Blunt Polytrauma Research Articles

Time trajectories and within-subject correlations of matrix metalloproteinases 3, 8, 9, 10, 12, and 13 serum levels and their ability to predict mortality in polytraumatized patients: a pilot study

BackgroundManaging polytrauma victims poses a significant challenge to clinicians since applying the same therapy to patients with similar injury patterns may result in different outcomes. Using serum biomarkers hopefully allows for treating each multiple injured in the best possible individual way. Since matrix metalloproteinases (MMPs) play pivotal roles in various physiological processes, they might be a reliable tool in polytrauma care.MethodsWe evaluated 24 blunt polytrauma survivors and 12 fatalities (mean age, 44.2 years, mean ISS, 45) who were directly admitted to our Level I trauma center and stayed at the intensive care unit for at least one night. We determined their MMP3, MMP8, MMP9, MMP10, MMP12, and MMP13 serum levels at admission (day 0) and on days 1, 3, 5, 7, and 10.ResultsMedian MMP8, MMP9, and MMP12 levels immediately rose after the polytrauma occurred; however, they significantly decreased from admission to day 1 and significantly increased from day 1 to day 10, showing similar time trajectories and (very) strong correlations between each two of the three enzyme levels assessed at the same measurement point. For a two-day lag, autocorrelations were significant for MMP8 (− 0.512) and MMP9 (− 0.302) and for cross-correlations between MMP8 and MMP9 (− 0.439), MMP8 and MMP12 (− 0.416), and MMP9 and MMP12 (− 0.307). Moreover, median MMP3, MMP10, and MMP13 levels significantly increased from admission to day 3 and significantly decreased from day 3 to day 10, showing similar time trajectories and an (almost) strong association between every 2 levels until day 7. Significant cross-correlations were detected between MMP3 and MMP10 (0.414) and MMP13 and MMP10 (0.362). Finally, the MMP10 day 0 level was identified as a predictor for in-hospital mortality. Any increase of the MMP10 level by 200 pg/mL decreased the odds of dying by 28.5%.ConclusionsThe time trajectories of the highly varying individual MMP levels elucidate the involvement of these enzymes in the endogenous defense response following polytrauma. Similar time courses of MMP levels might indicate similar injury causes, whereas lead–lag effects reveal causative relations between several enzyme pairs. Finally, MMP10 abundantly released into circulation after polytrauma might have a protective effect against dying.

Serum Angiopoietin-2 level increase differs between polytraumatized patients with and without central nervous system injuries

Since endothelial cells rapidly release Angiopoietin-2 (Ang-2) in response to vascular injury and inflammatory stimuli, we aimed to investigate if its serum levels increase in polytraumatized patients. Our cohort study evaluated 28 blunt polytrauma survivors (mean age, 38.4 years; median ISS, 34) who were directly admitted to our level I trauma center in 2018. We assessed the serum Ang-2 level at admission and on days 1, 3, 5, 7, and 10 during hospitalization. Ang-2 was released into the circulation immediately after polytrauma. At admission (day 0), it amounted to 8286 ± 5068 pg/mL, three-and-a-half times the reference value of 2337 ± 650 pg/mL assessed in a healthy control group. Subgroup analysis provided a higher mean Ang-2 level in the CNSI group combining all patients suffering a brain or spinal cord injury compared to the non-CNSI group solely on day 0 [11083 ± 5408 pg/mL versus 3963 ± 2062 pg/mL; p < 0.001]. Whereas the mean Ang-2 level increased only in the non-CNSI group from day 0 to day 3 (p = 0.009), the respective curves showed similar continuous decreases starting with day 3. Multivariate logistic regression analysis revealed an association between the Ang-2 day 0 level and the presence of a CNSI (OR = 1.885; p = 0.048). ROC analysis provided a cutoff level of 5352 pg/mL. In our study group, serum Ang-2 levels assessed at admission differed between polytraumatized patients with and without brain or spinal cord injuries. Based on our findings, we consider serum Ang-2 levels an effective biomarker candidate for indicating CNSI in these patients at admission, worthy of further evaluation in large multicenter studies.

Tension Pneumopericardium Causing Cardiogenic Shock due to Blunt Injury to the Chest.

Pneumopericardium is an exceptionally uncommon phenomenon in the setting of blunt polytrauma. It is imperative for trauma providers to identify tension pneumopericardium despite its rarity. A 22-year-old male motorcyclist presented to the hospital after colliding with a car going approximately 50mph. The patient was hemodynamically unstable and had diminished breath sounds bilaterally. Bilateral chest tubes were placed, yielding little improvement in condition. While obtaining CT imaging, pneumopericardium was promptly identified. Pulses were lost immediately before pericardiocentesis, and resuscitative thoracotomy was performed. The pericardial sac was tense and an immediate gush of air released upon incising the sac. The patient was taken immediately to the Operating Room for further exploration and repair.

Costal cartilage fractures in blunt polytrauma patients — a prospective clinical and radiological follow-up study

PurposeTo assess the healing of costal cartilage fractures (CCFX) in patients with blunt polytrauma with follow-up imaging and clinical examination. Effect on physical performance and quality of life (QoL) was also evaluated.MethodsThe study group comprised twenty-one patients with diagnosed CCFX in trauma CT. All the patients underwent MRI, ultrasound, ultra-low-dose CT examinations, and clinical status control. The patients completed QoL questionnaires. Two radiologists evaluated the images regarding fracture union, dislocation, calcifications, and persistent edema at fracture site. An attending trauma surgeon clinically examined the patients, with emphasis on focal tenderness and ribcage mobility. Trauma registry data were accessed to evaluate injury severity and outcome.ResultsThe patients were imaged at an average of 34.1 months (median 36, range 15.8–57.7) after the initial trauma. In 15 patients (71.4%), CCFX were considered stable on imaging. Cartilage calcifications were seen on healed fracture sites in all the patients. The fracture dislocation had increased in 5 patients (23.8%), and 1 patient (4.8%) showed signs of a non-stable union. Four patients (19.0%) reported persistent symptoms from CCFX.ConclusionNon-union in CCFX is uncommon but may lead to decreased stability and discomfort. Both clinical and radiological examinations play an important part in the post-traumatic evaluation of CCFX. CT and MRI visualize the healing process, while dynamic ultrasound may reveal instability. No significant difference in QoL was detected between patients with radiologically healed and non-healed CCFX. Post-traumatic disability was mostly due to other non-thoracic injuries.

Evaluation of the efficacy of BIG score and injury severity score in the prediction of mortality in pediatric blunt polytrauma

Background Pediatric polytrauma is the first cause of death in childhood, representing more than all other causes of death combined; it also represents the leading cause of permanent disability in this population. Aim Our aim was to discover the effectiveness of BIG score (abbreviation taken of the first letter of Base deficit, International normalized ratio, and Glasgow coma scale) injury severity score (ISS) in children less than 16 years presenting with blunt polytrauma as an early predictor for mortality in the Emergency Department, Tanta University Hospital. Patients and methods A prospective study was conducted on 105 cases of less than 16 years with blunt polytrauma of both sexes, who were admitted to the Emergency and Traumatology Department in Tanta University Hospitals, in the period from March 2019 till March 2020. Results BIG score was superior to ISS in the prediction of mortality and superior also to Glasgow coma scale, international normalized ratio, or base deficit alone. Taking the cutoff more than or equal to 18 of BIG score to predict mortality has a sensitivity of 97.62%, specificity of 85.71, and a cutoff more than or equal to 21 of ISS to predict mortality has a sensitivity of 75% and a specificity of 80.95%. Conclusion Pediatric BIG score is an easily applicable method for predicting mortality in the pediatric emergency and is superior to ISS in the prediction of mortality. This may represent a guide in the evaluation of early invasive and noninvasive monitoring and treatment plans in the ICU.

Diagnostic accuracy, yield, and comparative effectiveness of whole-body computed tomography in blunt trauma: A protocol for systematic review and meta-analysis.

Controversies emerge over routine performances of whole-body computed tomography (WBCT) in patients with blunt polytrauma. The existing randomized and non-randomized evidence is inconclusive, and during observations of non-trauma, incidental findings, detected by WBCT, have left uncertainty regarding their consequences and optimal management. Additionally, previous meta-analyses have failed to address the limitations of primary studies and issues associated with incidental findings. Therefore, we planned a new systematic review to address these points. We will search the PubMed, EMBASE, and Cochrane Central databases from inception to December 31, 2020, with no language restriction and perform full-text evaluation of potentially relevant articles. We will include prospective and retrospective studies with a single-gate design that assessed diagnostic accuracy and/or yield of WBCT to detect traumatic injuries, and studies that assessed incidental findings detected by WBCT. Additionally, we will include randomized controlled trials and non-randomized comparative studies that assessed the effectiveness of WBCT against conventional care, including selective computed tomography (CT). Studies of patients of all ages with blunt traumatic injuries, assessed at an emergency department, will be included. Two reviewers will extract data and rate the study validity via standard quality assessment tools. The primary outcome of interest will be reduction in mortality. Our secondary outcomes will include diagnostic accuracy and yield, detection of incidental findings and clinical outcomes associated with these detections, and improvement in other non-mortality clinical outcomes. We will qualitatively assess study, patient, and intervention characteristics and clinical outcomes. If appropriate, we will perform random-effects model meta-analyses to obtain summary estimates. Finally, we will assess the certainty of evidence by the grading the quality of evidence and strength of recommendations. Ethics approval is not applicable, as this is a secondary analysis of publicly available data. The review results will be submitted for publication in peer-reviewed journals. CRD42020187852.

Association of Low-Dose Whole-Body Computed Tomography with Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

Morbidity and mortality related to trauma patients has decreased significantly over the past several decades due to the advent of various protocols such as Advanced Trauma Life Support (ATLS) guidelines, point of care (POC) ultrasonography, and pelvic stabilization. Many patients with blunt, suspected polytrauma, receive whole body computed tomography (WBCT) as an initial screening to identify injuries. There is controversy surrounding this as computed tomography (CT) has varying sensitivity despite great specificity and exposes the patient to large amounts of radiation that may be unnecessary. Recent advances in CT scanner software allow for better imaging processing while at the same time reducing the radiation dosage. The objective of this study was to assess if low dose WBCT could be used as an initial screening tool for blunt polytrauma, without increasing the risk of missed injuries compared to standard dose WBCT.

Impact of Polytrauma and Acute Respiratory Distress Syndrome on Markers of Fibrinolysis: A Prospective Pilot Study.

Acute respiratory distress syndrome (ARDS), which is associated with major morbidity and high mortality, is commonly developed by polytraumatized patients. Its pathogenesis is complex, and its development is difficult to anticipate, as candidate biomarkers for the prediction of ARDS were found not to be reliable for clinical use. In this prospective study, we assessed the serum antigen levels of tissue plasminogen activator (tPA) and plasminogen activator inhibitor type-1 (PAI-1) of 28 survivors of blunt polytrauma (age ≥18 years; injury severity score ≥16) at admission and on days 1, 3, 5, 7, 10, 14, and 21 of hospitalization. Our results show that these patients presented high mean tPA and PAI-1 antigen levels at admission; despite their decline, these parameters remained elevated for 3 weeks. Over this period, the mean tPA antigen level was higher in polytrauma victims suffering from ARDS than in those without ARDS, whereas the mean PAI-1 level was higher in polytrauma victims sustaining pneumonia than in those without pneumonia. Moreover, in each individual developing ARDS, the polytrauma-related elevated tPA antigen level either continued to rise after admission or suffered a second increase up to the onset of ARDS, declining immediately thereafter. Therefore, our findings support the assessment of serum tPA antigen levels after the initial treatment of polytraumatized patients, as this parameter shows potential as a biomarker for the development of ARDS and for the consequent identification of high-risk individuals.

Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma.

Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy (ATT) and endovascular stents. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI. A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol versus no screening protocol (odds ratio [OR], 4.74; 95% confidence interval [CI], 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR, 12.7; 95% CI, 6.24-25.62; p = 0.003). The use of ATT versus no ATT resulted in a decreased risk of stroke (OR, 0.20; 95% CI, 0.06-0.65; p < 0.0001) and mortality (OR, 0.17; 95% CI, 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to ATT versus ATT alone (OR, 1.63; 95% CI, 0.2-12.14; p = 0.63). We recommend using a screening protocol to detect BCVI in blunt polytrauma patients. Among patients with high-risk cervical spine injuries, we recommend screening computed tomography angiography to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a computed tomography angiography to detect BCVI. We recommend the use of ATT in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to ATT in patients with Grade II or III BCVIs. Guidelines, Level III.

An analysis of adverse events and human error associated with the imaging of patients at a major trauma centre in South Africa.

There is growing realisation that human error contributes significantly to morbidity and mortality in modern healthcare. Anumber of taxonomies and classification systems have been developed in an attempt to categorise errors and quantify their impact. To record and identify adverse events and errors as they impacted on acute trauma patients undergoing a computed tomography (CT) scan, and then quantify the effect this had on the individual patients. It is hoped that these data will provide evidence to develop error prevention programmes designed to reduce the incidence of human error. The trauma database was interrogated for the period December 2012 - April 2017. All patients aged &gt;18 years who underwent a CT scan for blunt trauma were included. All recorded morbidity for these patients was reviewed. During the period under review, a total of 1 566 patients required a CT scan at our institution following blunt trauma. Of these, 192 (12.3%, 134 male and 58 female) experienced an error related to the process of undergoing a CT scan. Of 755 patients who underwent a CT scan with intravenous contrast, detailed results were available for 312, and of these 46 (14.7%) had an acute deterioration in renal function. According to Chang's taxonomy, physical harm occurred as follows: grade I n=6, grade II n=62, grade III n=45, grade IV n=11, grade V n=27, grade VI n=21, grade VII n=15, grade VIII n=3 and grade IX n=2. Adverse events were performing an unnecessary scan (n=24), omitting an indicated scan (n=23), performing the scan incorrectly (n=8), scanning the wrong body part (n=7), equipment failure (n=18), omitting treatment following the scan (n=6), incorrect interpretation of the scan (n=65), deterioration during the scan (n=6) and others (n=35). The setting for the error was the ward (n=19), the radiology suite (n=126), the emergency department (n=45) and the operating theatre (n=2). The staff responsible for the adverse events were medical (n=155), nursing (n=4) and radiology staff (n=15). There were 67errors of commission and 125 errors of omission. The primary cause was a planning problem in 78 cases and an execution problem in 114. Errors and adverse events related to obtaining a CT scan following blunt polytrauma are not uncommon and may impact significantly on the patient. Communication is essential to eliminate errors related to performing the wrong type of scan. The commonest errors relate to misinterpretation of the scan.

Isolated free fluid on computed tomography for blunt abdominal trauma.

The clinical significance of isolated free fluid on abdominal computed tomography (CT) in patients with blunt abdominal trauma is unclear. This audit reviews our unit's experience with isolated free fluid and attempts to refine our clinical algorithms for the assessment of patients with blunt abdominal trauma. All patients who sustained blunt abdominal trauma between December 2012 and December 2017 who were subjected to multidetector CT of the abdomen as part of their initial investigation were included in this study. During the five-year period under review, a total of 1066 patients underwent abdominal CT following blunt poly trauma. A total of 84 (7.9%) patients died. There were 148 (14%) patients with CT finding of isolated free fluid. Of these, 128 (67%) were selected for non-operative management, which included a period of serial abdominal examinations. In this non-operative group, five patients failed their abdominal observations and underwent laparotomy. Findings in these five cases were negative (1), non-therapeutic (1), splenic injury (1), Pancreatic and splenic injury (1) and bladder injury (1). Thirteen patients (10%) died, none of whom had surgery. The causes of death were exsanguination from a major traumatic lower limb injury (1), multiple organ failure (1), traumatic brain injury (10) and spinal cord injury (1). The remaining 20 patients underwent laparotomy. The indications were failed non-operative management (5), abdominal distension (1) and suspicion of a missed hollow viscus injury (14). In this group there were 11 therapeutic and 6 non-therapeutic surgeries and three negative laparotomies. For the 15 patients selected for operative management, the findings were as follows: hollow viscus injury (3), mesenteric bleeds (2), splenic and pancreatic injury (1), liver and bladder injury (1), splenic and bladder injury (1), non-therapeutic (4), negative (3). The finding of isolated free fluid on CT is 98% sensitive and 96% specific for true isolated free fluid (chi square 331.598; P = 0.000). This finding predicts successful non-operative management with a positive predictive value of 93% and a negative predictive value of 96%. In patients with blunt abdominal trauma, the finding of isolated free fluid on abdominal CT alone is no longer an indication for laparotomy. Other clinical factors must be taken into account when deciding on the need for laparotomy, such as haemodynamic status, clinical abdominal findings and the ability to reliably assess the abdomen. In the absence of a clinical indication for urgent laparotomy, patients with isolated free fluid may be observed.

Quantifying the burden of trauma imaging on the CT scan service at a major trauma centre in South Africa

Imaging is an integral part of trauma management and the huge burden of trauma in South Africa places substantial pressures on radiology resources. This study aims to provide a holistic overview of the burden of trauma imaging and the cost of trauma to a busy CT scanning facility at a tertiary hospital in South Africa. We set out to describe and quantify the impact of blunt poly-trauma on CT scanning services at Grey's Hospital in Pietermaritzburg. We aimed to provide a holistic assessment in terms of use of equipment and staff, cost to the hospital and overall usage of CT scanning. Over the four-year study period, 1572 patients required a CT scan following blunt torso trauma (mean age: 30 years, 81% males). Of the 1572 patients, 625 had a chest radiograph (40%), 383 a cervical spine X-ray (24%), 347 a pelvic X-ray (22%), 292 a skull X-ray (18%), 193 a limb X-ray (12%), 133 an abdominal radiograph (8%), and 86 a FAST scan (5%). The 1572 CT included: 967 head, 568 neck, 65 chest, 241 abdominal, 228 pelvic, 12 upper limb, 38 lower limb and 394 had full body (Pan) CT scan. The mean total cost of the CT scanning for blunt poly-trauma is ZAR 12 000. The total cost of CT scanning for blunt poly-trauma is 0.92% of the total hospital expenditure. Roughly 7.8% of the total hours worked by the CT scanner over the time period under review was dedicated to blunt poly-trauma. Blunt poly-trauma is a preventable disease, which has a major financial impact on the healthcare system in general. This study has documented the tremendous burden it places on an already stretched CT scanning service.

Intra-abdominal injury identified by CTA in stable blunt polytrauma patients

Background: Patients with multiple injuries are a challenge to evaluate and to exclude abdominal injury, especially those who are intubated and sedated. Ultrasound is a screening tool and peritoneal lavage is unreliable. The aim of the study was to determine the incidence of intra-abdominal injury and describe the subsequent management after CT “panscan” in patients sustaining blunt trauma with injuries both above the thoracic and below the pelvic diaphragm. Methods: In a retrospective analysis anonymised patient data were extracted from a prospective ethics approved database of patients admitted to the level I Trauma Unit at Inkosi Albert Luthuli Central Hospital for the period from April 2007 to March 2011. Blunt polytrauma patients, aged 2 years and older with injuries above the diaphragm and below the pelvic floor were included, provided they were investigated by a full-body trauma Computed Tomography contrast study. Descriptive statistics were employed for all variables of interest, with counts/frequencies and associated percentages being reported. Results: Of 284 patients with injuries above the thoracic and below the pelvic diaphragm, 87 (30.6%) had intra-abdominal injury and 197 (69.4%) had no intra-abdominal injuries. Of those 87 patients, 54 (62.1%) were treated non-operatively and 33 (37.9%) were treated surgically with regard to their abdominal injuries. Twenty (22.9%) patients died, 4 due to intraabdominal injuries and 16 due to of extra-abdominal injuries. Nine (45%) of the twenty patients who died were treated operatively for intra-abdominal injuries and the remaining 11 (55%) were treated non-operatively. Conclusion: Around thirty percent of patients with injuries above the thoracic and below the pelvic diaphragm had concomitant intra-abdominal injuries. Of those with abdominal injury, just over half required laparotomy. For haemodynamically stable patients CT scanning identified those who require surgical intervention and those who may be managed non-operatively, therefore liberal CT-scanning is advisable for this patient group.

Multi-Disciplinary Approach after Blunt Polytrauma

Multi-Disciplinary Approach after Blunt Polytrauma

Polytrauma patients in the Netherlands and the USA: A bi-institutional comparison of processes and outcomes of care

BackgroundModern trauma systems differ worldwide, possibly leading to disparities in outcomes. We aim to compare characteristics and outcomes of blunt polytrauma patients admitted to two Level 1 Trauma Centers in the US (USTC) and the Netherlands (NTC). MethodsFor this retrospective study the records of 1367 adult blunt trauma patients with an Injury Severity Score (ISS) ≥ 16 admitted between July 1, 2011 and December 31, 2013 (640 from NTC, 727 from USTC) were analysed. ResultsThe USTC group had a higher Charlson Comorbidity Index (mean [standard deviation] 1.15 [2.2] vs. 1.73 [2.8], p<0.0001) and Injury Severity Score (median [interquartile range, IQR] 25 [17–29] vs. 21 [17–26], p<0.0001). The in-hospital mortality was similar in both centers (11% in USTC vs. 10% NTC), also after correction for baseline differences in patient population in a multivariable analysis (adjusted odds ratio 0.95, 95% confidence interval 0.61–1.48, p=0.83). USTC patients had a longer Intensive Care Unit stay (median [IQR] 4 [2–11] vs. 2 [2–7] days, p=0.006) but had a shorter hospital stay (median [IQR] 6 [3–13] vs. 8 [4–16] days, p<0.0001). USTC patients were discharged more often to a rehabilitation center (47% vs 10%) and less often to home (46% vs. 66%, p<0.0001), and had a higher readmission rate (8% vs. 4%, p=0.01). ConclusionAlthough several outcome parameters differ in two urban area trauma centers in the USA and the Netherlands, the quality of care for trauma patients, measured as survival, is equal. Other outcomes varied between both trauma centers, suggesting that differences in local policies and processes do influence the care system, but not so much the quality of care as reflected by survival.

Abdominal and Pelvic Trauma: Misses and Misinterpretations at Multidetector CT: Trauma/Emergency Radiology.

HomeRadioGraphicsVol. 37, No. 2 Previous RadioGraphics FundamentalsAbdominal and Pelvic Trauma: Misses and Misinterpretations at Multidetector CT: Trauma/Emergency RadiologyMichael N. Patlas , David Dreizin, Christine O. Menias, Nikki Tirada, Sanjeev Bhalla, Savvas Nicolaou, Nataly Farshait, Douglas S. KatzMichael N. Patlas , David Dreizin, Christine O. Menias, Nikki Tirada, Sanjeev Bhalla, Savvas Nicolaou, Nataly Farshait, Douglas S. KatzAuthor AffiliationsFrom the Division of Emergency/Trauma Radiology, Department of Radiology, McMaster University, Hamilton General Hospital, 237 Barton St E, Hamilton, ON, Canada L8L 2X2 (M.N.P.); Department of Diagnostic Radiology, University of Maryland Medical Center, R. Adams Cowley Shock Trauma Center, Baltimore, Md (D.D.); Department of Radiology, Mayo Clinic School of Medicine, Scottsdale, Ariz (C.O.M.); Department of Radiology, Brigham and Women’s Hospital, Brookline, Mass (N.T.); Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Mo (S.B.); Division of Emergency/Trauma Radiology, Department of Radiology, University of British Columbia, Vancouver, BC, Canada (S.N.); Infection Prevention and Control, Humber River Hospital, Toronto, Ont, Canada (N.F.); and Department of Radiology, Winthrop-University Hospital, Mineola, NY (D.S.K.).Address correspondence to M.N.P. (e-mail: [email protected]).Michael N. Patlas David DreizinChristine O. MeniasNikki TiradaSanjeev BhallaSavvas NicolaouNataly FarshaitDouglas S. KatzPublished Online:Mar 13 2017https://doi.org/10.1148/rg.2017160067MoreSectionsFull textPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In AbstractBeing mindful of potential diagnostic pitfalls in trauma imaging; having a thorough, efficient, and informed search strategy; and developing a working knowledge of commonly missed traumatic injuries can help radiologists improve the care of patients with abdominopelvic trauma.Suggested ReadingsChernyak V, Patlas MN, Menias CO, et al. Traumatic and non-traumatic adrenal emergencies. Emerg Radiol 2015;22(6):697–704. Crossref, Medline, Google ScholarDreizin D, Munera F. Blunt polytrauma: evaluation with 64-section whole-body CT angiography. RadioGraphics 2012;32(3):609–631. Link, Google ScholarLubner M, Menias C, Rucker C, et al. Blood in the belly: CT findings of hemoperitoneum. RadioGraphics 2007;27(1):109–125. Link, Google ScholarArticle HistoryReceived: Mar 21 2016Revision requested: July 11 2016Revision received: July 18 2016Accepted: Aug 8 2016Published online: Mar 13 2017Published in print: Mar 2017 FiguresReferencesRelatedDetailsCited ByRadiopaedia.orgLizSilverstone2023CT Imaging and Management of Blunt Splenic Trauma: Lessons for Today and TomorrowMichael N. Patlas, 2 February 2021 | Radiology, Vol. 299, No. 1Invited Commentary: Imaging and Management of Pancreatic TraumaMichael N. Patlas, 7 January 2021 | RadioGraphics, Vol. 41, No. 1Radiology and A Radiologist: A Keystone in the Turmoil of Trauma SettingKhadijaHussain, DeepakVerma, AmenaFiroz, Karez SNamiq, MahamRaza, MuhammadHaris, ManelBouchama, SafeeraKhan2021 | CureusImaging Evaluation of Abdominopelvic Gunshot TraumaFaezeh Sodagari, Douglas S. Katz, Christine O. Menias, Mariam Moshiri, John S. Pellerito, Adel Mustafa, Margarita V. Revzin, 1 October 2020 | RadioGraphics, Vol. 40, No. 6Errors in ImagingHarisChrysikopoulos2020Imaging of blunt bowel and mesenteric injuries: Current statusMostafaAlabousi, Vincent M.Mellnick, RayehKashef Al-Ghetaa, Michael N.Patlas2020 | European Journal of Radiology, Vol. 125Changes in Approach to Solid Organ Injury: What the Radiologist Needs to KnowSiobhán B.O’Neill, SairaHamid, SavvasNicolaou, Sadia R.Qamar2020 | Canadian Association of Radiologists Journal, Vol. 71, No. 3Errors in Emergency and Trauma RadiologyKateHames, Michael N.Patlas, Vincent M.Mellnick, Douglas S.Katz2019Errors in Emergency and Trauma RadiologyGabrieleMasselli, MartinaDerme2019Diagnostic Imaging in Polytrauma PatientsStefanoGiannecchini, ValentinaCaturano, CarmeloRende, ViolaValentini, MargheritaTrinci, VittorioMiele2018Multi-modality imaging of the leaking ureter: why does detection of traumatic and iatrogenic ureteral injuries remain a challenge?AbdullahAlabousi, Michael N.Patlas, Christine O.Menias, DavidDreizin, SanjeevBhalla, ManHon, AndresO’Brien, Douglas S.Katz2017 | Emergency Radiology, Vol. 24, No. 4Accompanying This ArticleAbdominal and Pelvic Trauma: Misses and Misinterpretations at Multidetector CTMay 30 2018Default Digital Object SeriesRecommended Articles CT of Penetrating Abdominopelvic TraumaRadioGraphics2021Volume: 41Issue: 4pp. 1064-1081Imaging Evaluation of Abdominopelvic Gunshot TraumaRadioGraphics2020Volume: 40Issue: 6pp. 1766-1788Invited Commentary: Key Concepts of CT for Penetrating Abdominopelvic InjuriesRadioGraphics2021Volume: 41Issue: 4pp. E119-E120Multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic InjuriesRadioGraphics2019Volume: 39Issue: 4pp. 1183-1202Imaging Evaluation of Tracheobronchial InjuriesRadioGraphics2020Volume: 40Issue: 2pp. 515-528See More RSNA Education Exhibits Traumatic Diaphragm Rupture: A Pictorial ReviewDigital Posters2020Trauma Meets the Urinary Tract: What the Surgeions Needs to KnowDigital Posters2020Current State of Affairs in Trauma Body Imaging: Computed Tomography (CT) ProtocolingDigital Posters2020 RSNA Case Collection Traumatic Pseudoaneurysm RSNA Case Collection2021Left Hemidiaphragmatic Rupture RSNA Case Collection2021Traumatic Diaphragmatic RuptureRSNA Case Collection2020 Vol. 37, No. 2 Slide PresentationSupplemental MaterialMetrics Altmetric Score PDF download

Pan computed tomography for blunt polytrauma: Are we doing too many?

Pan computed tomography (CT) is widely used in the evaluation of patients with blunt polytrauma, but there is growing concern about the radiation risks imposed. To ascertain whether we were possibly overutilising pan CT in our trauma service, and whether we could safely cut down on scans without missing significant injuries. We audited all pan scans performed in the Metropolitan Trauma Service, Pietermaritzburg, South Africa, during the 12-month period 1 January - 31 December 2012. An analysis was done to determine what injuries were identified and how these findings influenced our management. Of the 140 pan scans, 108 (77.1%) influenced management. These included the following components: 62 brain scans (44.3%), 16 cervical spine scans (11.4%), 50 chest scans (35.7%) and 31 abdominal scans (22.1%). The remaining 32 pan scans (22.9%) did not influence management. However, it turned out that many of these 'clinically negative' scans were in fact clinically important, ruling out injury in patients in whom clinical assessment was regarded as unreliable: 3 patients (2.1%) were hypoxic and had to be sedated, intubated and ventilated; 14 (10.0%) had a Glasgow Coma Score (GCS) of &lt;15; and 9 (6.4%) had major distracting injuries. This left only 6 pan scans (4.3%) that were not regarded as clinically helpful. In our setting, the majority of pan scans influence management. By ruling out significant injuries, clinically negative scans are valuable in patients who are obtunded, intubated and ventilated, or have major distracting injuries. In patients with a GCS of 15, not sedated and ventilated and with no major distracting injuries, clinical assessment and alternative imaging modalities may suffice.

T-helper cell polarisation following severe polytrauma

Introduction Severe polytrauma induces an immunosuppressive response and is associated with a very high incidence of nosocomial infections. Previous studies have inferred that this detrimental immune response results from polarisation of the T helper (Th) response towards an anti-inflammatory, TH2 dominated, response at the expense of a bactericidal, Th1 response [1]. Objectives 1) To define alterations in TH cell subsets following severe blunt polytrauma. Methods Patients presenting to the emergency department within 2 hours of severe polytrauma were eligible if intubated either at the scene or in ED. Isolated head injuries and those not expected to survive 24 hours were excluded. EDTA anti-coagulated blood was drawn at 0hr (within 2 hours of injury), at 24 and 72hrs. Samples were immediately lysed, washed, stained and analysed using a standardised human 8-colour TH 1, 2 & 17 panel [2] on an LSR II flow cytometer. A paired white cell count differential was obtained at each sampling point. Patients were followed until discharge or death. Data were analysed using non-parametric statistics, with results presented as median and IQR. Results 15 consecutive severe polytrauma patients requiring Intensive Care Unit (ICU) admission were recruited. Demographic and clinical data are outlined in Figure 1. Twelve (80%) lymphocytosis (3.3x109/L, 2.5 - 4.4x109/L) (Figyre 2A). At 72 hours leukocytes had fallen (P < 0.01, figure 2A) such that 6 (54%) of those surviving were lymphopenic (0.9x109/L, 0.6 - 1.2x109/L). Circulating CD4+ (P = 0.01; Figure 2B) and CD4+CD25+ (P < 0.05) lymphocytes increased over 72 hours. When expressed as a percentage of total circulating lymphocytes no significant change in the proportions of the TH 1, 2 & 17 subpopulations was detected (Figure 2C-E). Conclusions Severe polytrauma patients swiftly become lymphopenic. Although a failure to normalise this during the ICU stay correlates with higher mortality [3] our study of TH cell subtypes demonstrates no evidence of a switch to a detrimental anti-inflammatory TH2 subtype at the expense of the potentially protective bactericidal TH1 subtype.

Changes in the Management of Femoral Shaft Fractures in Polytrauma Patients : From Early Total Care to Damage Control Orthopedic Surgery

major fractures in patients with blunt multiple injuries continues to be discussed. The aim of this study is to investigate the clinical course of poly- trauma patients treated at a Level I trauma cen- ter within the last two decades regarding the ef- fect of changes in the management of their femoral shaft fracture. Methods: In a retrospective cohort study performed at a Level I trauma center, the pa- tient's injuries and clinical outcomes were stud- ied. Adult blunt polytrauma patients were in- cluded if a femoral shaft fracture eligible for intramedullary stabilization was stabilized (in- cluding external fixation) primarily < 8 hours after primary admission. Patients were separated according to the management strategies for the Results: The patient groups were com- parable regarding age, gender distribution, and the mechanism of injury. Primary external fixa- tion was performed significantly more frequent in the INT (23.9%) and DCO (35.6%) groups com- pared with the ETC group (16.6%) (p 0.02 ETC vs. DCO). Plating of the femur was almost abolished in the 1990s (DCO, 6.8%; ETC, 23.4%). In the subgroups categorized to I°EF (ETC, 41.1 points; INT, 37.1 points; DCO, 39.1 points), the general injury severity was higher in comparison with the I°IMN group (ETC, 38.3%; INT, 36.1%; DCO, 35.8%). Thoracic or abdom- inal injuries accounted for significantly higher numbers of patients submitted to I°EF in the INT (13.6%, p 0.03) and DCO (17.3%, p 0.01) groups, compared with the ETC (8.1%) group. A higher incidence of reamed nailing was present in the ETC group compared with the other groups (ETC, 96.1%; INT, 73.7%; DCO, 13.5%). No significant differences in the incidence of local complications were found. The incidence of mul- tiple organ failure decreased significantly from the ETC to the DCO period regardless of the type of treatment of the femoral fracture. Moreover, there was a significantly higher incidence of acute respiratory distress syndrome (ARDS) when I°IMN (15.1%) and I°EF (9.1%) in the DCO subgroup were compared. Conclusion: A significant reduction in the incidence of general systemic complications regardless of the type of femur fixation used was found when comparing the time periods of 1981 to 1989 (ETC), 1990 to 1992 (INT), and 1993 to 2000 (DCO). The change in treatment protocols to external fixation and from reamed to unreamed nailing was not associated with an increased rate of local complications (pin-track infections, delayed unions, nonunions). Among other causes for the improved general outcome during the most recent time period (DCO), an increase in the frequency of air rescue, a change from reamed to unreamed nailing, and an in- creased awareness toward thoracic and abdom- inal injuries may have played a role. Even dur- ing the DCO era, IMN was associated with a higher rate of ARDS than I°EF. In view of a lower complication rate despite higher injury severity compared with the ETC period, the introduction of DCO appears to be an adequate alternative for patients at high risk of develop- ing posttraumatic systemic complications such as ARDS and multiple organ failure.

Motor vehicle collision patient with simultaneous duodenal transection and thoracic aorta injury: a case report and review of the literature.

Blunt polytrauma can present complex management decisions. Here we report the case of a 31-year-old male involved in a high speed motor vehicle collision resulting in both duodenal and thoracic aorta injury that was managed collaboratively between the trauma, vascular, and cardiothoracic surgical teams. The patient went on to a full recovery. We also review the management of such injuries which has evolved over the past two decades resulting in less morbidity and mortality.