Repeat abdominal computed tomography scans after pediatric blunt abdominal trauma: missed injuries, extra costs, and unnecessary radiation exposure

Purpose

We hypothesized that pediatric blunt trauma patients, initially evaluated at nontrauma centers with abdominal computed tomography (CT) scans, often undergo repeat scans after transfer. This study was designed to quantify this phenomenon, assess consequences, and elucidate possible causes.

Methods

This article is an institutional review board-approved, retrospective chart review of pediatric blunt abdominal trauma patients transferred to a level I trauma center from 2002 to 2007 and evaluated with abdominal CT at the trauma center or at a referring facility.

Results

A total of 388 patients met the study criteria, with 6 patients being excluded because of inability to verify outside records resulting in study group of 382 patients. Of those 382 patients, 199 (52%) underwent abdominal CT before transfer. Thirty-six (18%) of those 199 patients underwent repeat CT scanning at our level I trauma center. Of these 36 patients, 19 (53%) were transferred without their outside CT scans, with 10 (53%) of these 19 having significant abdominal injuries. Of the remaining 17, 6 (17%) had repeat scans to assess changes in vital signs, or patient condition, or because of inadequate outside imaging. The remaining 11 (30%) were repeated despite an acceptable outside CT and no change in patient condition. Only 2 of 11 resulted in changed management. Additional radiation delivered from these repeat scans totaled 180 mSv, and additional patient charges totaled more than $110,000. There was an apparent trend toward increased repeat scanning (from 6.7% in 2002 to 16.7% in 2007).

Conclusions

Abdominal CT scans, for evaluation of pediatric blunt trauma, are frequently repeated after transfer from outside hospitals. In many cases, repeat scans provide useful diagnostic information. However, more than 80% of repeat scanning is potentially preventable with better education of transport personnel (paramedics, emergency medical technicians, and nurses) and emergency department physicians.     

Clinical significance of isolated intraperitoneal fluid on computed tomography in pediatric blunt abdominal trauma

Purpose

The finding of isolated free intraperitoneal fluid (FIPF) on computed tomography of the abdomen (CTA) in children after blunt trauma is of unclear clinical significance and raises suspicion for a solid or hollow viscus injury. In our institution, pediatric blunt trauma patients presenting with isolated FIPF on CTA who are hemodynamically stable and have no peritoneal signs on initial physical examination (iPE) have been historically approached nonoperatively. We reviewed our level 1 trauma center experience with this subset of the trauma population and sought to (1) justify an initial nonoperative approach and (2) identify early predictors of the eventual need for surgical exploration.

Methods

Data on all trauma patients less than 14 years of age admitted to our hospital from 2001 to 2006 after Blunt Abdominal Trauma (BAT) whose screening CTA showed FIPF and no other radiographic signs of solid or hollow viscus injury were retrieved from the local trauma registry. Clinical progress, operative findings, and follow-up were obtained by hospital and office chart review, as well as telephone contact. Mechanism of injury (MOI); Injury Severity Score (ISS); Revised Trauma Score; Pediatric Trauma Score (PTS); the presence of abdominal tenderness or external signs of injury on iPE; and quantity, location, and density of the FIPF were statistically analyzed as possible early predictors of the eventual need for surgical exploration.

Results

A total of 670 children admitted to our institution after blunt trauma were evaluated with CTA during the time of enrollment. Isolated FIPF was found in 94 individuals (14%). Mean age was 9.7 (±SD 3.2) years; 52% were males. Motor vehicle crash was the most common MOI. Mean PTS was 10.6 (±SD 1.8). Mean ISS was 10.2 (±SD 7.2). Free intraperitoneal fluid was most commonly found in only one intraperitoneal region (93%). Most patients (97%) were discharged home without undergoing a surgical procedure. Three other patients developed peritonitis on serial physical examination and were surgically explored. Hollow viscus injuries were found in 2 of these individuals and treated with primary repair or segmental bowel resection. All surgical patients enjoyed a full recovery, with no postoperative complications. The presence of abdominal tenderness on iPE and the quantity of FIPF on initial CTA were the only studied variables to reach statistical significance as predictors of the eventual need for operative intervention. Follow-up after hospital discharge was obtained in 46.8% (44/94) and averaged 124.9 weeks.

Conclusion

To the best of our knowledge, this is the largest series of pediatric blunt trauma patients with isolated FIPF on CTA ever reported. Our findings justify an initial nonoperative approach for the management of these individuals. Abdominal tenderness on iPE and the quantity of FIPF on initial CTA were predictors of the eventual need for operative intervention.     

Small bowel perforations after blunt abdominal trauma: evaluation with computed tomographic scan and laparoscopy

Small bowel perforations are the consequences of violent blunt abdominal trauma. Diagnosis of small bowel perforation is suspected in case of acute pain associated with peritoneal signs (tenderness, followed by rigidity). Computed tomographic scan performed in emergency is often specific, showing intraperitoneal fluid without visible solid organ injury, bowel wall thickening, bowel wall discontinuity, extraluminal gas or small pneumoperitoneum. Explorative laparoscopy confirms the diagnosis of blunt bowel injuries and allows usually its treatment. We report herein two cases where we have chosen this strategy.     

Compliance with evidence-based guidelines for computed tomography of children with head and abdominal trauma

Introduction

Recently, two large prospective clinical trials developed and validated prediction rules for children at very low risk for clinically important traumatic brain injuries (ciTBI) or abdominal injury for whom CT is unnecessary. Specific criteria/guidelines were identified which if met would obviate the need for CT scanning. The purpose of this study was to assess compliance at a level one pediatric center with these guidelines as a tool for quality improvement.

Evaluation of ultrasound,lavage, and computed tomography in blunt abdominal trauma

Summary We have analysed the data of 136 patients with multiple injuries treated between 1983 and 1988 in order to assess the sensitivity, specificity, and accuracy of ultrasound, lavage and computed tomography (CT) for the preoperative diagnosis of blunt abdominal trauma. CT was carried out in doubtful cases (n=29) if ultrasound and lavage had not provided sufficient information. Fifty-eight patients were primarily excluded from the study because neither clinical examination nor ultrasound gave any sign of an intra-abdominal lesion. In 25 cases, sonography could be compared with lavage, CT, and the intraoperative situs. Ultrasound showed reliable results in respect to accuracy (100%), sensitivity (84%), and specificity (98%). Computed tomography confirmed all sonographic diagnoses in 29 patients but did not provide further information. Peritoneal lavage gave correct information in all patients operated upon. Our 5-years' experience suggests that ultrasound is a reliable, quick, cheap, and repeatable technique of great value in patients with blunt abdominal traumata.Presented at the International Congress on Surgical Endoscopy, Ultrasound, and Interventional Techniques, Berlin 1988     

Prevalence and importance of pneumothoraces visualized on abdominal computed tomographic scan in children with blunt trauma

BACKGROUND: Chest radiographs are routinely obtained for the identification of pneumothoraces in trauma patients. Computed tomographic (CT) scanning has a higher sensitivity for the detection of pneumothoraces, but the prevalence and importance of pneumothoraces detectable by CT scan but not by chest radiography in children sustaining blunt trauma is unclear. METHODS: We conducted a prospective observational cohort study of children less than 16 years old with blunt trauma undergoing both abdominal CT scan and chest radiography in the emergency department of a Level I trauma center over a 28-month period. All abdominal CT scans were interpreted by a single faculty radiologist. The chest radiographs of all patients with pneumothoraces detected on CT scan as well as a random sample of chest radiographs from pediatric blunt trauma patients without pneumothoraces on abdominal CT scan (in a ratio of four normals per pneumothorax) were reviewed by a second faculty radiologist. Both radiologists were masked to all clinical data as well as to the objective of the study. RESULTS: Five hundred thirty-eight children underwent both abdominal CT scan and chest radiography in the emergency department. Twenty patients (3.7%; 95% confidence interval [CI], 2.3-5.7%) were found to have pneumothoraces on CT scan. Of these 20 patients, 9 (45%; 95% CI, 23-68%) had pneumothoraces identified on initial chest radiography and 11 patients did not ("unsuspected pneumothoraces"). Twelve pneumothoraces were identified in these 11 patients; 6 were graded as minuscule and 6 as anterior according to a previously established scale. One patient with an unsuspected pneumothorax underwent tube thoracostomy. None of the 10 patients (0%; 95% CI, 0-26%) with unsuspected pneumothoraces who were managed without thoracostomy (including two patients who underwent positive pressure ventilation) had complications from their pneumothoraces. CONCLUSION: Less than half of pediatric blunt trauma patients with pneumothoraces visualized on abdominal CT scan had these pneumothoraces identified on initial chest radiograph. Patients with pneumothoraces identified solely on abdominal CT scan, however, uncommonly require tube thoracostomy.     

Chinese Journal of Traumatology won the financial aid from ＂Global Influ- ence Promotion Project for Chinese Scientific and Technical Journals＂

Objective： To determine the frequency of adrenal injuries in patients presenting with blunt abdomi- nal trauma by computed tomography （CT）. Methods： During a 6 month period from January 1, 2011 to June 30, 2011, 82 emergency CT examinations were performed in the setting of major abdominal trauma and ret- rospectively reviewed for adrenal gland injuries. Results： A total of 7 patients were identified as having adrenal gland injuries （6 males and 1 female）. Two patients had isolated adrenal gland injuries. In the other 5 patients with nonisolated injuries, injuries to the liver （1 case）, spleen （1 case）, retroperitoneum （2 cases） and mesentery （4 cases） were identified. Overall 24 cases with liver injuries （29 %）, 11cases with splenic injuries （13%）, 54 cases with mesenteric injuries （65%）, 14 cases （17%） with retroperitoneal injuries and 9 cases with renal injuries were identified. Conclusion： Adrenal gland injury is identified in 7 patients （11.7%） out of a total of 82 patients who underwent CT after major abdominal trauma. Most of these cases were nonisolated injuries. Our experience indicates that adrenal injury resulting from trauma is more common than suggested by other reports. The rise in incidence of adrenal injuries could be attributed to the mode of injury.     

Evaluation of the lower spine after blunt trauma using abdominal computed tomographic scanning supplemented with lateral scanograms

BACKGROUND: Patients at risk for thoracolumbar junction (TLJ) and lumbar spine (LS) injury after blunt trauma are classically evaluated using conventional radiographs. Frequently, these patients also undergo abdominal and pelvic computed tomographic (CT) scanning to exclude the presence of associated intra-abdominal injuries. Standard abdominal and pelvic CT scan usually includes an anteroposterior (AP) scout film (scanogram) obtained before the cross-sectional imaging. The objective of this study was to determine whether a lateral CT scanogram and axial CT views would provide adequate imaging to allow for evaluation of the TLJ and LS and therefore eliminate the need for conventional screening computed lumbar spine radiographs (CLSRs). METHODS: Patients who sustained blunt injury and required both CLSRs as well as abdominal and pelvic CT scans were prospectively identified. The study protocol (CT + S) added lateral CT scanograms to all helical abdominal and pelvic CT scan studies. The AP and lateral CT scanograms were included with the axial images, and these views were reviewed together during final radiographic interpretation and diagnosis. The results of CT + S were compared with readings of the CLSRs (AP and lateral) in a blinded fashion by a trauma radiologist. RESULTS: Lateral scanograms were generated for 71 patients. All scanograms were technically adequate, with image quality equal or superior to computed plain radiographs. Ten patients were found to have 20 fractures, 19 acute and 1 chronic. All abnormalities identified by plain radiographs were seen using CT + S (sensitivity, 100%; specificity, 100%). Eight transverse process and two spinous process fractures not seen on CLSRs were identified using CT + S. CONCLUSION: Our CT + S protocol (axial CT images plus AP and lateral scanograms) outperformed screening CLSRs in the detection of fractures of the lower spine (TLJ + LS) after blunt trauma. In addition, scanogram imaging is less dependent on body habitus and adds no additional cost or time to abdominal and pelvic CT scanning. Further study is required to determine whether CT + S can routinely replace conventional radiographs of the lower spine after blunt trauma.     

ICU management of patients with suspected positive findings of diagnostic peritoneal lavage following blunt abdominal trauma

tiscontroversialwhethertoperformanexploratorylaparotomyona patientwithsuspectedbluntabdominaltrauma (BAT )suggestedby probablepositivediagnosticperitoneallavage(DPL)findings .1WereviewedthedatafromMay 1994toSeptember2 0 0 4 .Seventy sixpatients ,withuncertainresults ,weresenttoICUinourhospitalwithvitalsignscloselyandcontinuouslymonitored .TheyreceivedrepeatedDPLs ,ultrasoundorcontrastenhancedCTscanswhennecessary .Positiveresultswerefoundamong 17ofthem .Theyreceivedsurgicaltreatmentwithf…     

Isolated free fluid on computed tomographic scan in blunt abdominal trauma: a systematic review of incidence and management

BACKGROUND: Abdominal computed tomographic (CT) scan is accepted as the primary diagnostic modality in stable patients with blunt abdominal trauma. A recent survey of 328 trauma surgeons demonstrated marked variation in the management of patients with head injuries and the finding of free intra-abdominal fluid without solid organ injury on CT scan. This study was undertaken to attempt to determine what to do when free fluid without solid organ injury is seen on abdominal CT scan in patients with blunt trauma. METHODS: Articles concerning the incidence and significance of free intra-abdominal fluid on CT scan of blunt trauma patients without solid organ injury were systematically reviewed. A MEDLINE search was performed using terms such as tomography-x-ray computed, wounds-nonpenetrating, small intestine/injuries, time factors, and abdominal trauma and diagnostic tests. Bibliographies of pertinent articles were reviewed. Appropriate articles were evaluated for quality and data were combined to reach a conclusion. RESULTS: Meta-analysis could not be performed because no randomized, prospective, controlled trials could be found. Forty-one articles were excluded from the analysis because they looked at only patients with known injuries to intestine, diaphragm, or pancreas and the investigation of the CT scan findings did not include negative scans. Ten articles, which described CT scan results for all patients presenting with blunt abdominal trauma for a defined period of time, formed the basis of this study. Isolated free fluid was seen in 463 (2.8%) of over 16,000 blunt trauma patients scanned. A therapeutic laparotomy was performed in only 122 (27%) of these patients. CONCLUSION: The isolated finding of free intra-abdominal fluid on CT scan in patients with blunt trauma and no solid organ injury does not warrant laparotomy. Alert patients may be followed with physical examination. Patients with altered mental status should undergo diagnostic peritoneal lavage.     

The use of chest computed tomography versus chest X-ray in patients with major blunt trauma

INTRODUCTION: Computed tomography (CT) scans are often used in the evaluation of patients with blunt trauma. This study identifies the clinical features associated with further diagnostic information obtained on a CT chest scan compared with a standard chest X-ray in patients sustaining blunt trauma to the chest. METHODS: A 2-year retrospective survey of 141 patients who attended a Level 1 trauma centre for blunt trauma and had a chest CT scan and a chest X-ray as part of an initial assessment was undertaken. Data extracted from the medical record included vital signs, laboratory findings, interventions and the type and severity of injury. RESULTS: The CT chest scan is significantly more likely to provide further diagnostic information for the management of blunt trauma compared to a chest X-ray in patients with chest wall tenderness (OR=6.73, 95% CI=2.56, 17.70, p<0.001), reduced air-entry (OR=4.48, 95% CI=1.33, 15.02, p=0.015) and/or abnormal respiratory effort (OR=4.05, 95% CI=1.28, 12.66, p=0.017). CT scan was significantly more effective than routine chest X-ray in detecting lung contusions, pneumothoraces, mediastinal haematomas, as well as fractured ribs, scapulas, sternums and vertebrae. CONCLUSION: In alert patients without evidence of chest wall tenderness, reduced air-entry or abnormal respiratory effort, selective use of CT chest scanning as a screening tool could be adopted. This is supported by the fact that most chest injuries can be treated with simple observation. Intubated patients, in most instances, should receive a routine CT chest scan in their first assessment.     

Contrast material extravasation on contrast-enhanced helical computed tomographic scan of blunt abdominal trauma: its significance on the choice,time, and outcome of treatment

BACKGROUND: Contrast-enhanced helical computed tomographic (CT) scan of blunt abdominal trauma is valuable for detecting contrast material extravasation (CME). The aims of this study were to determine its significance and investigate factors associated with the choice, time, and outcome of management. METHODS: CT scans of 32 consecutive trauma patients who had CME were reviewed for the sources of CME, types of CME, flat inferior vena cava, and multiple abdominal injuries. The medical records were reviewed for demographics, systolic blood pressure, Injury Severity Score (ISS), choice of management, time interval between CT scan and intervention, and outcome of intervention. RESULTS: Systolic blood pressure < 100 mm Hg was the most important factor (p = 0.0064) that failed observational therapy. When proceeding to intervention treatment, patients with a flat inferior vena cava (1.6 +/- 1.1 hours) had a significantly shorter time interval between CT scan examination and intervention when compared with those with a normal cava (10.9 +/- 16.0 hours) ( p= 0.0124). The mortality rate after intervention treatment was 18.8%. High ISS, uncontained CME in the extraperitoneum, and multiple abdominal injuries were important risk factors. After adjusted for ISS and multiple abdominal injuries, the risk of dying from extraperitoneal CME remained significant when compared with intraperitoneal CME (adjusted odds ratio, 82.26; 95% confidence interval, 1.06-6,363.17). CONCLUSION: Termination of observational therapy was appropriate for trauma patients who had CME and systolic blood pressure < 100 mm Hg. The coexistence of a flat inferior vena cava and CME was associated with early intervention treatment. Despite early intervention, the mortality rate was 18.8%. High ISS and multiple abdominal injuries were important factors, but the risk of dying from uncontained extraperitoneal CME was 82 times the risk of dying from intraperitoneal CME.     

Hospital factors associated with higher costs in pediatric blunt abdominal trauma: A national study

Background/PurposeOur objective was to evaluate hospital factors, including children's hospital status, associated with higher costs for blunt solid organ pediatric abdominal trauma.MethodsWe queried the 2012 Healthcare Cost and Utilization Project (HCUP) Kid's Inpatient Database (KID) for patients 18 years or younger with low-grade and high-grade blunt abdominal trauma. We calculated total hospital costs and adjusted cost ratios (CR) controlling for patient and hospital-level characteristics.ResultsThe 2012 KID included 882 low-grade and 222 high-grade pediatric abdominal trauma patients. Median (interquartile range) per hospitalization costs were similar at children's and nonchildren's hospitals for both low-grade (children's = $6575 [$4333–$10,862], nonchildren's $7027 [$4230–$12,219] p = 0.47) and high-grade (children's = $10,984 [$6211- $20,007] nonchildren's $10,156 [$5439–$18,404] p = 0.55) groups. Adjusted cost ratios demonstrated higher costs in the West and among investor owned hospitals for low-grade and high-grade injuries, respectively. Costs at rural hospitals were higher in both groups (low-grade CR = 2.35 95% CI 2.02, 2.74, high-grade CR = 2.78 95% CI 2.13, 3.63) compared to urban teaching hospitals. Cost ratios did not differ based on children's hospital status.ConclusionHospital costs were similar for children's and nonchildren's hospitals caring for pediatric abdominal trauma. Costs at rural hospitals are higher and may suggest financial instability or nonstandardized care of pediatric trauma patients.Level of evidenceIII     

Massive per rectal bleeding following blunt abdominal trauma: First presentation of Crohn's disease

Introduction

Inflammatory bowel disease is a chronic and relatively common disorder with heterogeneous presentation. Peak incidence occurs in the second and third decades of life. We present a patient with Crohn''s disease whose first presentation was profuse bleeding/rectum following blunt abdominal trauma.

presentation of case

A 29 year old previously healthy man presented one hour after sustaining relatively mild abdominal trauma, due to fall onto the ball during a rugby match. He complained of abdominal pain and one episode of large fresh rectal bleeding. He was pale and distressed with hypotension, tachycardia and abdominal guarding & fresh blood on digital rectal examination. With a provisional diagnosis of intestinal injury he was taken to theatre. Right hemi-colectomy was done for a thickened and inflamed segment of distal ileum, a large adjacent mesenteric haematoma & mesenteric lymph nodes and blood in distal bowel. Histology confirmed the features of Crohn''s disease.

discussion

Crohn''s disease is unusual cause of massive lower gastrointestinal bleeding occurring in 0.9–6% of patients. Rectal bleeding associated with diarrhoea is relatively more common than massive bleeding. The presence of Crohn''s disease in young patients presenting like this is unlikely to be suspected and diagnosis could only be made after laparotomy.     

腹腔镜在急腹症和腹部外伤诊治中的体会

目的:探讨应用腹腔镜诊断和治疗外科急腹症及腹部外伤的价值。方法:回顾分析腹腔镜在58例外科急腹症和腹部外伤应用中的临床资料。结果:58例中有27例在不明确病因的情况下由腹腔镜得到确诊,确诊率为100%,其中24例在腹腔镜下治疗,3例中转开腹;31例病例在已明确病因下用腹腔镜治疗,内2例胃十二指肠溃疡穿孔术后出现腹腔脓肿。31例中有3例死亡,其中1例胃穿孔因延误了手术时机而死于感染性休克,2例死于急性重症胰腺炎并发症,其余均痊愈出院,治疗成功率为90.3%。结论:腹腔镜技术在外科急腹症诊断及治疗中具有独特的优势,既可明确诊断,又能同时进行治疗,且有良好的临床应用价值。     

355例以腹部损伤为主的严重创伤救治分析

【摘要】〓目的〓探讨腹部损伤为主的严重创伤的诊断及救治措施。方法〓对1999年9月~2012年9月救治的355例以腹部损伤为主的严重创伤进行分析总结。结果〓本组急诊腹部手术319例/次,其中103例/次在一次麻醉下分组同台完成了两个以上部位的手术。重症监护病房(ICU)平均住院日28.6±10.8天。临床治愈237例(66.8%),致残78例(22.0%),死亡40例(11.2%)。结论〓病史和体格检查应同抢救治疗同步(如维持呼吸道通畅、止血措施,抗休克等);应积极采用诊断性腹腔穿刺、B超、CT等比较简洁和敏感的快速诊断方法;手术顺序应按受损器官的重要性和损伤的严重程度决定,尽可能在一次麻醉下分组同台处理不同部位的损伤;主动采用损伤控制性外科(DCS)策略,可有效降低死亡率。严重多发伤病人术后均应进入ICU监护和治疗。     

Hepatobiliary scintigraphy in management of bile leaks in patients with blunt abdominal trauma

Background: Hepatobiliary scintigraphy (HBS) is a useful diagnostic tool in detecting the presence and site of bile leaks. Methods: We present a retrospective analysis of HBS carried out in 35 patients with blunt abdominal trauma over a period of 5 years from 2001 to 2006. Results: Twenty‐three of 35 patients with blunt abdominal trauma had localized bile leaks and were managed conservatively. The bile leak was found to have completely resolved in the follow‐up HBS. Two patients did not show any evidence of bile leak. Remaining 10 of 35 patients with blunt abdominal trauma showed active bile leak and were subjected to surgical management. Follow‐up scans in these patients showed resolution of bile leaks and patent bilioenteric pathway. Clinical management decisions based on scintigraphic evidence led to less invasive drainage procedures over time and shorter hospital stay. Conclusion: Our study thus suggests that HBS facilitates rapid and precise diagnosis of bile leaks.     

Axial computed tomography and duplex scanning for the determination of maximal abdominal aortic diameter in patients with abdominal aortic aneurysms

Summary BACKGROUND: The aim of this study is to assess differences between axial computed tomography and duplex ultrasound, based on measurements of maximal aortic diameter in patients with abdominal aortic aneurysms. METHODS: From January 2002 until December 2004, 322 patients were admitted with an abdominal aortic aneurysm. All of them underwent abdominal duplex ultrasound scanning and computed tomography by separate laboratories in order to determine the maximal aortic diameter. The computed tomography technologists were blinded to all duplex results and vice versa. RESULTS: Mean computed tomography maximal aortic diameter was 56.17 mm and mean duplex maximal aortic diameter was 53.44 mm. Computed tomography measurements were greater than duplex in 97.83% of the patients. CONCLUSIONS: Axial computed tomography consistently overestimates the maximal aortic diameter measurements in patients with abdominal aortic aneurysms compared with duplex ultrasound.      

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

Background

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

Study design

A retrospective study from 2005 to 2011 was undertaken.

Results

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

Conclusions

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