Whole-Body CT after Motor Vehicle Crash: No Benefit after High-Energy Impact and with Normal Physical Examination

Physical examination and CT to assess thoracic injury in 137 cats presented to UK referral hospitals after trauma

OBJECTIVES

The aim of the study was to describe clinical examination and thoracic CT (TCT) findings in cats after trauma, and to identify physical examination findings associated with both abnormalities on TCT and the need for therapeutic interventions.

METHODS

A multicentre, retrospective, observational study was conducted. Cats admitted to the participating hospitals with a history of blunt trauma and that underwent TCT were eligible. Data were collected on signalment, history, physical examination, TCT findings and subsequent interventions.

RESULTS

In total, 137 cats were included. Road traffic accidents (RTAs) were the most frequently reported cause of trauma (69%). Tachypnoea (32%), pale mucous membranes (22%) and dyspnoea (20%) were the most common abnormal findings on thoracic examination. The most frequently identified thoracic pathologies on TCT were atelectasis (34%), pulmonary contusions (33%), pneumothorax (29%) and pleural effusion (20%). Thoracocentesis was the most commonly performed intervention (12%), followed by chest drain placement (7%). A total of 45 (33%) cats had no physical examination abnormalities but did have abnormalities detected on TCT; six of these cats required interventions. Increasing numbers of thoracic abnormalities on clinical examination were associated with increasing likelihood of having abnormal findings on TCT (odds ratio [OR] 2.04, 95% confidence interval [CI] 1.21-3.44, P = 0.008) and of requiring an intervention (OR 1.82, 95% CI 1.32-2.51, P <0.001).

CONCLUSIONS AND RELEVANCE

RTAs were the most common reported cause of blunt trauma. Atelectasis, pulmonary contusions and pneumothorax were the most common abnormalities identified on TCT, and thoracic drainage was the most utilised intervention. TCT may be useful in identifying cats with normal thoracic physical examination findings that have significant thoracic pathology, and a high number of abnormal findings on thoracic examination should raise suspicion for both minor and major thoracic pathology. The results of this study can be used to assist in selecting appropriate cases for TCT after blunt trauma.

Can the use of whole-body CT be reduced in cases of kinetic-based polytrauma patients without a clinical severity criterion? A bi-center retrospective study

OBJECTIVE

To identify clinical and biological criteria predictive of significant traumatic injury in only kinetic-based polytrauma patients without clinical severity criteria. To propose a decisional algorithm to assist the emergency doctor in deciding whether or not to perform a WBCT in the above population.

METHODS

Retrospective bi-center study. 1270 patients with high velocity trauma without clinical severity criteria, for whom a WBCT was performed in 2017, were included. Patients with hemodynamic, respiratory or neurological severity criterion or those requiring pre-hospital resuscitation measures were excluded. Our primary endpoint was the identification of a significant lesion, i.e. any lesion that led to hospitalization > 24 h for monitoring or medico-surgical treatment. Data collected were age, sex, mechanism of injury, Glasgow Coma Scale score, number of symptomatic body regions, blood alcohol level, and neutrophil count.

RESULTS

Multivariate analysis found independent predictors of significant injury: fall > 5 m (OR: 14.36; CI: 2.3-283.4; p = 0.017), Glasgow score = 13 or 14 (OR: 4.40; CI:1.30-18.52; p = 0.027), presence of 2 symptomatic body regions (OR: 10.21; CI: 4.66-23.72; p = 0.05), positive blood alcohol level (OR: 2.81; CI: 1.13-7.33; p = 0.029) and neutrophilic leukocytosis (OR: 8.76; CI: 3.94-21.27; p = 0.01). A composite clinico-biological endpoint predictive of the absence of significant lesion was identified using a Classification and Regression Tree: number of symptomatic regions < 2, absence of Neutrophilic leukocytosis and negative blood alcohol concentration.

CONCLUSION

A simple triage algorithm was created with the objective of identifying, in high velocity trauma without clinical severity criteria, those without significant traumatic injury.

Comparing diagnostic findings and cost of whole body computed tomography to traditional diagnostic imaging in polytrauma patients

OBJECTIVE

To compare the diagnostic utility of traditional diagnostic tests (ie, radiographs and focused assessment using sonography for trauma [FAST] scans) to whole-body computed tomography (WBCT) for characterizing injuries in polytrauma patients. A secondary objective was to compare costs of traditional diagnostic tests to WBCT.

DESIGN

Prospective, observational study.

SETTING

Private, level 1 veterinary trauma center.

ANIMALS

Convenience sample of 21 client-owned cats and dogs presenting with polytrauma.

INTERVENTIONS

Abdominal and thoracic FAST were performed by the primary clinician, if indicated. Radiographs were performed on areas concerning for trauma at the primary clinician's discretion. A WBCT was performed on each patient within 24 h of presentation and was blindly interpreted by a board-certified radiologist. Patients were only placed under anesthesia if further procedures were planned. IV contrast administration was employed at the discretion of the primary clinician and radiologist.

MEASUREMENTS AND MAIN RESULTS

Twenty-one patients (14 dogs and 7 cats) were enrolled. Sources of trauma included blunt force (80%), penetrating wounds (10%), and unknown sources (10%). Twelve injuries were missed on traditional diagnostics tests. Injuries missed on traditional diagnostic workup included pneumothorax, pneumomediastinum, pulmonary contusions, pleural effusion, traumatic bulla, peritoneal effusion, and an appendicular skeleton fracture. A distal metacarpal fracture was missed on WBCT. Traditional diagnostic tests misdiagnosed a diaphragmatic hernia and a ruptured urinary bladder, whereas WBCT was able to rule out these injuries. There were no adverse outcomes associated with missed injuries. The median cost of traditional diagnostic tests was significantly less than the cost of WBCT (P < 0.001).

CONCLUSIONS

Although cost is higher, WBCT is a single test that can provide more comprehensive information and may help decrease the risk of missed injuries compared to traditional diagnostic tests. WBCT may be considered as a first-line diagnostic in severely traumatized patients.

Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma

In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist's expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.

Major trauma with only dynamic criteria: is the routine use of whole-body CT as a first level examination justified?

PURPOSE

Risks and benefits of systematic use of whole-body CT (WBCT) in patients with major trauma when no injury is clinically suspected is still subject of controversy. WBCT allows early identification of potentially evolving lesions, but exposes patients to the risk of high radiation dose and iodine contrast agent. The study aimed to assess if WBCT could be avoided in trauma patients with negative clinical examination.

MATERIALS AND METHODS

This retrospective study included polytrauma patients admitted to the Emergency Department in a six-month period, who had undergone a WBCT scan for major dynamic criteria, with hemodynamic stability, absence of clinical and medical risk factors for major trauma. The patients (n = 233) were divided into two groups according to the absence (n = 152) or presence (n = 81) of clinical suspicion of organ injury. The WBCT results were classified as negative, positive for minor and positive for major lesions.

RESULTS

The average patient age was 44 years. CT scans were completely negative in 111 (47.6%) patients, whose 104 (93.7%) were in the negative clinic group. 122 (52.4%) CT scans were positive, 69 (56.6%) for minor lesions and 53 (43.4%) for major lesions. Among the 48 (39.3%) positive CT scans in patients with negative clinic, only 5 (10.4%) were positive for major lesions. We found a significant difference in the frequency of injuries between the clinically negative and clinically positive patient groups (p < 0.001).

CONCLUSION

A thorough clinical examination associated with a primary radiological evaluation may represent a valid diagnostic approach for trauma with only major dynamic criteria to limit the use of WBCT.

Correlation Between Traumatic Skin and Subcutaneous Injuries and the Severity of Polytrauma Injury

PURPOSE

 To examine the relationship between superficial lesions (such as bruises, hematomas, deep abrasions, and soft tissue emphysema) and internal post-traumatic injuries, assessed using whole-body computed tomography (WBCT), and to determine if these are valid markers for internal injuries.

METHODS AND MATERIALS

 250 patients who underwent WBCT emergency scans for suspected polytrauma were retrospectively analyzed after institutional review board approval of the study. The scans were carried out on patients who met the criteria for standard operating procedures for WBCT emergency scans. WBCT covering the entire head, neck, chest, and abdomen (including pelvis and proximal lower extremities) and at least one phase with intravenous contrast agent were included in the study. Initial analyses of immediate WBCT scans was carried out by a consultant radiologist and a radiological resident. The first reading focused on internal damage that needed immediate therapy. The second reading focused on a detailed analysis of the skin and subcutaneous tissue and their relation to internal injuries without the time pressure of an emergency setting, carried out by another experienced radiologist. All skin lesions and the degree of penetration and a comparison between the two readings were reported in tables.

RESULTS

 Superficial lesion of the chest was detected in 19 patients, 17 of them had an internal injury of the thorax while only two patients, with hematoma of the chest wall, had no internal injuries. Skin and subcutaneous lesions of the chest had the strongest association with an internal injury. Skin lesions of the abdominal wall were observed in 30 patients. In only 11 cases, these lesions were correlated with internal injuries, such as fractures or active bleeding. 52 skin and subgaleal lesions of the scalp were observed. In 20 of these patients, an intracranial or internal injury was detected. In 3 patients, skin abrasions of the neck were present and in only one of them, this finding was associated with an internal injury.

CONCLUSION

 Trauma patients whose history and clinical presentation meet the standard operating procedures for WBCT emergency scans and who present with a cutaneous lesion, especially at the neurocranium or chest wall, should be observed for internal injuries by WBCT.

KEY POINTS

  · Presence or lack of a superficial injury of the abdominal wall is not a reliable predictive indication of any internal abdominal injury.. · Superficial lesions of the chest and the neurocranium require a CT scan.. · Superficial injuries of the chest wall had the strongest association with internal injuries..

CITATION FORMAT

· Klempka A, Fischer C, Kauczor H et al. Correlation Between Traumatic Skin and Subcutaneous Injuries and the Severity of Trauma. Fortschr Röntgenstr 2021; 193: 177 - 185.

Conditional unnecessity of head CT for whole-body CT of traffic accident victims: a pilot study

PURPOSE

To investigate whether head CT should be included in whole-body CT in road traffic accident victims.

METHODS

A review of electronic medical records identified 124 patients (81 males, 43 females; age 4 to 92 years, mean 47.7 years) involved in a road traffic accident in a 12-month period. All had undergone whole-body CT and physical and neurologic examinations. We recorded their age, sex, Glasgow Coma Scale (GCS), systolic blood pressure (SBP), the type of traffic accident, and the presence/absence of visible trauma above the clavicles (VTCs) and of acute traumatic brain injury (TBI) on CT. Statistical analyses were performed to evaluate predictors of acute TBI.

RESULTS

Of 124 patients, 34 (27%) manifested acute TBI on CT. Univariate analysis identified their age, GCS, SBP, VTCs, and the accident type as statistically significant factors for acute TBI (p < 0.05). Multivariate analysis demonstrated VTCs, GCS score < 15, and SBP ≤ 90 mmHg were significant independent predictors of acute TBI (p = 0.001, p = 0.001, and p = 0.004, respectively); the odds ratio was 16.07 for VTCs, 14.85 for GCS score < 15, and 13.78 for SBP ≤ 90 mmHg. No patients without both decrease in GCS score and VTCs manifested acute TBI.

CONCLUSION

Our pilot study showed that visible trauma above the clavicles and decrease in GCS score were highly associated with the presence of acute TBI in road traffic accident victims. In whole-body CT, a head CT may not be indicated in patients without these factors.

Pulmonary contusion mimicking COVID-19: A case report

BACKGROUND

Coronavirus disease 2019 (COVID-19) is a major public health emergency with obvious characteristics of human-to-human transmission, and there are infective asymptomatic carriers. Early identification and proper management of patients with COVID-19 are important. Features in chest computed tomography (CT) can facilitate identifying newly infected individuals. However, CT findings of some lung contusions are similar to those of COVID-19, as shown in the present case.

CASE SUMMARY

A 46-year-old woman was admitted to hospital for backache and foot pain caused by a fall injury 1 d before hospitalization. She was suspected of having COVID-19, since there was a confirmed COVID-19 case near her residence. But she had no fever, cough, chest tightness, difficult breathing, nausea, vomiting, or diarrhea, etc. On physical examination, the lower posterior chest of both sides showed dullness on percussion and moist rales at the end of inspiration on auscultation. The white blood cell count and lymphocyte count were 10.88 × 10⁹/L and 1.04 × 10⁹/L, respectively. CT performed on February 7, 2020 revealed that both lungs were scattered with patchy ground-glass opacity. The patient was diagnosed with pulmonary contusion with thoracic spinal fracture (T12), calcaneal fracture, and pelvic fracture. On day 9 after conservative treatment, her condition was alleviated. On review of the chest CT, the previous shadows were significantly reduced.

CONCLUSION

Differential diagnosis of lung contusion and COVID-19 must be emphasized. Both conditions require effective prompt actions, especially COVID-19.

Emergent Comprehensive Imaging of the Major Trauma Patient: A New Paradigm for Improved Clinical Decision-Making

Modern advances in the medical imaging layered onto sophisticated trauma resuscitation strategies in highly organized regionalized trauma systems have created a paradigm shift in the management of severely injured patients. Although immediate exploratory surgery to identify and control life-threatening injuries still has its place, accelerated image acquisition and interpretation procedures now make it rare for trauma surgeons in major centers to venture into damage control surgery unaided by computed tomography (CT) or other imaging, particularly in cases of blunt trauma. Indeed, because of the high incidence of clinically occult injuries associated with major mechanism trauma, and even lower energy trauma in frail or elderly patients, CT imaging has become as invaluable as physical examination, if not more so, in critical decision-making in support of optimal outcomes. In particular, whole-body computed tomography (WBCT) completed promptly after initial assessment of a major trauma provides a quick, comprehensive survey of injuries that enables better surgical planning, obviates the need for multiple subsequent studies, and permits specialized reconstructions when needed. For those at risk for problematic occult injury after modest trauma, WBCT facilitates safer discharge planning and simplified follow-up. Through standardized guidelines, streamlined protocols, synoptic reporting, accessible web-based platforms, and active collaboration with clinicians, radiologists dedicated to trauma and emergency imaging enable clearer understanding of complex injuries in high-risk patients which leads to superior clinical decision-making. Whereas dated dogma has long warned that the CT scanner is the last place to take a challenging trauma patient, modern practice suggests that, more often than not, early comprehensive imaging can be done safely and efficiently and is in the patient's best interest. This article outlines how the role of diagnostic imaging for major trauma has evolved considerably in recent years.

Torso injuries after fall from standing-empiric abdominal or thoracic CT imaging is not indicated

PURPOSE

Falls from standing (FFS) have become the most common mechanism of injury at many trauma centers. Liberal imaging of low energy trauma has questionable value. We hypothesize that torso trauma intervention is rare in the FFS population, and physical examination sufficiently screens for torso injuries needing intervention.

METHODS

We queried our ACS-verified Level 1 trauma center registry for falls from standing from 1/1/14 to 12/31/16. Exclusion criteria were: falls from height, falls associated with penetrating trauma, lack of an abdominal or chest CT, a Glasgow Coma Scale Score (GCS) less than 15, and surgical intervention at another facility prior to arrival at our center. Demographics, historical details, hemodynamics, injuries, injury severity, procedures, initial vital signs, and outcome were recorded.

RESULTS

1,654 patients had a FFS during our study period. 728 had an abdominal or chest CT and a GCS of 15 and comprised the evaluable population. Mean age was 56.5 years. 55.8% were female. The mortality rate was 8%. There were 179 chest injuries in 121 patients, and 54 abdominal injuries in 43 patients. 379 patients had a GCS of 15 and underwent thoracic CT, yet only 11 (3%) underwent intervention. The negative predictive value for physical exam was 100% for chest intervention. 349 patients had a GCS of 15 and abdominal CT, yet only 13 (3.7%) underwent procedural intervention. Abdominal physical exam had a negative predictive value of 99.7% for intervention, but when combined with vital signs, the value was 100%.

CONCLUSION

Torso injuries in FFS are rare. Of our study population, 13 abdominal injuries underwent intervention, and 11 chest injuries underwent intervention. Screening patients by physical examination and vital signs is sufficient and safely allows for the use of selective abdominal and chest CT.

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

PURPOSE

To determine whether torso CT can be avoided in patients who experience high-energy blunt trauma but have normal vital signs.

METHODS

High-energy blunt trauma patients with normal vital signs were retrieved retrospectively from our registry. We reviewed 1317 patients (1027 men and 290 women) and 761 (57.8%) fulfilled the inclusion criteria. All patients were initially evaluated at the emergency room (ER), with a set of tests, part of a specific protocol. Patients with at least one altered exam at initial examination or after six-hour observation received a torso CECT. Sensitivity, specificity, accuracy, positive (PPV) and negative predictive values (NPV), and likelihood ratio (LH) of the protocol were evaluated.

RESULTS

Of 761 patients, 354 (46.5%) received torso CECT because of the positive ER test, with 330 being true positive and 24 being false positive. The remaining 407 patients were negative at ER tests and did not receive torso CECT, showing a significantly (P < 0.001) lower Injury Severity Score (ISS). The positive and negative LH of the protocol to detect torso injuries were respectively 16.5 and 0.01 (overall accuracy of 0.96).

CONCLUSIONS

Torso CT can be avoided without adverse clinical outcomes in patients who experience high-energy blunt trauma, are hemodynamically stable, and have normal initial laboratory and imaging tests.