Initial Evaluation Of Blunt Trauma Research Articles

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.

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Reliance on chest-abdomen-pelvis computed tomography (CAP) in the initial evaluation of blunt trauma is a major source of patient radiation exposure. Our trauma surgeon group (TSG) modified its practice to limit the use of CAP. We evaluated the effect of this practice change on patient radiation exposure and diagnostic accuracy. We compared data on blunt injury trauma activations evaluated by the five-member TSG for two 6-month intervals, before (T1) and after (T2) instituting the practice change. Patient demographic and injury data, complications, torso imaging and radiation dosage were collected. Following analysis of T1, the surgeon with the lowest CAP use was identified and found to have no errors or delays in diagnosis. The TSG agreed to adopt that surgeon's focus on findings of the physical examination and Focused Assessment Sonography for Trauma to reduce CAP use in the initial evaluation. T2 was analyzed to assess the effect of implementation of this guideline. There were 897 patients in T1 and 948 in T2. In the two intervals, patients did not differ by age, sex, mortality, or probability of survival. CAP use decreased by 38.5% with a significant drop in mean patient radiation exposure (p < 0.001). There were no missed injuries or delays in diagnosis in either interval. The use of CAP and its associated radiation burden in the initial evaluation of blunt trauma can be reduced without diagnostic errors by comparing use and identifying best practice. This process has implications for optimal trauma care. Diagnostic study, level IV; case management study, level IV.

COMPUTERIZED TOMOGRAPHY CYSTOGRAPHY FOR THE DIAGNOSIS OF TRAUMATIC BLADDER RUPTURE

We present our experience with computerized tomography (CT) cystography for diagnosing bladder rupture in patients with blunt abdominal and pelvic trauma, and compare the results of CT cystography with those of surgical exploration. We identified all patients with blunt trauma diagnosed with bladder rupture from 1992 to September 1998. We reviewed the radiology computerized information system for all CT cystography performed to evaluate blunt trauma during the same period. We also reviewed the medical records and pertinent radiographic studies of patients with bladder rupture who underwent CT cystography as part of the hospital admission evaluation. Operative and radiographic findings were compared. CT cystography was performed in 316 patients as part of the initial evaluation of blunt trauma. Of the 44 patients with the ultimate diagnosis of bladder rupture CT cystography revealed bladder rupture in 42, while 23 of the 28 (82%) who underwent formal bladder exploration had operative findings that exactly matched the CT cystography interpretation in terms of the presence and type of rupture. In the 316 patients CT cystography detected bladder rupture with an overall sensitivity and specificity of 95% and 100%, respectively. For intraperitoneal rupture sensitivity was 78% and specificity was 99%. CT cystography provides expedient evaluation of bladder rupture due to blunt trauma and has accuracy comparable to that reported for plain film cystography. We recommend CT cystography over plain film cystography in patients undergoing CT for other injuries associated with blunt trauma.