Role of CT in diagnosis of major arterial injury after blunt thoracic trauma

The role of computed tomography (CT) in the diagnosis of blunt thoracic vascular injury is controversial. Several recent reports have advocated the use of CT to exclude aortic and major branch injuries in hemodynamically stable patients with blunt trauma. This approach potentially avoids invasive angiography and unnecessary treatment delays in multiply injured patients but risks missed aortic transections if the CT or its interpretation is not accurate. We prospectively evaluated 153 consecutive trauma patients in whom we suspected blunt aortic injury between September 1985 and August 1988. All hemodynamically stable patients underwent contrast-enhanced chest CT followed by immediate aortic arch angiography. Forty-nine unstable patients underwent immediate angiography without chest CT, and 11 (22%) had major thoracic arterial injuries. Data from the remaining 104 stable patients indicate that the sensitivity of chest CT for diagnosis of major thoracic injury is 55%; specificity, 65%. If the chest CT had been used as a screening modality to perform aortic angiography, two transected aortas and three major aortic branch injuries would have been missed. We conclude that chest CT has no screening role in the evaluation of blunt trauma patients with possible major vascular injury.     

The trend of using computed tomography in the detection of acute thoracic aortic and branch vessel injury after blunt thoracic trauma: single-center experience over 13 years

BACKGROUND: The purpose of this study was to review the trend of using chest computed tomography (CT) and aortography in evaluating patients with blunt thoracic trauma. METHODS: A total of 85 patients who had blunt aortic injury diagnosed by chest CT, aortography, or both were included in this study. RESULTS: Aortography was the dominant modality before 1998, and the use of chest CT has increased to 50% of patients with aortic injuries as of 2001. Isolated aortic, branch vessel, or combined injuries were found in 71 (84%), 11 (13%), and 3 (4%) patients, respectively. All 14 patients with branch vessel injuries were diagnosed by aortography. Ninety-eight percent of patients with aortography were true-positives, and 20% of patients with chest CT had indirect signs of aortic injury. CONCLUSION: Our institution has increased the use of chest CT to evaluate blunt thoracic trauma. Patients with indirect signs of aortic injuries shown on chest CT require further evaluation. In our experience, angiography remains the optimal diagnostic modality for evaluating aortic branch vessel injuries.     

The clinical significance of occult thoracic injury in blunt trauma patients

Increased use of thoracic CT (TCT) in diagnosis of blunt traumatic injury has identified many injuries previously undetected on screening chest x-ray (CXR), termed "occult injury". The optimal management of occult rib fractures, pneumothoraces (PTX), hemothoraces (HTX), and pulmonary contusions is uncertain. Our objective was to determine the current management and clinical outcome of these occult blunt thoracic injuries. A retrospective review identified patients with blunt thoracic trauma who underwent both CXR and TCT over a 2-year period at a Level I urban trauma center. Patients with acute rib fractures, PTX, HTX, or pulmonary contusion on TCT were included. Patient groups analyzed included: (1) no injury (normal CXR, normal TCT, n=1337); (2) occult injury (normal CXR, abnormal TCT, n=205); and (3) overt injury (abnormal CXR, abnormal TCT, n=227). Patients with overt injury required significantly more mechanical ventilation and had greater mortality than either occult or no injury patients. Occult and no injury patients had similar ventilator needs and mortality, but occult injury patients remained hospitalized longer. No patient with isolated occult thoracic injury required intubation or tube thoracostomy. Occult injuries, diagnosed by TCT only, have minimal clinical consequences but attract increased hospital resources.     

Pulmonary contusion in the pan-scan era

BackgroundAlthough pulmonary contusion (PC) is traditionally considered a major injury requiring intensive monitoring, more frequent detection by chest CT in blunt trauma evaluation may diagnose clinically irrelevant PC.ObjectivesWe sought to determine (1) the frequency of PC diagnosis by chest CT versus chest X-ray (CXR), (2) the frequency of PC-associated thoracic injuries, and (3) PC patient clinical outcomes (mortality, length of stay [LOS], and need for mechanical ventilation), considering patients with PC seen on chest CT only (SOCTO) and isolated PC (PC without other thoracic injury).MethodsFocusing primarily on patients who had both CXR and chest CT, we conducted a pre-planned analysis of two prospectively enrolled cohorts with the following inclusion criteria: age >14 years, blunt trauma within 24 h of emergency department presentation, and receiving CXR or chest CT during trauma evaluation. We defined PC and other thoracic injuries according to CT reports and followed patients through their hospital course to determine clinical outcomes.ResultsOf 21,382 enrolled subjects, 8661 (40.5%) had both CXR and chest CT and 1012 (11.7%) of these had PC, making it the second most common injury after rib fracture. PC was SOCTO in 739 (73.0%). Most (73.5%) PC patients had other thoracic injury. PC patients had higher admission rates (91.9% versus 61.7%; mean difference 30.2%; 95% confidence interval [CI] 28.1–32.1%) and mortality (4.7% versus 2.0%: mean difference 2.8%; 95% CI 1.6–4.3%) than non-PC patients, but mortality was restricted to patients with other injuries (injury severity scores > 10). Patients with PC SOCTO had low rates of associated mechanical ventilation (4.6%) and patients with isolated PC SOCTO had low mortality (2.6%), comparable to that of patients without PC.ConclusionsPC is commonly diagnosed under current blunt trauma imaging protocols and most PC are SOCTO with other thoracic injury. Given that they are associated with low mortality and uncommon need for mechanical ventilation, isolated PC and PC SOCTO may be of limited clinical significance.     

The sensitivity of chest X-ray (CXR) for the detection of significant thoracic injury in children exposed to blast

IntroductionThoracic trauma is an important cause of morbidity and mortality in children exposed to blast and early recognition of these injuries is vital. While numerous studies have investigated the sensitivity of chest X-ray (CXR) for the detection of chest injury in blunt trauma, none have evaluated its performance in paediatric blast injury.MethodsCXR and Computed Tomography (CT) thorax findings were compared for 105 children who were injured by blast and presented to the UK Role 3 Hospital, Camp Bastion, Helmand Province, during the recent conflict in Afghanistan from 2011 to 2013. CXR performance was evaluated compared to the ‘gold standard’ of CT for the detection of significant thoracic injuries, defined as pneumothorax, haemothorax, aortic or great vessel injury, 2 or more rib fractures, ruptured diaphragm, sternal fracture, penetrating fragments and pulmonary contusion or laceration.ResultsThe sensitivity of CXR for the detection of significant injuries was: pneumothorax 43%, haemothorax 40%, contusion 44%, laceration 100%, blast lung 80% and subdermal metallic fragments 75%. CXR missed all cases of diaphragm injury, ≥2 rib fractures, clavicle fracture and pleural effusion, although numbers of each were small. Specificity for CXR injury detection was 94% for contusion and 93% for fragment, and 100% otherwise. The sensitivity and specificity of CXR for identifying an abnormality that would prompt CT imaging was 72% (95% CI 55–85%) and 82% (95% CI 70–90%).ConclusionsCXR has a poor sensitivity for the identification of significant thoracic injury in children exposed to blast. We argue that, given the challenge of clinical assessment of injured children and the potential for serious adverse consequences of missed thoracic injuries, there should be a low threshold for the use of CT chest in the evaluation of children exposed to blast.     

The frequency and significance of thoracic injuries detected on abdominal CT scans of multiple trauma patients

Of 174 multiple trauma patients undergoing abdominal CT examination for suspected abdominal trauma, 65 patients had 109 chest injuries detected by abdominal CT, chest film, or both examinations. Forty-one patients had 55 chest injuries at the base of the thorax which were not detected on the initial chest film. The most frequent chest injuries detected only by CT were pneumothroax, fracture (rib, thoracic spine, and sternum), lung contusion, aspiration pneumonia, hemothorax, and post-traumatic atelectasis. Seven patients whose chest injury initially was seen only at abdominal CT required treatment of the injury, suggesting that a variety of chest injuries which may vitally affect patients can be detected early in multiple trauma patients by abdominal CT, and that all abdominal trauma CT scans should be scrutinized for signs of a chest injury.     

Comparison of multiplane transesophageal echocardiography and contrast-enhanced helical CT in the diagnosis of blunt traumatic cardiovascular injuries

BACKGROUND: Multiplane transesophageal echocardiography (TEE) and helical computed tomography (CT) of the chest have been validated separately against aortography for the diagnosis of acute traumatic aortic injuries (ATAI). However, their respective diagnostic accuracy in identifying blunt traumatic cardiovascular lesions has not been compared. METHODS: During a 3-yr period, 110 consecutive patients with severe blunt chest trauma (age: 41 +/- 17 yr; injury severity score: 34 +/- 14) prospectively underwent TEE and chest CT as part of their initial evaluation. Results of both imaging methods were interpreted independently by experienced investigators and subsequently compared. All cases of subadventitial acute traumatic aortic injury were surgically confirmed. RESULTS: Seventeen patients had vascular injury and 11 had cardiac lesions. TEE and CT identified all subadventitial disruptions involving the aortic isthmus (n = 10) or the ascending aorta (n = 1) that necessitated surgical repair. In contrast, CT only depicted one disruption of the innominate artery. TEE detected injuries involving the intimal or medial layer, or both, of the aortic isthmus in four patients with apparently normal CT results who underwent successful conservative treatment. All cardiac injuries but two were identified only by TEE. CONCLUSIONS: In patients with severe blunt chest trauma, TEE and CT have similar diagnostic accuracy for the identification of surgical acute traumatic aortic injuy. TEE also allows the diagnosis of associated cardiac injuries and is more sensitive than CT for the identification of intimal or medial lesions of the thoracic aorta.     

Newer diagnostic modalities for vascular injuries: the way we were, the way we are.

The article discusses the role of modalities in diagnosing vascular injuries starting with angiography and tracing the evolution of the use of color flow Doppler, CT, and CT angiography. It also addresses the controversy of minimal vascular injury and outlines vascular injuries that may be safely observed and followed-up. Finally, the evolution from angiography to the use of helical CT for the diagnosis of thoracic aortic injuries is reviewed in detail.     

胸椎骨折伴胸骨骨折9例分析

目的对胸椎骨折伴发胸骨骨折进行初步探讨与分析。方法自2001年11月至2006年l0月，共收治胸椎骨折伴胸骨骨折患者9例，全部病例行X线、CT及MRI检查。根据患者年龄、性别、受伤原因、胸骨骨折部位、胸椎损伤节段及类型、脊髓损伤程度及其他合并伤等资料均作为相关信息列入分析。结果损伤原因以交通伤和坠落伤为主，3例为多节段骨折，9例合并多发创伤或多发骨折。脊髓损伤发生率高，损伤程度严重。结论胸椎骨折伴胸骨骨折的临床特点为致伤暴力强大，脊柱骨折、脊髓损伤严重，合并多发伤发生率高。胸骨是胸廓环的重要组成结构，并在维持胸椎的稳定性中发挥着重要的作用。     

Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest

BackgroundThe precise role of thoracic CT in penetrating chest trauma remains to be defined. We hypothesized that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM).MethodsA ten-year review of all penetrating torso cases was retrospectively analyzed from our urban University-based trauma center. We included hemodynamically normal patients (systolic blood pressure ≥90) with penetrating chest injuries that underwent screening thoracic CT. Hemodynamically unstable patients and diaphragmatic injuries were excluded. The sensitivity, specificity, positive predictive value and negative predictive value were calculated.ResultsA total of 212 patients (mean injury severity score = 24, Abbreviated Injury Score for Chest = 3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM.ConclusionsThoracic CT has a negative predictive value of 99% in triaging hemodynamically normal patients with penetrating chest trauma. Screening thoracic CT successfully excludes surgery in patients with non-significant radiologic findings.     

Role of angiography in the detection of aortic branch vessel injury after blunt thoracic trauma.

PURPOSE: The occurrence of aortic arch branch vessel injury as an isolated occurrence or in association with aortic injury after blunt chest trauma has not been emphasized in the literature. The imaging evaluation is also controversial. METHODS: We reviewed thoracic aortograms of 166 patients examined at our institution from May 1995 to May 1999 performed after blunt thoracic trauma. We evaluated the aortograms for aortic and arch branch vessel injuries. Twenty-four injuries were detected and all patients had either a wide mediastinum demonstrated on plain radiographs (22 patients) or mechanism of injury conducive to aortic injury. RESULTS: Of the 166 patients, 24 (14%; 16 men, 8 women; mean age, 50 years) had aortic or arch branch vessel injuries. Isolated aortic injury occurred in 15 (9%) of 166 patients. Branch vessel injury occurred in 9 (5%) of 166 patients; seven patients (10 branch vessels) had isolated branch vessel injury and two patients (three branch vessels) had branch vessel injury associated with aortic injury. The injured branch vessels were brachiocephalic artery (four), left common carotid artery (four), left subclavian artery (three), right internal mammary artery (one), and left vertebral artery (one). The types of branch vessel injuries included intimal tears (nine vessels; 69%), and transection causing a pseudoaneurysm (four vessels; 31%). Revised Trauma Scores in patients with branch vessel injuries were 12 in seven patients and 11 and 4 in one each. CONCLUSION: We emphasize the angiographic findings in these patients that can at times be quite subtle. Awareness of the incidence of such injuries either in isolation or associated with aortic injury has implications regarding evaluation of this patient population with less invasive techniques such as CT or transesophageal echocardiography.     

Scapular fractures and concomitant injuries

Objective: The association of scapular fractures with other life-threatening injuries including blunt thoracic aortic injury is widely recognized.Few studies have investigated this presumed association...     

The multiply injured patient

The multiply injured patient with significant thoracic and extra-thoracic injuries poses a number of challenges. Pericardial tamponade, tension pneumothorax and massive hemothorax can and should be diagnosed clinically. In more stable patients, chest computed tomography (CT) scan is an excellent screening test. The concept of damage control resuscitation and damage control surgery have shown promise in patients with multiple, critical injuries. Beta-blockade of patients with blunt thoracic aortic injuries can be used as a temporizing damage control measure when the risks of operation or intervention are very high (traumatic brain injury, severe right or bilateral pulmonary contusion, unstable pelvic fractures). Patients with multiple penetrating wounds require the surgical team to be expeditious and flexible, and damage control is a helpful strategy in these patients.     

Blunt thoracic trauma in children: review of 137 cases.

OBJECTIVE: Thoracic injuries are uncommon in children and few report present on blunt ones. METHODS: Between 1994 and 2003, 137 children with blunt thoracic injury were reviewed. RESULTS: The mean age of children was 6.9+/-7.3 (1-16) years. Etiology was falls in 46.7%, traffical accidents in 51% and abuse in 2.2%. Average height in fallen-down cases was 6.4+/-2 (range: 3-11) m. Calculated mean kinetic energy transfer to body was 1923+/-1056 J. When first seen, 70% (82/117) of the patients had vital signs that were within normal limits. Forty-two (35.9%) children had isolated thoracic injury. Associated injuries were present in 75 (64.1%) children. Head injury was the most common associated injury present in 33 (28.2%). Pulmonary contusion was the most common thoracic injury with 68 (49.6%). Seventeen (12.4%) required surgery, 11 (8%) of them were thoracic (4 for diaphragmatic tear, 2 for flail chest, 2 for tracheobronchial injuries, 2 for laceration, 1 for esophageal rupture). Surgical group had higher ISS (26.8 vs 36.2, P = 0.001). Fifteen were lost (10.9%): There were lethal injuries in 7; chest tube treatment in 3; intensive care unit management in 2; mechanical support in 2 and observation in 1 patient. No death occurred for operations. Mortality rate was the lowest at injuries to chest alone and the highest for multi-system injuries (P < 0.05). The hospital length of stay for averaged 13.4+/-8.8 (range: 4-49) days. CONCLUSION: Associated injury is the most important mortality factor. Thoracic operations can be performed with minimal morbidity and without mortality in children with blunt thoracic trauma.     

Computed tomography of the spine as an important diagnostic tool in the management of war missile spinal trauma

Twenty-two patients with spinal injury were evaluated by plain radiography immediately after hospital admission. In 14 patients whose condition was stable, we performed computed tomography (CT) scanning through the involved segments. To provide better planning before neurosurgical management, we divided the vertebral column in thirds. According to this division, we concluded that these injuries are mostly extensive, severely damaging all three thirds of the vertebral column and accompanying neural structures in the majority of cases. The information acquired by CT concerning bony fragments, bone destruction, dural tear, spinal cord and nerve root compression, and neural damage directly influenced the surgical management. All patients except one underwent surgery while associated injuries of other organs were given priority in management. Injuries of the thoracic and the lumbar spine were the most common ones, frequently found in association with lesions of nearby organs. Penetrating injuries with a dural lesion were present in the majority of cases, while spinal cord injury was obvious in some. They were all well visualized using spinal CT scanning. Our view is that the role of CT is essential in guiding surgical management of war missile injuries to the spine. Received: 18 February 1997     

家兔闭合性胸部创伤早期影像学检查的诊断价值

目的探讨放射性核素显象、胸部CT和X线检查对家兔闭合性胸部创伤的早期诊断价值. 方法建立单侧胸部撞击伤动物模型,采用单光子发射计算机断层显象(SPECT)、胸部CT和X线片对闭合性胸部创伤进行早期诊断,并与病理解剖结果进行对照观察. 结果伤后30分钟伤侧肺感兴趣区致伤部位/心脏部位(ROI2/ROI1)比值立即升高,至伤后6小时达到高峰;对侧肺相对应部位/心脏部位(ROI3/ROI1)比值缓慢升高,至伤后6小时达到高峰,但仍小于伤侧肺,双侧肺之间比较差别具有显著性意义(P＜0.01). 结论胸部X线片检查仍是诊断胸部创伤最基本的方法,但对严重的胸部创伤和多发伤患者应尽早做胸部CT检查,SPECT对肺挫伤有较高的诊断价值.CT对肺挫伤的诊断敏感性优于X线片,但对渗出和水肿则不如SPECT灵敏、准确. 因此,对严重胸部创伤、多发伤患者,急诊检查应采用CT,以尽快明确诊断.     

上胸椎椎弓根螺钉固定并发症的探讨

目的分析上胸椎椎弓根螺钉固定的并发症,总结其手术技巧和经验。方法回顾性分析2009年4月至2012年4月采用T1~4椎弓根螺钉技术治疗的各类上胸椎损伤68例(共384枚螺钉),上胸椎骨折/脱位45例,均行Ⅰ期后路切开复位内固定术;结核合并后凸畸形23例,均行前路病灶清除植骨融合内固定术+后路矫形术。所有患者结合术中胸椎椎弓根四壁探查、术后手术节段椎体X线片、CT扫描,观察螺钉在椎弓根内的位置、角度及与椎弓根壁的关系和距离。结果椎弓根壁损伤54枚(14.06%),其中外侧壁损伤39枚(10.16%),包括Ⅰ级损伤27枚(7.03%),Ⅱ级损伤12枚(3.12%);内侧壁损伤15枚,均为Ⅰ级损伤。无1枚螺钉损伤上下壁,无1枚螺钉同时损伤超过2个壁,无术中置钉失败,螺钉松动位移2枚,创伤患者Frankel分级无加重,非创伤患者脊髓功能JOA评分由术前的5.9分提高至术后的11.5分,未发现植骨不融合、假关节形成或节段不稳表现。结论上胸椎椎弓根螺钉固定的并发症发生率低,是相对安全的操作方法。术前详细分析影像学资料、熟悉局部解剖特点、掌握合理的置钉技术,可有效避免并发症的发生。     

Celiac dissection after blunt abdominal trauma complicated by acute hepatic failure: case report and review of literature

Injuries of the abdominal visceral vessels are uncommon but devastating entities resulting in extremely high rates of mortality. The most common cause of abdominal vascular injuries is penetrating trauma, accounting for 90% to 95% of these injuries. In contrast, blunt trauma accounts for 5% to 10% of all abdominal vascular lesions. Although traumatic injury to the celiac artery is among the rarest of all vascular injuries, mortality can be as high as 75%. We report a 66-year-old patient who sustained multiple injuries in a motor vehicle crash. The initial whole-body computed tomography (CT) scan revealed a combination of severe brain injury and bilateral thoracic lesions. On day 6 after the accident, the patient's clinical situation deteriorated rapidly. At this time, the abdominal arterial CT scan showed a dissection of the celiac artery. Therapeutic anticoagulation was not feasible because of the intracranial hemorrhage. Also the patient's clinical situation worsened so rapidly that interventional therapy, including surgical and endovascular treatment, could not be performed. Finally, the patient died of fulminant hepatic failure, therefore not surviving a potentially treatable injury. The diagnosis of celiac artery dissection in this patient was significantly delayed because the initial trauma CT protocol did not include an arterial phase of the abdominal vessels.     

Clinical study of multiple traumas with severe facial injury undergoing emergency endovascular treatment: significance of emergency embolization of the external carotid artery

The outcome of multiple injures freqently depends on the priority of treatments, and the decision as to the procedures and timing of primary care is extremely important. We studied the patients with multiple trauma whounderwent emergency endovascular treatment for facial hemorrhage related to external carotid arterial injury. The subjects are 5 patients who underwent embolization of the external carotid artery by an endovascular approach among patients with multiple traumas who were brought to our hospital by ambulance. In these patients, the vital signs on arrival, interval between injury and intravascular surgery, type of brain injury, type and grade of concurrent injury and outcome were studied. Three patients showed hemorrhagic shock on arrival, and 1 patient showed hemorrhagic shock immediately after arrival. The mean interval between injury and endovascular surgery was 3.9 hours. All patients had skull base fracture, and abnormal intracranial lesions on initial CT including 4 focal injuries and 1 diffuse injury. Moderate to severe thoracic/abdominal injuries were noted in 3 patients. In the remaining 2 patients, there was no trauma in the thoracic or abdominal regions. Intraperitoneal hemorrhage with splenic injury was observed in 3 patients. In 3 of 4 patients died by hemorrhagic shock because of the delay of endvascular treatments. In trauma patients with persistent hemorrhage, emergency endovascular treatment should be considered as a primary survey for initial treatment without delay under intensive conservative treatment.