American Association For The Surgery Of Trauma Grading Research Articles

The Comparison of Multi-Slice CT-Scan and Laparotomy Findings in Blunt Splenic and Hepatic Trauma

Background: Liver and spleen are the most common injured organs in abdominal blunt trauma which can lead to life threatening bleeding. Fast and reliable evaluation of these injuries is important to manage them immediately. In this study, the level of agreement between multidetector CT-Scan and surgical findings is evaluated. Methods: Multidetector CT-scan and explorative laparotomy of the patients with blunt abdominal trauma were assessed retrospectively. Characteristics of the injuries were categorized on the basis of the American Association for the Surgery of Trauma (AAST) grading system and the findings were analyzed using kappa test. Results: The findings of 35 patients were analyzed. According to the kappa test, there were Moderate agreement between CT-Scan and surgery in evaluation of lacerations, location and AAST grade of splenic injuries, and disagreement in evaluation of splenic hematoma. In assessment of lacerations and AAST grading of hepatic injuries, there was only Fair agreement between CT-Scan and surgery. Conclusions: Multidetector CT-Scan is an appropriate method for evaluating splenic and hepatic blunt trauma, even more accurate than surgery in some limited cases. However, only Moderate and Fair agreements, indicate that initial measures such as history taking and abdominal physical examination, specifically for unstable patients that they not have enough time to do CT-Scan, should be properly considered before using this method. Furthermore, in case of other organ injuries, CT-Scan can be an appropriate method for prioritizing other damages to splenic and hepatic injuries or vice versa, on the basis of intensity, characteristics and the grade of injury.

Increased anatomic severity predicts outcomes: Validation of the American Association for the Surgery of Trauma's Emergency General Surgery score in appendicitis.

Determination and reporting of disease severity in emergency general surgery lacks standardization. Recently, the American Association for the Surgery of Trauma (AAST) proposed an anatomic severity grading system. We aimed to validate this system in patients with appendicitis and determine if cross-sectional imaging correlates with disease severity at operation. Patients 18 years or older undergoing treatment for acute appendicitis between 2013 and 2015 were identified. Baseline demographics, procedure types were recorded, and AAST grades were assigned based on intraoperative and radiologic findings. Outcomes including length of stay, 30-day mortality, and complications based on Clavien-Dindo categories and National Surgical Quality Improvement Program variables. Summary statistical univariate, nominal logistic, and standard least squares analyses were performed comparing AAST grade with key outcomes. Bland-Altman analysis compared operative findings with preoperative cross-sectional imaging to compare assigning grades. Three hundred thirty-four patients with mean (±SD) age of 39.3 years (±16.5) were included (53% men), and all patients had cross-sectional imaging. Two hundred ninety-nine underwent appendectomy, and 85% completed laparoscopic. Thirty-day mortality rate was 0.9%, complication rate was 21%. Increased (median [interquartile range, IQR]) AAST grade was recorded in patients with complications (2 [1-4]) compared with those without (1 [1-1], p = 0.001). For operative management, (median [IQR]) AAST grades were significantly associated with procedure type: laparoscopic (1 [1-1]), open (4 [2-5]), conversion to open (3 [1-4], p = 0.001). Increased (median [IQR]) AAST grades were significantly associated in nonoperative management: patients having a complication had a higher median AAST grade (4 [3-5]) compared with those without (3 [2-3], p = 0.001). Bland-Altman analysis comparing AAST grade and cross-sectional imaging demonstrated no difference (-0.02 ± 0.02; p = 0.2; coefficient of repeatability 0.9). The AAST grading system is valid in our population. Increased AAST grade is associated with open procedures, complications, and length of stay. The AAST emergency general surgery grade determined by preoperative imaging strongly correlated to operative findings. Epidemiologic/prognostic study, level III.

Imaging characteristics associated with failure of nonoperative management in high-grade pediatric blunt renal trauma

Some children who sustain high-grade blunt renal injury may require operative intervention. In the present study, it was hypothesized that there are computed tomography (CT) characteristics that can identify which of these children are most likely to need operative intervention. A retrospective review was performed of all pediatric blunt renal trauma patients at a single level-I trauma center from 1990 to 2015. Inclusion criteria were: children with American Association for the Surgery of Trauma (AAST) Grade-IV or V renal injuries, aged ≤18 years, and having available CT images with delayed cuts. The CTs were regraded according to the revised AAST grading system proposed by Buckley and McAninch in 2011. Radiographic characteristics of renal injury were correlated with the primary outcome of any operative intervention: ureteral stent, angiography, nephrectomy/renorrhaphy, and percutaneous nephrostomy/drain. One patient had a Grade-V injury and 26 patients had Grade-IV injuries. Nine patients (33.3%) underwent operative interventions. Patients in the operative intervention cohort were more likely to manifest a collecting system filling defect (P=0.040) (Fig. A) and lacked ureteral opacification (P=0.010). The CT characteristics, including percentage of devascularized parenchyma, medial contrast extravasation, intravascular contrast extravasation, perirenal hematoma distance and laceration location, were not statistically significant. Of the 21 patients who had a collecting system injury, eight (38.1%) needed ureteral stents. Renorrhaphy was necessary for one patient. Although the first operative intervention occurred at a median of hospital day 1 (range 0.5-2.5), additional operative interventions occurred from day 4-16. Thus, it is prudent to closely follow-up these patients for the first month after injury. Two patients with complex renal injuries had an accessory renal artery resulting in well-perfused upper and lower pole fragments, and were managed nonoperatively without readmission (Fig. B). Collecting system defects and lack of ureteral opacification were significantly associated with failure of nonoperative management. A multicenter trial is needed to confirm these findings and whether nonsignificant CT findings are associated with operative intervention. In the month after renal injury, these patients should be mindful of any changes in symptoms, and maintain a low index of suspicion for an emergency room visit. For the physician, close follow-up and appropriate counseling of these high-risk patients is advised.

Organ laceration grading adherence by radiologists.

American Association for the Surgery of Trauma (AAST) abdominopelvic organ laceration grading is used to determine which patients can be managed non-operatively. We assess a change in the use of AAST grading system by radiologists at a single, large, academic institution before and after a one-time departmental intervention and reviewed non-graded reports evaluating if grading could be inferred. After IRB approval, a keyword search for "laceration" identified traumatic abdominopelvic CT reports in a 2-year period before and after the one-time intervention. Reports were reviewed to determine if an organ laceration was seen, if it was graded by AAST criteria, and if grading could be inferred for non-graded reports. T test was performed to assess statistical significance. Before the intervention, 348 reports contained the keyword "laceration," 81 with lacerations, 31 graded (38 %). After the intervention, 302 reports were found, 79 with lacerations, 59 graded (75 %). The increase was statistically significant (p < 0.0001). A decreasing trend in grading was seen over time following the intervention. Two out of 50 (4 %) pre-intervention and four out of 20 (20 %) post-intervention reports gave enough detailed descriptions for the grading to be inferred when it was not explicitly stated. Non-graded reports did not describe laceration parenchymal depth and subcapsular hematoma surface area percentage; however, the presence/absence of active extravasation, omitted in the 20-year-old AAST grading scheme, was described in every report. One-time departmental intervention yielded a significant increase in adherence to AAST laceration grading. Lack of perfect compliance, which diminished over time, suggests a need for further reinforcement.

External Validation of a Substratification of the American Association for the Surgery of Trauma Renal Injury Scale for Grade 4 Injuries

The traditional American Association for the Surgery of Trauma (AAST) grading of renal injury does not adequately identify the subset of patients who are most likely to require intervention for bleeding. Recently, several high-risk criteria (HRC) for bleeding after renal injury were identified, and we sought to externally validate these criteria among patients with grade 4 renal injury. All patients presenting to a level I trauma center with blunt grade 4 renal injuries from 2003 to 2010 were reviewed, and stage was determined by the 1989 AAST staging criteria. Dependent variables included the presence of a hilar injury or any of the HRC (perirenal hematoma size, intravascular contrast extravasation, and medial or complex laceration). The primary outcome was the need for intervention (renorrhaphy, nephrectomy, or angiography) for hemodynamic instability. A total of 84 patients with grade 4 renal lacerations were identified. Two or more HRC were present in 18 patients (21%), and intervention for hemodynamic instability was performed in 14 patients (17%). Compared with patients with 0 or 1 HRC, those with ≥ 2 HRC were approximately 25 times more likely to require intervention for hemodynamic instability (odds ratio [OR]24.9, 95% CI 5.5 to 112.9, p < 0.001). Patients with no HRC were unlikely to require intervention for hemodynamic instability. Among patients with blunt grade 4 renal injury, the presence of ≥ 2 HRC effectively predicts the need for intervention for hemodynamic instability and can be used to identify patients who require intensive monitoring. The AAST grading system for renal injury should be modified to better reflect injury severity.

Reliability of injury grading systems for patients with blunt splenic trauma

ObjectivesThe most widely used grading system for blunt splenic injury is the American Association for the Surgery of Trauma (AAST) organ injury scale. In 2007 a new grading system was developed. This ‘Baltimore CT grading system’ is superior to the AAST classification system in predicting the need for angiography and embolization or surgery. The objective of this study was to assess inter- and intraobserver reliability between radiologists in classifying splenic injury according to both grading systems. MethodsCT scans of 83 patients with blunt splenic injury admitted between 1998 and 2008 to an academic Level 1 trauma centre were retrospectively reviewed. Inter and intrarater reliability were expressed in Cohen's or weighted Kappa values. ResultsOverall weighted interobserver Kappa coefficients for the AAST and ‘Baltimore CT grading system’ were respectively substantial (kappa=0.80) and almost perfect (kappa=0.85). Average weighted intraobserver Kappa's values were in the ‘almost perfect’ range (AAST: kappa=0.91, ‘Baltimore CT grading system’: kappa=0.81). ConclusionThe present study shows that overall the inter- and intraobserver reliability for grading splenic injury according to the AAST grading system and ‘Baltimore CT grading system’ are equally high. Because of the integration of vascular injury, the ‘Baltimore CT grading system’ supports clinical decision making. We therefore recommend use of this system in the classification of splenic injury.

67 CONTEMPORARY EVALUATION AND MANAGEMENT OF 111 HIGH-GRADE BLUNT RENAL INJURIES

You have accessJournal of UrologyTrauma/Reconstruction: Trauma & Reconstructive Surgery II1 Apr 201067 CONTEMPORARY EVALUATION AND MANAGEMENT OF 111 HIGH-GRADE BLUNT RENAL INJURIES Thomas Smith, Hunter Wessells, and Bryan Voelzke Thomas SmithThomas Smith Houston, TX More articles by this author , Hunter WessellsHunter Wessells Seattle, WA More articles by this author , and Bryan VoelzkeBryan Voelzke Seattle, WA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2010.02.114AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Blunt trauma is the most common form of injury to the kidney. American Association for the Surgery of Trauma (AAST) low-grade renal injuries (I-III) are typically managed conservatively; however, high-grade blunt renal injury (IV-V) lacks standardized management. We analyzed our extensive experience with high-grade blunt renal injuries to evaluate contemporary management and outcome. METHODS From 2003-2007, 111 consecutive patients presented to Harborview Medical Center with blunt grade IV-V renal injury. Initial evaluation included vital signs, Glasgow Coma Score, laboratory evaluation, and contrast CT of the abdomen/pelvis with delayed images. Each CT was retrospectively evaluated by urology staff (TS, BV) using the AAST grading system. In patients with grade III or higher injury, repeat CT with delayed images was performed 36-48 hours later. Follow-up included clinical exam, creatinine, and imaging (CT, ultrasound, or functional studies). RESULTS Patient mean age was 33.3 years and 67.6% were male. Median length of hospitalization was 6 days (0-73). In the 111 patients, there were 104 grade IV and 7 grade V injuries. Among the grade IV cohort, intervention was performed in 32 (19 minimally invasive, 13 operative). Renal salvage for AAST IV renal injury was 96% (100/104). In patients with AAST grade V injury, 6 procedures were performed including 5 nephrectomies. 16 patients required ureteral stents and additional percutaneous drainage was required in 6. Overall mortality for the entire cohort was 7.3% (8/111). After discharge, 52 patients returned for follow-up. Nuclear medicine imaging was performed in 35 at a mean of 105 days after discharge. Acceptable renal function, > 20%, was noted in 32. No patient had evidence of hypertension. CONCLUSIONS High-grade blunt renal trauma is a complex management issue. Most injuries can be managed conservatively, however, a low threshold for intervention is necessary. Partial nephrectomy, while more challenging, is technically feasible. Despite the heterogeneous nature of this patient population, high renal salvage rates are achievable and should be sought when clinical status dictates. Renal salvage is more difficult in grade V injuries reflecting both the severity of the renal injury and the injury severity of the patient. Management Interventions AAST injury grade N Angiography Embolization Stent Exploration Partial Nephrectomy Total Nephrectomy IV parenchyma 77 4 15 3 6 4 IV vascular 27 1 1 1 V parenchyma 4 4 V vascular 3 1 1 Total 111 1 6 16 3 6 9 © 2010 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 183Issue 4SApril 2010Page: e28-e29 Peer Review Report Advertisement Copyright & Permissions© 2010 by American Urological Association Education and Research, Inc.MetricsAuthor Information Thomas Smith Houston, TX More articles by this author Hunter Wessells Seattle, WA More articles by this author Bryan Voelzke Seattle, WA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Only Moderate Intra- and Inter-observer Agreement between Radiologists and Surgeons when Grading Blunt Paediatric Hepatic Injury on CT Scan

The American Pediatric Surgical Association developed guidelines for the management of haemodynamically stable children with hepatic or splenic injury, based on grade of injury on CT scan. This study investigated the intra- and inter-observer agreement of radiologists, paediatric surgeons, trauma surgeons and hepatobiliary surgeons when scoring liver injury based on CT scan findings. CT scans of patients with blunt abdominal trauma were independently assessed twice by a fellow and a consultant radiologist, paediatric surgeon, trauma surgeon and one consultant hepatobiliary surgeon. Reviewers were unaware of the clinical course. All scans were multislice CTs with a slice thickness of 3 mm, and both the arterial and venous phase were assessed. Injury was scored using the American Association for the Surgery of Trauma (AAST) liver injury scale. Intra-observer agreement was tested using Cohen's kappa coefficient. Inter-observer agreement was tested using Cohen's kappa for the second reading of individual observers and Spearman's rank correlation for the mean of both readings from each observer. CT scans of 27 patients (11 girls and 16 boys, median age 11.7+/-5.2 years) were reviewed. Mean AAST grade of liver injury was 3.3+/-1.1 for radiologists, 2.9+/-1.0 for paediatric surgeons, 3.0+/-0.9 for trauma surgeons and 3.2+/-0.8 for the hepatobiliary surgeon (p=0.30) Intra-observer agreement was moderate, with kappa below 0.7 for all observers except for one of the radiologists. Inter-observer correlation using Cohen's kappa coefficient was also moderate, with kappa below 0.5. In contrast, inter-observer correlation using Spearman's test was good, suggesting that there is agreement on the general severity of injury but not on the exact grading of injury using the AAST scoring system. Intra-observer agreement is only moderate when assessing liver injury using the AAST grading system. Only the most experienced radiologist demonstrated good intra-observer agreement which might indicate the necessity of the presence of a senior trauma radiologist at all times. However, this is not possible in most centres. Although there was agreement concerning the general severity of injury, inter-observer agreement is also moderate. These data cast doubt on the use of the AAST liver injury score alone as a decision-making tool when assessing haemodynamically stable children with blunt hepatic injury.

A clinically relevant liver injury grading system by CT, preliminary report

Current computed tomography (CT) grading scales are anatomic and do not reliably identify those liver injuries requiring intervention (surgery or angioembolization). We propose a clinically relevant CT grading system that could predict need for intervention. CT scans of 11 patients with hepatic injury were reviewed to establish criteria that correspond with intervention. Five features were identified that were associated with intervention: laceration in greater than or equal to three segments, laceration extending into the hilum, hemoperitoneum, active extravasation, and sentinel clot. Radiologists then evaluated the predictability of these criteria by analyzing 24 CT scans. Inter-observer agreement of the American Association for the Surgery of Trauma (AAST) grading system was compared to this new system. In the analysis of 24 CT scans, active extravasation and sentinel clot demonstrated the highest specificity for intervention. This new grading system had superior inter-observer agreement (k=0.56) as compared to the AAST grading system (k=0.47). Active extravasation and the presence of sentinel clot should form the foundation of a new liver grading system.

Management of Trauma to the Male External Genitalia: The Usefulness of American Association for the Surgery of Trauma Organ Injury Scales

Injury to the male external genitalia is rare and, therefore, there are little data in the literature regarding the options for nonoperative management and outcome. To assist in defining the indications for nonoperative management the usefulness of the American Association for the Surgery of Trauma (AAST) organ injury scales for these injuries was examined. We retrospectively reviewed the medical records of 116 male patients with trauma to the external genitalia in a 10-year period and classified injuries according to the organ injury severity scales (scrotum, testis, penis and urethra) of the AAST. Based on AAST grading management and outcome was reviewed. Mean patient age was 28 years and 79% of the injuries were due to gunshot wounds. A total of 87 patients (75%) underwent surgery, while 27 penile injuries and 8 scrotal/testicular injuries were managed nonoperatively. There were 54 scrotal explorations, 33 testicular injuries and 20 orchiectomies (bilateral in 1) for a testicular salvage rate of 39%. Documented followup by the trauma or genitourinary service was achieved in 47 of 110 survivors. No patient reported impotence or difficulty with fertility. The AAST grading for male external genital trauma readily characterizes patients with high grade injuries that require operative management as well as select patients in whom injury can be safely managed nonoperatively.

Utility of radiographic hepatic injury grade in predicting outcome for children after blunt abdominal trauma

Background/Purpose: The American Association for the Surgery of Trauma (AAST) liver injury grading system has been adopted in the management of pediatric hepatic injuries. However, the usefulness of this grading system in children remains undefined. The authors, therefore, examined the validity of AAST grading in the management of pediatric blunt liver injury. Methods: The authors identified 152 patients, ages 0 to 18 years, with blunt hepatic injury treated at our pediatric trauma center between 1995 and 2000. Radiographic AAST grade was assigned retrospectively by 2 radiologists. Variables analyzed included age, gender, Glasgow Coma Score (GCS), Injury Severity Score (ISS), and associated injuries. Outcome measures were mortality rate and length of stay (LOS). Statistical analysis was performed using analysis of variance or linear regression. Results: Computed tomography (CT) scans were available for 95 patients. Radiographic injury grade did not correlate with mortality rate, hospital LOS or intensive care unit (ICU) LOS. ISS and associated injury, but not age, gender, or GCS, were predictive of LOS. Grade did not correlate with mortality rate, ICU LOS, or hospital LOS. Conclusions: Radiographic liver grading does not predict outcome reliably in children and should not be the main parameter utilized to guide clinical decision making. A role for scoring systems that utilize factors such as associated injuries and ISS is indicated.