Evaluation Of Blunt Trauma Patients Research Articles

Clinical and Laboratory Evaluation of Blunt Trauma Patients for the Early Diagnosis of Intra-Abdominal Injuries

Background: Blunt abdominal trauma is seen with increasing frequency in emergency rooms and is continuous to be associated with significant morbidity and mortality. Intra-abdominal injuries following blunt trauma are of great medico-legal importance to forensic experts. Aim: The study aimed to investigate the contribution of non-invasively and rapidly obtained clinical presentation and biochemical parameters in the early diagnosis of intra- abdominal (IA) injuries in blunt trauma patients, then develop a scoring system and investigate its clinical applicability as pre-test to determine whether abdominal CT should be performed during the diagnosis or not. This may help to decrease number of malpractice claims due to medical negligence. Methods and results: A prospective study was conducted on 30 adult patients with blunt abdominal trauma presented to Emergency department (ED) of Ain shams university hospitals (ASUHS). Patients were classified into two groups: group 1: adult patients with blunt abdominal trauma with normal CT abdomen. Group 2: adult patients with blunt abdominal trauma with abnormal CT abdomen. For every patient, demographic, trauma, and clinical data were collected. Laboratory parameters measured included blood hemoglobin level, liver enzymes, kidney function tests, pancreatic enzymes and finally CT abdomen was done. The mean age for the adult patients with blunt abdominal trauma was 34 ± 11 years. Male to female ratio was 2:1 with no significant importance. There was no significant difference between both groups of the study as regards aetiology and delay time of trauma and the most common cause of BAT was motor car accidents that compromised (36.7%) of all patients. There was no significant difference between both groups of study as regards abdominal symptoms and signs. Regarding vital signs, incidence of patients with high pulse rate per minute more than 100 bpm and high respiratory rate more than 20 brpm were highly significant in group II than group I. There was no significant difference between both groups regarding blood pressure. As regards the conscious level, there was significant difference between both groups of study. Hemoglobin level was significantly lower group II than group I with cutoff point level equal to or less than 9.8gm/dl. AST, ALT, urea, creatinine, amylase and lipase levels showed no significant difference between both groups. According to CT, the spleen was the most injured organ in blunt abdominal trauma patients (43.8%) followed by the liver 4 cases (25%). Conclusion: A scoring system could be done by the sum of points obtained from each parameter (Hb level, pulse rate, respiratory rate, and conscious level). The score points range from (0-4). It was found that the patients with score (0-2) were mainly with normal CT abdomen. On the other hand, patients with score (1-4) were mainly with positive CT findings. So, this scoring system can be used for the early prediction of the presence of IAIs in BAT patients and as a pretest for the need of CT. Recommendations: Blood hemoglobin level, pulse rate, respiratory rate and conscious level can be used as early predictors of IAIs in BAT patients. A scoring system using blood hemoglobin, pulse rate, respiratory rate and conscious level can be used as a pretest probability to determine the need for abdominal CT for the detection of intra-abdominal injury.

Role of cervical spine MRI in the setting of negative cervical spine CT in blunt trauma: Critical additional information in the setting of clinical findings suggestive of occult injury

Background and purposeCervical spine injury is common in the setting of blunt trauma and there is consensus that cervical spine CT (CSCT) is the image modality of choice for initial evaluation for blunt trauma related injuries of the cervical spine. However, there is disagreement in the literature with regards to further evaluation of blunt trauma patients with cervical spine MRI (CSMRI) after negative CSCT when there is persistent clinical concern for occult trauma related injury. The purpose of this study is to examine the utility of CSMRI for detection of occult injury in blunt trauma patients after negative CSCT. Materials and methodsWe reviewed records for 7,301 patients admitted for blunt trauma (November 2007–December 2013) and identified 259 who underwent CSMRI after a negative CSCT. These CSMRIs were reviewed to determine the number and type of significant CT occult injuries identified and clinical indications that led to CSMRI acquisition. Results and conclusionsCSMRI detected significant injuries following negative CSCT in 31% (81/259) of patients. There were 15 cord contusions/infarcts, 9 bone contusions/fractures, 7 spinal canal hemorrhages and 66 soft tissue injuries. Upper extremity neurological deficit had greatest positive predictive value (PPV) for detection of CT-occult injury on CSMRI of 43% (23/53), followed by equivocal CSCT findings (38%, 18/47), presence of extra-cervical injuries (34%, 20/58), midline cervical tenderness (20%, 17/85), and isolated lower extremity neurological deficit (0%, 0/16). CSMRI is recommended following negative CSCT in the evaluation of blunt cervical spine trauma when appropriate clinical concerns are present.

Using Serial Hemoglobin Levels to Detect Occult Blood Loss in the Early Evaluation of Blunt Trauma Patients

BackgroundSerial hemoglobin measurement (ΔHgb) is intended to aid in the early identification of blunt trauma patients who have significant blood loss requiring intervention. However, the utility of ΔHgb has yet to be rigorously studied. ObjectiveWe sought to determine if ΔHgb is a reliable diagnostic tool in assessing blood loss in blunt trauma patients. MethodsWe enrolled consecutive blunt trauma patients ≥18 years of age who presented to a level I trauma center. We measured 2 hemoglobin levels spaced 5 min apart and calculated the difference (ΔHgb) for each patient. We also recorded whether each patient required any of the following interventions to treat their injuries: 1) operation or procedure to control hemorrhage; 2) radiographic embolization; 3) administration of blood and blood products; 4) administration of ≥3 liters of intravenous fluids; and 5) exsanguination. Our primary outcome was the area under the receiver operating characteristic (ROC) curve. ResultsWe enrolled 251 patients, including 192 males and 59 females with a mean age of 40 years. Interventions occurred in 56 patients and were withheld in 195. The median ΔHgb was −0.1 gm/dL (interquartile range −0.5 to 0.1 gm/dL) for patients requiring intervention and 0.0 gm/dL (interquartile range −0.6 to 0.3 gm/dL) for patients not requiring intervention. We found the area under the ROC curve to be 0.53 (95% confidence interval 0.44–0.62). ConclusionsOur results indicated that ΔHgb does not reliably distinguish between blunt trauma patients who require intervention and those who do not.

Negative computed tomography can safely rule out clinically significant intra-abdominal injury in the asymptomatic patient after blunt trauma: Prospective evaluation of 1193 patients.

Computed tomography of the abdomen and pelvis (CTAP) is highly specific for injury identification and commonly used in the evaluation of blunt trauma patients. Despite this, there is no consensus on the required clinical observation period after negative imaging, often impacting patient flow and hospital cost. The purpose of this study was to evaluate the use of CTAP after blunt trauma and the need for observation after negative imaging. A prospective analysis at a large Level I trauma center was conducted from November 2014 to May 2015. All blunt trauma patients, older than 14 years with CTAP on admission were included. Symptomatic patients were defined as having abdominal pain or external signs of trauma on admission. The main outcome was missed injury. Over the study period, there were 1,468 blunt trauma admissions, of which 1,193 patients underwent CTAP. Eight hundred six (67.6%) patients were evaluable on admission (Glasgow Coma Scale score, 15), and of these, 327 (40.6%) were symptomatic, 479 (59.4%) asymptomatic. Among the evaluable asymptomatic patients, there were 65 (13.6%) positive computed tomography scans including 11 patients with grade III, IV, or V solid organ injury and three that required operation. In the 414 evaluable asymptomatic patients with negative imaging, median length of stay was 3 days, and there were zero missed injuries. All images were reviewed by an attending radiologist. Abdominal imaging after trauma is justified in the appropriate clinical setting to evaluate for significant abdominal injury regardless of symptomatology. In asymptomatic, evaluable patients with a negative CTAP, clinically significant abdominal injury is unlikely, and these patients may be considered for early discharge or disposition to another treatment service. Diagnostic, level III; Therapy, level IV.

A nomogram predicting the need for abdominal and pelvic computed tomography in blunt trauma patients: A retrospective cohort study

BackgroundAbdominal and pelvic computed tomography (APCT) has become the preferred means for the initial evaluation of blunt trauma patients. However, computed tomography examination has some disadvantages, such as radiation exposure, the requirement for intravenous iodinated contrast medium, high cost, and time. We aimed to develop a nomogram to predict the need for APCT scanning after the primary survey of blunt trauma patients. Materials and methodsWe conducted a retrospective observational cohort study at a single-center and reviewed medical records of 972 trauma patients admitted between January 2013 and June 2016. We enrolled 786 blunt trauma patients who had undergone APCT and were 16 years of age or older. A multivariate logistic regression model was used to determine independent predictors for trauma-related findings on APCT scans. A nomogram was constructed to predict injury on APCT scans based on each predictive factor. ResultsOf 786 patients, 355 (45%) patients had at least 1 injury on APCT scans. Results of multivariate logistic regression analysis showed that independent predictive factors of injuries on APCT scans were as follows: falls (≥3 m high); pain (abdominal, back, flank, or pelvic); positive peritoneal signs; abnormal findings on chest radiographs; abnormal findings on pelvic radiographs; and positive findings on focused assessment with ultrasonography for trauma. The nomogram was developed using these parameters. The area under a receiver operating characteristic curve of the multivariate model for discrimination was 0.865 (95% confidence interval, 0.840–0.892). The calibration plot showed good agreement between predicted and observed outcomes. The maximal Youden index was 0.59, corresponding to a cutoff value > 59 points, which was considered the optimal cutoff value for the probability that the injury would be detected on APCT scans. ConclusionThe nomogram, based on initial clinical findings in blunt trauma patients, will help clinicians be more selective in their use of APCT evaluations.

Evidence for cost-effectiveness of ultrasound in evaluation of blunt trauma patients

The evaluation of the blunt trauma patient frequently includes the Focused Assessment with Sonography for Trauma (FAST) exam. Additional point-of-care applications for ultrasound in blunt trauma patients are emerging. Ultrasound is a noninvasive diagnostic technique generally considered to be relatively inexpensive, offering the potential for improved outcomes and lower costs. However, formal evaluation of ultrasound’s effect on cost-effectiveness has occurred in a piecemeal fashion. The aim of this review is to evaluate the available evidence regarding whether ultrasound is cost-effective for evaluation of blunt trauma patients, and what factors may affect its cost-effectiveness.

Skip and save: utility of pelvic x-rays in the initial evaluation of blunt trauma patients

BackgroundThe cost of medical care is an area of major emphasis in the current healthcare environment. Medical providers have a significant role in reducing costs. One way to achieve this goal is to eliminate practices that add little value to patient care. The pelvic x-ray (PXR) obtained during the initial evaluation of blunt trauma may be an example. The objective of this study was to explore the utility of the pelvic x-ray in the initial evaluation of blunt trauma patients. MethodsBlunt trauma patients with pelvic fractures of any type admitted to our urban trauma center from January 2012 to December 2013 were reviewed. Demographics including age, sex, race, mechanism of injury, and outcomes were collected. Findings on PXR and computed tomography (CT) were compared for correlation. Patients requiring surgery for their pelvic fractures were identified. ResultsOf the 3,217 trauma admissions over the 2-year period, 153 patients sustained a pelvic fracture. Mean age was 50 years (15 to 97), male 54%, and Caucasian 46%, Hispanic 31%, African American 22%, and Asian 1%. The average injury severity score was 12.9. The main mechanism of injury was motor vehicle collisions 45%, followed by fall from standing 22% and auto and/or pedestrian accidents 12%. There were 22 patients that did not have both CT and pelvic imaging for comparison. Of the 131 patients with both CT and pelvic films, findings were the same in 43 (33%). CT identified one or more additional pelvic fractures in 88 (67%) patients compared with the PXR. In 29 patients (22%), pelvic fractures were not evident on PXR with fractures only identified by CT. The most common missed fractures on PXR were sacral and iliac injuries. Of the 153 patients with pelvic fractures, 24% required surgery for their pelvic injuries. Mortality was 4% for nonpelvic fracture-related causes. The PXR findings did not change management provided by trauma team in the emergency department. ConclusionsAs expected, CT is more sensitive in identifying pelvic fractures compared with PXR. Most blunt trauma patients are undergoing further evaluation with CT. We therefore propose that in patients that are normotensive with no pelvic instability or hip dislocation on physical examination who are to undergo further imaging with CT, the pelvic film should be avoided as it adds little value to patient management. The Advanced Trauma Life Support (ATLS) guidelines should be revised to reflect a diminishing role of the PXR in blunt trauma patients.

Thoracoabdominal Computed Tomography in Trauma Patients: A Cost-Consequences Analysis

Background:CT is increasingly used during the initial evaluation of blunt trauma patients. In this era of increasing cost-awareness, the pros and cons of CT have to be assessed.Objectives:This study was performed to evaluate cost-consequences of different diagnostic algorithms that use thoracoabdominal CT in primary evaluation of adult patients with high-energy blunt trauma.Materials and Methods:We compared three different algorithms in which CT was applied as an immediate diagnostic tool (rush CT), a diagnostic tool after limited conventional work-up (routine CT), and a selective tool (selective CT). Probabilities of detecting and missing clinically relevant injuries were retrospectively derived. We collected data on radiation exposure and performed a micro-cost analysis on a reference case-based approach.Results:Both rush and routine CT detected all thoracoabdominal injuries in 99.1% of the patients during primary evaluation (n = 1040). Selective CT missed one or more diagnoses in 11% of the patients in which a change of treatment was necessary in 4.8%. Rush CT algorithm costed € 2676 (US$ 3660) per patient with a mean radiation dose of 26.40 mSv per patient. Routine CT costed € 2815 (US$ 3850) and resulted in the same radiation exposure. Selective CT resulted in less radiation dose (23.23 mSv) and costed € 2771 (US$ 3790).Conclusions:Rush CT seems to result in the least costs and is comparable in terms of radiation dose exposure and diagnostic certainty with routine CT after a limited conventional work-up. However, selective CT results in less radiation dose exposure but a slightly higher cost and less certainty.

Positive FAST Without Hemoperitoneum Due to Fluid Resuscitation in Blunt Trauma

BackgroundThe focused assessment with sonography in trauma (FAST) examination is an important screening tool in the evaluation of blunt trauma patients. ObjectivesTo describe a case of a hemodynamically unstable polytrauma patient with positive FAST due to fluid resuscitation after blunt trauma. Case ReportWe describe a case of a hemodynamically unstable polytrauma patient who underwent massive volume resuscitation prior to transfer from a community hospital to a trauma center. On arrival at the receiving institution, the FAST examination was positive for free intraperitoneal fluid, but no hemoperitoneum or significant intra-abdominal injuries were found during laparotomy. In this case, it is postulated that transudative intraperitoneal fluid secondary to massive volume resuscitation resulted in a positive FAST examination. ConclusionThis case highlights potential issues specific to resuscitated trauma patients with prolonged transport times. Further study is likely needed to assess what changes, if any, should be made in algorithms to address the effect of prior resuscitative efforts on the test characteristics of the FAST examination.

Systematic review of flexion/extension radiography of the cervical spine in trauma patients

IntroductionThe aim of this review was to investigate whether Flexion/Extension (F/E) radiography adds diagnostic value to CT or MRI in the detection of cervical spine ligamentous injury and/or clinically significant cervical spine instability of blunt trauma patients. MethodsA systematic search of literature was done in Pubmed, Embase and Cochrane Library databases. Primary outcome was sensitivity and specificity of F/E radiography. Secondary outcomes were the positive predicting value (PPV) and negative predicting value (NPV) (with CT or MRI as reference tests due to the heterogeneity of the included studies) of each modality and the quality of F/E radiography. ResultsF/E radiography was overall regarded to be inferior to CT or MRI in the detection of ligamentous injury. This was reflected by the high specificity and NPV for CT with F/E as reference test (ranging from 97 to 100% and 99 to 100% respectively) and the ambiguous results for F/E radiography with MRI as its reference test (0–98% and 0–83% for specificity and NPV respectively). Image quality of F/E radiography was reported to have 31 to 70% adequacy, except in two studies which reported an adequacy of respectively 4 and 97%. ConclusionThis systematic review of the literature shows that F/E radiography adds little diagnostic value to the evaluation of blunt trauma patients compared to CT and MRI, especially in those cases where CT or MRI show no indication of ligamentous injury.

Implementation of a Cost-Saving Algorithm for Pelvic Radiographs in Blunt Trauma Patients

In a previous retrospective study, we demonstrated that pelvic radiographs (PXRs) in the evaluation of blunt trauma patients undergoing abdominal computed tomographic (CT) scanning have limited utility in the absence of hemodynamic instability and significant physical findings. The purpose of this study was to prospectively validate an algorithm defining indications for PXR in blunt trauma patients in the emergency department. We performed a prospective observational study of consecutive blunt trauma patients over 6 months at a single Level 1 trauma center. The trauma faculty agreed to implement an algorithm of obtaining PXRs in patients undergoing abdominal CT scanning only if a specific set of criteria were met: systolic blood pressure <90 mm Hg, hemoglobin <8 mg/dL, a drop in Hgb of more than 3 mg/dL while in the trauma bay, or significant physical examination findings. The algorithm could be overridden at the discretion of the attending physician. Nine hundred ninety-five consecutive blunt trauma patients whose evaluation was to include an abdominal CT scan were included in the study. Only 54 patients (6%) received a PXR. Fifty-six indications for PXR were provided: 35 (63%) severe pelvic pain, 14 (25%) proximal fractures, 3 (5%) hip dislocations, and only 4 (7%) had unexplained hypotension. No adverse events or delays in care occurred such as hypotension in the CT scanner or a delay in contacting interventional radiology, blood transfusion, or application of a pelvic binder. The algorithm selected PXR for patients who were more likely to have a pelvic fracture (33% vs. 4.5%, p < 0.001), hip dislocation (7.4% vs. 0.1%, p < 0.001), femur fracture (22.2% vs. 2.7%, p < 0.001), and to require blood transfusion (11.1% vs. 1.9%, p < 0.001). Implementation of this algorithm resulted in a decrease in charges of >$226,000 in 6 months. When objective evaluation of the abdomen is to be obtained via CT scanning, PXR in the emergency department is obsolete in the absence of hemodynamic instability and significant physical examination findings. Implementation of a selective algorithm in this patient population can result in significant cost savings without adverse patient outcomes.

Pediatric Radiation Exposure During the Initial Evaluation for Blunt Trauma

Increased utilization of computed tomography (CT) scans for evaluation of blunt trauma patients has resulted in increased doses of radiation to patients. Radiation dose is relatively amplified in children secondary to body size, and children are more susceptible to long-term carcinogenic effects of radiation. Our aim was to measure radiation dose received in pediatric blunt trauma patients during initial CT evaluation and to determine whether doses exceed doses historically correlated with an increased risk of thyroid cancer. A prospective cohort study of patients aged 0 years to 17 years was conducted over 6 months. Dosimeters were placed on the neck, chest, and groin before CT scanning to measure surface radiation. Patient measurements and scanning parameters were collected prospectively along with diagnostic findings on CT imaging. Cumulative effective whole body dose and organ doses were calculated. The mean number of scans per patient was 3.1 ± 1.3. Mean whole body effective dose was 17.43 mSv. Mean organ doses were thyroid 32.18 mGy, breast 10.89 mGy, and gonads 13.15 mGy. Patients with selective CT scanning defined as ≤2 scans had a statistically significant decrease in radiation dose compared with patients with >2 scans. Thyroid doses in 71% of study patients fell within the dose range historically correlated with an increased risk of thyroid cancer and whole body effective doses fell within the range of historical doses correlated with an increased risk of all solid cancers and leukemia. Selective scanning of body areas as compared with whole body scanning results in a statistically significant decrease in all doses.

Evaluation of pelvic fracture stability and the need for angioembolization: pelvic instabilities on plain film have an increased probability of requiring angioembolization

Background The use of pelvic x-rays (PXRs) as an early diagnostic adjunct in the evaluation of blunt trauma patients has become widely accepted, and computed tomographic (CT) scanning is now used universally in the assessment of abdominal and pelvic injuries. In this study, we have attempted to identify patients with pelvic fractures who might be at risk for vessel hemorrhage and determine if early angioembolization was required in these patients. Material and Methods We retrospectively reviewed patients who presented with pelvic fractures from June 2005 to August 2007. Both PXRs and CT scans were reviewed. Patients who presented with bleeding due to other associated injuries or who did not receive a CT scan were excluded. Patients with either initial hemodynamic instability or contrast extravasation on enhanced CT scan underwent angioembolization. Patient demographics, Injury Severity Score, the amount of blood transfused, and the relationship between the fracture pattern and angioembolization were analyzed. Results A total of 54 patients were enrolled. A diagnosis of an unstable pelvic fracture on PXR was associated with a higher probability of angioembolization. Seven patients received incompatible diagnoses from the PXR and CT scan; these patients received larger amounts of transfused blood and demonstrated an increased need for angioembolization. Conclusions Although CT scan is more sensitive in the identification of acetabular or small pelvic fractures, PXR is sufficient for the early evaluation of pelvic fracture stability. Based on the current series, early angioembolization is suggested for patients with an initial diagnosis of an unstable pelvic fracture. In addition, patients receiving large amounts of transfused blood are more likely to require early angioembolization.

CT of blunt abdominal and pelvic vascular injury

Computed tomography (CT) has been shown to be increasingly useful in the evaluation of blunt trauma patients with suspected abdominopelvic vascular injuries. CT findings of abdominopelvic vascular insult may be broadly characterized as end-organ abnormalities or direct evidence of vascular injury. End-organ abnormalities implying an underlying vascular insult include identifying an area of relative hypoperfusion in solid organ injury. Direct evidence of a vascular injury includes identifying an irregular or thrombosed vessel or an area of active hemorrhage, among other findings. This review article aims to review and illustrate these findings of blunt abdominopelvic vascular trauma. Also, evolving lessons from our level I trauma center in the use of multiphasic imaging to further characterize sources of a vascular blush and the differentiation of arterial from venous sources of active hemorrhage are discussed.

The Prevalence of Incidental Findings on Abdominal Computed Tomography Scans of Trauma Patients

Abdominal computed tomography scanning (AbdCTS) is the standard of care in the evaluation of blunt trauma patients. The liberal use of AbdCTS coupled with advancing imaging technology often results in the detection of incidental findings. We sought to characterize the incidence and prevalence of such findings, describe the lesions most frequently seen on AbdCTS performed on patients admitted to a Level I trauma center, and develop a plan for follow-up through our performance improvement process. AbdCTS reports of all admissions to a Level I trauma center between January 2000 and December 2002 were reviewed. Incidental findings identified were classified into benign anatomic variants, benign pathologic lesions, and pathologic lesions requiring further work-up. A total of 3,113 patients were evaluated by AbdCTS during this time period. There were 1474 incidental findings in 1,103 patients. Seventy-five percent of patients with incidental lesions had no traumatic findings. Benign anatomic variants were present in 1.8%, benign pathologic findings in 27.5%, and pathologic findings requiring work-up in 6.1%. Congenital renal anomalies and duplicate inferior vena cava were the most common benign anatomical findings. Renal and hepatic cysts were the most frequent benign lesions and non-calcified pulmonary nodules and adrenal masses were the pathologic lesions most commonly seen. Incidental findings are seen in up to 35% of trauma AbdCTS. No concomitant traumatic injuries are present in up to 75% of these patients. Protocols for appropriate intervention or arrangements for follow-up care need to be incorporated into the care of the trauma patients.

Is The Lateral Cervical Spine Plain Film Obsolete?

The objective of this study was to determine the utility of a lateral cervical spine plain film in the evaluation of blunt trauma patients. We prospectively evaluated blunt trauma patients from February 2004 to September 2006 who had both a lateral cervical spine (LCS) film and a computed tomography of the cervical spine (CTC), comparing the diagnostic accuracy of the LCS to the CTC. There were 1004 patients who met inclusion criteria. Eighty-four patients had a cervical spine fracture while 920 patients had no fracture on CTC. Of the 84 patients with fractures by CTC, 68 had a negative or incomplete LCS. Of the 920 negative CTC, there were 7 false positive LCSs. LCS compared with CTC showed a sensitivity of 19% (16/84) and positive predictive value of 69.6% (16/23). Of the 981 negative or incomplete LCS films, 96.9% were incomplete (951/981). Of the seven patients with a false positive LCS (negative CTC), none was subsequently found to have a cervical spine fracture on further evaluation. Elimination of the LCS would result in charge savings of $265,056.00 (LCS charges with interpretation, $264 each) and increase patient safety by eliminating error. LCS has no value as a screening tool in the blunt trauma patient since most are either inaccurate or incomplete. It should be eliminated from the Advanced Trauma Life Support algorithm, and CTC should receive emphasis as the diagnostic gold standard.

QS249. Is the Lateral Cervical Spine Plain Film Obsolete

Background: Physical examination has been shown to be extremely inaccurate in cervical spine evaluation in trauma activation patients as compared to the “gold standard” of computed tomography of the cervical spine (CTC). The objective of the current study is to determine the utility of a lateral cervical spine plain film (the recommended initial approach by ATLS) in the evaluation of blunt trauma patients. Methods: We prospectively evaluated blunt trauma patients from February 2004 to September 2006.

The Value of Indicated Computed Tomography Scan of the Chest and Abdomen in Addition to the Conventional Radiologic Work-up for Blunt Trauma Patients

Multidetector computed tomography (CT) is more sensitive and specific in detecting traumatic injuries than conventional radiology is. However, still little is known about the diagnostic value and the therapeutic impact of indicated thoraco-abdominal CT scan when it is performed in addition to the complete conventional radiologic work-up for blunt trauma patients. Clinical and radiologic data from 106 consecutive blunt trauma patients were reviewed. Diagnoses revealed by conventional work-up of the chest, abdomen, pelvis, and thoracolumbar spine were compared with that detected by CT scan of the chest and abdomen. Unexpected findings by CT scan and rejected diagnoses by CT scan were collected. Therapeutic consequences of these diagnoses were determined both theoretically and collected from the medical records. In 74% (95% confidence interval [CI] 65-82) of the 106 patients, 1 or more diagnoses were demonstrated by chest or abdominal CT scan, whereas they had not been revealed by preceding conventional work-up. This resulted in an actual change of treatment in 34% (95% CI 25-43) of the patients. CT scan of the chest resulted in a change of treatment in 33% (95% CI 23-44) and abdominal CT scan in 16% (95% CI 9-24). CT scan of the chest and abdomen has a high diagnostic value in the evaluation of blunt trauma patients, when it is selectively performed in addition to the early conventional radiologic work-up. Unexpected pathologic findings are detected by CT scan in the majority of the patients. These findings result in an adaptation of treatment in a substantial number of the patients.

Utility of Plain Film Pelvic Radiographs in Blunt Trauma Patients in the Emergency Department

The objective of this study was to evaluate the utility and sensitivity of routine pelvic radiographs (PXR) in the initial evaluation of blunt trauma patients. A retrospective review was performed. One hundred seventy-four patients with a pelvic fracture who had computed tomography (CT) and PXR were included (average age, 36.1; average Injury Severity Score, 16.3). Nine (5%) patients died. Five hundred twenty-one fractures were identified on CT. One hundred sixteen (22%) of these fractures were missed by PXR. Eighty-eight (51%) patients were underdiagnosed by PXR alone. The most common fractures missed by PXR were sacral and iliac fractures. Eight patients required angiograms, with four undergoing therapeutic pelvic embolization. Forty-seven (27%) patients were hypotensive or required a transfusion in the emergency department. These patients were more likely to require an angiogram (17% vs 0%, P < 0.0001) and were more likely to require embolization (9% vs 0%, P < 0.001). This study demonstrates that CT scan is highly sensitive in identifying and classifying pelvic fractures. PXR has a sensitivity of only 78 per cent for identification of pelvic fractures in the acute trauma patient. In hemodynamically stable patients who are going to undergo diagnostic CT scan, PXR is of little value. The greatest use of PXR may be as a screening tool in hemodynamically unstable patients and/or those that require transfusion to allow for early notification of the interventional radiology team.

The Role of Negative CT of the Abdomen and Pelvis in the Decision to Admit Adults From the Emergency Department After Blunt Trauma

Computed tomography (CT) is widely used in the initial evaluation of blunt trauma patients and is associated with a high rate of negative imaging. A described benefit of negative imaging is prompt discharge. This study examined a single level 1 trauma center to determine whether adult blunt trauma patients are discharged from the emergency department (ED) after negative CT of the abdomen and pelvis (CT AP). The authors retrospectively created a data set of adult blunt trauma patients who received CT AP in the ED from August to November 2003. Statistical analysis of admission rates on the basis of positivity or negativity on CT AP was performed to determine if the test influenced admission rates. Additional subgroup analysis was made between the patients admitted with negative CT AP and those who were discharged from the ED. Two thirds (316/469) had negative CT AP. Whereas 80.4% of the patients (254/316) with negative CT AP were admitted, 98.0% (148/151) with positive CT AP were admitted, a statistically significant difference in admission rate (P < .0001). The vast majority (208/254, 81.9%) of patients with negative CT AP were admitted for extra-abdominal injuries. There was no statistical difference in the characteristics of a subgroup of 45 patients who were admitted without any documented injuries from the group discharged from the ED in terms of age, gender, comorbidity, Glasgow Coma Scale score, or intoxication. Under current practice, negative CT AP after blunt trauma results in a statistically significant decrease in admissions.