Significance of minimal or no intraperitoneal fluid visible on CT scan associated with blunt liver and splenic injuries: a multicenter analysis

Traumatic Splenic Infarction and Pulmonary Embolism: A Case Report of Rare Radiological Finding

Focused abdominal sonography in trauma (FAST) and contrast-enhanced computed tomography (CECT) abdomen are important radiological tests for evaluating the abdomen in polytrauma cases. When vitals are stable, they help to reach a diagnosis in the majority of patients. However, in a small number of cases they fail to explain the clinical scenario. A continued serial clinical assessment may be helpful in these circumstances. A polytrauma patient was found to be FAST positive. The CT scan revealed pulmonary embolism, splenic infarction, perisplenic and perihepatic hematoma. The patient was complaining of pain abdomen and it worsened on day three of the injury. An exploratory laparotomy was performed. A circumferential intestinal wall hematoma with a tear in mesentery was found. This is a rare case of traumatic splenic infarction with evidence of pulmonary embolism. The serial clinical assessment was helpful as it indicated the need for intervention.

Predictive value of a false-negative focused abdominal sonography for trauma (FAST) result in patients with confirmed traumatic abdominal injury

Objective

To investigate if patients with confirmed traumatic abdominal injury and a false-negative focused abdominal sonography for trauma (FAST) examination have a more favorable prognosis than those with a true-positive FAST.

Methods

This study included 97 consecutive patients with confirmed traumatic abdominal injury (based on computed tomography [CT] and/or surgical findings) who underwent FAST.

Results

FAST was false-negative in 40 patients (41.2%) and true-positive in 57 patients (58.8%). Twenty-two patients (22.7%) had an unfavorable outcome (defined as the need for an interventional radiologic procedure, laparotomy, or death due to abdominal injury). Univariately, a false-negative FAST (odds ratio [OR] 0.24; p = 0.017) and a higher systolic blood pressure (OR, 0.97 per mmHg increase; p = 0.034) were significantly associated with a favorable outcome, whereas contrast extravasation on CT (OR, 7.17; p = 0.001) and shock index classification (OR, 1.89 for each higher class; p = 0.046) were significantly associated with an unfavorable outcome. Multivariately, only contrast extravasation on CT remained significantly associated with an unfavorable outcome (OR, 4.64; p = 0.016). When excluding contrast extravasation on CT from multivariate analysis, only a false-negative FAST result was predictive of a favorable outcome (OR, 0.28; p = 0.038).

Conclusion

Trauma patients with confirmed abdominal injury and a false-negative FAST have a better outcome than those with a positive FAST. FAST may be valuable for risk stratification and prognostication in patients with a high suspicion of abdominal injury when CT has not been performed yet or when CT is not available.

Influences on the amount of intraperitoneal haemorrhage after blunt liver injury: a retrospective autopsy study

OBJECTIVE

The amount of intraperitoneal blood loss due to traumatic liver injury is rarely addressed in correlation with concomitant injuries or pre-existing liver disease.

METHODS

We carried out a retrospective review of autopsy reports from 1995 until 2007 at the Institute of Forensic Medicine (Bern, Switzerland), and evaluated 126 cases of blunt liver trauma for the amount of blood in the abdominal cavity, severity of liver injury, pre-existing liver disease and concomitant injuries.

RESULTS

Grades IV and V liver injuries (American Association for the Surgery of Trauma classification) showed greater blood loss than grades I and II liver injuries. Grade III liver injuries showed no significant difference in the amount of intraperitoneal blood compared with grades IV and V liver injuries and 53 cases of liver injuries (42%) did not bleed at all. The amount of blood found in the abdominal cavity ranged from 0 to 4500 ml. Pre-existing liver steatosis showed no significant difference in injury pattern or bleeding from the liver. Three cases with liver haemangiomas and one with a liver cyst showed no lesion to their focal alteration. Because of the small number of cases, no statistical analysis was made concerning concomitant injuries such as head, thoracic or limb trauma.

CONCLUSION

Higher grades of liver injury severity are associated with higher blood loss into the abdominal cavity. In addition, a patient with pre-existing liver steatosis seems not to be at any greater risk of having a larger rupture or having stronger bleeding from the liver after a blunt impact compared with a patient with a normal liver.

The role of early multislice computed tomography in major trauma

Whole-body multislice spiral computed tomography (MSCT) has become a very important dignostic tool in the management of patients with multiple injuries. Many reports exist which demonstrate the feasibility and the benefit when using whole-body MSCT in the early phase of in-hospital management of trauma patients. Even in hemodynamically instable patients (except cardiac arrest), whole-body MSCT can be used and is a safe diagnostic procedure. While the diagnostic superiority of multislice computed tomography is proven for different organ regions (e.g. head/brain, chest, abdomen, pelvis and spine), its use as a single whole-body scan is still part of an ongoing discussion. Especially concerns about radiation exposure are the reason for uncertainty about when using whole-body trauma scan. Predefined scan protocols and individual positioning of patients may help to keep radiation dose as minimal as possible. To justify higher radiation dose, the indication must be chosen appropriately. Therefore, the use of a sensitive and specific triage scheme seems to be reasonable. Overscanning patients with minor trauma needs to be avoided, while the benefit for patients with severe multiple injuries is obvious.

Correlation of operative and pathological injury grade with computed tomographic grade in the failed nonoperative management of blunt splenic trauma

BACKGROUND

Computed tomography (CT) is the standard for grading blunt splenic injuries, but the true accuracy, especially for grade IV or V injuries as compared to pathological findings, is unknown.

STUDY DESIGN

A retrospective study from 2005 to 2011 was undertaken.

RESULTS

There were 214 adults admitted with blunt splenic injury and 170 (79%) were managed nonoperatively. The remaining 44 patients (21%) required surgical intervention. There was a significant difference in the Injury Severity Score (ISS) between those who did and those who did not require splenectomy: median 31 (interquartile [IQ] range 11-51) versus 22 (IQ range 9-35, p = 0.0002). Ten patients presented in shock, had a positive ultrasound, and went to surgery. The remaining 34 had CT scans prior to surgery. Twenty-five (73%) had injury grades IV or V. The CT scan correctly graded the injury in 14 (41%) and was incorrect in 20 (59%). The assigned grade by the CT scan underestimated the true injury grade by one grade in six cases (30%), by two or more grades in nine (45%), and the CT images were obscured by blood and deemed "ungradeable" in five (25%). The CT scan was more accurate for grades I and II (100%) than for grades III-V (25-43%). The reasons for inaccuracy were either inability to visualize that the laceration involved the hilar vessels or excessive perisplenic blood which obscured the injury and/or the hilum.

CONCLUSIONS

CT for splenic injury is accurate for grades I and II, but underestimates the true extent of injury for grades III-V. The reasons for the lack of correlation are the inability to determine hilar involvement and excessive perisplenic blood obscuring the injury. Patients with these image characteristics by CT scan should undergo splenectomy earlier if there are any signs of hemodynamic instability.

Low-dose MDCT findings of blunt hepatobiliary trauma

This pictorial essay shows low-dose multi-detector computed tomography (MDCT) findings of blunt hepatobiliary trauma, and describes the indications and protocol for MDCT. Given the universal usage of MDCT in assessing the liver in blunt abdominal trauma, reduction of patient dose is essential. The new l0se MDCT protocol presented here can achieve up to 50% dose reduction while maintaining diagnostic image quality and thus facilitate dose sensitive patient management. Our institution's blunt hepatobiliary MDCT imaging algorithm can help determine which patients require operative therapy. Injury to the liver is graded on various schemes, one being the Organ Injury Scale devised by the American Association for the Surgery of Trauma classification based on the extension of the lesion and bleeding.

Adrenal injury following blunt abdominal trauma

BACKGROUND

Adrenal injury secondary to abdominal trauma is quite rare because the adrenal gland is located deep in the retroperitoneum and is well cushioned by surrounding soft tissues. This report presents our experiences of managing patients with adrenal injury following abdominal blunt trauma.

METHODS

The medical records of 11 patients who had been treated for adrenal gland injury between January 1998 and June 2009 were retrospectively reviewed.

RESULTS

Of the 11 patients, nine were male and two were female and the mean age was 31.5 years. The causes of trauma were motor vehicle accident (8 cases) and fall (3 cases). The majority of injuries occurred on the right side (8 cases), two were on the left side, and one patient had bilateral injury. Three cases presented as isolated adrenal gland injuries, and eight were combined with other internal organ injuries. The most common coinjured organ was the liver, followed by the kidney. The most useful diagnostic modality was computed tomography (CT). Ten cases were treated successfully using conservative management, while one required a left partial adrenalectomy and splenectomy due to active bleeding.

CONCLUSIONS

Adrenal injury due to blunt abdominal trauma is extremely rare. The majority of cases can be diagnosed using CT. Most cases involve the right side and can be treated successfully using conservative management. Surgery is required only in cases of active bleeding.

[Prognostic factors related to non surgical treatment failure of splenic injuries in the abdominal blunt trauma]

OBJECTIVE

Identify prognostic factors related to treatment failure of blunt splenic injuries managed by non surgical treatment (NST).

METHODS

Fifty six adult patients submitted to NST were prospectively studied. The injuries were diagnosed by computed axial tomography scan and classified according to AAST (American Association for Surgery of Trauma) criteria. Patients were divided in success and failure groups. NST failure was defined as the need for laparotomy for any reason.

RESULTS

NST failures (19.6%) were due to: abdominal pain (45.4%), hemodinamic instability (36.4%), splenic haematoma associated to a fall in hematocrit (9.1%) and splenic abscess (9.1%). There were no failures in grade I and II of the splenic injuries; failure rate was 17.5% in grade III and IV injuries grouped, and 80% in grade V injuries (p = 0,0008). In the success group, 31.3% patients received red cell transfusions, versus 63.6% patients in the failure group (p = 0,05). Failure rate in patients with ISS = 8 was zero; 15.9% in patients with ISS 9 to 25; and 50% in patients with ISS = 26 (p = 0,05). There were no deaths or missed bowel injuries.

CONCLUSION

ISS and splenic injury grade were related to failure of NST.

Free abdominal fluid without obvious solid organ injury upon CT imaging: an actual problem or simply over-diagnosing?

Whereas a non-operative approach for hemodynamically stable patients with free intraabdominal fluid in the presence of solid organ injury is generally accepted, the presence of free fluid in the abdomen without evidence of solid organ injury not only presents a challenge for the treating emergency physician but also for the surgeon in charge. Despite recent advances in imaging modalities, with multi-detector computed tomography (CT) (with or without contrast agent) usually the imaging method of choice, diagnosis and interpretation of the results remains difficult. While some studies conclude that CT is highly accurate and relatively specific at diagnosing mesenteric and hollow viscus injury, others studies deem CT to be unreliable. These differences may in part be due to the experience and the interpretation of the radiologist and/or the treating physician or surgeon.A search of the literature has made it apparent that there is no straightforward answer to the question what to do with patients with free intraabdominal fluid on CT scanning but without signs of solid organ injury. In hemodynamically unstable patients, free intraabdominal fluid in the absence of solid organ injury usually mandates immediate surgical intervention. For patients with blunt abdominal trauma and more than just a trace of free intraabdominal fluid or for patients with signs of peritonitis, the threshold for a surgical exploration - preferably by a laparoscopic approach - should be low. Based on the available information, we aim to provide the reader with an overview of the current literature with specific emphasis on diagnostic and therapeutic approaches to this problem and suggest a possible algorithm, which might help with the adequate treatment of such patients.

Abdominal trauma: from operative to nonoperative management

The nonoperative care of intraabdominal trauma in the polytraumatised patient greatly depends on imaging techniques. The haemodynamically unstable patient should undergo expedient sonography to rule out abdominal haemorrhage. The use of computer tomography (CT) in this difficult patient group is also currently evaluated, however it takes specific amendments to the protocol and institution. In the hemodynamically stable patient however, computer tomography is the modality of choice to evaluate the injured abdomen. Nonoperative treatment can be successful in up to 80% of selected cases. Adjuncts to nonoperative care include embolisation of the spleen and liver in cases of arterial bleeding, and endoscopic retrograde cholangio pancreaticography (ERCP) and stenting for injuries to the biliary tree.

CEUS in abdominal trauma: multi-center study

The objective of this study was to evaluate the concordance of US and contrast-enhanced US (CEUS) with CT in the assessment of solid organ injury following blunt trauma. Patients underwent complete US examination, including free fluid search and solid organ analysis. CEUS followed, using low-mechanical index techniques and SonoVue. CT was performed within 1 h. Among 156 enrolled patients, 91 had one or more abnormalities (n = 107) at CT: 26 renal, 38 liver, 43 spleen. Sensitivity, specificity, and accuracy for renal trauma at baseline US were 36%, 98%, and 88%, respectively, after CEUS values increased to 69%, 99%, and 94%. For liver baseline US values were 68%, 97%, and 90%; after CEUS were 84%, 99%, and 96%. For spleen, results were 77%, 96%, and 91% at baseline US and 93%, 99%, and 97% after CEUS. Per patient evaluation gave the following results in terms of sensitivity, specificity and accuracy: 79%, 82%, 80% at baseline US; 94%, 89%, and 92% following CEUS. CEUS is more sensitive than US in the detection of solid organ injury, potentially reducing the need for further imaging. False negatives from CEUS are due to minor injuries, without relevant consequences for patient management and prognosis.

Whole-body multislice computed tomography as the first line diagnostic tool in patients with multiple injuries: the focus on time

OBJECTIVE

Whole-body multislice helical computed tomography (MSCT) becomes increasingly important as a diagnostic tool in patients with multiple injuries. We describe time requirement of two different diagnostic approaches to multiple injuries one with whole-body-MSCT (MSCT Trauma-Protocol) as the sole radiologic procedure and one with conventional use of radiography, combined with abdominal ultrasound and organ focused CT (Conventional-Trauma-Protocol).

METHODS

Observational study with retrospective analysis of time requirements for resuscitation, diagnostic workup and transfer to definitive treatment after changing from conventional to MSCT Trauma-Protocol. Group I: data from trauma patients imaged with whole-body MSCT. Group II: data of trauma patients investigated with conventional trauma protocol before the introduction of MSCT-Trauma-Protocol.

RESULTS

The complete diagnostic workup in group I (n = 82) was finished after 23 minutes (17-33 minutes) [median; interquartile range (IQR)] and after 70 minutes (IQR, 56-85) in group II (n = 79). The definitive management plan based on a completed diagnostic workup was devised after 47 minutes (IQR, 37-59) in group I and after 82 minutes (IQR, 66-110) in group II.

CONCLUSION

A whole-body MSCT-based diagnostic approach to multiple injuries might shorten the time interval from arrival in the trauma emergency room until obtaining a final diagnosis and management plan in patients with multiple injuries and might, therefore, contribute to improvements in patient care.

The accuracy of FAST in relation to grade of solid organ injuries: a retrospective analysis of 226 trauma patients with liver or splenic lesion

Background

This study investigated the role of a negative FAST in the diagnostic and therapeutic algorithm of multiply injured patients with liver or splenic lesions.

Methods

A retrospective analysis of 226 multiply injured patients with liver or splenic lesions treated at Bern University Hospital, Switzerland.

Results

FAST failed to detect free fluid or organ lesions in 45 of 226 patients with spleen or liver injuries (sensitivity 80.1%). Overall specificity was 99.5%. The positive and negative predictive values were 99.4% and 83.3%. The overall likelihood ratios for a positive and negative FAST were 160.2 and 0.2. Grade III-V organ lesions were detected more frequently than grade I and II lesions. Without the additional diagnostic accuracy of a CT scan, the mean ISS of the FAST-false-negative patients would be significantly underestimated and 7 previously unsuspected intra-abdominal injuries would have been missed.

Conclusion

FAST is an expedient tool for the primary assessment of polytraumatized patients to rule out high grade intra-abdominal injuries. However, the low overall diagnostic sensitivity of FAST may lead to underestimated injury patterns and delayed complications may occur. Hence, in hemodynamically stable patients with abdominal trauma, an early CT scan should be considered and one must be aware of the potential shortcomings of a "negative FAST".

Multislice computed tomography in blunt abdominal trauma

Blunt abdominal trauma is a frequent finding in patients with multiple trauma, and is associated with significant morbidity and mortality. Multislice computed tomography (MSCT), allowing for multiplanar reconstructions and three-dimensional images, has become the imaging modality of choice for these patients. MSCT is indicated in all haemodynamically stable patients with suspected blunt abdominal trauma. A `focussed CT' algorithm, as recommended by the Advanced Trauma Life Support (ATLS®) program, may be useful for patients with isolated abdominal trauma who are conscious and cooperative. For unconscious patients with or without multiple trauma `unfocussed' whole-body MSCT algorithms should be used, as these lead to earlier as well as more accurate diagnosis. MSCT allows for rapid diagnosis of abdominal and retroperitoneal injuries and for grading of solid organ injuries. Active haemorrhage may be detected with accuracy similar to angiography. Even bowel, diaphragmatic and bladder injuries, where CT used to miss a significant number of injuries, can be diagnosed with high accuracy by the new generation of MSCT scanners.

Emergency room management of patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified by an urban trauma center

BACKGROUND

The early clinical management of patients with major trauma still represents a challenge. To clinically evaluate the full extent of a patient's injuries is difficult, especially when the patient is unconscious. Before December 2002, trauma patients admitted to our emergency room (ER) underwent a diagnostic protocol including physical examination, conventional radiography (CR), sonography and further procedures if necessary. After the installation of a MSCT scanner, all trauma patients underwent the "MSCT protocol" immediately after admission. The aim of the study was to compare the "MSCT-protocol" as it is performed at our institution, with the "Pre-MSCT-protocol".

METHODS

We compared 185 patients undergoing the "Pre MSCT-protocol" with 185 patients undergoing "MSCT protocol". We evaluated the efficacy, speed and accuracy of the "MSCT protocol" using several variables. Time periods from admission to the ER to admission to the intensive care unit were compared as well as outcome parameters such as length of ICU stay, ventilation period and rates of organ. Dichotomous data were analyzed by Chi-square analysis; continuous data were analyzed by Student's t test. Any values of p < 0.05 were considered significant for any test.

RESULTS

No significant differences were found regarding demographic data. The full extent of injuries was definitively diagnosed after 12 +/- 9 minutes in 92.4% of the "MSCT protocol" cohort. In only 76.2% of "Pre-MSCT protocol" cohort definitive diagnosis was possible after 41 +/- 27 minutes. Total ER time was 104 +/- 21 minutes with the "Pre-MSCT protocol" and 70 +/- 17 minutes with "MSCT protocol" (p < 0.05). "Pre-MSCT protocol" patients had a significantly longer ICU stay than "MSCT protocol" patients (p < 0.05). "MSCT protocol" patients had significantly fewer ventilation days (14.3 vs. 10.9 days). Furthermore, rates of organ failure were lower in patients undergoing the "MSCT protocol".

CONCLUSION

We could demonstrate that immediate MSCT in patients with blunt major trauma leads to more accurate and faster diagnosis, and reduction of early clinical time intervals. We also observed a reduction in ventilation, ICU, and hospital days, and in organ failure rates, though this might have been partly due to small differences in case mix. The "MSCT protocol" algorithm seems to be safe and effective.

Selective nonoperative management of blunt abdominal trauma

The management of patients with blunt abdominal trauma has evolved over the past two decades with increasing reliance on a non-operative approach. An in-depth understanding of the clinical and radiographic parameters used to determine those who may be eligible for this form of treatment is an essential component of modern trauma care. This case-based review highlights critical aspects of non-operative management and provides a framework for the role of the emergency medicine provider.

Blunt trauma to the spleen: ultrasonographic findings

The spleen is the most frequently injured organ in adults who sustain blunt abdominal trauma. Splenic trauma accounts for approximately 25% to 30% of all intra-abdominal injuries. The management of splenic injury has undergone rapid change over the last decade, with increasing emphasis on splenic salvage and non-operative management. Identifying the presence and degree of splenic injury is critical in triaging the management of patients. Imaging is integral in the identification of splenic injuries, both at the time of injury and during follow-up. Although CT remains the gold standard in blunt abdominal trauma, US continues to play an important role in assessing the traumatized spleen. This pictorial review illustrates the various ultrasonographic appearances of the traumatized spleen. Correlation with other imaging is presented and complications that occur during follow-up are described.

Is definitive abdominal evaluation required in blunt trauma victims undergoing urgent extra-abdominal surgery?

OBJECTIVES

To evaluate the utility of routine abdominal computed tomographic (CT) scanning for abdominal evaluation of blunt trauma patients before urgent extra-abdominal surgery.

METHODS

In this observational cohort study, we prospectively enrolled all blunt trauma patients at least 8 years of age presenting to the emergency department of a Level 1 trauma center who were initially considered to require urgent extra-abdominal surgery within 24 hours of presentation. Patients were excluded if they had any of the following: 1) isolated extremity trauma, 2) signs or symptoms of intra-abdominal injury (including systolic blood pressure < 90 mm Hg; abdominal, flank, or costal margin tenderness; abdominal wall contusion or abrasion; pelvic fracture; and gross hematuria), or 3) unreliable findings on abdominal examination (Glasgow Coma Scale score < 14, paralysis, or mental retardation). Clinical data were documented on a data sheet before abdominal CT scanning.

RESULTS

A total of 254 patients, with a mean (+/-SD) age of 32.3 (+/-16.1) years, were enrolled. A total of 201 patients ultimately underwent urgent extra-abdominal surgery for the following procedures: orthopedic, 182 (91%); facial, 17 (8%); laceration, 7 (3%); vascular, 6 (2%); neurosurgical, 3 (1%); urology, 2 (1%); and ophthalmology, 1 (0.4%). Three patients (1.2%; 95% confidence interval = 0.2% to 3.4%) were found to have intra-abdominal injuries. Two patients had splenic injuries that required only observation. One patient (0.4%; 95% confidence interval = 0% to 2.2%) underwent laparotomy. This patient sustained multiple injuries in a motorcycle crash, including splenic, kidney, and pancreatic injuries, and underwent a splenectomy.

CONCLUSIONS

Abdominal CT scanning has a low yield in trauma patients whose sole indication for diagnostic abdominal evaluation is the need for general anesthesia for urgent extra-abdominal surgery. A small percentage of these patients, however, will have important intra-abdominal injuries such that further refinement of the recommendations for diagnostic study in this select population is needed.

Sonography as the primary screening method in evaluating blunt abdominal trauma

PURPOSE

The radiological evaluation of patients with blunt abdominal trauma can be done with either ultrasound (US) or computed tomography (CT) with strategies varying considerably among institutions. We evaluated the efficacy of our current strategy in which US is used at our hospital as the primary screening tool for patients with blunt abdominal trauma.

METHODS

We retrospectively analysed all patients admitted to our hospital with possible blunt abdominal trauma who underwent abdominal US, abdominal CT and/or a laparotomy during the initial trauma assessment from 1998 until 2002 (n = 1149).

RESULTS

Nine-hundred sixty-one of the 1149 patients had a negative US, of which 922 were true negative, resulting in a negative predictive value of 96%. A CT of the abdomen was performed in 7%. In 1.7% there was delayed diagnosis with no significant additional morbidity. Fourteen of the 103 laparotomies (14%) were non-therapeutic; in 5 of these cases the patients underwent non-therapeutic laparotomy despite the performance of a CT. Seven were emergency operations.

CONCLUSIONS

In our practice, the use of US for the evaluation of acute blunt abdominal trauma is adequate, with a high negative predictive value, a small number of delayed diagnoses, and an acceptable rate of non-therapeutic laparotomies.

Blunt hepatic trauma: evaluation with contrast-enhanced sonography: sonographic findings and clinical application

OBJECTIVE

The purpose of this study was to report our initial experience in the assessment of liver trauma with real-time contrast-enhanced sonography (CES).

METHODS

From January 2000 to December 2003, there were 431 hemodynamically stable patients evaluated with sonography for blunt abdominal trauma. Among these patients, 87 were selected to undergo second-level imaging, consisting of CES and computed tomographic (CT) evaluation. Indications for further assessment were baseline sonographic findings positive for liver injury, baseline sonographic findings positive for injury to other abdominal parenchyma, baseline sonographic findings positive for free fluid only, baseline sonographic findings indeterminate, and baseline sonographic findings negative with persistent clinical or laboratory suspicion.

RESULTS

There were 23 hepatic lesions shown by CT in 21 patients. Peritoneal or retroperitoneal fluid was identified in 19 of 21 positive cases by all 3 imaging modalities. Liver injury was found in 15 patients on sonography and in 19 on CES. Contrast-enhanced sonography compared better than unenhanced sonography with the criterion standard for related injury conspicuity, injury size, completeness of injury extension, and involvement of the liver capsule. Both CES and CT showed intrahepatic contrast material pooling in 2 cases. All patients with false-negative sonographic or CES findings recovered uneventfully.

CONCLUSIONS

Contrast-enhanced sonography is an effective tool in the evaluation of blunt hepatic trauma, being more sensitive than baseline sonography and correlating better than baseline sonography with CT findings. In institutions where sonography is regarded as the initial procedure to screen patients with trauma, this technique may increase its effectiveness. In addition, CES may be valuable in the follow-up of patients with conservatively treated liver trauma.

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.

Performance of abdominal ultrasonography in blunt trauma patients with out-of-hospital or emergency department hypotension

STUDY OBJECTIVES

We determine the test performance of abdominal ultrasonography for detecting hemoperitoneum in blunt trauma patients with out-of-hospital or emergency department (ED) hypotension.

METHODS

We reviewed the medical records of all blunt trauma patients hospitalized at a Level I trauma center. Patients were included if they were older than 6 years and had out-of-hospital or ED hypotension (systolic blood pressure < or =90 mm Hg) and underwent ED ultrasonography. The initial interpretation of the abdominal ultrasonography was recorded, including the presence or absence of intraperitoneal fluid and the specific location of such fluid. Presence or absence of intra-abdominal injury was determined by abdominal computed tomography scan, laparotomy, or clinical follow-up.

RESULTS

Four hundred forty-seven patients with a mean age of 36.0+/-17.5 years were enrolled. One hundred forty-eight (33%) patients had intra-abdominal injuries, and 116 (78%) of these patients had hemoperitoneum. Abdominal ultrasonography had the following test performance for detecting patients with intra-abdominal injury and hemoperitoneum: sensitivity 92/116 (79%; 95% confidence interval [CI] 71% to 86%), specificity 316/331 (95%; 95% CI 93% to 97%), positive predictive value 92/107 (86%; 95% CI 78% to 92%), and negative predictive value 316/340 (93%; 95% CI 90% to 95%). The positive likelihood ratio was 15.8, and the negative likelihood ratio was 0.22. One hundred five (91%) of the 116 patients with intra-abdominal injuries and hemoperitoneum underwent a therapeutic laparotomy. Abdominal ultrasonography demonstrated intraperitoneal fluid in 87 (sensitivity 83%; 95% CI 74% to 90%) of these 105 patients.

CONCLUSION

Of patients with out-of-hospital or ED hypotension, abdominal ultrasonography identifies most patients with hemoperitoneum and intra-abdominal injuries. Hypotensive patients with negative abdominal ultrasonography results, however, must be further evaluated for sources of their hypotension, including additional abdominal evaluation, once they are hemodynamically stabilized.

Transesophageal Echocardiographic Diagnosis of a Liver Laceration Accompanied by Hemodynamic Instability

Transesophageal echocardiography (TEE) is a useful adjunct in the evaluation of trauma patients, particularly in the area of aortic injury and cardiac tamponade. Little has been written on the use of this modality in the evaluation of extra-cardiac injury. We present a case of a trauma patient in whom TEE was used to evaluate hemodynamic instability; during the course of the examination a previously undiagnosed liver laceration was identified. We report the diagnosis of a liver laceration in a trauma patient by novel use of the transesophageal echocardiographic imaging modality.

Sonographic patterns of intraperitoneal hemorrhage associated with blunt splenic injury

OBJECTIVE

To determine the correlation between sonographic detection of free fluid in the left upper quadrant and blunt splenic injury.

METHODS

A retrospective review was conducted of all consecutive emergency blunt trauma sonograms obtained at a level I trauma center from January 1995 to January 2001. Data were collected on demographics, free fluid location, and patient outcome. Injuries were determined from computed tomography, diagnostic peritoneal lavage, laparotomy, or a combination thereof.

RESULTS

A total of 4320 blunt trauma sonograms were obtained, and 596 patients (14%) had intra-abdominal injuries. The mean age was 33.7 +/- 19.1 years (range, 1-95 years), with 294 (49%) male and 302 (51%) female. There was no statistical difference between age, sex, or mechanism for all subgroups. There were 409 true-positive, 187 false-negative, 88 false-positive, and 3636 true-negative findings. Sensitivity of sonography for detecting all intra-abdominal injuries was 68%, and specificity was 97.6%; sensitivity for detecting isolated splenic injuries was 73.8%. Locations of free fluid in patients with nonsplenic injuries were compared with those in patients with splenic injuries. Isolated left upper quadrant free fluid was significantly associated with splenic injury (odds ratio = 3.0; P = .002), followed by diffuse free fluid (odds ratio = 2.1; P = .005). A subanalysis of isolated splenic injuries also revealed a significant association with left upper quadrant free fluid (odds ratio = 3.1; P = .007) and diffuse free fluid (odds ratio = 2.7; P = .0007).

CONCLUSIONS

Free fluid in the left upper quadrant is significantly associated with splenic injury. This finding should triage patients more rapidly to computed tomography, angiography, embolization, and laparotomy.

The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries

BACKGROUND

The evaluation of multitrauma patients for blunt truncal injuries remains open for debate. We sought to evaluate the role of routine computed tomography (CT) of the chest, abdomen, and pelvis as a screening tool for patients already undergoing cranial CT studies.

METHODS

Charts of blunt trauma patients admitted from June 2000 to June 2001 were reviewed for demographics, Glascow Coma Scale (GCS), physical and radiological findings, and length of stay.

RESULTS

Our study found that 38% of patients undergoing cranial CT scanning had a unexpected finding on body scans. Changes were made in 26% of the study group because results found on the adjuvant CTs.

CONCLUSIONS

Additional body CTs add minimal cost to the care of trauma patients but can significantly change the management. We believe it is beneficial to perform routine body CT examinations when performing cranial imaging for blunt head injury.

Blunt liver injuries in polytrauma: results from a cohort study with the regular use of whole-body helical computed tomography

The estimated prevalence of liver injury in patients with blunt multiple trauma ranges from 1% to 8%. The objective of this study was to investigate the profile of accompanying liver injury in a cohort of polytraumatized patients who had regularly undergone contrast-enhanced, whole-body helical computed tomography (CT). We enrolled consecutive patients admitted between September 1997 and January 2001 to a level I trauma center. Clinical baseline data were compiled as part of a nationwide trauma registry. Morphologic features were evaluated descriptively, whereas prognostic variables were assessed by logistic regression analysis. We identified 218 patients [149 men, mean age 35 +/- 18 years, mean injury severity score (ISS) 35 +/- 10], 55 of whom had sustained blunt liver trauma [25.2%, 95% confidence interval (CI) 19.6-31.5%]. The prevalence of Moore III to V lesions was 10.1%. There were 99 parenchymal contusions, 15 capsular tears, and 2 liver fractures. Surgery was required in 15 patients and was best predicted by the classification of the American Association for the Surgery of Trauma [odds ratio (OR) 3.91, 95% CI 1.59-9.61]. The mortality rate was 0.0035/person/day. Patients requiring surgical repair had fourfold increased relative odds of case fatality (OR 4.50, 95% CI 1.01-19.96). Sevenfold increased relative odds were observed if liver laceration was considered the leading injury (OR 7.17, 95% CI 1.17-43.97). The prevalence of liver lacerations among multiple-trauma patients is likely to be underestimated and must be determined by the independent application of reference standards, such as helical CT. High-grade hepatic injuries and the need for surgical repair are associated with poorer survival prognosis.

Splenic trauma: evaluation with contrast-specific sonography and a second-generation contrast medium: preliminary experience

OBJECTIVE

To report our experience in the assessment of splenic trauma with contrast-coded sonography and a second-generation contrast medium.

METHODS

From January to May 2002, 120 patients were studied with sonography for suspected splenic trauma. Twenty-five were selected for further imaging because of sonographic findings positive for splenic injury, findings positive for peritoneal fluid only, indeterminate findings, and negative findings with high clinical or laboratory suspicion. These patients underwent contrast-enhanced harmonic sonography and contrast-enhanced helical computed tomography.

RESULTS

Among the 25 patients studied, 6 had no spleen trauma at initial and follow-up evaluation. One patient had a hypoperfused spleen without parenchymal damage, and 18 had splenic injuries; these 19 patients were considered positive. Hemoperitoneum was identified by sonography, contrast-enhanced sonography, and contrast-enhanced computed tomography in 74% of the 19 positive cases. Perisplenic clots were recognized in 58% of the cases by computed tomography and in 42% by baseline and enhanced sonography. Splenic infarctions were found in 11% of cases by contrast-enhanced sonography and computed tomography; none was found by unenhanced sonography. Parenchymal traumatic lesions were identified in 12 of 18 patients with splenic injuries by unenhanced sonography, in 17 cases by contrast-enhanced sonography, and in all 18 cases by contrast-enhanced computed tomography. A minimal splenic lesion was found in the single patient with a false-negative contrast-enhanced sonographic finding. Contrast-enhanced sonography correlated appreciably better than unenhanced sonography in detecting injuries and in estimating their extent. Findings undetectable on unenhanced sonography were also noted: splenic hypoperfusion in 11% of positive cases on both contrast-enhanced sonography and contrast-enhanced computed tomography, contrast medium pooling in 21% of cases on both contrast-enhanced sonography and computed tomography, and contrast extravasation in 11% of cases on computed tomography and 5% on contrast-enhanced sonography.

CONCLUSIONS

Contrast-enhanced sonography is a promising tool in the assessment of splenic trauma. In institutions where sonography is used as the initial procedure, this technique may increase its effectiveness.

Predicting the need for laparotomy in pediatric trauma patients on the basis of the ultrasound score

BACKGROUND

It is possible to quantify the amount of hemoperitoneum seen on focused assessment with sonography for trauma (FAST) using a simple scoring system that had previously been shown to correlate with the need for subsequent laparotomy in adults. A score of 3 or greater was shown to be highly accurate in predicting the need for laparotomy. We hypothesized that this scoring system might also predict the need for laparotomy in pediatric trauma patients.

METHODS

We retrospectively reviewed all records for patients 15 years and younger who underwent FAST after blunt trauma. A "positive" ultrasound examination was defined as one containing free intraperitoneal fluid with or without solid organ injury. The ultrasound score (USS) was defined as the depth of the deepest pocket of fluid collection measured in centimeters plus the number of additional spaces where fluid was seen.

RESULTS

Thirty-eight (19.6%) of 193 patients who had FAST performed had positive ultrasound examinations. Thirty-seven patients with complete records were analyzed. There were no differences between patients with a USS < or = 3.0 and those with a USS > 3.0 in terms of admission pulse, Glasgow Coma Scale score, Injury Severity Score, or the proportion of patients who were initially hypotensive. One of 22 patients with a USS < or = 3.0 required therapeutic laparotomy versus 8 of 15 patients with a USS > 3.0 ( = 0.002). For a USS > 3.0, sensitivity, specificity, and accuracy in predicting therapeutic laparotomy were 89%, 75%, and 78%, respectively.

CONCLUSION

Ultrasound quantification of hemoperitoneum by a simple scoring system may serve as a useful adjunct to traditional clinical parameters in predicting the need for subsequent laparotomy in pediatric patients. Prospective validation with a larger study is required.

A 10-year experience of complex liver trauma

BACKGROUND

Liver trauma is a relatively rare surgical emergency but mortality and morbidity rates remain significant. It is likely that surgeons outside specialist centres will have limited experience in its management; therefore best practice should be identified and a specialist approach developed.

METHODS

Data collected from 52 consecutive patients over a 10-year interval were examined to identify best practice in the management of these injuries.

RESULTS

The majority of injuries occurred as a result of road traffic accidents; 39 (75 per cent) of the 52 patients were stable at presentation to the referring hospital. In 36 patients (69 per cent) the liver injury was a component of multiple trauma. Ultrasonography, computed tomography or no radiological investigation was used in the referring hospital in 18 (35 per cent), 25 (48 per cent) and nine (17 per cent) patients respectively. Operative management was undertaken in the referring hospital in 26 patients (50 per cent). The overall mortality rate was 23 per cent (12 of 52 patients), and increased with increasing grade of severity. Eight of 26 patients managed surgically at the referring hospital died, compared with four of the 26 patients managed without operation (P not significant). The median time from arrival at the referring hospital to operation was 4 h for haemodynamically stable patients and 3 h for those who were haemodynamically unstable.

CONCLUSION

Most patients with liver trauma can be managed conservatively. Operative management carried out in non-specialized units is associated with high mortality and morbidity rates. Abdominal injuries should raise a high index of suspicion of liver injury, and the data suggest that computed tomography of the abdomen should precede laparotomy (even in some haemodynamically unstable patients) to facilitate discussion with a specialist unit at the earliest opportunity.

Clinical importance of intraperitoneal fluid in patients with blunt intra-abdominal injury

The purpose of this study was to determine the prevalence of intraperitoneal fluid (IF) in blunt trauma patients with intra-abdominal injuries, to determine the rate of exploratory laparotomy in patients with and without IF, and to identify the location of this IF. We retrospectively reviewed the records of 604 patients with intra-abdominal injuries after blunt trauma who were admitted to a level 1 trauma center over a 42-month period. Patients were considered to have intra-abdominal injuries if an injury to the spleen, liver, urinary tract, pancreas, adrenal glands, gallbladder, or gastrointestinal tract was identified on abdominal computed tomography (CT) or at exploratory laparotomy. Patients were considered to have IF if fluid was identified on abdominal CT or during exploratory laparotomy. In patients undergoing abdominal CT or abdominal ultrasound (US), the specific location of the IF was identified. Four hundred forty-three (73%, 95% confidence interval [CI] 69 - 77%) of the 604 patients with intra-abdominal injuries had IF. Patients with IF had an increased risk of laparotomy (344/443 [78%] v 44/161 [27%], odds ratio = 9.2, 95% CI 6.1-13.9). Of the 539 patients undergoing abdominal CT or abdominal US, IF was identified in 389 (72%) and was visualized in the following locations: 258 of 389 (66%) in Morison's pouch, 216 of 389 (56%) in the left upper quadrant, 187 of 389 (48%) in the pelvis, and 139 of 390 (36%) in paracolic gutters. Three patients with IF visualized solely in the paracolic gutters underwent laparotomy. The majority of patients with intra-abdominal injuries have IF, and these patients are more likely to undergo laparotomy. Morison's pouch is the most common location for IF to be detected with radiologic imaging. However, visualization of the paracolic gutters with abdominal US may detect IF in patients with intra-abdominal injuries that would otherwise not be detected by US.

The hand-held FAST: experience with hand-held trauma sonography in a level-I urban trauma center

AIMS

To describe the effectiveness of a portable hand-held ultrasound machine when used by clinicians in the early evaluation and resuscitation of trauma victims.

METHODS

The study was a prospective evaluation in a level-I urban trauma center. The focussed assessment with sonography for trauma is a specifically defined examination for free fluid known as the focused assessment with sonography for trauma (FAST) exam. Seventy-one patients had a hand-held FAST (HHFAST) examination performed with a Sonosite 180, 2.4 kg ultrasound machine. Sixty-seven examinations were immediately repeated with a Toshiba SSH 140A portable floor-based machine. This repeat scan (formal FAST or FFAST) was used as a comparison standard between the devices for study purposes. Four patients had a HHFAST only, all with positive result, two being taken for immediate laparotomy, and two having a follow-up computed tomographic (CT) scan. Patient follow-up from other imaging studies, operative intervention, and clinical outcomes were also compared to the performance of each device.

RESULTS

There were 58 victims of blunt, and 13 of penetrating abdominal trauma. One examination was indeterminate using both machines. The apparent HHFAST performance yielded; sensitivity, specificity, positive predictive value, negative predictable value, and accuracy (S, S, PPV, NPV, A) of 83, 100, 100, 98, 98%. Upon review, a CT scan finding and benign clinical course found the HHFAST diagnosis to be correct rather than the FFAST in one case. Considering the ultimate clinical course of the patients, yielded a (S, S, PPV, NPV, A) of 78, 100, 100, 97, and 97% for the HHFAST and 75, 98, 86, 97, and 96% for the FFAST. Statistically, there was no significant difference in the actual performance of the HHFAST compared to the FFAST in this clinical setting.

DISCUSSION

Hand-held portable sonography can simplify early and accurate performance of FAST exams in victims of abdominal trauma.

[Strategies diagnosis of polytraumatized adult patients with coma]

OBJECTIVE

To review the diagnostic strategy of management of multiple trauma patient during the first hours.

DATA SOURCES

Extraction from Pubmed database of French and English articles on the management of multiple trauma patient published for ten years.

DATA SELECTION

The collected articles were reviewed and selected according to their quality and originality. The more recent data were selected.

DATA SYNTHESIS

The first hours of management of multiple trauma patients are a particular challenge. The first dilemma is to drive the patient toward an adequate structure. In case of poor haemodynamic tolerance, the patient will be drive in the nearest hospital. When haemodynamic parameters are restored, multiple trauma patient has to be receive in a high level hospital by a trained medical team with an anesthesiologist, intensivist, neurosurgeon, general surgeon and radiologist. The initial assessment may have two priorities: quality and speed. The total body CT scan is actually the answer to these priorities.

Pattern of abdominal free fluid following isolated blunt spleen or liver injury in the pediatric patient

BACKGROUND

This study correlated isolated, blunt liver or spleen injury with the presence, location, and amount of free fluid in the pediatric blunt trauma patient.

METHODS

The hospital trauma registry was reviewed for the period 1/89 to 12/99 for pediatric patients (age < or = 17 years) who sustained blunt, isolated spleen or liver injury and had an abdominal CT scan. Patients with other intraabdominal injuries or inadequate scans were excluded. CT scans were reviewed by two radiologists and the isolated liver or spleen injury confirmed and graded. The presence, location, and amount of free fluid were evaluated in the RUQ, LUQ, and pelvis. Free fluid was quantified as 0 = no fluid, 1 = small amount, 2 = moderate, and 3 = large for each area.

RESULTS

There were 134 pediatric patients with an isolated spleen (n = 66) or liver (n = 68) injury. Free fluid was noted in 101 patients (75%), more commonly with spleen (82%) than with liver (69%) injuries. As injury grade increased, so did frequency of patients with free fluid (grade 1 = 50% to grade 5 = 100%) and mean total volume (sum of fluid scores from each region) of free fluid (grade 1 = 0.75 to grade 5 = 6.5). The mean total volume of free fluid was greater for splenic injury (3.1) than for liver injury (1.7). The pelvis was the most common location for free fluid (liver 53%, spleen 71%) and had the greatest mean volume of free fluid (liver 0.9, spleen 1.5) of any single region.

CONCLUSION

There is a direct correlation between the severity of the isolated injury and the likelihood and volume of associated free fluid. The pelvis was the most common location to detect free fluid and had the greatest estimated fluid volume.

Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma

PURPOSE

The aim of this study was to evaluate the accuracy of emergency department (ED) ultrasound scan in identifying which children with blunt torso trauma have intraperitoneal fluid associated with intraabdominal injuries (IAI).

METHODS

The authors conducted a prospective, observational study of children (< 16 years old) with blunt trauma who presented to a level 1 trauma center over a 29-month period and underwent abdominal ultrasound scan while in the ED. Ultrasound examinations were ordered at the discretion of the trauma surgeons or ED physicians caring for the patients, performed by trained sonographers, and interpreted at the time of the ultrasound. Ultrasound examinations were interpreted solely for the presence or absence of intraperitoneal fluid. Hypotension was defined as > or = 1 standard deviation below the age-adjusted mean. Patients underwent follow-up to identify those with intraperitoneal fluid and IAI.

RESULTS

A total of 224 pediatric blunt trauma patients had ultrasound scan performed and were enrolled. Thirty-three patients had IAI with intraperitoneal fluid, and ultrasound scan was positive in 27. The accuracy of abdominal ultrasound for detecting intraperitoneal fluid associated with IAI was sensitivity, 82% (95% confidence interval [CI] 65% to 93%); specificity, 95% (95% CI 91% to 97%); positive predictive value, 73% (95% CI 56% to 86%); and negative predictive value, 97% (95% CI 93% to 99%). In the 13 patients who were hypotensive, ultrasound scan correctly identified intraperitoneal fluid in all 7 patients (sensitivity 100%) with IAI, and hemoperitoneum and was negative in all 6 patients (specificity 100%) who did not have hemoperitoneum. Nine patients had IAI without intraperitoneal fluid, and ultrasound scan result was negative for fluid in all 9.

CONCLUSIONS

ED abdominal ultrasound scan used solely for the detection of intraperitoneal fluid in pediatric blunt trauma patients has a modest accuracy. Ultrasonography has the best test performance in those children who are hypotensive and should be obtained early in the ED evaluation of these patients.

Blunt thoraco-abdominal injury

Recent advances in blunt thoraco-abdominal trauma management include improvements in imaging, particularly in trauma bay ultrasound. Indications for non-operative management have expanded for solid organ and aortic injury. The physiology of abdominal compartment syndrome continues to be defined, with resulting improvements in care.