Arterial bleeding diagnosed by CT in hemodynamically stable victims of blunt trauma

Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury

BACKGROUND

Nonoperative management (NOM) has become the standard treatment of blunt hepatic injury (BHI) for stable patients. Contrast extravasation (CE) on computed tomography (CT) scan had been reported as a sign that is associated with NOM failure. The goal of this study was to further investigate the risk factors of NOM failure in patients with CE on CT scan.

METHODS

From January 2005 to September 2009, patients with CE noted on a CT scan as a result of BHI were studied retrospectively. Physiological parameters, severity of injury, amount of transfusion, type of contrast extravasation, as well as treatment outcome were compared between patients with NOM failure and NOM success.

RESULTS

A total of 130 patients were enrolled. Injury severity scores, amount of blood transfusion before hemostatic procedure, and grade of liver injury were significantly higher in NOM failure than in NOM success patients. There was no statistical difference in the NOM success rate between patients with contrast leakage into the peritoneum and those with contrast confined in the hepatic parenchyma.

CONCLUSIONS

Higher injury severity score, more blood transfusion, and higher grade of liver injury are factors that correlate with NOM failure in patients with BHI. Contrast leakage into the peritoneum is not always a definite sign of NOM failure in BHI. Early and aggressive angioembolization is an effective adjunct of NOM in BHI patients, even with contrast leakage into peritoneum.

Extravasation of intravenous computed tomography scan contrast in blunt abdominal and pelvic trauma

BACKGROUND

Intravenous contrast extravasation (CE) on computed tomography (CT) scan in blunt abdominal trauma is generally regarded as an indication for the need for invasive intervention (either angiography or laparotomy). More recently, improvements in CT scan technology have increased the sensitivity in detecting CE, and, thus, we postulate that not all patients with this finding require intervention.

METHODS

This study is a retrospective review of all patients who underwent a CT scan for blunt abdominal trauma between January 1999 and September 2003. Patterns of injury, associated injuries, management, and outcomes were examined for patients with CE.

RESULTS

Seventy of 1,435 patients (4.8%) demonstrated CE. Mean age was 44 years and mean Injury Severity Score was 39. The location of CE was intra-abdominal in 25, pelvis/retroperitoneum in 39, and both areas in 3 patients. Six patients received supportive treatment for nonsurvivable head injury and were excluded from further analysis. Overall, 30 (47%) patients underwent immediate intervention (angiography or laparotomy) and 34 (53%) were managed nonoperatively. Of those who had initial nonoperative management, overall seven (20.5%) underwent intervention, with the remainder being managed without intervention. The success for nonoperative management was greater for those with pelvic/retroperitoneal CE (4 of 7: 57%) than for intra-abdominal extravasation (23 of 27: 85%).

CONCLUSION

Although evidence of CE may suggest significant vascular injury, our data suggest that not all patients require invasive intervention. Further studies are needed to better define criteria for nonoperative management in patients with CE identified on their initial CT scan.

Nonoperative management of spleen and liver injuries

The spleen and liver are the 2 most commonly injured abdominal organs following trauma. Trends in management have changed over the years, and the majority of these injuries are now managed nonoperatively. Splenic injuries can be managed via simple observation or with angiography and embolization. Recent data suggest that there are few true contraindications in the setting of hemodynamic stability. Success rate of nonoperative management may be as high as 95%. Liver injuries can be approached similarly. In the setting of a hemodynamically stable patient, observation with or without angiography and embolization may similarly be used. As many as 80% of patients with liver injury can be successfully managed without laparotomy. This review will discuss current concepts in nonoperative management of liver and spleen, including diagnosis, patient selection, nonoperative management strategies, benefits, risks, and complications.

Active abdominal bleeding: contrast-enhanced sonography

Active contrast medium extravasation is a recognized and important angiographic and computed tomographic (CT) sign of bleeding. It is an indicator of active, ongoing, and potentially life-threatening hemorrhage and, hence, of the need for an immediate surgical or interventional treatment. Sonography (US) is frequently used as the first imaging option for screening patients with traumatic and nontraumatic abdominal emergencies. Owing to the current possibilities of low-mechanical index, real-time, contrast-specific systems, it is now possible to detect a contrast leakage by using US. This finding opens new possibilities in the assessment and management of several abdominal emergencies, including trauma (initial workup and monitoring), spontaneous hematomas, and rupture of aneurysms or masses. This article describes the technique, findings, possibilities, and limitations of contrast-enhanced US in the evaluation of active abdominal bleeding.

Real-time, contrast-enhanced sonography: a new tool for detecting active bleeding

BACKGROUND

Active contrast medium extravasation is a known angiographic and computed tomographic sign of ongoing, potentially life-threatening hemorrhage. Sonography (US) is frequently the first imaging option for screening patients with abdominal emergencies. Because of the current possibilities of low-mechanical-index, real-time, contrast-specific systems, it is possible to detect contrast leakage by using US. The purpose of this article is report our pilot experience in the evaluation of active traumatic and nontraumatic bleeding with contrast-enhanced US.

METHODS

In a 2-year period, we performed 153 consecutive emergent contrast-enhanced US studies. Traumatic emergencies accounted for 83 examinations and nontraumatic emergencies accounted for 70. We used the contrast-specific mode Contrast Tuned Imaging and the contrast medium SonoVue. A 2.4- to 4.8-mL contrast medium bolus was injected with continuous US acquisition, starting immediately after contrast injection and lasting 1 to 6 minutes.

RESULTS

Contrast extravasation was found in 20 cases (13%). These included spleen injury (n = 8), liver injury (n = 3), kidney injury (n = 1), abdominal aortic aneurysm rupture (n = 5), splenic angiosarcoma rupture (n = 1), postsurgical bleeding after abdominal aortic aneurysm repair (n = 1), and postsplenectomy bleeding (n = 1). Active extravasation appeared as a round, hyperechoic pool or as a fountain-like, hyperechoic jet.

CONCLUSION

Our retrospective clinical study shows for the first time how US can detect contrast medium extravasation, a significant indicator of active hemorrhage and of need for prompt surgical or interventional treatment.

Unsuspected internal organ traumatic injuries

Emergency medicine physicians can avoid missed traumatic intra-abdominal injury by adopting a paradigm for patient evaluation that recognizes the patterns of injury associated with pathology, the importance of positive and negative physical findings, and the limitations of diagnostic studies. The burden of avoiding missed traumatic injuries does not rest with emergency medicine physicians alone, however. A missed diagnosis may be the result of a medical error involving multiple systems and individuals.Ultimately, decreasing the incidence of missed traumatic injury is an opportunity for quality improvement for all practitioners involved in the care of patients with trauma.

The significance of contrast blush on computed tomography in children with splenic injuries

PURPOSE

Most children and adults with blunt splenic injuries are treated nonoperatively by well-established management protocols. The "blush sign" is an active pooling of contrast material within or around the spleen seen during intravenous enhanced computed tomography (CT) scan. Adult treatment algorithms often include the "blush sign" as an indication for embolization or surgical intervention. This study was designed to evaluate the implications of the "blush sign" in children with blunt splenic injuries.

METHODS

A review was performed of all children with blunt splenic injuries treated between January 1996 and December 2001 at a level I pediatric trauma center using an established solid organ injury protocol. The demographic, CT imaging, and outcome data were recorded. Treatment was categorized as operative or nonoperative. A single pediatric radiologist retrospectively reviewed all available CT scans to confirm injury grade and the presence or absence of a "blush sign."

RESULTS

There were 133 eligible children admitted with blunt splenic trauma, with a mean age of 9.1 years (range, 1 to 15), including 86 children with an abdominal CT available for review. A "blush sign" on initial CT scan was noted in 6 children, all with grade 3 or above splenic injuries, 5 of who were treated nonoperatively. In this series, the single child with a "blush sign" who did not respond to nonoperative treatment had a severe polytrauma requiring urgent splenectomy and left nephrectomy. None of the children died of their splenic injury.

CONCLUSIONS

Although associated with higher grades of injury, the blush sign did not mandate embolization or surgical intervention in children with blunt splenic trauma in this series. Severe splenic injuries with a blush sign on the initial CT scan may be successfully treated nonoperatively when using an established treatment protocol. Management should be based primarily on physiological response to injury rather than the radiologic features of the injury.

Multidetector CT: detection of active hemorrhage in patients with blunt abdominal trauma

OBJECTIVE

The aim of this study was to determine the imaging findings and the prevalence of active hemorrhage on contrast-enhanced multidetector CT in patients with blunt abdominal trauma.

MATERIALS AND METHODS

Contrast-enhanced multidetector CT images of 165 patients with blunt abdominal trauma were reviewed for the presence of extravasated contrast agent, a finding that represents active hemorrhage. The site and appearance of the hemorrhage were noted on multidetector CT images. These findings were compared with surgical and angiographic results or with clinical follow-up.

RESULTS

On multidetector CT images, active hemorrhage was detected in 22 (13%) of 165 patients with a total of 24 bleeding sites (14 intraperitoneal sites and 10 extraperitoneal sites). Active hemorrhage was visible most frequently as a jet of extravasated contrast agent (10/24 bleeding sites [42%]). Diffuse or focal extravasation was less frequently seen (nine [37%] and five [21%] bleeding sites, respectively). CT attenuation values measured in the aorta (mean, 199 H) were significantly higher than those measured in extravasated contrast material (mean, 155 H) (p < 0.001). Sixteen (73%) of 22 patients with active bleeding on multidetector CT images underwent immediate surgical or angiographic intervention. One patient received angiographic therapy 10 hr after undergoing multidetector CT, and five patients died between 1 and 3 hr after multidetector CT examination.

CONCLUSION

Active hemorrhage in patients after blunt abdominal trauma is most frequently visible as a jet of extravasated contrast agent on multidetector CT. When extravasation is detected, immediate surgical or angiographic therapy is required.

Classification and treatment of pooling of contrast material on computed tomographic scan of blunt hepatic trauma

BACKGROUND

Pooling of contrast material on computed tomographic (CT) scan represents free extravasation of blood as a result of active bleeding. For patients with blunt hepatic injury, aggressive management such as angiography or celiotomy is usually indicated if this sign is detected. The purposes of this study were to further categorize this CT scan finding and to correlate its characteristics with clinical outcomes. This CT scan classification might be helpful for the selection of appropriate management.

METHODS

During a 42-month period, 276 patients with blunt hepatic injury were treated. Two hundred twelve of them were hemodynamically stable after initial resuscitation and underwent abdominal CT scan examination. Pooling of contrast material was detected on the CT scans of 15 patients. The CT scans and medical records were reviewed. Special attention was paid to the presence, location, and character of the extravasated contrast material.

RESULTS

The finding of pooling of contrast material on CT scan was categorized into three types according to its location and character. Type I showed extravasation and pooling of contrast material in the peritoneal cavity (six patients). All patients with type I CT scan findings became hemodynamically unstable soon after CT scan examination and required emergent laparotomy. Type II findings showed simultaneous presence of hemoperitoneum and intraparenchymal contrast material pooling (six patients). Four patients with type II CT scan findings required laparotomy for hemostasis. Type III findings showed intraparenchymal contrast material pooling without hemoperitoneum (three patients). All patients with type III CT scan signs remained hemodynamically stable.

CONCLUSION

With the use of a high-speed spiral CT scanner, it is possible to predict the necessity of operative management or angiography for patients with blunt hepatic injury before deterioration of hemodynamic status. The presence of pooling of contrast material within the peritoneal cavity indicates active and massive bleeding. Patients with this CT scan finding show rapid deterioration of hemodynamic status. Most of these patients might require emergent surgery. Pooling of contrast material in a ruptured hepatic parenchyma indicates active bleeding. Close monitoring and emergent angiography should be performed. Deterioration of hemodynamic status in these patients usually requires prompt surgical intervention. Intraparenchymal pooling of contrast material with unruptured liver capsule often indicates a self-limited hemorrhage. Patients with this CT scan finding have a high possibility of successful nonoperative treatment.

Pediatric hepatic trauma: does clinical course support intensive care unit stay?

PURPOSE

The objective of this study is to determine if grade of liver injury predicts outcome after blunt hepatic trauma in children and to initiate analysis of current management practices to optimize resource utilization without compromising patient care.

METHODS

A retrospective review of 36 children who had blunt hepatic trauma treated at a pediatric trauma center from 1989 to present was performed. Hepatic injuries graded (AAST Organ Injury Scaling) ranged from grade I to IV. Injury Severity Score (ISS), Glasgow Coma Score (GCS), transfusion requirements, liver transaminase levels, associated injuries, intensive care unit (ICU) length of stay, and survival were analyzed.

RESULTS

Mean (+/-SEM) age was 6.6+/-0.8 years, mean grade of hepatic injury was 2.4+/-0.2, mean ISS was 17+/-2.6, mean GCS was 13+/-1, and mean transfusion was 15.4 mL/kg of packed red blood cells (PRBC). There were three deaths with a mean ISS of 59+/-9 and a mean GCS of 3+/-0. Death was not associated with a high-grade liver injury, survivors versus nonsurvivors, 2.3+/-0.2 versus 2.7+/-0.3, but was associated with ISS, 13+/-1.4 versus 59+/-9 (P = .005) and GCS, 14+/-1 versus 3+/-0 (P = .005). Only one patient (grade III, ISS = 43) underwent surgery. There were no differences in mean ISS or GCS between grades I to IV patients. The hepatic injury grades of patients requiring transfusion versus no transfusion were significantly different, 3.4+/-0.2 versus 2.2+/-0.2 (P = 0.04). Abused patients had high-grade hepatic injuries and significant laboratory and clinical findings. Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) were significantly higher in grade III and IV injuries than in grades I and II, 1,157+/-320 versus 333+/-61 (P= .02) and 1,176+/-299 versus 516+/-86 (P= .04), respectively. No children with grade I or II injury had a transfusion requirement or surgical intervention. There were no liver-related complications.

CONCLUSIONS

Mortality and morbidity rates in pediatric liver injuries, grades I to IV, correlate with associated injuries not the degree of hepatic damage. ALT, AST, and transfusion requirements are significantly related to degree of liver injury. Low-grade and isolated high-grade liver injuries seldom require transfusion. Blunt liver trauma rarely requires surgical intervention. In retrospect, the need for expensive ICU observation for low-grade and isolated high-grade hepatic injuries is questionably warranted.

Pediatric blunt abdominal trauma: role of computed tomography vascular blush

Nonoperative management of blunt abdominal trauma is widely accepted in pediatric patients. There are few factors prospectively available to predict reliably which children will not respond to nonoperative treatment. Computed tomography scans demonstrating a vascular contrast blush are associated with arterial bleeding and the failure of nonoperative management of splenic injuries in adults. The authors describe five hemondynamically stable pediatric patients who have intraabdominal injury and a characteristic vascular contrast blush who acutely did not respond to nonoperative treatment. Vascular blush may be an indication for early laparotomy in pediatric trauma patients.