CT diagnosis of cardiac and pericardial injuries

The purpose of this retrospective study was to determine the CT findings diagnostic of cardiac and pericardial injury, including signs of pericardial tamponade, in patients suffering from blunt and penetrating trauma. A search of the CT radiology database at a level I trauma center was performed to identify cases in which injury to the heart or pericardium was diagnosed, as well as to identify cases of pericardial tamponade. All cases were reviewed to ascertain the specific CT findings, and medical records were reviewed to assess the influence of CT findings on management and to assess for clinical evidence of pericardial tamponade. Eighteen patients had direct CT evidence of cardiac or pericardial injury, including nine cases of pneumopericardium, eight cases of hemopericardium, and one case of intrapericardial gastric herniation. Four of these patients were found to have direct cardiac injuries. Three additional cases with CT evidence of pericardial tamponade were identified, two secondary to cardiac compression by an anterior mediastinal hematoma and one following repair of left ventricular rupture. Of 11 patients with CT evidence of tamponade, only three were suspected clinically. Cardiac and pericardial injuries are usually diagnosed surgically and are often clinically unsuspected, particularly in blunt trauma. As CT is increasingly utilized as a general screening test for thoracic/abdominal trauma, these injuries may be first suspected on the basis of CT findings, and knowledge of the CT findings of cardiac injury or tamponade is crucial.     

Routine abdominal ultrasonography and computed tomography in multiple trauma patients: relevance to therapy in 105 patients

Purpose: To examine treatment decisions in multiple trauma patients and determine how often these decisions are based on abdominal ultrasonography (US) findings, and how frequently these decisions are altered by subsequent computed tomographic (CT) imaging. Methods: From August 1996 to July 1997 we prospectively performed abdominal US followed by abdominal CT in all hemodynamically stable multiple trauma victims who did not need immediate surgery. We recorded the results from both modalities, as well as the treatment decisions based on these results. We also noted how frequently therapy based on US results was altered by the subsequent CT findings. Results: Treatment decisions were influenced by either US or CT in 27 of 105 patients (25.7 %). US was interpreted as normal in 76 patients (72.4 %), including 5 (6.6 %) who were subsequently found to have therapeutically significant findings on CT. US was interpreted as abnormal in 29 (27.6 %) patients, 12 of whom (41.4 %) had their management altered by subsequent CT results. Conclusions: Abdominal CT findings prompt changes in therapy in only a small number of stable multiple trauma patients who exhibit normal abdominal US. On the other hand, CT may have an impact on acute therapy in a large number of patients who exhibit abnormal US. Our results demonstrate that a diagnostic approach in hemodynamically stable patients is possible with US serving as a decision maker to determine whether further CT imaging is needed.     

Computed tomography of blunt and penetrating diaphragmatic injury: sensitivity and inter-observer agreement of CT Signs

Diaphragmatic injury is an uncommon but clinically important entity in the setting of trauma. Computed tomography (CT) is widely used to evaluate hemodynamically stable trauma patients. While prior studies have identified CT signs of diaphragm injury in blunt or penetrating trauma, no study has directly compared signs across these two types of injuries. We identified patients with surgically proven diaphragm injuries who underwent CT at presentation. Three reviewers examined each for 12 signs of diaphragm injury, as well as for an overall impression of diaphragm injury. We reviewed a total of 84 patients (37 % blunt trauma, 63 % penetrating). The initial interpreting radiologists discovered 77 % of blunt and 47 % of penetrating injuries (p?=?0.01). We found that the majority of signs of diaphragmatic injury were split between those common in blunt trauma and those common in penetrating trauma, with minimal overlap. The presence of at least one blunt injury sign has 90 % sensitivity for diaphragm injury in blunt trauma; the presence of a wound tract traversing the diaphragm has 92 % sensitivity in penetrating trauma. Inter-observer reliability of these signs is also high (κ?>?0.65). Penetrating diaphragm injuries present a different spectrum of imaging findings from those in blunt trauma and are underdiagnosed at CT; looking for a wound tract traversing the diaphragm is highly sensitive for diaphragm injury in these cases. Signs of organ or diaphragm fragment displacement are sensitive for blunt diaphragm injuries, consistent with these injuries being caused by increased intra-abdominal pressure.     

Cervical spine injury: accuracy of helical CT used as a screening technique

Objective: The study objective was to determine the sensitivity and specificity of a helical CT technique to screen for cervical spine injury in a high-risk trauma population. Materials and methods: The helical CT reports for a consecutive series of 601 high-risk adult blunt trauma victims were reviewed. Findings were confirmed using an independent reference standard, which consisted of additional cervical spine imaging (CT, MRI, or radiography), operative findings, autopsy results or clinical outcome. Results: Sensitivity and specificity of helical CT for injury were 77/81 (95 %; 95 % confidence limits: 90–100 %) and 484/520 (93 %; 95 % confidence limits 91–95 %) respectively. Four false negative cases were comprised of three missed ligamentous injuries and one missed fracture. False positive cases (n = 36) were mostly attributed to possible facet fracture (n = 6), possible ligamentous injury (n = 8) or technically inadequate scan (n = 6).The overall accuracy of the helical CT protocol for cervical spine injury in this population was 561/601 (93 %; 95 % confidence limits 91–95 %). Conclusion: Helical CT has high accuracy for cervical spine injury. We believe that helical CT should be the preferred imaging strategy in high-risk blunt trauma patients.     

Blunt injury to mesentery and small bowel: CT evaluation

Helical CT now allows rapid acquisition of sections through the abdomen and pelvis with optimal vascular opacification and minimal motion artifact. Oral contrast may aid in the identification of subtle bowel and mesenteric injuries and does not have any significant deleterious effects. CT findings of extraluminal enteric contrast, active hemorrhage, or free intraperitoneal-retroperitoneal air allow accurate diagnosis of SBMI in the setting of blunt abdominal trauma. Mesenteric hematoma in association with bowel wall thickening or the presence of significant amounts of free fluid without solid organ injury is highly suspicious for SBMI requiring laparotomy. CT alone or in concert with DPL and physical examination is a valuable tool in the timely diagnosis and treatment of bowel and mesenteric injury caused by blunt trauma.     

CT scanning of children with blunt abdominal trauma – is oral contrast useful?

Purpose: To determine the usefulness of oral contrast in CT scanning of children with blunt abdominal trauma by comparing scans performed with and without oral contrast. Methods: CT scans of 273 children with abdominal trauma and 40 without trauma were reviewed. Results: Of the trauma patients, 116 (43 %) were scanned with oral contrast, 157 (57 %) without. Among the children who underwent laparotomy, CT scanning identified 6 of 6 organ injuries in those scanned with oral contrast and 11 of 12 in those scanned without. CT scanning identified all bowel injuries. The pancreatic body and tail were significantly better visualized in scans with oral contrast. Detection of pancreatic or liver injury was not, however, significantly different in the two groups. Opacification of the bowel by contrast was significantly better in elective than in trauma patients. Conclusion: There was no difference in detection of injuries between children scanned with and without oral contrast.     

Acute tamponade after blunt chest trauma

We report a case of high-impact blunt chest trauma resulting in bilateral lung contusion and rupture of the right atrial appendage with subsequent hemopericardium leading to acute right heart failure. Although tamponade remains a clinical diagnosis, in this case CT findings confirmed the diagnosis, initially unsuspected, which led to successful therapeutic intervention. We believe that in patients with high-velocity trauma and possible blunt injury to the chest, a cardiac injury should always be searched for and excluded.     

Computed tomography of pediatric blunt abdominal trauma

Computed tomography (CT) is the imaging method of choice in the evaluation of hemodynamically stable children after blunt abdominal trauma. Evaluation with CT will show whether intraperitoneal fluid or blood is present and whether the liver, spleen, kidneys, and pancreas are intact. Although the principal role of CT after blunt abdominal trauma is the assessment of solid viscus injury, an unintended consequence of the increased utilization of CT in this setting is that an increased number of children with hollow viscus injury are being evaluated. CT can reliably depict injury to these hollow viscera, although the diagnosis of such injury is not as straightforward as with solid viscus injury. This essay reviews indications for CT, technique for the performance of CT, and CT findings associated with hollow and solid viscus injury and posttraumatic shock.     

Should an MR scan be performed routinely after a normal clearance CT scan in the trauma patient? Experience with 59 cases

Magnetic resonance (MR) imaging is not routinely used to exclude ligamentous and other soft tissue injury in the unconscious trauma patient. In order to determine the frequency and types of soft tissue injuries detected by MR imaging but not by computed tomography (CT), we performed a retrospective investigation comparing the MR findings in 59 trauma patients, either alert or unconscious, who previously had undergone a negative clearance multislice CT study of the cervical spine. Six patients had abnormalities not identified on the CT studies, including four cases of ligamentous injury.     

Perisplenic pseudolesion: a case report and literature review

Distinguishing a normal variant from true pathology is a frequent task of the imager. In the assessment of the trauma patient, rapid determination of the presence or absence of intraabdominal injury is of paramount importance. We present the sonographic findings of an anatomic variant detected in a patient following blunt abdominal trauma. Trauma sonogram revealed an elongated left lobe of the liver mimicking a subcapsular splenic hematoma. This case illustrates the importance of recognizing this potential pitfall in the setting of abdominal trauma. An equivocal trauma sonogram can lead to critical delays in treatment of associated injuries and unnecessary additional imaging or even surgery.     

CT cystography versus conventional cystography in evaluation of bladder injury.

OBJECTIVE: The objective of this study was to evaluate prospectively the use of CT cystography, using retrograde filling of the bladder with diluted iodinated contrast material, versus conventional cystography to identify bladder injury in patients with hematuria after blunt abdominal trauma. SUBJECTS AND METHODS: Inclusion criteria consisted of the adult hemodynamically stable abdominal trauma patient with hematuria referred for abdominopelvic CT and also being considered for cystography. An initial abdominopelvic CT scan using IV iodinated contrast material was obtained, as would have been done routinely in the trauma victim. A second CT scan through the pelvis was obtained after retrograde distention of the bladder with dilute iodinated contrast material. CT cystography revealing bladder injury was followed with appropriate therapy. CT cystograms not revealing injury were followed by conventional cystography. Results of patient outcome were evaluated. RESULTS: Over a 21-month period from January 1995 through September 1996, CT cystography was performed on 55 patients who presented with hematuria after blunt abdominal trauma. Five of the 55 patients had bladder injury on CT cystography. The injury in each of these five patients was confirmed intraoperatively. In the remaining 50 patients, both CT and conventional cystography did not reveal bladder injury. CONCLUSION: CT cystography is an accurate method for evaluating bladder injury in the blunt abdominal trauma victim with hematuria. CT cystography, performed in conjunction with routine CT of the abdomen and pelvis for evaluating traumatic hematuria, would therefore preclude conventional cystograms in these patients.     

Imaging of blunt chest trauma

In western European countries most blunt chest traumas are associated with motor vehicle and sport-related accidents. In Switzerland, 39 of 10,000 inhabitants were involved and severely injured in road accidents in 1998. Fifty two percent of them suffered from blunt chest trauma. According to the Swiss Federal Office of Statistics, traumas represented in men the fourth major cause of death (4 %) after cardiovascular disease (38 %), cancer (28 %), and respiratory disease (7 %) in 1998. The outcome of chest trauma patients is determined mainly by the severity of the lesions, the prompt appropriate treatment delivered on the scene of the accident, the time needed to transport the patient to a trauma center, and the immediate recognition of the lesions by a trained emergency team. Other determining factors include age as well as coexisting cardiac, pulmonary, and renal diseases. Our purpose was to review the wide spectrum of pathologies related to blunt chest trauma involving the chest wall, pleura, lungs, trachea and bronchi, aorta, aortic arch vessels, and diaphragm. A particular focus on the diagnostic impact of CT is demonstrated. Received: 29 November 1999; Accepted: 28 January 2000     

Thoracic computed tomography in victims of blunt trauma: changes in utilization after the introduction of helical technology

Purpose: In blunt trauma, CT of the thorax is often performed because of the limitations of plain film chest radiography in accurately depicting injuries to the thoracic aorta. The advent of helical CT has allowed the entire chest to be imaged more expeditiously. We will evaluate the extent to which this ability to rapidly obtain additional images of the thorax has increased the utilization of chest CT in blunt trauma. Methods: The radiologic records of all victims of blunt trauma who underwent total body CT (TBCT), which included abdomen, pelvis, and chest images, in the 10 months before and 10 months after our institution acquired helical CT (HCT), were retrospectively evaluated. Results: In the 10 months before we obtained HCT, 520 conventional CT of the abdomen and pelvis were completed, of which only 11 (2.1 %) included images of the full thorax. After HCT was instituted, 684 abdomen and pelvis CT were performed, of which 59 (8.6 %) were ordered with the entire chest. Of the 11 conventional TBCT, 6 (55 %) showed findings in the chest; in 2 of these cases (18 %) the abnormalities were confined exclusively to the thorax. Similarly, of the 59 helical TBCT, 31 (53 %) depicted traumatic abnormalities in the thorax, and in 23 of these cases (39 %) injuries were only within the chest. In 4 of the latter the injuries were mediastinal hematomas, 1 of which (25 %) was confirmed angiographically to represent an aortic laceration. Conclusion: The speed and ease with which additional images can be obtained by HCT has greatly increased utilization of cross-sectional imaging of the thorax after blunt trauma (approximately four-fold). Over half of these depict traumatic injuries.     

CT evaluation of pediatric abdominal trauma: pitfalls and quandaries

CT of the pediatric abdomen after blunt trauma has become a widely accepted technique for evaluation of hepatic and splenic injury. However, detection of hollow viscus and pancreatic injury remains challenging and controversial. Detection of bowel rupture (extravasated oral contrast, bowel discontinuity), pancreatic injury (laceration, separation of fragments) and bladder rupture may be difficult, particularly with inadequate technique and lack of vigilance. This article reviews findings associated with several injuries which may present diagnostic pitfalls as well as technical factors relating to the administration of enteric contrast and CT cystography.     

Diagnostic pelvic computed tomography in the rectal-injured combat casualty

BACKGROUND: The current standard for evaluating trauma patients for penetrating rectal injury is to perform a rigid proctoscopy. This can be laborious and inaccurate. Injuries are often not visualized and a small number of unnecessary colostomies may be created. Computed tomography (CT) scanning of the pelvis may be useful in identifying penetrating rectal injuries. STUDY DESIGN: A retrospective analysis was performed on data regarding all casualties admitted to the 10th Combat Support Hospital during the period of November 2005 through March 2006. Nineteen patients were identified. Patients that were hemodynamically stable underwent preoperative CT scanning. All rectal injuries diagnosed preoperatively were confirmed through a different diagnostic modality in the OR. RESULTS: Nineteen patients with rectal injury or suspected rectal injury were identified. Eight of the 19 were hemodynamically unstable in the emergency medical treatment area and were taken emergently to surgery. For discussion, only stable patients with gunshot wound or blast/fragmentation injury mechanisms were included. No injuries were missed by CT scanning, but there were two false-positive scans. CONCLUSIONS: In our brief experience, CT scanning was a useful screening tool to assist in identifying patients with penetrating traumatic rectal injuries. It allowed us to improve triage and make effective use of limited operative resources.     

Odontoid fractures following blunt trauma

Fractures of the odontoid process typically result from forceful blunt trauma. They often produce instability of the cervical spine, and may be associated with neurologic impairment. This study was designed to examine the epidemiology and demographics of odontoid injuries, including their incidence and prevalence relative to other spine injuries, the prevalence of associated injuries, and the likelihood of neurologic impairment. Of 34,069 enrolled blunt trauma victims, 818 (2.4 %) sustained a cervical spine injury, 94 of whom had a fracture of the odontoid. The relative prevalence of odontoid fractures varied by age, ranging from less than 3 % among individuals under age 20 years, to greater than 20 % in patients over 80 years old. Classification by Anderson–D'Alonzo criteria revealed 6 type I injuries, 60 type II injuries, and 27 type III injuries; one vertical injury could not be categorized. Over half of the odontoid fracture victims sustained additional cervical spine injuries, with 90 % of these injuries involving the atlanto-axial complex. In addition, non-spine-related injuries were found in 52 % of odontoid injury victims, over one-third (34 %) presented with an altered level of alertness, and almost one-quarter (23 %) exhibited some form of focal neurologic deficit associated with their injury. Fractures of the odontoid are among the most frequently encountered cervical spine injuries, and increase in prevalence with increasing patient age. Odontoid fracture victims often have other spine injuries, particularly to the atlanto-axial complex, and may harbor other non-spine-related injuries and neurologic pathology.     

Nonoperative management of hepatic trauma

In an attempt to determine whether selective, nonoperative management of hepatic trauma might be efficacious, a retrospective review of liver injuries was undertaken. Of the 48 patients with liver injuries identified, there were 34 men and 14 women with an average age of 28.5 years. Mechanism of injury consisted of blunt trauma in 23 patients, stab wounds in 14 patients, and 11 patients had gunshot wounds. There were 12 grade I injuries, 15 grade II injuries, 17 grade III injuries, 2 grade IV injuries, and 1 grade V injury. Diagnosis of liver trauma was made at the time of exploratory laparotomy in 15 patients and suggested by abdominal computed tomography (CT) scan in 18 patients; the remaining 15 patients had a positive peritoneal lavage which led to exploratory laparotomy. Following blunt trauma, 14 patients, all of whom underwent diagnostic abdominal CT scans which confirmed hepatic injury, had nonoperative treatment. All patients who received nonoperative management maintained stable vital signs and only five required transfusion. None of the patients who were treated nonoperatively developed complications or required delayed laparotomy. There were no deaths in this group. Of the 34 patients undergoing exploratory laparotomy, 19 required either no treatment or minor hepatorrhaphy. However, 17 of 25 patients with penetrating wounds had associated abdominal injuries which required operative treatment. Based on the information obtained in this review, it is recommended that stable patients with isolated hepatic injuries, secondary to blunt trauma confirmed by CT scan, may be managed nonoperatively. Due to the high frequency of associated injuries found in patients with penetrating trauma, nonoperative therapy is not advised.     

Thoracic venous injuries: an imaging and management overview

Thoracic venous injuries are predominantly attributed to traumatic and iatrogenic causes. Gunshot wounds and knife stabbings make up the vast majority of penetrating trauma whereas motor vehicle collisions are the leading cause of blunt trauma to the chest. Iatrogenic injuries, mostly from central venous catheter complications are being described in growing detail. Although these injuries are rare, they pose a diagnostic challenge as their clinical presentation does not substantially differ from that of arterial injury. Furthermore, the highly lethal nature of some of these injuries provides limited literature for review and probably underestimates their true incidence. The widespread use of multi-detector computed tomography (MDCT) has increased the detection rate of these lesions in hemodynamically stable patients that survive the initial traumatic event. In this article, we will discuss and illustrate various causes of injury to each vein and their supporting CT findings while briefly discussing management. The available literature will be reviewed for penetrating, blunt, and iatrogenic injuries to the vena cava, innominate, subclavian, axillary, azygos, and pulmonary veins.     

Standardized whole-body computed tomography as a screening tool in blunt multitrauma patients

The authors present the potential of using a preset CT protocol covering the whole body of the patient who has suffered blunt trauma to screen for injuries, based on a review of the literature and on 4 years' direct experience. Standardized whole-body CT is the fastest method of examining the whole body, capable of detecting a wide variety of traumatic lesions with a high sensitivity and specificity. Multidetector CT allows a full-body examination to be completed within 5 min, thus minimizing time to diagnosis and the institution of definitive clinical care. Current imaging algorithms that include abdominal ultrasonography and plain radiographic studies need to be reassessed in view of the technical advances in CT diagnosis, but should ultimately depend on the particular imaging capabilities and experience of a given trauma center.     

CT diagnosis of diaphragm injuries

Admission supine chest radiographs are the initial and most commonly performed imaging study to evaluate the thorax following trauma. Whenever the chest radiograph is ambiguous or suggestive of a diagnosis of acute diaphragmatic injury, CT is the next study of choice since it is generally available and often used to examine other body regions of the polytraumatized patient. CT is usually diagnostic, particularly if supplemented by multiplanar reformations obtained using a thin slice thickness. Currently MR imaging is used at our trauma center to evaluate the diaphragm in patients with an indeterminate diagnosis after spiral CT. A limited MR imaging examination with T1-weighted sagittal and coronal imaging has been extremely accurate in establishing or excluding diaphragm injury.