in adult trauma patients.

PATIENTS AND METHODS

All consecutive trauma patients that underwent total-body CT scanning between January 2009 and December 2011 were analysed. Incidental findings were divided in three categories: category I (potentially severe condition, further diagnostic work-up is required), category II (diagnostic work-up dependent on patients' symptoms) and category III (findings of minor concern, no diagnostic work-up required).

RESULTS

There were 2248 trauma room presentations; 321 patients underwent a total-body CT scan (14.3%). In 143 patients (44.5%), 186 incidental findings were reported. There were 13 category I findings (7.0%), 45 category II findings (24.2%) and 128 category III incidental findings (68.8%). Overall, 18 patients (5.6%) required additional diagnostic work-up. Four patients underwent work-up by additional radiologic imaging. Three patients required further invasive work-up or treatment. Three patients were transferred to another hospital, no extended follow-up was performed. In three patients, there was no documentation of follow-up. Five patients deceased before diagnostic work-up of the incidental finding could start.

CONCLUSION

Total-body CT scanning as part of the evaluation of trauma patients leads to a substantial amount of incidental findings. Documentation of incidental findings and their clinical consequences was incomplete. Therefore, the findings of this study have prompted us to add an item to our electronic trauma room report that obliges residents to report whether or not incidental findings are found during trauma imaging.

[Computed tomography evaluation of human mandibles with regard to layer thickness and bone density of the cortical bone]

PURPOSE

Application of function-restoring individual implants for the bridging of defects in mandibles with continuity separation requires a stable fixation with special use of the cortical bone stumps.

MATERIALS AND METHODS

Five section planes each of 100 computed tomographies of poly-traumatized patients' jaws were used for measuring the thickness of the cortical layer and the bone density of the mandible. The CT scans of 28 female and 72 male candidates aged between 12 and 86 years with different dentition of the mandible were available.

RESULTS

The computed tomographic evaluations of human mandibles regarding the layer thickness of the cortical bone showed that the edge of the mandible in the area of the horizontal branch possesses the biggest layer thickness of the whole of the lower jaws. The highest medians of the cortical bone layer thickness were found in the area of the molars and premolars at the lower edge of the lower jaws in 6-o'clock position, in the area of the molars in the vestibular cranial 10-o'clock position and in the chin region lingual-caudal in the 4-o'clock position. The measurement of the bone density showed the highest values in the 8-o'clock position (vestibular-caudal) in the molar region in both males and females.

CONCLUSION

The average values available of the bone density and the layer thickness of the cortical bone in the various regions of the lower jaw, taking into consideration age, gender and dentition, are an important aid in practice for determining a safe fixation point for implants in the area of the surface layer of the mandible by means of screws or similar fixation elements.

Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients

BACKGROUND

The aim of this review was to assess the value of immediate total-body computed tomography (CT) during the primary survey of injured patients compared with conventional radiographic imaging supplemented with selective CT.

METHODS

A systematic search of the literature was performed in MEDLINE, Embase, Web of Science and Cochrane Library databases. Reports were eligible if they contained original data comparing immediate total-body CT with conventional imaging supplemented with selective CT in injured patients. The main outcomes of interest were overall mortality and time in the emergency room (ER).

RESULTS

Four studies were included describing a total of 5470 patients; one study provided 4621 patients (84.5 per cent). All four studies were non-randomized cohort studies with retrospective data collection. Mortality was reported in three studies. Absolute mortality rates differed substantially between studies, but within studies mortality rates were comparable between immediate total-body CT and conventional imaging strategies (pooled odds ratio 0.91, 95 per cent confidence interval 0.79 to 1.05). Time in the ER was described in three studies, and in two was significantly shorter in patients who underwent immediate total-body CT: 70 versus 104 min (P = 0.025) and 47 versus 82 min (P < 0.001) respectively.

CONCLUSION

This review showed differences in time in the ER in favour of immediate total-body CT during the primary trauma survey compared with conventional radiographic imaging supplemented with selective CT. There were no differences in mortality. The substantial reduction in time in the ER is a promising feature of immediate total-body CT but well designed and larger randomized studies are needed to see how this will translate into clinical outcomes.

Incidental Findings on Routine Thoracoabdominal Computed Tomography in Blunt Trauma Patients

BACKGROUND:: Thoracoabdominal MultiDetector-row Computed Tomography (MDCT) is frequently used as a diagnostic tool in trauma patients. One potential side-effect of performing MDCT is the detection of incidental findings and their subsequent consequences on medical treatment. The objective was to evaluate frequency and effects of incidental findings in trauma patients. METHODS:: The reports of 1,047 consecutive blunt trauma patients (mean age, 40 years) who underwent routine contrast-enhanced thoracoabdominal MDCT were evaluated. Incidental findings were categorized by a trauma radiologist into four hierarchic categories based on their clinical consequences. We recorded additional diagnostic workup and treatment performed in conjunction with these incidental findings. RESULTS:: Of the 1,047 patients, 372 (mean age, 56 years; 61% male) had one or more incidental findings on thoracoabdominal MDCT. Complementary investigation or therapy was performed in 72 of these 372 patients; 29 of these patients required additional invasive evaluation or treatment. Nineteen patients underwent surgery due to an incidental finding. Nine patients were diagnosed with a not previously identified malignancy. CONCLUSIONS:: Routine thoracoabdominal MDCT in the evaluation of trauma patients revealed a significant number of incidental findings. Based on radiologic findings it is possible to decide whether additional follow-up or treatment is necessary.

[Different case fatality rates at German trauma centres : Critical analysis]

OBJECTIVE

The level of trauma care in Germany belongs to one of the best worldwide. Nevertheless, previous studies have shown significant differences in the case fatality rates of multiple trauma patients in German trauma centres. The objective of this study was to indentify the reasons for the different outcomes based on data of the trauma registry of the German Society of Orthopaedic Surgery and Traumatology.

METHODS

Due to the inadequacy of comparing only the case fataltiy rates in the different trauma centres, the data recorded in the trauma registry were analyzed in a retrospective, multicentre study to calculate the probability of survival, revised injury severity classification (RISC) and, additionally, the standardized mortality ratio (SMR) for ranking of the participating trauma centres. As a criterion for inclusion in the study, a minimum of 100 trauma patients admitted directly from the scene within a 4 year period was set. The ranking was carried out using the SMR (observed mortality divided by probability of survival). With the help of data from the trauma registry an attempt was made to find the differences in trauma management between the top 10 centres (lowest SMR), the 10 middle and the last 10 centres (highest SMR) in the ranking.

RESULTS

The data of 6,522 patients were included in the study. There were significant differences in the pre-hospital time, the time spent in the emergency room (ER) and time until a CT scan had been performed. Pre-hospital time was longer in patients admitted to the top centres, whereas time in the ER was longer in the last centres of the ranking. Comparing the sum of pre-hospital time and time in the ER, there were no differences between the top and the last centres. At the scene of accident overall intubation rate and intubation rate in patients with traumatic brain injury were higher in patients admitted to the top centres. Regarding the transport modality, significantly more patients were transported by helicopter in the group of the top centres. In top centres CT scans, in particular whole-body CTs, were initiated sooner and used much more frequently so that the rate of missed injuries was much lower. The amount of fluid given at the scene of accident did not differ between the centres but the amount of fluid given in ER and the operating room until admission to the intensive care unit was significantly higher in the top centres.

CONCLUSION

There are significant differences in the pre-hospital and clinical care of patients admitted to German trauma centres. Under clinical conditions a tight time management, an immediate and complete diagnostic approach, particularly by means of whole-body CT and a liberal fluid resuscitation seem to be favorable factors.

[Multidetector computed tomography in abdominal emergencies]

Abdominal emergencies encompass traumatic events in the region of the abdomen as well as the clinical term acute abdomen. Multidetector CT (MDCT) represents one of the most important imaging modalities for detection and correct diagnosis in such abdominal emergencies. Based on the acquired data MDCT allows a stable imaging of the abdomen in an extremely short time even in critically ill patients. Multiplanar reconstructions can be created based on the high resolution data allowing an impressive visualization of the pathology. In this review article the most important abdominal pathologies of the abdomen diagnosed by MDCT are presented with special emphasis on the liver, bile ducts, spleen and kidneys as well as the gastro-intestinal tract. Additionally, MDCT imaging of the individual organ regions will be dealt with in detail.