Rate and prediction of traumatic injuries detected by abdominal computed tomography scan in intubated children

BACKGROUND: Recent concerns about the lifetime cancer risk associated computed tomography (CT) caused us to reevaluate the utility of this test in traumatized children. In addition, little is known regarding the utility of abdominal CT in children who have been emergently intubated. We sought to describe the injuries identified by abdominal CTs in intubated pediatric trauma patients and create a derivation set of predictors of intra-abdominal injury in this patient population. METHODS: A review was conducted of patients cared for at a Level I pediatric trauma center. Patients were included if they were emergently intubated after blunt trauma and had an emergent abdominal CT performed. Outcome measures included the presence of an intra-abdominal injury on CT, the need for exploratory laparotomy (ELAP), the findings of the ELAP, and death. Logistic regression was used to determine which variables were associated with an abnormal abdominal CT scan. RESULTS: In all, 118 met inclusion criteria; the median age was 7.2 years. Thirty- two patients (27.1%) were found to have at least one abdominal injury on CT scan. One ELAP was performed and 12 patients died. Of the variables analyzed, abdominal examination abnormalities and elevated liver function tests (LFTs) were significantly associated with injuries. When both were abnormal, 75% of patients (12/16) had abnormal scans (sensitivity = 71%, specificity = 92%, positive predictive value = 75%, negative predictive value = 91%). CONCLUSIONS: In this series, a significant number of intubated pediatric trauma victims had intra-abdominal injuries identified by CT scan. The presence of abnormal abdominal examination findings and elevated LFTs appear to predict an abnormal CT scan.     

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.     

Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study

HYPOTHESIS: The use of liberal whole body imaging (pan scan) in patients based on mechanism is warranted, even in evaluable patients with no obvious signs of chest or abdominal injury. DESIGN: Prospective observational study. SETTING: Academic level I trauma center. PATIENTS: All patients admitted following blunt multisystem trauma. INTERVENTION: Pan scan, including computed tomography (CT) of the head, cervical spine, chest, abdomen, and pelvis, with the following inclusion criteria: (1) no visible evidence of chest or abdominal injury, (2) hemodynamically stable, (3) normal abdominal examination results in a neurologically intact patient or unevaluable abdominal examination results secondary to a depressed level of consciousness, and (4) significant mechanisms of injury. Radiological findings and changes in treatment based on these findings were recorded. MAIN OUTCOME MEASURE: Any alteration in the normal treatment plan as a direct result of CT scan findings. These alterations include early hospital discharge, admission for observation, operative intervention, and additional diagnostic studies or interventions. RESULTS: One thousand patients underwent pan scan during the 18-month observation period, of which 592 were evaluable patients with no obvious signs of abdominal injury. Clinically significant abnormalities were found in 3.5% of head CT scans, 5.1% of cervical spine CT scans, 19.6% of chest CT scans, and 7.1% of abdominal CT scans. Overall treatment was changed in 18.9% of patients based on abnormal CT scan findings. CONCLUSIONS: The use of pan scan based on mechanism in awake, evaluable patients is warranted. Clinically significant abnormalities are not uncommon, resulting in a change in treatment in nearly 19% of patients.     

Clinical predictors of abnormal chest CT scan findings following blunt chest trauma: A cross-sectional study

Purpose:Some surgeons believe that chest computed tomography(CT)scan should be used more prudently in management of blunt chest trauma patients.This study aimed to evaluate the clinical predictors of abnormal chest CT scan findings in trauma patients.Methods:This cross-sectional study was conducted on blunt chest trauma patients aged
18 years who were referred to the emergency departments of two educational hospitals and underwent chest CT scan.These patients were enrolled in the study using a non-probability sampling method.The exclusion criteria included:class III or IV hemodynamic shock,need for immediate surgical or neurosurgical interventions,penetrating trauma,lack of required information,and pregnancy.Demographic factors,accident details,trauma mechanism,vital signs,and level of consciousness in predicting abnormal chest CT scan findings were evaluated.Analysis was performed using IBM SPSS statistics 21.Results:A total of 977 patients(male 51.5%,female 48.5%)with the mean age of(41.71±14.24)years,range 18e88 years were studied;34.2% of them with high energy trauma mechanism.With 334(34.2%)patients had abnormal findings on chest X-ray(CXR)and 332(34.0%)cases had an abnormal findings on chest CT scan(agreement rate was 99.4%).There was a significant correlation between male gender(p<0.0001),GCS<15(p<0.0001),high energy trauma mechanism(p<0.0001),unstable hemodynamics(p<0.01),and clinical signs and symptoms(p<0.0001)with chest CT findings.Chest wall deformity(odds=8;p<0.0001),generalized tenderness(odds=6.6,p<0.0001),and decreased cardiac sound(odds=3.8,p<0.0001)were the important and independent clinical predictors of abnormal chest CT scan findings.Conclusion:Based on the findings,chest wall deformity,generalized tenderness,decreased cardiac sound,distracting pain,chest wall tenderness,high energy trauma mechanism,male gender,respiratory rate>20 breathes/min,decreased pulmonary sound,and chest wall crepitation were independent clinical predictors of abnormal chest CT scan findings following blunt trauma.     

Not so FAST

BACKGROUND: Focused assessment with sonography for trauma (FAST) as a screening tool in the evaluation of blunt abdominal trauma will lead to underdiagnosis of abdominal injuries and may have an impact on treatment and outcome in trauma patients. METHODS: From October 2001 to June 2002, a protocol for evaluating hemodynamically stable trauma patients with suspected blunt abdominal injury (BAI) admitted to our institution was implemented using FAST examination as a screening tool for BAI and computed tomographic (CT) scanning of the abdomen and pelvis as a confirmatory test. At the completion of the secondary survey, patients underwent a four-view FAST examination (Sonosite, Bothell, WA) followed within 1 hour by an abdominal/pelvic CT scan. The FAST examination was considered positive if it demonstrated evidence of free intra-abdominal fluid. Clinical, laboratory, and imaging results were recorded at admission, and FAST examination results were compared with CT scan findings, noting the discordance. RESULTS: Patients with suspicion for BAI were evaluated according to protocol (n = 372). Thirteen cases were excluded for inadequate FAST examinations, leaving 359 patients for analysis. There were 313 true-negative FAST examinations, 16 true-positives, 22 false-negatives, and 8 false-positives. Using CT scanning as the confirmatory test for hemoperitoneum, FAST examination had a sensitivity of 42%, a specificity of 98%, a positive predictive value of 67%, a negative predictive value of 93%, and an accuracy of 92%; chi analysis showed significant discordance between FAST examination and CT scan (5.85%, < 0.001). Six patients with false-negative FAST examinations required laparotomy for intra-abdominal injuries; 16 patients required admission for nonoperative management of injury. Of the 313 true-negative FAST examinations, 19 patients were noted to have intra-abdominal injuries without hemoperitoneum and 11 patients were noted to have retroperitoneal injuries. CONCLUSION: Use of FAST examination as a screening tool for BAI in the hemodynamically stable trauma patient results in underdiagnosis of intra-abdominal injury. This may have an impact on treatment and outcome in trauma patients. Hemodynamically stable patients with suspected BAI should undergo routine CT scanning.     

Evaluation of selective treatment of penetrating abdominal trauma

OBJECTIVE: In penetrating abdominal trauma, diagnostic imaging and the application of selective clinical management may avoid negative celiotomy and improve outcome. DESIGN: We prospectively observed patients with penetrating abdominal trauma over 15 months and recorded demographics, presentation, imaging, surgical procedure, and outcome. Patients who underwent immediate laparotomy were compared with patients who were observed and/or had a computed tomography (CT) scan. Outcomes of negative versus positive and immediate versus delayed celiotomy were compared. Chi-square and Student t tests were used. A p value of less than 0.05 was considered significant. SETTING: A level 1 trauma center. PARTICIPANTS: Adult patients who presented with penetrating abdominal injury. RESULTS: In all, 100 consecutive patients (mean age, 32 years) were included (male:female, 91:9; gunshot wound:stab wound, 65:35). Overall, 60 immediate and 10 delayed laparotomies were performed; 30 patients did not undergo surgery. Predictors of immediate celiotomy were hypotension (p = 0.03), anteriorly located entrance wounds (p = 0.0005), and transaxial wounds (p = 0.03). Overall morbidity and mortality was 32% and 2%, respectively. The negative celiotomy rate was 25%. Patients with a positive celiotomy had higher morbidity (p = 0.006) and longer hospital length of stay (p = 0.003) compared with negative celiotomy. A CT scan was employed in 32% of patients, with 100% sensitivity and 94% specificity. Delayed celiotomy (10%) did not adversely impact morbidity (p = 0.70) and was 100% therapeutic, with no deaths. CONCLUSION: Nonselective immediate celiotomy for penetrating abdominal trauma results in a high rate of unnecessary surgery. Hemodynamically stable patients can safely be observed and/or have contrast CT scans and undergo delayed celiotomy, if indicated. This selective treatment had no adverse effect on patient outcomes and can potentially improve overall outcome.     

Computed tomography in the evaluation of children with blunt abdominal trauma.

OBJECTIVE: This study determined the sensitivity, specificity, and accuracy of CT in pediatric patients with blunt trauma. Correlation of the CT-identified injuries and intraoperative findings with comparison to the results of DPL was performed. SUMMARY BACKGROUND DATA: Clinical evaluation frequently is unreliable in determining the presence of intra-abdominal injury in children with blunt trauma. Peritoneal lavage has been used to establish the need for operative intervention and has been found to be safe, efficient, and reliable (98%). In many institutions, abdominal CT scans are used to evaluate these children. Because most reports involve nonoperative management, operative confirmation of CT-identified injuries is available only for those children in whom nonoperative treatment is unsuccessful. METHODS: Sixty children sustaining blunt abdominal trauma were included in the study. CT scans with both oral and IV contrast were performed before open lavage, and positive results were confirmed by operation in 18 patients. RESULTS: CT had a sensitivity of 67%, however, only 60% of the actual organ injuries were identified by the scan. In contrast, DPL has a sensitivity of 94%. Both studies were equally specific (100%). DPL was also more accurate, 98% as compared with 89% for CT. CONCLUSIONS: Although the abdominal CT scan is useful in evaluating children with blunt abdominal trauma, a number of significant injuries were missed. Based on the low sensitivity of the CT, the authors suggest diagnostic peritoneal lavage may offer advantages over CT as the initial study in the evaluation of children with blunt abdominal trauma.     

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.     

The occult pneumothorax: an increasing diagnostic entity in trauma

The increasing use of CT for the evaluation of blunt abdominal trauma has diagnosed undetected pneumothoraces in many patients. We performed a retrospective study at a major trauma center to determine the incidence of occult pneumothorax in the trauma patient. All trauma patients (3121) admitted to a Level I trauma center over a 51-month period were reviewed to determine the incidence of pneumothorax and occult pneumothorax, the method of diagnosis, and treatment. All major trauma patients received a chest X-ray (CXR), whereas 842 patients (27%) underwent an abdominal CT scan. In the 172 patients diagnosed with pneumothorax, 157 abdominal CT scans were performed and 143 were positive for pneumothorax. CXR revealed 49 right-sided pneumothoraces and 58 left-sided pneumothoraces in 95 patients. Abdominal CT scans diagnosed 73 right pneumothoraces and 90 left pneumothoraces in 143 patients. There were 67 patients (71 thoraces) who were seen to have a pneumothorax on abdominal CT scan not seen on admission CXR. This represents 2.2 per cent of all trauma patients and 7.9 per cent of patients with abdominal CT scans. In looking at just trauma patients with pneumothorax, the CT scan was responsible for diagnosing 39 per cent of the patients with a pneumothorax. The occult pneumothorax is being diagnosed more frequently as methods of evaluating and diagnosing trauma patients become more sensitive.     

Abdominal computed tomography scan in pediatric blunt abdominal trauma.

The purpose of this study was to evaluate the role of abdominal CT scans in pediatric patients and correlate the findings with the clinical examination. A 2-year retrospective review of 88 patients with an abdominal CT scan after blunt trauma was performed. Seventy-two patients were identified with complete clinical examination data available. In its ability to predict the need for surgery, the CT scan had a sensitivity of 67 per cent and a negative predictive value of 98.7 per cent. The combination of the clinical examination and the CT scan findings did not miss any significant injuries. No patient with a soft, nontender abdomen and a negative CT scan required an abdominal operation. We conclude that the CT scan alone may miss clinically significant injuries. In blunt abdominal trauma in the pediatric population, the CT scan findings should be coupled with the clinical examination to ensure that no significant abdominal injuries are missed.     

Scout anteroposterior and lateral CT scans as a screening test for thoracolumbar spine injury in blunt trauma

Anteroposterior and lateral radiographs have traditionally been required to clear the thoracolumbar spine (TLS) after blunt trauma. The routine use of CT scans led to a pilot trial to determine if CT scout images can accurately evaluate the TLS after blunt trauma. The purpose of the study was to determine the sensitivity, specificity, positive and negative predictive values of CT scout images for the evaluation of the TLS. Patients admitted to our level II trauma center requiring CT evaluation of the chest, abdomen, and pelvis were considered for this study. Patients with blunt trauma, without neurologic deficits, or other evidence of spinal trauma on physical examination were included. Charts were reviewed for demographics, scout CT image findings, and full CT scan findings. Scout CT images were compared with reconstructed spine CT scans from chest, abdomen, and pelvis CT scans. Injuries to the TLS were defined as compression fractures, burst fractures, and subluxation. One hundred seventeen patients were included. Average Injury Severity Score was 25.1 (+/-9.4) and average age was 42.5 years. Twenty-three patients had diffuse back tenderness, three had ecchymosis, and 64 had distracting injuries. Twelve injuries to the TLS were present; 11 were seen on scout images. Sensitivity was 92 per cent, specificity 100 per cent, positive predictive value 100 per cent, and negative predictive value 99 per cent. Scout CT images provide an accurate assessment of the TLS after blunt trauma. We are encouraged by the results and will continue to investigate to identify the criteria that allow scout CT images to safely replace anteroposterior and lateral radiographs in the evaluation of the TLS in blunt trauma.     

Complementary roles of diagnostic peritoneal lavage and computed tomography in the evaluation of blunt abdominal trauma.

OBJECTIVE: To assess in randomized prospective format sensitivity, laparotomy rate, and cost-effectiveness of using diagnostic peritoneal lavage (DPL) in a complementary role with computed tomography (CT) in the evaluation of blunt abdominal trauma. METHODS: Blunt trauma patients greater than 18 years of age were eligible for entry in the study. The study period was from February 1999 to July 2000 at an urban Level I trauma center. All patients were hemodynamically stable upon study entry and had abdominal tenderness with Glasgow Coma Scale (GCS) scores > 13 or GCS < 14. Patients were randomized to a DPL arm (DPL-CT) versus a CT arm. If randomized to the CT arm, patients underwent abdominal/pelvis CT. If CT was positive for solid organ injury, patients were observed. If free fluid was identified on CT without solid organ injury, patients were explored. If randomized to DPL-CT, patients underwent closed infraumbilical DPL, except pelvic fractures that were done with the open supraumbilical technique. If the DPL result was > 20,000 RBCs/mm3, patients underwent abdominal/pelvis CT. If the CT following DPL was consistent with solid organ injury, patients were observed. If the CT following DPL identified free fluid without solid organ injury and DPL was > 100,000 RBCs/mm3, patients were explored. RESULTS: Two hundred fifty-two patients were entered; 127 patients were randomized to DPL-CT and 125 to CT. Of the 125 patients randomized to CT, 102 (82%) CT scans were negative, 19 (15%) were positive for solid organ injury, and 3 (2%) had free fluid. Three (2%) of the initial negative CT scan patients underwent delayed laparotomy for missed injuries. Of the 127 patients randomized to DPL-CT, 26 (20%) required CT scan, of which 13 (10%) were positive for solid organ injury and 13 (10%) for free fluid. Positive DPL results that were indications for CT ranged from 21,000 to 1 million RBCs/mm3. Eight of the 13 DPL-CT patients with free fluid on CT had DPL results less than 100,000 RBCs/mm3 and did not require laparotomy. There were no known missed injuries in the DPL-CT arm. Seven (6%) laparotomies were performed in the DPL-CT arm and 10 (8%) in the CT arm. The average cost to the patient for abdominal evaluation in the CT arm was 1611 dollars and 650 dollars in the DPL-CT arm. CONCLUSION: Screening DPL with complementary CT has a low nontherapeutic laparotomy rate and is a sensitive and cost-effective method for the evaluation of blunt abdominal trauma.     

Pattern of abdominal free fluid following isolated blunt spleen or liver injury in the pediatric patient.

BACKGROUND: This study correlated isolated, blunt liver or spleen injury with the presence, location, and amount of free fluid in the pediatric blunt trauma patient. METHODS: The hospital trauma registry was reviewed for the period 1/89 to 12/99 for pediatric patients (age < or = 17 years) who sustained blunt, isolated spleen or liver injury and had an abdominal CT scan. Patients with other intraabdominal injuries or inadequate scans were excluded. CT scans were reviewed by two radiologists and the isolated liver or spleen injury confirmed and graded. The presence, location, and amount of free fluid were evaluated in the RUQ, LUQ, and pelvis. Free fluid was quantified as 0 = no fluid, 1 = small amount, 2 = moderate, and 3 = large for each area. RESULTS: There were 134 pediatric patients with an isolated spleen (n = 66) or liver (n = 68) injury. Free fluid was noted in 101 patients (75%), more commonly with spleen (82%) than with liver (69%) injuries. As injury grade increased, so did frequency of patients with free fluid (grade 1 = 50% to grade 5 = 100%) and mean total volume (sum of fluid scores from each region) of free fluid (grade 1 = 0.75 to grade 5 = 6.5). The mean total volume of free fluid was greater for splenic injury (3.1) than for liver injury (1.7). The pelvis was the most common location for free fluid (liver 53%, spleen 71%) and had the greatest mean volume of free fluid (liver 0.9, spleen 1.5) of any single region. CONCLUSION: There is a direct correlation between the severity of the isolated injury and the likelihood and volume of associated free fluid. The pelvis was the most common location to detect free fluid and had the greatest estimated fluid volume.     

The utility of focused abdominal ultrasound in blunt abdominal trauma: a reappraisal

BACKGROUND: Focused assessment with sonography for trauma (FAST) has become commonplace in the management of blunt abdominal trauma. However, newer computed tomography (CT) scanners have decreased imaging time for trauma patients and provide more detailed examination of abdominal contents. It was the aim of the current study to evaluate practice patterns of FAST and abdominal CT in blunt trauma victims. METHODS: This was a retrospective study of all blunt trauma patients (N = 299) who received at least 1 FAST examination in the emergency department by surgeons and were admitted. Patients were tracked for subsequent CT scanning, disposition from the emergency department, any operative findings, and survival. RESULTS: Twenty-one of 299 patients (7%) had a positive FAST. There were 7 deaths and 14 patients were taken directly to the operating room (OR) for control of abdominal bleeding. Thirty-one of 299 (10%) had equivocal FAST. There were 4 deaths and 8 patients were taken to the OR for control of abdominal bleeding. A total of 247 of the 299 patients had a negative FAST. CT scans were performed in 193: 15 showed a visceral injury. There were 13 deaths and 29 patients were taken to the OR (4 for bleeding). Patients with a positive FAST had a higher mortality than FAST-negative patients (P < .001) and greater likelihood for operation (P < .001). Those with equivocal FAST had a greater likelihood for operation than FAST-negative patients (P < .05). CONCLUSIONS: FAST examinations can identify patients at risk for hemorrhage and in whom operation may be needed and, therefore, can guide mobilization of hospital resources. FAST-negative patients can be managed expectantly, using more specific imaging techniques.     

The use of delayed computerized tomography in the evaluation of blunt abdominal trauma: a preliminary report

This purpose of this study was to analyze the use of abdominal computed tomography (CT) imaging in patients with possible blunt abdominal trauma. A retrospective analysis of all trauma patients over a 1-year period (1993-1994) was conducted, with prospective study protocol in 52 patients using serial abdominal exam and hematocrits (Hcts) instead of abdominal CT for evaluation of blunt abdominal trauma. Urgent abdominal CT was used as the initial diagnostic test for evaluation of blunt abdominal trauma in 813 patients over this 1-year period. CT was obtained in 379 (46.6%) of these patients who arrived hemodynamically stable (admission systolic blood pressure > or = 90), had a Glasgow Coma Scale > 13, and had admission Hct > or = 35 because of distracting injuries, possible traumatic brain injury, or alcohol/drug use, which might render the abdominal physical exam unreliable. Only 47 CT scans (12.4%) were positive, and three patients (0.8%) required laparotomy. In an effort to more efficiently use abdominal CT, we performed a prospective study in 52 patients with possible blunt abdominal trauma, admission systolic blood pressure > or = 90, Hct > or = 35, Glasgow Coma Scale > 13, and a normal abdominal exam on admission. These patients were followed with serial abdominal examinations and Hcts every 6 hours for 24 hours, and delayed CT, when applicable. CT was obtained in seven patients (13.5%) for evaluation of fall in Hct or abnormal abdominal examination; all were negative for abdominal injury. A protocol using serial abdominal exams, Hcts, and delayed abdominal CT imaging may be useful in select patients to decrease the high number of negative routine abdominal CTs that are obtained in the evaluation of blunt abdominal trauma.     

Computed tomography in the initial evaluation of patients with blunt trauma.

Two hundred sixty-six of 374 consecutive blunt trauma patients underwent emergency computed tomographic (CT) scanning during evaluation at a level I trauma center. The purpose of this study was to develop guidelines for use of CT scanning in the initial evaluation of blunt trauma patients. Of the 131 CT scans of the head obtained, 20 (15%) had positive results. Seven patients whose initial neurologic examinations were normal had abnormal results on head CT scans; none required emergent treatment of their head injury. This suggests that, in the presence of a normal neurologic examination, head CT scans can safely be delayed until other more serious injuries are addressed. Twenty-six CT scans of the chest were performed and ten (38%) were interpreted as abnormal. Chest CT scans provided information about the extent of the injury but did not alter the initial management of any patient and therefore are rarely indicated in the acute evaluation of trauma patients. A total of 110 abdominopelvic CT scans were performed and 20 (19%) were interpreted as positive. Seventy-five percent of those patients with positive CT scans were treated successfully in a nonsurgical fashion.     

Periaortic hematoma on abdominal computed tomographic scanning as an indicator of thoracic aortic rupture in blunt trauma

BACKGROUND: In our institution, we have noted an association between periaortic hematomas (PH) present on abdominal computed tomographic (CT) scans and patients with thoracic aortic rupture (TAR) in blunt trauma. This 5-year retrospective study determined the sensitivity and specificity of PH and left hemothorax seen on abdominal CT scan as an indicator of TAR. METHODS: The trauma registry and records identified 54 blunt trauma patients who had a CT scan of the abdomen and an arch aortogram. Fourteen patients with TAR and 40 patients without TAR were selected for analysis. A digital photograph of an upper cut of the abdominal CT scan for each patient was examined by radiology staff for the presence or absence of PH and left hemothorax. RESULTS: The sensitivity, specificity, positive predictive value, and negative predictive value of PH as a predictor of TAR were 88%, 99%, 97%, and 96%, respectively. CONCLUSION: The finding of PH on CT scan of the abdomen in blunt trauma patients should alert the clinician to the high likelihood of thoracic aortic injury.     

Computed tomographic scanning reduces cost and time of complete spine evaluation

BACKGROUND: We hypothesize that data collected from computed tomographic (CT) scans obtained for workup of chest or abdominal injuries provide data that are sufficient to screen for spinal fractures and will decrease the cost and time of spine evaluation after trauma. METHODS: We reviewed plain radiographs from 55 selected trauma patients who also underwent CT scanning of the chest, abdomen, and pelvis. We also timed the radiologic workup of 50 consecutive trauma patients to determine the time required to complete radiographic spine evaluation. RESULTS: Forty-seven patients had thoracolumbar fractures. Thirteen patients were found to have 33 thoracolumbar spine fractures identified by CT scan but not plain radiography. Fractures were found on initial trauma CT scans of the chest, abdomen, and pelvis obtained to evaluate for visceral injuries. No injuries seen on plain film were missed on CT scan. CONCLUSION: We recommend using the data acquired from CT scans to evaluate the spine, supplementing them with additional studies only when needed for further clarification.     

Accuracy of computed tomography in the detection of blunt bowel and mesenteric injuries

BACKGROUND: There are conflicting views on the accuracy of computed tomography (CT) findings in patients with bowel and mesenteric injuries (BMIs) following blunt abdominal trauma. The aim of the present study was to assess the accuracy of the CT report during a trauma call. METHODS: Ninety-eight patients underwent preoperative abdominal spiral CT and subsequent laparotomy following blunt trauma between January 1996 and March 2001 at a level I trauma centre. The immediate results of the scans were reported by the on-call radiology registrar and written in the medical notes by the trauma team leader. Seventy of the 98 preoperative abdominal CT scans were retrieved from the radiology department and reported by two consultant radiologists with a special interest in trauma radiology. RESULTS: The sensitivity and specificity of the 70 expert CT reports were 80 (95 per cent confidence interval (c.i.) 66 to 94) and 78 (95 per cent c.i. 65 to 90) per cent respectively for diagnosing a BMI. The sensitivity and specificity of the immediate CT reports were 93 (95 per cent c.i. 84 to 100) and 71 (95 per cent c.i. 60 to 83) per cent respectively. CONCLUSION: Spiral CT is highly sensitive for detecting a BMI following blunt abdominal trauma. This sensitivity is maintained when the scan is reported by a radiology registrar.     

Computed tomography and nonoperative treatment for blunt abdominal trauma

Studies were undertaken to determine if computed tomography (CT) could reliably assist physical examination in the initial assessment of blunt abdominal trauma, and also to examine how various abdominal injuries were managed with the guidance of CT. A total of 255 patients underwent emergency abdominal CT following blunt abdominal trauma over a period of seven years. One hundred and fifty two patients had abnormal CT scans, including 58 hepatic, 36 renal, 25 splenic and 9 pancreatic injuries as well as 67 patients with intra-abdominal hemorrhage and 21 patients with free abdominal air. A comparative study on the detection of pneumoperitoneum revealed CT to be far superior to plain radiography. One hundred and three patients had normal CT scans, all of whom were managed nonoperatively, except for three false-negative cases and two nontherapeutic cases. The patients with injury to the parenchymal organs were given nonoperative treatment if they had stable vital signs and no evidence of associated injuries demanding immediate surgery and the majority of these patients were managed well nonoperatively. CT was thus found to be a useful adjunct in the management of victims of blunt abdominal trauma, since in a rapid and noninvasive fashion, CT accurately defined the extent of parenchymal organ injury and also disclosed any other abdominal injuries.