Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis

Diagnostic utility of whole-body computed tomography/pan-scan in trauma: a systematic review and meta-analysis study

Trauma is a significant cause of mortality and morbidity. It is crucial to diagnose trauma patients quickly to provide effective treatment interventions in such conditions. Whole-body computed tomography (WBCT)/pan-scan is an imaging technique that enables a faster and more efficient diagnosis for polytrauma patients. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of WBCT in diagnosing injuries in polytrauma patients. We will also assess its impact on the mortality rate and length of hospital stay among trauma centers between patients who underwent WBCT and those who did not (non-WBCT). Twenty-seven studies meeting our inclusion criteria were selected among PubMed, Scopus, Web of Science, and Google Scholar. The criteria were centered on the significance of WBCT/pan-scan application in trauma patients. Stata version 15 was used to perform statistical analysis on the data. The authors have also used I2 statistics to evaluate heterogeneity. Egger and Begg's tests were performed to rule out any publication bias. Total of twenty-seven studies including 68,838 trauma patients with a mean age of 45.0 ± 24.7 years were selected. Motor vehicle collisions were the most common cause of blunt injuries (80.0%). Head, neck, and face injuries were diagnosed in 44% (95% CI, 0.28-0.60; I2 = 99.8%), 6% (95% CI, 0.02-0.09; I2 = 97.2%), and 9% (95% CI, 0.05-0.13; I2 = 97.1%), respectively. Chest injuries were diagnosed by WBCT in 39% (95% CI, 0.28-0.51; I2 = 99.8%), abdominal injuries in 23% (95% CI, 0.03-0.43; I2 = 99.9%) of cases, spinal injuries 19% (95% CI, 0.11-0.27; I2 = 99.4%), extremity injuries 33% (95% CI, 0.23-0.43; I2 = 99.2%), and pelvic injuries 11% (95% CI, 0.04-0.18; I2 = 97.4%). A mortality odd ratio of 0.94 (95% CI, 0.83-1.06; I2 = 40.1%) was calculated while comparing WBCT and non-WBCT groups. This systematic review and meta-analysis provide insight into the possible safety, efficacy, and efficiency of WBCT/pan-scan as a diagnostic tool for trauma patients with serious injuries, regardless of their hemodynamic status. In patients with serious injuries from trauma, whether or not there are indicators of hemodynamic instability, our recommended approach is to, wherever possible, perform a WBCT without stopping the hemostatic resuscitation. By using this technology, the optimal surgical strategy for these patients can be decided upon without causing any delays in their final care or greatly raising their radiation dose.

Performance of trauma scoring systems in predicting mortality in geriatric trauma patients: comparison of the ISS, TRISS, and GTOS based on a systemic review and meta-analysis

PURPOSE

This meta-analysis aimed to evaluate the performance of the Injury Severity Score (ISS), Trauma and Injury Severity Score (TRISS), and the Geriatric Trauma Outcome Score (GTOS) in predicting mortality in geriatric trauma patients.

METHODS

The MEDLINE, Web of Science, and EMBASE databases were searched for studies published from January 2008 to October 2023. Studies assessing the performance of the ISS, TRISS, or GTOS in predicting mortality in geriatric trauma patients (over 60 years old) and reporting data for the analysis of the pooled area under the receiver operating characteristic curve (AUROC) and the hierarchical summary receiver operating characteristic curve (HSROC) were included. Studies that were not conducted in a group of geriatric patients, did not consider mortality as the outcome variable, or had incomplete data were excluded. The Critical Appraisal Skills Programme (CASP) Clinical Prediction Rule Checklist was utilized to assess the risk of bias in included studies. STATA 16.0. was used for the AUROC analysis and HSROC analysis.

RESULTS

Nineteen studies involving 118,761 geriatric trauma patients were included. The pooled AUROC of the TRISS (AUC = 0.82, 95% CI: 0.77-0.87) was higher than ISS (AUC = 0.74, 95% CI: 0.71-0.79) and GTOS (AUC = 0.80, 95%CI: 0.77-0.83). The diagnostic odds ratio (DOR) calculated from HSROC curves also suggested that the TRISS (DOR = 21.5) had a better performance in predicting mortality in geriatric trauma patients than the ISS (DOR = 6.27) and GTOS (DOR = 4.76).

CONCLUSION

This meta-analysis suggested that the TRISS showed better accuracy and performance in predicting mortality in geriatric trauma patients than the ISS and GTOS.

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.

Correlation Analysis Between Computed Tomography and Magnetic Resonance Imaging for Assessing Thoracic Pedicle Morphology

OBJECTIVE

This study aimed to determine the accuracy and reliability of using magnetic resonance imaging (MRI) to characterize thoracic pedicle morphology in the normal population.

METHODS

Computed tomography (CT) and MRI datasets of 63 surgically treated patients were included in the study. Bilateral T3, T6, T9, and T12 vertebral levels were evaluated for the type of pedicle, pedicle chord length, and pedicle isthmic diameter on both MRI and CT scans. Pedicles were classified according to Sarwahi et al. into type A (normal pedicle), >4 mm cancellous channel; type B, 2-4 mm channel; type C, completely cortical channels >2 mm; and type D, <2 mm cortical bone channel.

RESULTS

Of 504 pedicles, 294 were classified as type A, 173 as type B, 24 as type C, and 13 as type D based on a CT scan. MRI had an overall accuracy rate of 92.86% for detecting type A, 96.53% for type B, and 100% for type C and type D compared with CT scans. Regarding the thoracic levels, MRI had an overall concordance of 97.98% at T3 level, 94.43% at T6 level, 98.11% at T9 level, and 99.3% at T12 level with CT readings. Comparing measurements between MRI and CT studies for pedicle isthmic diameter and pedicle chord length showed moderate to good reliability at all measured levels.

CONCLUSIONS

Pedicle measurements obtained by MRI may be used to estimate pedicle dimensions, allowing surgeons to preoperatively determine pedicle screw sizes based on MRI scans alone.

Multiple trauma in pregnant women: injury assessment, fetal radiation exposure and mortality. A multicentre observational study

BACKGROUND

Fetal radiation exposure in pregnant women with trauma is a concern. The purpose of this study was to evaluate fetal radiation exposure with regard to the type of injury assessment performed.

METHODS

It is a multicentre observational study. The cohort study included all pregnant women suspected of severe traumatic injury in the participating centres of a national trauma research network. The primary outcome was the cumulative radiation dose (mGy) received by the fetus with respect to the type of injury assessment initiated by the physician in charge of the pregnant patient. Secondary outcomes were maternal and fetal morbi-mortality, the incidence of haemorrhagic shock and the physicians' imaging assessment with consideration of their medical specialty.

RESULTS

Fifty-four pregnant women were admitted for potential major trauma between September 2011 and December 2019 in the 21 participating centres. The median gestational age was 22 weeks [12-30]. 78% of women (n = 42) underwent WBCT. The remaining patients underwent radiographs, ultrasound or selective CT scans based on clinical examination. The median fetal radiation doses were 38 mGy [23-63] and 0 mGy [0-1]. Maternal mortality (6%) was lower than fetal mortality (17%). Two women (out of 3 maternal deaths) and 7 fetuses (out of 9 fetal deaths) died within the first 24 h following trauma.

CONCLUSIONS

Immediate WBCT for initial injury assessment in pregnant women with trauma was associated with a fetal radiation dose below the 100 mGy threshold. Among the selected population with either a stable status with a moderate and nonthreatening injury pattern or isolated penetrating trauma, a selective strategy seemed safe in experienced centres.

Increased CT Use and No Change in Injury Severity among Child Motor Vehicle Victims: A National Trauma Database Study in Japan

The number of fatalities associated with traffic accidents has been declining owing to improvements in vehicle safety performance and changes in the law. However, injuries in children can lead to social and economic losses. We examined 10-year changes in the characteristics of traffic trauma among pediatric motor vehicle passengers by analyzing data from the Japan Trauma Data Bank (JTDB). Among the 36,715 injured motor vehicle passengers under the age of 15 years who were registered in the JTDB from 2004 to 2019, we compared the groups injured during 2004-2007 (n = 94) and 2017-2019 (n = 203). Physiologically, the 2004-2007 group had a lower body temperature and Glasgow Coma Scale score as well as a higher mortality. Anatomical severity was higher in the 2004-2007 group for the head, face, and neck, according to the Abbreviated Injury Scale. In terms of treatment, only craniotomy as a primary surgery was significantly lower in the 2017-2019 group. The 2017-2019 group had significantly higher rates of receiving whole-body computed tomography (CT). Because the rate of performing CT has increased, with no changes in the injury severities of the trunk and extremities, limiting the number of CT examinations is suggested for pediatric motor vehicle passengers involved in road traffic collisions. The severity of trunk and extremity injuries has not improved in more than 10 years; further preventive measures for these injuries should be considered.

Comparison of fatal traumatic medico-legal cases with postmortem computed tomography and autopsy: A pilot study in Taiwan

In order to determine the performance of postmortem computed tomography (PMCT) in identifying traumatic-relevant macroscopic findings in medico-legal cases, this retrospective observational pilot study involving nine trauma casualties who had received PMCT prior to autopsy. The comparison of these findings in six anatomical regions as dictated in Injury Severity Score (ISS) were performed. 104 traumatic-relevant findings were identified with achievement of 51% congruent findings. PMCT and autopsy had additionally found 22 and 29 findings respectively. PMCT had highest sensitivity for extremity injury (81.82%), followed by chest (73.91%), head, neck and face (71.43%), and abdomino-pelvic area (50%). It had excellent detection rate in abnormal air collection, fracture, foreign body localization, internal ballistic and intracranial pathology. However, the solid organ and vascular injuries as well as integumentary lesions were the major drawback. In conclusion, incorporation of PMCT to autopsy in medico-legal investigation helps to preserve the most abundant traumatic-relevant injuries compared to either modality.

Whole-Body Magnetic Resonance Tomography and Whole-Body Computed Tomography in Pediatric Polytrauma Diagnostics-A Retrospective Long-Term Two-Center Study

Although serious accidents remain the leading cause of pediatric mortality, protocols to orient diagnostic procedures towards a certain type of initial imaging are widely needed. Since 2007, we have performed whole-body magnetic resonance imaging (WBMR) and whole-body computed tomography (WBCT) for diagnoses of severely injured children. We retrospectively reviewed 134 WBMR and 158 WBCT in patients younger than 16 years that were performed at two trauma centers between 2007 and 2018. A higher Injury Severity Score (ISS) was found in WBCT vs. WBMR (10.6 vs. 5.8; p = 0.001), but without any significant difference in mortality. The WBMR was significantly preferred at younger ages (9.6 vs. 12.8 years; p < 0.001). The time between patient's arrival until diagnosis was 2.5 times longer for WBCT (92.1 vs. 37.1 min; p < 0.001). More patients in the CT group received analgesic sedation and/or intubation at 37.3% vs. 21.6% in the MRI group. Of these patients, 86.4% (CT) and 27.6% (MRI) were already preclinically sedated (p < 0.001). Correspondingly, 72.4% of the patients were first sedated in-hospital for MRIs. In conclusion, WBMR is an alternative and radiation-free imaging method for high-energy-traumatized children. Although the selected diagnostics seemed appropriate, limitations regarding longer duration or additional analgesic sedation are present, and further studies are needed.

Team Approach: Perioperative Management of Pilon Fractures

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Tibial pilon fractures are devastating injuries requiring complexsurgical management resulting in a challenging postoperativecourse.

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A multidisciplinary approach is required to manage these injuries in addition to patients' medical comorbidities and concomitant injuries to achieve optimal outcomes.

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The case presented here demonstrates the importance of communication and teamwork between specialties in the management of a patient with a tibial pilon fracture that was medically optimized for surgery using a team-based approach.

Structured approach with primary and secondary survey for major trauma care: an overview of reviews

BACKGROUND

A structured approach involves systematic management of trauma patients. We aim to conduct an overview of reviews about the clinical efficacy and safety of structured approach (i.e., primary and secondary survey) by guideline checklist compared to non-structured approach (i.e. clinical examination); moreover, routine screening whole-body computer tomography (WBCT) was compared to non-routine WBCT in patients with suspected major trauma.

METHODS

We systematically searched MEDLINE (PubMed), EMBASE and Cochrane Database of Systematic Reviews up to 3 May 2022. Systematic reviews (SRs) that investigated the use of a structured approach compared to a non-structured approach were eligible. Two authors independently extracted data, managed the overlapping of primary studies belonging to the included SRs and calculated the corrected covered area (CCA). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.

RESULTS

We included nine SRs investigating two comparisons in stable trauma patients: structured approach vs non-structured approach (n = 1) and routine WBCT vs non-routine WBCT (n = 8). The overlap of included primary studies was generally high across outcomes (CCA ranged between 20.85 and 42.86%) with some discrepancies in the directions of effects across reviews. The application of a structured approach by checklist may improve adherence to guidelines (e.g. Advanced Trauma Life Support) during resuscitation and might lead to a reduction in mortality among severely injured patients as compared to clinical examination (Adjusted OR 0.51; 95% CI 0.30-0.89; p = 0.018; low certainty of evidence). The use of routine WBCT seems to offer little to no effects in reducing mortality and time spent in emergency room or department, whereas non-routine WBCT seems to offer little to no effects in reducing radiation dose, intensive care unit length of stay (LOS) and hospital LOS (low-to-moderate certainty of evidence).

CONCLUSIONS

The application of structured approach by checklist during trauma resuscitation may improve patient- and process-related outcomes. Including non-routine WBCT seems to offer the best trade-offs between benefits and harm. Clinicians should consider these findings in the light of their clinical context, the volume of patients in their facilities, the need for time management, and costs.

Team Approach: Management of Geriatric Acetabular Fractures

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Geriatric acetabular fractures are defined as fractures sustained by patients who are ≥60 years old. With the rapidly aging American populace and its increasingly active lifestyle, the prevalence of these injuries will continue to increase.

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An interdisciplinary approach is necessary to ensure successful outcomes. This begins in the emergency department with hemodynamic stabilization, diagnosis of the fracture, identification of comorbidities and concomitant injuries, as well as early consultation with the orthopaedic surgery service. This multifaceted approach is continued when patients are admitted, and trauma surgery, geriatrics, and cardiology teams are consulted. These teams are responsible for the optimization of complex medical conditions and risk stratification prior to operative intervention.

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Treatment varies depending on a patient's preinjury functional status, the characteristics of the fracture, and the patient's ability to withstand surgery. Nonoperative management is recommended for patients with minimally displaced fractures who cannot tolerate the physiologic stress of surgery. Percutaneous fixation is a treatment option most suited for patients with minimally displaced fractures who are at risk for displacing the fracture or are having difficulty mobilizing because of pain. Open reduction and internal fixation is recommended for patients with displaced acetabular fractures who are medically fit for surgery and have a displaced fracture pattern that would do poorly without operative intervention. Fixation in combination with arthroplasty can be done acutely or in delayed fashion. Acute fixation combined with arthroplasty benefits patients who have poorer bone quality and fracture characteristics that make healing unlikely. Delayed arthroplasty is recommended for patients who have had failure of nonoperative management, have a fracture pattern that is not favorable to primary total hip arthroplasty, or have developed posttraumatic arthritis.

Assessment of Rib Fracture in Acute Trauma Using Automatic Rib Segmentation and a Curved, Unfolded View of the Ribs: Is There a Saving of Time?

Introduction: The fast and accurate diagnosis of rib fractures in polytrauma patients is important to reduce the mortality rate and relieve long-term pain and complications. Aim: To evaluate the diagnostic accuracy and potential time savings using automatic rib segmentation and a curved, unfolded view for the detection of rib fractures in trauma patients. Methods: The multidetector computed tomography raw data of 101 consecutive polytrauma patients (72 men; mean age 45 years, age range 17 to 84 years) admitted to a university hospital were retrospectively post-processed to generate a curved, unfolded view of the rib cage. No manual corrections were performed. Patients with reconstruction errors and movement artifacts were excluded from further analysis. All fractures were identified and classified by the study coordinator using the original data set. Two readers (reader 1 and reader 2) evaluated the original axial sections and the unfolded view, separately. The fracture locations, fracture type, and reading times were recorded. Sensitivity and specificity were calculated on a per-rib basis using a ratio estimator. Cohen’s Kappa was calculated as an index of inter-rater agreement. Results: 26 of 101 patients (25.7%) were excluded from further analysis owing to breathing artifacts (6.9%) or incorrect centerline computation in the unfolded view (18.8%). In total, 107 (5.9%) of 1800 ribs were fractured in 25 (33%) of 75 patients. The unfolded view had a sensitivity/specificity of 81%/100% (reader 1) and 71%/100% (reader 2) compared to 94%/100% (reader 1; p = 0.002/p = 0.754) and 63%/99% (reader 2; p < 0.001/p = 0.002). The sensitivity (reader 1; reader 2) was poor for buckled fractures (31%; 38%), moderate for undislocated fractures (78%; 62%), and good for dislocated fractures (94%; 90%). The assessment of the unfolded view was performed significantly faster than that of the original layers (19.5 ± 9.4 s vs. 68.6 ± 32.4 s by reader 1 (p < 0.001); 24.1 ± 9.5 s vs. 40.2 ± 12.7 s by reader 2 (p < 0.001)). Both readers demonstrated a very high interobserver agreement for the unfolded view (κ = 0.839) but only a moderate agreement for the original view (κ = 0.529). Conclusion: Apart from a relatively high number of incorrect centerline reconstructions, the unfolded view of the rib cage allows a faster diagnosis of dislocated rib fractures.

Emergency Radiology: Evolution, Current Status, and Future Directions

Emergency Radiology is a clinical practice and an academic discipline that has rapidly gained increasing global recognition among radiology and emergency/critical care departments and trauma services around the world. As with other subspecialties, Emergency Radiology practice has a unique scope and purpose and presents with its own unique challenges. There are several advantages of having a dedicated Emergency Radiology section, perhaps most important of which is the broad clinical skillset that Emergency Radiologists are known for. This multi-society paper, representing the views of Emergency Radiology societies in Canada and Europe, outlines several value-oriented contributions of Emergency Radiologists and briefly discusses the current state of Emergency Radiology as a subspecialty.

Usefulness and outcome of whole-body computed tomography (pan-scan) in trauma patients: A prospective study

Background

Severe trauma can cause multi-organ injuries, and the mortality rate may increase if significant organ injuries are missed. This study was performed to determine whether whole-body computed tomography scan (pan-scan) can detect significant injury and leads to proper management, including alteration the priority of management.

Methods

This prospective study was conducted from January 2019 to March 2021 and involved trauma patients level 1, level 2, and dangerous mechanism of trauma. Additionally, the data of trauma patients who had selective computed tomography scan were retrospectively reviewed to compared the clinical benefits.

Results

Twenty-two patients were enrolled in the prospective study. The pan-scan detected significant organ injury in 86% of the patients. Prioritization of organ injury management changed after performance of the pan-scan in 64% (major change in 64.29% and minor change in 35.71%). Skull base fracture, small bowel injury, retroperitoneal injury, kidney and bladder injury, and occult pneumothorax were the majority of injuries which was not consider before underwent pan-scan (p < 0.05). The door-to-scan time tended to be shorter in the pan-scan group than in the selective scan group without a significant difference [mean (SD), 59.5 (34) and 72.0 (86) min, respectively; p = 0.13]. Pan-scan contribute 100% confidence for trauma surgeon in diagnosis of specific organ injuries in severe injured patients.

Conclusions

The pan-scan facilitates timely detection of significant unexpected organ injuries such as the skull base, occult pneumothorax, small bowel, and retroperitoneum. It also helps to prioritize management and increases the diagnostic confidence of trauma surgeons, leading to better outcomes without delay.

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The pan-scan facilitates timely detection of significant unexpected organ injuries.

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Pan-scan helps to prioritize management and increases the diagnostic confidence leading to better outcomes without delay.

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Pan-scan contribute 100% confidence for trauma surgeon in diagnosis of specific organ injuries in severe injured patients.

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Contrast-induced nephropathy from pan-scan is lower than that in selective CT scan accumulated on the same admission.

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.

Tertiary Survey in the Days of Modern Imaging: Assessing the Detection Rate of Clinically Significant Injuries on Tertiary Survey in a Level 2 Trauma Centre

Aim: To determine the utility of tertiary survey (TS) in patients subjected to whole-body CT (WBCT) or selective CT (SCT) following trauma.

Methods: A retrospective analysis was performed on trauma patients admitted to a level 2 trauma centre following the introduction of a standardised TS form in 2017. The initial imaging protocol (WBCT versus selective CT versus x-ray), subsequently requested imaging, standardised injury data, and length of stay (LOS) were recorded. Clinically significant injuries were defined as those with an Injury Severity Score (ISS) of 1 on the Abbreviated Injury Scale (AIS).

Results: Five hundred and seven patients were included. The rate of additional significant injuries at the time of TS was 1.18% (n=6), each requiring conservative management only. There was no significant difference in injury detection based on the initial imaging protocol; however, there were three near-misses identified. Of these patients, two underwent selective CT and one was subjected to a plain film series, with clinically significant injuries identified early upon completion of trauma imaging. Overall, 2.9% (n=15) of patients had completed trauma imaging during the same admission. WBCT was associated with higher ISS and length of stay (p<0.05). After controlling for ISS, there was no difference in length of stay between imaging modalities except in those patients with an ISS of 0 (no clinically significant injuries), who appeared to have longer admissions if subject to WBCT (p<0.001).

Conclusion: The rate of missed injuries identified at TS is low. The imaging modality did not alter this. This may allow for the omission of the tertiary survey and earlier discharge in many trauma patients.

Avoiding immediate whole-body trauma CT: a prospective observational study in stable trauma patients

High energy blunt trauma patients with normal vital signs are usually investigated with a Contrast Enhanced Computed Tomography (CECT) for torso injuries. CECT involves high levels of radiations, often showing no injuries in patients over-triaged to the trauma center. The aim of our study was to suggest an alternative diagnostic protocol based on Emergency Room (ER) tests (physical exam, blood tests, extended FAST, Chest and Pelvis X-ray) to avoid CECT in selected patients. A prospective cohort study was conducted from September 2018 to September 2019. Five hundred patients fulfilled the inclusion criteria. Patients received torso-CECT scan only if they had at least one positive ER test. The validity of the single component of the protocol and the global validity of the ER tests to detect torso injuries was assessed through sensitivity, specificity, positive (PPV) and negative (NPV) predictive value, positive (+ LR) and negative (- LR) likelihood ratio. Multivariate analysis was performed to identify independent predictors of torso injuries. One hundred and seventy patients received a torso-CECT scan because of positive ER tests. ER tests showed a global sensitivity for torso injuries of 86.96% (95% CI 80.17-92.08) specificity of 83.98%(95% CI 79.79-87.60), PPV of 67.42% (95% CI 61.83-72.54), NPV of 94.41% (95% CI 91.63-96.30) + LR of 5.43 (95% CI 4.25-6.93), - LR of 0.16 (95% CI 0.10-0.24). ER tests in an experienced center seem to be able to identify more severe blunt trauma patients needing CECT. Further studies are advisable to confirm these results.

Mortality Rate of Trauma Patients with ESI Triage Level 1-2 Who Underwent Computerized Tomography-PANSCAN versus Conventional Computerized Tomography Scan

Objective

The treatment of severe trauma patients requires a fast and accurate method to diagnose life-threatening conditions. Computerized tomography (CT)-PANSCAN has been widely used for the last 20 years to diagnose many patients in critical condition. However, no research has been performed into the efficacy of CT-PANSCAN. This research aims to compare the mortality rate of trauma patients who underwent CT-PANSCAN versus conventional CT scan.

Methods

This retrospective cohort study enrolled patients who were at triage ESI level 1–2 in the emergency department of Ramathibodi Hospital from January 2013 to December 2018 and analyzed the mortality rate between those who underwent CT-PANSCAN and conventional CT scan.

Results

The study enrolled 123 trauma patients; 61 patients underwent CT-PANSCAN, whereas 62 patients underwent conventional CT scan. There were 1 and 7 patients who expired in the CT-PANSCAN and conventional CT scan groups, respectively. After multivariate regression analysis, the result revealed that patients who underwent CT-PANSCAN had a lower mortality rate (adjusted odds ratio = 0.023; p-value = 0.018; 95% CI 0.001–0.518).

Conclusion

Undergoing a CT-PANSCAN can reduce the mortality rate in trauma patients, especially in ESI level 1, 2 traumatic patients, and CT-PANSCAN available facilities.

Diagnostic accuracy, yield, and comparative effectiveness of whole-body computed tomography in blunt trauma: A protocol for systematic review and meta-analysis

OBJECTIVES

Controversies emerge over routine performances of whole-body computed tomography (WBCT) in patients with blunt polytrauma. The existing randomized and non-randomized evidence is inconclusive, and during observations of non-trauma, incidental findings, detected by WBCT, have left uncertainty regarding their consequences and optimal management. Additionally, previous meta-analyses have failed to address the limitations of primary studies and issues associated with incidental findings. Therefore, we planned a new systematic review to address these points.

METHODS

We will search the PubMed, EMBASE, and Cochrane Central databases from inception to December 31, 2020, with no language restriction and perform full-text evaluation of potentially relevant articles. We will include prospective and retrospective studies with a single-gate design that assessed diagnostic accuracy and/or yield of WBCT to detect traumatic injuries, and studies that assessed incidental findings detected by WBCT. Additionally, we will include randomized controlled trials and non-randomized comparative studies that assessed the effectiveness of WBCT against conventional care, including selective computed tomography (CT). Studies of patients of all ages with blunt traumatic injuries, assessed at an emergency department, will be included. Two reviewers will extract data and rate the study validity via standard quality assessment tools. The primary outcome of interest will be reduction in mortality. Our secondary outcomes will include diagnostic accuracy and yield, detection of incidental findings and clinical outcomes associated with these detections, and improvement in other non-mortality clinical outcomes. We will qualitatively assess study, patient, and intervention characteristics and clinical outcomes. If appropriate, we will perform random-effects model meta-analyses to obtain summary estimates. Finally, we will assess the certainty of evidence by the grading the quality of evidence and strength of recommendations.

ETHICS AND DISSEMINATION

Ethics approval is not applicable, as this is a secondary analysis of publicly available data. The review results will be submitted for publication in peer-reviewed journals.

PROSPERO REGISTRATION

CRD42020187852.

Whole-body computed tomography is safe, effective and efficient in the severely injured hemodynamically unstable trauma patient

Trauma is a complex pathology that requires an experienced multidisciplinary team with an inherent quick decision-making capacity, given that a few minutes could represent a matter of life or death. These management decisions not only need to be quick but also accurate to be able to prioritize and to efficiently control the injuries that may be causing impending hemodynamic collapse. In essence, this is the cornerstone of the concept of damage control trauma care. With current technological advances, physicians have at their disposition multiple diagnostic imaging tools that can aid in this prompt decision-making algorithm. This manuscript aims to perform a literature review on this subject and to share the experience on the use of whole body computed tomography as a potentially safe, effective and efficient diagnostic tool in cases of severely injured trauma patients regardless of their hemodynamic status. Our general recommendation is that, when feasible, perform a whole body computed tomography without interrupting ongoing hemostatic resuscitation in cases of severely injured trauma patients with or without signs of hemodynamic instability. The use of this technology will aid in the decision-making of the best surgical approach for these patients without incurring any delay in definitive management and/or increasing significantly their radiation exposure.

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.

Comparison of Preoperative Pedicle Screw Measurement Between Computed Tomography and Magnet Resonance Imaging

BACKGROUND

Pedicle screw fixation is commonly used in the treatment of spinal pathologies. While the biomechanical factors that affect bone fixation have been frequently described, questions remain as to which imaging modality is the ideal medium for preoperative planning. Due to its perceived superiority in assessing bony changes, computed tomography (CT) scan is assumed to be the gold standard for preparative planning, and we hypothesize that magnetic resonance imaging (MRI) is sufficiently accurate to predict screw length and diameter compared to CT.

METHODS

We retrospectively measured the length and diameter of vertebral bodies in the lumbar region in both MRI and CT and tested for differences between the modalities as well as for confounding effects of age, sex, and the presence of spondyloarthrosis.

RESULTS

We found a significant difference in pedicle screw length between CT and MRI measurements for both sides. For the left pedicle, the mean difference was 1.89 mm (95% confidence interval [CI] -3.03 to -0.75; P < .002), while for the right pedicle, the mean difference was 2.05 mm (95% CI -3.27 to -0.84; P = .001). We also found a significant difference in diameter measurements between CT and MRI for the left pedicle (0.53 mm; 95% CI 0.13 to 0.93; P = .011) but not for the right pedicle (0.36 mm; 95% CI -0.06 to 0.78; P = .094). We identified no significant effect of sex, age or spondyloarthrosis on the results (P > .05).

CONCLUSIONS

Pedicle screw planning measurements were more accurate using CT images compared to MRI images. CT scan remains the gold standard for pedicle screw planning in trauma surgery. When using MRI images, the surgeon should be aware of the differences in screw length and diameter compared to CT in order to avoid intra- and postoperative risks.

The incidence of geriatric trauma is increasing and comparison of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients

Purpose

The study aimed to examine the changing incidence of geriatric trauma and evaluate the predictive ability of different scoring tools for in-hospital mortality in geriatric trauma patients.

Methods

Annual reports released by the National Trauma Database (NTDB) in the USA from 2005 to 2015 and the Trauma Register DGU® in Germany from 1994 to 2012 were analyzed to examine the changing incidence of geriatric trauma. Secondary analysis of a single-center cohort study conducted among 311 severely injured geriatric trauma patients in a level I trauma center in Switzerland was completed. According to the in-hospital survival status, patients were divided into the survival and non-survival group. The differences of the ISS (injury severity score), NISS (new injury severity score), TRISS (Trauma and Injury Severity Score), APACHE II (Acute Physiology and Chronic Health Evaluation II), and SPAS II (simplified acute physiology score II) between two groups were evaluated. Then, the areas under the receiver-operating characteristic curve (AUC-ROC) of different scoring tools for the prediction of in-hospital mortality in geriatric trauma patients were calculated.

Results

The analysis of the NTDB showed that the increase in the number of geriatric trauma ranged from 18 to 30% between 2005 and 2015. The analysis of the DGU® showed that the mean age of trauma patients rose from 39.11 in 1993 to 51.10 in 2013, and the proportion of patients aged ≥ 60 years rose from 16.5 to 37.5%. The findings from the secondary analysis showed that 164 (52.73%) patients died in the hospital. The ISS, NISS, APACHE II, and SAPS II in the death group were significantly higher than those in the survival group, and the TRISS in the death group was significantly lower than those in the survival group. The AUCs of the ISS, NISS, TRISS, APACHE II, and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients were 0.807, 0.850, 0.828, 0.715, and 0.725, respectively.

Conclusion

The total number of geriatric trauma is increasing as the population ages. The accuracy of ISS, NISS and TRISS was higher than the APACHE II and SAPS II for the prediction of in-hospital mortality in geriatric trauma patients.

Validity of physical examination in the thorax and abdomen of intoxicated trauma patients following a fall: An exploratory retrospective review

Background

Whole-Body Computerized Topography (WBCT) scans can be used to identify injuries related to trauma in intoxicated patients who often cannot provide a reliable history. While WBCT scans are associated with a decreased mortality and hospital stay in patients with a high energy mechanism of injury, their utility in intoxicated patients following a fall remain unclear. The objective of this study was to evaluate the validity of physical examination in the thorax and abdomen to identify injuries in the intoxicated patient following a fall when compared to WBCT scan findings.

Methods

A retrospective chart review was performed over a two-year period of intoxicated trauma patients who were found down secondary to a witnessed fall <20 ft, GCS > 8 and not requiring intubation. Documented physical examination findings were compared to WBCT results. Sensitivity, specificity, positive predictive value, and negative predictive value were calculated. A t-test was used to identify differences between clinical variables of false-negative and true-negative physical examinations.

Results

A total of 523 intoxicated patients presented to the ED with 43 meeting the inclusion criteria. All patients had an injury that required admission to the hospital. Of 19 patients with a positive chest CT, 13 had a negative physical exam, for sensitivity of 32% and specificity of 96%. Of eight patients with a positive abdominal CT, six had a negative physical exam, sensitivity and specificity were 16% and 98% respectively. No clinical variables were found to be different between falsely negative and true negative physical exam results.

Conclusion

In the acutely intoxicated trauma patient, physical examination findings of the thorax and abdomen were associated with a low validity, having missed an unacceptably high number of injuries, when compared to WBCT scans.

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

Purpose

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

Methods

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

Results

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

Conclusions

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

Electronic supplementary material

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

Prevalence and outcome of contrast-induced nephropathy in major trauma patients

Background

Contrast-induced nephropathy (CIN) has been well investigated in patients undergoing coronary angiography, but not in trauma patients. The main aim of this study was to determine the prevalence and to investigate independent risk factors for the development of CIN.

Methods

Between 2008 and 2014, all pre-hospital intubated major trauma patients with documented serum creatinine levels (SCr) undergoing a contrast-enhanced whole-body CT at admission were retrospectively analyzed. CIN was defined as a relative increase in SCr > 25% over the baseline value or an absolute SCr increase of > 44 µmol/l within 72 h. Univariate and multivariable regression analyses were performed to identify significant risk factors. A p value of < 0.01 was considered statistically significant and a p value of 0.01–0.049 suggested evidence.

Results

Of 284 analyzed patients, 41 (14%) met the criteria for CIN. There is suggestive evidence that age and lactate level influenced the development of CIN. Six patients (15%) had hemodialysis in the CIN-group and eight (3.3%) in the group without CIN. Complication and mortality rate was higher in patients with CIN (71% vs. 56% and 32% vs. 23%, respectively). CIN was not an independent risk factor for complications or mortality while controlling for age, gender, injury severity score, and lactate level. The length of stay was not affected by CIN.

Conclusion

CIN occurs frequently in trauma patients, but is not an independent risk factor for complications or mortality. Therefore, contrast enhanced whole-body CT can safely be performed in trauma patients.

Incidence and clinical impact of lower extremity vascular injuries in the setting of whole body computed tomography for trauma

PURPOSE

The aims of this study are to determine the incidence of lower extremity fractures and/or vascular injuries in the setting of whole body computed tomography (WBCT) for trauma and to determine lower extremity injury outcomes in this patient population.

METHODS

This is a retrospective observational study performed at a large urban Level 1 trauma center. Our institutional trauma registry was queried for patients who were evaluated with WBCT and lower extremity CT angiography (CTA) as a part of their initial imaging evaluation over a 43-month period. Patients with lower extremity fractures and/or vascular injuries were identified. Those patients with both lower extremity vascular injury and fracture were then analyzed to determine the physical relationship of the fracture to the vascular injury. Physical exam findings were extracted from the medical record. Interventions and long-term outcomes were determined from the medical record.

RESULTS

A total of 370 patients met the inclusion criteria, with 98% experiencing blunt trauma. Of these, 290 (78.4%) were positive for lower extremity injury, including 266 (71.9%) with isolated fractures, 2 (0.6%) with isolated vascular injury, and 22 (5.9%) with vascular injury associated with long bone fracture. Of the 22 patients with combined fracture and vascular injury, 8 received vascular intervention and 10 had long-term complications as a result of their injuries. Physical exam findings were insufficient to diagnose 57% of the vascular injuries.

CONCLUSIONS

The inclusion of lower extremity CTA as part of a WBCT imaging exam for trauma allows for the identification of vascular injuries that otherwise may have gone undetected or resulted in delayed diagnosis. Clinically occult lower extremity vascular injuries may be associated with poor outcomes.

Systematic review and meta-analysis of whole-body computed tomography compared to conventional radiological procedures of trauma patients

PURPOSE

The superior diagnostic accuracy of CT makes it an attractive tool for initial trauma imaging. This meta-analysis aimed to assess the evidence regarding the value of whole-body CT (WBCT) as part of the primary survey, in comparison to conventional radiological procedures.

METHODS

A comprehensive systematic search of the literature was conducted using keywords applied in Scopus, Cochrane and PubMed databases. Articles were eligible if they contained original data comparing the use of WBCT in the primary survey, with conventional radiological procedures. Outcomes included overall and 24 -h mortality, emergency department (ED) time, intensive care unit (ICU) and hospital length of stay (LOS), and multiple organ dysfunction syndrome/failure (MODS/MOF) incidence. Radiation dose, mechanical ventilation duration and cost were evaluated qualitatively. Analysis was performed with Covidence, MedCalc Version 19.1.3. and Meta-Essentials.

RESULTS

Fourteen studies were included. Statistical pooling demonstrated comparable rates between conventional procedures and WBCT (OR = 0.854, CI = 0.715-1.021, p = 0.083) in 63,529 patients across 11 studies. A significant finding favouring WBCT was discovered for ED time (SMD = -0.709, CI -1.198 to -0.220, p = 0.004). Patients experienced similar 24 -h mortality rates (p = 0.450), MODS/MOF incidence (p = 0.274), and hospital (p = 0.541) and ICU LOS (p = 0.457). WBCT is associated with increased radiation dose and mechanical ventilation duration.

CONCLUSION

This review demonstrates that WBCT markedly reduces time spent in ED. No significant differences in mortality rate are suggested. WBCT currently entails greater radiation dose and mechanical ventilation time. Further research is necessitated to address limitations of predominately retrospective observational data available.

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.

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

Purpose:

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

Methods:

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

Results:

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

Conclusion:

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

Uso de la tomografía corporal total en pacientes con trauma grave

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

Factors influencing vehicle passenger fatality have changed over 10 years: a nationwide hospital-based study

Traffic injury trends have changed with safety developments. To establish effective preventive measures against traffic fatalities, the factors influencing fatalities must be understood. The present study evaluated data from a national medical database to determine the changes in these factors over time, as this has not been previously investigated. This observational study retrospectively analysed data from the Japanese Trauma Data Bank. Vehicle passengers involved in collisions from 2004–2008 and 2016–2017 were included. Data were compared between the two study periods, and between fatal and non-fatal patients within each period. Multivariate logistic regression analyses were performed to determine the factors influencing fatalities. In 2016–2017, patients were older and had lower fatality rates. In 2004–2008, fatalities were more likely to involve older male front-seat passengers with low d-BP, BT, and GCS values, and high AIS of the neck and abdomen. However, in 2016–2017, fatalities were more likely to involve older males with low GCS, high AIS of the abdomen, and positive focused assessment with sonography for trauma results. Our study identified independent factors influencing vehicle passenger fatalities, which will likely continue to evolve with the aging of the population and changing manners of injury.

Implementation of new standard operating procedures for geriatric trauma patients with multiple injuries: a single level I trauma centre study

BACKGROUND

The demographic changes towards ageing of the populations in developed countries impose a challenge to trauma centres, as geriatric trauma patients require specific diagnostic and therapeutic procedures. This study investigated whether the integration of new standard operating procedures (SOPs) for the resuscitation room (ER) has an impact on the clinical course in geriatric patients. The new SOPs were designed for severely injured adult trauma patients, based on the Advanced Trauma Life Support (ATLS) and imply early whole-body computed tomography (CT), damage control surgery, and the use of goal-directed coagulation management.

METHODS

Single-centre cohort study. We included all patients ≥65 years of age with an Injury Severity Score (ISS) ≥ 9 who were admitted to our hospital primarily via ER. A historic cohort was compared to a cohort after the implementation of the new SOPs.

RESULTS

We enrolled 311 patients who met the inclusion criteria between 2000 and 2006 (group PreSOP) and 2010-2012 (group SOP). There was a significant reduction in the mortality rate after the implementation of the new SOPs (P = .001). This benefit was seen only for severely injured patients (ISS ≥ 16), but not for moderately injured patients (ISS 9-15). There were no differences with regard to infection rates or rate of palliative care.

CONCLUSIONS

We found an association between implementation of new ER SOPs, and a lower mortality rate in severely injured geriatric trauma patients, whereas moderately injured patients did not obtain the same benefit.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03319381, retrospectively registered 24 October 2017.

Clinical Utility of Routine Chest X-Rays During the Initial Stabilization of Trauma Patients

OBJECTIVES

The Advanced Trauma Life Support (ATLS) course encourages the use of chest x-ray (CXR) to identify injuries that may change clinical management during the initial stage of trauma resuscitations. Several studies have failed to show benefit for the routine use of CXR without a clinical indication, however. We sought to validate these findings by determining the incidence of clinically significant findings discovered on a portable single-view CXR during the initial stabilization of trauma patients at a Level 1 trauma center.

METHODS

Using our electronic medical record system, we searched for all of the patients who were brought in as a trauma activation that had a portable single-view CXR performed in the emergency department. We used a selected sampling of available subjects for inclusion into the study. We reviewed the staff radiologist reports for positive findings and reviewed the physician and nursing flow sheets for procedural interventions occurring after the CXR was performed but before leaving the resuscitation area. Subjects who were transferred from another facility, had a thoracic procedure performed before CXR or underwent computed tomography before CXRs were excluded.

RESULTS

From 2011 through 2012, we found 2101 subjects who had a portable CXR performed in the emergency department. We reviewed the first 400 subjects' records, with 33 (8.3%) subjects having positive findings on CXR. Of those 33, 8 met inclusion criteria and the remainder met exclusion criteria. The most common findings were pneumothorax (n = 4), clavicle fracture (n = 3), and rib fracture (n = 2). No subjects received a procedural intervention before leaving the resuscitation bay to be transported to the operating room or the computed tomography suite.

CONCLUSIONS

We observed a low incidence of abnormal findings on portable CXR during the initial stabilization of trauma patients, none of whom received an immediate procedural intervention. This dataset supports previously published reports that suggest that a more targeted approach to CXR use may reduce resource utilization.

[The TraumaRegister DGU® dataset, its development over 25 years and advances in the care of severely injured patients]

BACKGROUND

Since the publication in 1993, the dataset and documentation form of the TraumaRegister DGU® (TR-DGU) have continuously evolved. On the occasion of the 25th anniversary the authors have analyzed this evolution in order to reflect it in the light of medical progress in the treatment of the severely injured.

MATERIAL AND METHODS

Enrolled in the study were 5 reference data entry sheets from the years 1993, 1996, 2002, 2009 and 2016. Every piece of information (item) queried therein was entered into the study database, was categorized by topic and counted for further analysis.

RESULTS

The arrangement of the 4‑page data entry form has remained practically unchanged since 1993 and includes an average of 212 items. A total of 491 items were identified of which 64 were present throughout every dataset. Based on the average extent of the form this equals a proportion of approximately 30%. The dataset actually shows much more consistency than this number suggests because many changes can be traced back to a smarter design of the data entry form. Most items fell into the categories "results/diagnosis" (143 items/29.1%), "coagulation" (104/21.2%) and "surgical approach" (40/8.1%). Many items serve as raw data for the calculation of prognostic risk scores, such as the trauma and injury severity score (TRISS), the revised injury severity classification II (RISC II) and the trauma associated severe hemorrhage (TASH) score. Currently, nine scores can be calculated from the dataset.

CONCLUSION

The members of the working group TraumaRegister all actively participate in the treatment of severely injured patients. For 25 years this group has managed to unify the latest medical developments and well-established parameters within the TR-DGU dataset at a relatively constant degree of effort for documentation. Practice in place of theory is the driving force behind this development that serves quality assurance and research in the treatment of severely injured patients.

Incidence and significance of injuries on secondary CT imaging after initial selective imaging in blunt trauma patients

OBJECTIVE

It is unclear if additional computerized tomography (CT) imaging is warranted after injuries are identified on CT in blunt trauma patients. The objective of this study was to determine the incidence and significance of injuries identified on secondary CT imaging after identification of injuries on initial CTs in blunt trauma patients.

METHODS

This was a retrospective cohort study at an academic Level 1 trauma center with a two-tiered trauma system.

INCLUSION CRITERIA

age ≥ 18, level 2 trauma activation, injury identified on initial CT, and secondary CTs ordered. Secondary injuries were categorized as resulting in: no changes, minor changes, or major changes in management.

RESULTS

537 patients underwent 1179 initial CT scans which identified 744 injuries. There were 1094 secondary CTs which identified 143 additional injuries in 94 (18%) patients. 9 (1.7%) patients had at least one major management change and 64 (12%) had at least one minor management change. Rib fracture(s) was the most common injury on secondary scans [45/143 (32%)]. The major management changes were: tube thoracostomy for pneumothorax (4 patients), blood transfusion for hemoperitoneum (1 patient), surgery for acetabular fracture (1 patient), thoracolumbar brace for spine fracture (2 patients) and angiography for splenic injury (1 patient).

CONCLUSION

While a significant proportion of patients (18%) had injuries on secondary CT, only 1.7% of patients had a resultant major management change. Future research is warranted to determine the need for additional CT imaging after an initial selective imaging strategy in blunt trauma patients.

Early whole-body CT for treatment guidance in patients with return of spontaneous circulation after cardiac arrest

PURPOSE

Non-traumatic cardiac arrest (CA) and return of spontaneous circulation (ROSC) after cardiopulmonary resuscitation (CPR) are often associated with multiple pathologies. Expecting a high prevalence of important findings, a whole-body CT (WBCT) could be of relevance for therapy. The aim of this study is to investigate the feasibility and diagnostic yield of an early WBCT in this setting.

METHODS

This single-center retrospective study included 100 consecutive patients (27 female; 73 male; mean age 68.5± 12.57 years) with non-traumatic, in- and out-of-hospital CA and ROSC following CPR, who underwent a contrast-enhanced WBCT within 6 h after ROSC over 12 months. CT findings were determined corresponding to anatomical region.

RESULTS

Early WBCT was successfully carried out in 100% of the patients with CA and ROSC after CPR. Acute pathologies were found not only in the chest but also in the head (15%) and the abdomen (6%). Early global brain edema (n = 12), acute stroke (n = 3), pulmonary embolism (n = 10), pneumothorax (26%), acute abdominal pathologies (n = 6), iatrogenic bleeding (4%), and CPR-related injuries (93%) were detected by CT right from the beginning of the post-cardiac arrest care.

CONCLUSIONS

An early WBCT is feasible and provides added diagnostic value for patients with ROSC after non-traumatic CA.

[Imaging techniques in modern trauma diagnostics]

Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.

Whole-Body Computed Tomography During Initial Management and Mortality Among Adult Severe Blunt Trauma Patients: A Nationwide Cohort Study

BACKGROUND

Whole-body computed tomography (WBCT) is increasingly being incorporated into the initial management of blunt trauma patients. Several observational studies have suggested that, compared to selective CT, WBCT is associated with lower mortality. In contrast, a randomized controlled trial found no significant difference in survival between patients undergoing WBCT compared to selective CT. Our objective was to confirm the association between WBCT and in-hospital mortality among adult severe blunt trauma patients.

METHODS

This was a retrospective cohort study based on Japan Trauma Data Bank 2004-2015 registry data. The study population comprised adult severe blunt trauma patients with at least one abnormal vital sign: systolic blood pressure ≤100 mmHg, heart rate ≥120, respiratory rate ≥30 or ≤10, or Glasgow Coma Score ≤13. The primary outcome was in-hospital mortality. To adjust for both measured and unmeasured confounders, we performed instrumental variable (IV) analysis to compare the in-hospital mortality of patients undergoing WBCT with those undergoing selective CT.

RESULTS

Of 40,435 patients who were eligible for this study, 19,766 (48.9%) patients underwent WBCT. The proportion of patients undergoing WBCT significantly increased during the study period, from 10.7% in 2004 to 59.6% in 2015. Primary IV analysis showed a significant association between WBCT and lower in-hospital mortality (odds ratio 0.84, 95% confidence interval 0.72-0.98).

CONCLUSIONS

WBCT can be beneficial in patients with blunt trauma which has compromised vital signs. These findings from a nationwide study suggest that physicians should consider WBCT for blunt trauma patients when warranted by vital signs.

Usefulness of routine computed tomography in the evaluation of penetrating war injuries to the chest

OBJECTIVES

This review was conducted to compare the contributions of chest X-ray (CXR) and computed tomography (CT) towards detecting intrathoracic damage in patients with penetrating war injuries to the chest and to determine whether identification of additional injuries by chest CT will have an impact on the choice of therapeutic interventions and clinical outcomes.

METHODS

We reviewed records of 449 patients (374 men, mean age 29.3 ± 14.8 years) who were admitted to our hospital with penetrating war injuries to the chest over a 7-year period. Collected data included mechanisms of injury, associated injuries, results of CXRs and chest CTs, methods of management, in-hospital stays, complications and mortalities.

RESULTS

Immediate screening CXRs were obtained in all patients not requiring emergent thoracotomies, of which 91.4% showed positive signs of injury. Chest CTs were performed at the discretion of the physicians in 49.4% of patients, and CXR-positive findings were confirmed in all cases, while revealing additional injuries in 11% of patients. Chest CT findings led to additional closed chest drainage in 5.6% of patients but had no impact on treatment strategy in 94.4% of scanned patients. Follow-up CXRs showed new positive findings in 22 patients, leading to additional closed chest drainage in 3 patients and delayed open thoracotomies in 7 other patients.

CONCLUSIONS

CXRs continue as the primary diagnostic modality in the assessment of patients with penetrating war injuries to the chest. Chest CTs can be omitted in most patients, thus reducing CT imaging case-load substantially, while most clinically significant chest injuries remain sufficiently recognized.

The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury

Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.

Whole body computed tomography in multi trauma patients: Review of the current literature

Many authors adopt the Selected Computed Tomography (SCT) approach of the Advanced Trauma Life Support (ATLS) for the management of multiple trauma patients. In the SCT approach, the initial physical examination is followed by conventional radiography (cervical X-ray, chest X-ray, pelvic X-ray and Focused Abdominal Sonography in Trauma (FAST)), and the computed tomography (CT) of the specific body regions if indicated. An alternative to this traditional approach is the Whole-body Computed Tomography (WBCT) protocol, which became widespread all over the world in the last two decades to minimize the rate of missed injuries and decrease the mortality rate.

According to the literature, the WBCT approach is superior to the traditional SCT approach in the time of imaging, diagnostic accuracy, and mortality rates. Conversely, WBCT increases the cancer risk due to additional irradiation. Therefore, it is recommended that the WBCT protocol should be reserved for only severe multi-trauma patients. However, further studies to define severe patients, and clinical decision criteria for WBCT are needed.

Whole-body computed tomography in severely injured patients

PURPOSE OF REVIEW

To provide an update on the relevant and recent studies on whole-body computed tomography (WBCT) imaging of severely injured patients.

RECENT FINDINGS

The advantages of WBCT in time saving, diagnostic accuracy and even in survival have been proven in numerous studies. WBCT can also be beneficial in haemodynamically unstable major trauma patients. The CT scanner should be located close to the emergency department or even in the trauma room. The issue of radiation is still quite important, however, iterative as well as split-bolus protocols can nowadays reduce radiation significantly. The question: which trauma patient should receive WBCT and which not is not yet solved sufficiently. Postmortem WBCT has a promising potential to promptly define the definitive cause of death of trauma victims comparably to traditional autopsy.

SUMMARY

On account of the recent advances, whole-body CT has become a crucial part of the initial in-hospital assessment of severely injured patients. It is recommended as the standard radiological tool for the emergency diagnostic work-up in major trauma patients.

Benefits of Computed Tomography in Reducing Mortality in Emergency Medicine

Performing accurate diagnosis using computed tomography (CT) in emergency medicine may reduce mortality rates in various diseases. In this observational, correlational and cross-sectional study, we conducted multiple regression analyses to investigate the relationship between CT utilization rates and mortality. In addition, we estimated the annual net profits from CT to show the profitability of introducing a CT system in each Japanese prefecture.

We conducted a multiple regression analysis to investigate correlations between CT utilization rates and mortality from each disease adjusted for the population density, number of doctors, as well as transportation time to the medical institution.

The results of multiple regression analysis showed that traffic accident mortality was related to CT utilization rate and population density. Extrinsic death such as mortality due to falling, drowning and asphyxia was related to CT utilization, indicating that CT in emergency medicine reduced mortality. Moreover, the annual net profit from multi-slice CT (MSCT) was estimated as positive.

Our study clearly demonstrates that CT utilization rates relate to a reduction in mortality from accidents, indicating that screening patients with CT in the emergency room has a beneficial effect and reduces mortality. Therefore, CT equipment has a beneficial effect in both emergency medicine and hospital management.

Patterns of injury detected by pan-computed tomography after road traffic accidents: retrospective review from a trauma center in Saudi Arabia

BACKGROUND

Pan-scan (whole-body) computed tomography (CT) has a paramount role in the diagnosis of injuries in road traffic accidents (RTA).

OBJECTIVE

Identify patterns of injuries on pan-CT scans.

DESIGN

Retrospective medical record review.

SETTING

Tertiary care center.

PATIENTS AND METHODS

The records of all RTA patients who presented to the radiology department at King Fahad Military Medical Complex (KFMMC) in Dhahran for the 3-year period from July 2014 to July 2017 and underwent pan-CT were retrospectively reviewed. Drivers and front-seat passengers with complete clinical information on seating, safety and mechanism of injury were selected. Children under 5 years of age, pregnant women and back-seat passengers were excluded. Patterns of injuries were categorized as 'no abnormality detected' (NAD), isolated or combined head, face and neck (H), isolated or combined chest, abdomen and pelvis (C) or both regions of the body (B).

MAIN OUTCOME MEASURES

Injury patterns on pan-CT scans.

SAMPLE SIZE

305 RESULTS: Most patients were males (n=287, 94.1%). The median age was 26 years for males (IQR, 22-33 years) and 30 years for females (IQR, 28-39). More than two-thirds were drivers (all males); the remainder were front-seat passengers. Young males were most often involved. The most common type of accident was a roll-over. Of those who sustained injuries, 273 (89.5%) were not wearing a seat belt (unrestrained). The patterns of injuries were NAD (87, 28%), H (27, 9%), C (93, 30.5%), B (98, 32%).

CONCLUSION

When abnormalities were detected, most high-speed vehicular injuries affected the torso. Unrestrained young male drivers are most often involved in RTAs in Saudi Arabia.

LIMITATIONS

Retrospective study with a small sample size. Types and severity of injuries on pan-CT were not documented.

CONFLICT OF INTEREST

None.

[Imaging techniques in modern trauma diagnostics]

Modern trauma room management requires interdisciplinary teamwork and synchronous communication between a team of anaesthesists, surgeons and radiologists. As the length of stay in the trauma room influences morbidity and mortality of a severely injured person, optimizing time is one of the main targets. With the direct involvement of modern imaging techniques the injuries caused by trauma should be detected within a very short period of time in order to enable a priority-orientated treatment. Radiology influences structure and process quality, management and development of trauma room algorithms regarding the use of imaging techniques. For the individual case interventional therapy methods can be added. Based on current data and on the Frankfurt experience the current diagnostic concepts of trauma diagnostics are presented.

Ten-year inhospital mortality trends for patients with trauma in Japan: a multicentre observational study

OBJECTIVES

Trauma is one of the main causes of death in Japan, and treatments and prognoses of these injuries are constantly changing. We therefore aimed to investigate a 10-year trend (2004-2013) in inhospital mortality among patients with trauma in Japan.

DESIGN

Multicentre observational study.

SETTING

Japanese nationwide trauma registry (the Japan Trauma Data Bank) data.

PARTICIPANTS

All patients with trauma whose Injury Severity Score (ISS) were 3 and above, who were aged 15 years or older, and whose mechanisms of injury (MOI) were blunt and penetrating between 2004 and 2013 (n=90 833).

OUTCOME MEASURES

A 10-year trend in inhospital mortality.

RESULTS

Inhospital mortality for all patients with trauma significantly decreased over the study decade in our Cochran-Armitage test (P<0.001). Similarly, inhospital mortality for patients with ISS 16 or more and patients who scored 50% or better on the Trauma and Injury Severity Score (TRISS) probability of survival scale significantly decreased (P<0.001). In addition, the OR for inhospital mortality of these three patient groups decreased yearly after adjusting for age, gender, MOI, ISS, Glasgow Coma Scale, systolic blood pressure and respiratory rate on hospital arrival in multivariable logistic regression analyses. Furthermore, inhospital mortality for patient with blunt trauma significantly decreased in injury mechanism-stratified Mantel-extension testing (P<0.001). Finally, multivariable logistic regression analyses showed that the OR for inhospital mortality of patients with ISS 16 and over decreased each year after adding and adjusting for means of transportation and usage of whole-body CT.

CONCLUSION

Inhospital mortality for patients with trauma in Japan significantly decreased during the study decade after adjusting for patient characteristics, injury severity and the response environment after injury.