Occult Injuries Research Articles

Whole-body MR imaging in suspected physical child abuse: comparison with skeletal survey and bone scintigraphy findings from the PEDIMA prospective multicentre study.

To assess the contribution of whole-body magnetic resonance imaging (WBMRI) and bone scintigraphy (BS) in addition to skeletal survey (SS) in detecting traumatic bone lesions and soft-tissue injuries in suspected child abuse. In this prospective, multicentre, diagnostic accuracy study, children less than 3 years of age with suspected physical abuse were recruited. Each child underwent SS, BS and WBMRI. A blinded first review was performed in consensus by five paediatric radiologists and three nuclear medicine physicians. A second review investigated discrepancies reported between the modalities using a consensus result of all modalities as the reference standard. We calculated the sensitivity, specificity and corresponding 95% confidence interval for each imaging modality (SS, WBMRI and BS) and for the combinations [SS + WBMRI] and [SS + BS]. One hundred seventy children were included of which sixty-four had at least one lesion. In total, 146 lesions were included. The sensitivity and specificity of each examination were, respectively, as follows: 88.4% [95% CI, 82.0-93.1] and 99.7% [95% CI, 99.5-99.8] for the SS, 69.9% [95% CI, 61.7-77.2] and 99.5% [95% CI, 99.2-99.7] for WBMRI and 54.8% [95% CI, 46.4-63.0] and 99.7% [95% CI, 99.5-99.9] for BS. Sensitivity and specificity were, respectively, 95.9% [95% CI, 91.3-98.5] and 99.2% [95% CI, 98.9-99.4] for the combination SS + WBMRI and 95.2% [95% CI, 90.4-98.1] and 99.4% [95% CI, 99.2-99.6] for the combination SS + BS, with no statistically significant difference between them. SS was the most sensitive independent imaging modality; however, the additional combination of either WBMRI or BS examinations offered an increased accuracy. • SS in suspected infant abuse was the most sensitive independent imaging modality in this study, especially for detecting metaphyseal and rib lesions, and remains essential for evaluation. • The combination of either SS + BS or SS + WBMRI provides greater accuracy in diagnosing occult and equivocal bone injuries in the difficult setting of child abuse. • WBMRI is a free-radiation technique that allows additional diagnosis of soft-tissue and visceral injuries.

Injuries Suggestive of Physical Abuse in Young Children With Subconjunctival Hemorrhages.

The aim of this study was to compare the demographic characteristics, clinical presentations, medical evaluation, and injuries identified in a cohort of children with and without subconjunctival hemorrhage who were evaluated by a child abuse specialist. This was a case-control study that used data from the ExSTRA (Examining Siblings to Recognize Abuse) research network. Subjects with a subconjunctival hemorrhage(s) were designated as cases. Four controls matched for age and participating center were included for each case. Descriptive statistics were used to compare cases and controls. Fifty of the 2890 subjects in the parent study had a subconjunctival hemorrhage(s) and were designated as cases. The cases had a median (interquartile range) age of 5.0 months (2.0-23.6 months). Two hundred controls were matched to the cases. There was no difference in the demographics, clinical characteristics, medical evaluation, or rate of occult injuries identified in cases and controls. Almost one-quarter of children with subconjunctival hemorrhages had no other external sign of trauma but had the same rate of occult injuries as children with bruises. These data suggest that subconjunctival hemorrhages are relatively rare among children undergoing evaluation by a child abuse specialist, but that they are often an indicator of occult injury. Even in the absence of other external signs of trauma, the presence of subconjunctival hemorrhages should prompt an age-appropriate evaluation for physical abuse.

CT as a first-line modality in elderly patients with stable blunt chest trauma

PurposeBlunt thoracic injuries are common among elderly patients and may be a common cause of morbidity and death from blunt trauma injuries. We aimed to examine the impact of chest CT on the diagnosis and change of management plan in elderly patients with stable blunt chest trauma. We hypothesized that chest CT may play an important role in providing optimal management to this subgroup of trauma patients. MethodsA retrospective analysis was performed on all the admitted adult blunt trauma patients between January 2014 and December 2018. Stable blunt chest trauma patients with abbreviated injury severity (AIS) < 3 for extra-thoracic injuries confirmed with chest X-ray (CXR) and chest CT on admission or during hospitalization were included in the study. The AIS is an international scale for grading the severity of anatomic injury following blunt trauma. Primary outcome variables were occult injuries, change in management, need for surgical procedures, missed injuries, readmission rate, intensive care unit (ICU) and length of hospital stay. ResultsThere are 473 patients with blunt chest trauma included in the study. The study patients were divided into two groups according to the age range: group 1: 289 patients were included and aged 18–64 years; group 2: 184 patients were included and aged 65–99 years . Elderly patients in group 2 more often required ICU admission (11.4% vs. 5.2%), had a longer length of ICU stay (days) (median 11 vs. 6, p = 0.01), and the length of hospital stay (days) (median 14 vs. 6, p = 0.04). Injuries identified on chest CT has led to a change of management in 4.4% of young patients in group 1 and in 10.9% of elderly patients in group 2 with initially normal CXR. Chest CT resulted in a change of management in 12.8% of young patients in group 1 and in 25.7% of elderly patients in group 2 with initially abnormal CXR. ConclusionChest CT led to a change of management in a substantial proportion of elderly patients. Therefore, we recommend chest CT as a first-line imaging modality in patients aged over 65 years with isolated blunt chest trauma.

Evaluation of an Emergency Department High-risk Bruising Screening Protocol.

The objective of this study was to describe the outcomes of implementing a high-risk bruise screening pathway in a pediatric emergency department (ED). A retrospective observational study was performed of children aged 0 to <48 months who presented to the ED between December 1, 2016, and April 1, 2019, and had bruising that is high-risk for physical abuse on a nurse screening examination. A high-risk bruise was defined as any bruise if aged <6 months or a bruise to the torso, ears, or neck if aged 6 to <48 months. Records of children with provider-confirmed high-risk bruising were reviewed. Of the 49 726 age-eligible children presenting to the ED, 43 771 (88%) were screened for bruising. Seven hundred eighty-three (1.8%) of those children had positive screen results and 163 (0.4%) had provider-confirmed high-risk bruising. Of the 8635 infants aged <6 months who were screened, 48 (0.6%) had high-risk bruising and 24 of 48 (50%) were classified as cases of likely or definite abuse. Skeletal surveys were performed in 29 of 48 (60%) infants, and 11 of 29 (38%) had occult fracture. Of the 35 136 children aged 6 to <48 months who were screened, 115 of 35 136 (0.3%) had high-risk bruising and 32 of 115 (28%) were classified as cases of likely or definite abuse. High-risk bruising was rarely present. When infants aged <6 months were evaluated per recommendations, occult fracture was identified in one-third of patients. The screening pathway could help other institutions identify occult injuries in pediatric ED patients.

Screening for hemophagocytic lymphohistiocytosis in child abuse evaluations: Twelve years of data

BackgroundLaboratory evaluation is commonly integrated into evaluation of children with suspected physical abuse to identify occult injury and potential mimics of abuse, including hemophagocytic lymphohistiocytosis (HLH). We evaluated the utility of ferritin in laboratory screening panels for physical abuse. Objective(s)To determine if hyperferritinemia is a useful screening marker of HLH in physical abuse diagnostic evaluations. Participants and settingChildren being evaluated for physical abuse at a quaternary pediatric referral and level one trauma center in Houston, Texas. MethodsWe conducted a 12-year (2003 – 2015) retrospective descriptive analysis of all ferritin values obtained as part of routine screening panels for physical child abuse. Medical records were abstracted for patients with ferritin > 500 ng/mL. Results2954 ferritin levels were obtained in 3091 encounters for suspected physical abuse (median age 6.5 months, interquartile range 2.3–23.5 months). Elevated ferritin was found in 82/2954 (2.8 %); no child evaluated for physical abuse was found to have HLH (95 % CI: 0–4.5%). The child abuse team was consulted in 48/82 (58.5 %) of cases, with the final impression being physical abuse in 33/48 (68.8 %). ConclusionsWe found no instances where HLH was identified by institutional screening panels. The inclusion of ferritin in the screening panel was not beneficial. The presence of hyperferritinemia should not cast medical or legal doubt on physical abuse diagnoses when there is a high index of clinical suspicion. Novel hypotheses from case reports and case series should be studied more rigorously before affecting system change.

Skrytá poranění zadního segmentu pánve u starých pacientů se zlomeninou ramének stydké kosti

Skrytá poranění zadního segmentu pánve u starých pacientů se zlomeninou ramének stydké kosti

Is There a Need for Abdominal CT Scan in Trauma Patients With a Low-Risk Mechanism of Injury and Normal Vital Signs?

BackgroundClinically significant injuries are often missed in trauma patients with low-risk mechanisms of injury and lack of "red flags," such as abnormal vital signs. The purpose of this retrospective analysis was to evaluate the efficacy of computed axial tomography (CT) for identifying occult injuries in a high-volume trauma center.MethodsRecords from our institutional trauma registry were retrospectively extracted, examining encounters from January 2015 to October 2019. Those patients between the ages of 18 and 65 who were referred to the trauma team with a CT scan of the abdomen and had low-risk mechanisms of injury, a Glasgow Coma Scale (GCS) score of 15, and normal vital signs at presentation were included. Patients in the lowest trauma categorization (Level Three, Consult) met the study definition for the low-risk mechanism of injury. Demographic and clinical data were abstracted for all patients. For this analysis, patients were divided into two groups based on age (18 - 40 years or 40 - 65 years). Injuries found on CT, their clinical significance, and the likelihood of being missed without CT were determined.ResultsOf 2,103 blunt trauma patients that received a CT scan of the abdomen from January 2015 to October 2019, 134/2,103 (6.4%) met the inclusion criteria (mean age: 44.6 years; 72.3% male). Patients between the ages of 40 and 65 years comprised 61.2% (82/134) of the study population. Of the included patients, 17.2% (23/134) had at least one acute traumatic injury identified after CT imaging of the torso. Occult injuries found on CT included rib fracture with associated lung injuries (10/23, 43.5%), splenic laceration (4/23, 17.4%), liver laceration (3/23, 13.0%), gluteal hematoma with active bleeding (1/23, 4.3%), sternal fractures (3/23, 13.0%), and thoracic or lumbar spine fractures (2/23, 8.7%). An independent review of the medical records determined that 9.0% (12/134) of these patients had traumatic injuries that would have been missed based on clinical examination without CT.ConclusionsBased on our experience, utilizing CT imaging of at least the abdomen as a routine screening measure for all trauma consults - even low-risk patients with normal vital signs - can rapidly and accurately identify clinically significant injuries that would have been otherwise missed in a notable portion of the population.

ESOPHAGOPLEURAL FISTULA AFTER MULTI-HEART VALVE SURGERY AND CORONARY ARTERY BYPASS GRAFTING

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Esophageal perforation is an uncommon complication that carries significant morbidity and mortality (as high as 67.7% and 19.9%, respectively)1. It is commonly associated with advanced esophageal carcinoma, chemical injury after ingestion, radiation therapy, iatrogenic injury 55% , spontaneous perforation , foreign body and traumatic penetrating injury.2 CASE PRESENTATION: We present the case of a 67-year-old female with history of coronary artery disease, aortic stenosis, mitral and tricuspid insufficiency who underwent a 2-vessel CABG, tricuspid valve repair, aortic and mitral valve replacements. The patient’s micrognathia prevented intraoperative transesophageal echocardiography. On postoperative day 14, the patient developed a fever with a right sided pleural effusion requiring a chest tube. Over a period of 24 hours chest tube drainage turned milky white from straw colored. Fluid cultures grew multi-drug resistant pseudomonas, and the patient was started on appropriate antibiotics. On day 24, pink fluid resembling the patient’s strawberry supplement shakes was present in the chest tube drain. CT esophagram found contrast in the dependent portion of the right subpleural space, consistent with an esophagopleural fistula (figure 1). EGD showed a 5 cm esophageal opening starting approximately 30 cm from the incisors. This was treated with an esophageal stent, J-tube feedings and antibiotics. DISCUSSION: This case has several notable features in its presentation and its etiology remains unclear. The patient had no significant risk factors preoperatively that would have predisposed her to esophageal perforation. She did not have cirrhosis with esophageal varices or alcoholic history prominent in Booerhaves nor did she have a previous esophageal cancer history. The patient also had no transesophageal echocardiogram (TEE) performed or intra-operative trauma to the esophagus. If there had been an intraoperative occult injury of the esophagus, then it would have been anticipated much earlier. CONCLUSIONS: An esophagopleural fistula is a rare complication that can present after cardiothoracic surgery. As in this case, it can present as late as 4 weeks postoperatively. CT esophagram is the diagnostic method of choice and treatment requires prompt intervention with either a GI or thoracic specialist.3 Reference #1: 1.Schweigert, Michael, et al. “Spotlight on Esophageal Perforation: A Multinational Study Using the Pittsburgh Esophageal Perforation Severity Scoring System.” The Journal of Thoracic and Cardiovascular Surgery, vol. 151, no. 4, 2016, pp. 1002–1011 Reference #2: 2.Gimenez, Ana, et al. “Thoracic Complications of Esophageal Disorders.” RadioGraphics, vol. 22, 2002, pg 1001-1002 Reference #3: 3.Michel L, Grillo H C, Malt R A. Operative and nonoperative management of esophageal perforations. Ann Surg 1981; vol 194: 57–63 DISCLOSURES: No relevant relationships by Meghan Brennan, source=Web Response No relevant relationships by Edward McGough, source=Web Response No relevant relationships by Miguel Rovira, source=Web Response

Pediatric Seymour Fractures of the Toe.

Seymour fractures of the toe are physeal fractures with often occult concomitant nail bed injuries and thus are open fractures. They are uncommon injuries that without proper treatment can result in osteomyelitis. The literature has sparse information regarding the clinical outcomes for these injuries. A single-center retrospective review included juxta-epiphyseal fractures or Salter-Harris I/II fracture of the toe with documented concomitant nail bed injury or laceration. Clinical and radiographic data were recorded for consecutive fractures. The primary outcome was the incidence of osteomyelitis. Secondary outcomes included premature physeal arrest, development of nail dystrophy, and functionality of the toe. Between 2006 and 2019, 19 patients were treated for this injury by the pediatric orthopaedic division. Complications included osteomyelitis (n=6), physeal arrest (n=4), and nail dystrophy (n=1). Days from injury to definitive treatment were significantly greater in patients who developed osteomyelitis compared with those who did not (P<0.01). Patients were significantly more likely to develop osteomyelitis if they did not receive acute definitive treatment (<48 h) (P<0.001; likelihood ratio, 17.9). Prompt definitive treatment of Seymour fractures of the toe was associated with a lower incidence of osteomyelitis. Greater awareness for these seemingly innocuous injuries is needed to provide an early treatment that may reduce the rate of osteomyelitis. Level IV-case series.

Ankle Arthroscopy in Acute Ankle Fractures: Does It Make Sense?

Introduction: Displaced ankle fractures require surgery, bone healing generally occurs with satisfactory outcomes. In some cases, poor results are recorded related to posttraumatic arthritis or other complications. Occult lesions (osteochondral lesions, loose bodies, impingement syndrome) may be among the common causes of unsatisfactory outcomes. Most of them may be detected by a computed tomography (CT) scan at the emergency room; however, such evaluation is not routinely performed. The aim of this study was to evaluate the clinical results of patients undergoing open reduction and internal fixation (ORIF) and ankle arthroscopy for fractures associated with intra-articular lesions. Materials and Methods: Among 397 patients evaluated for displaced ankle fracture, we selected 13 patients who also presented with intra-articular alterations at the CT scan performed in the Emergency room. All subjects underwent ORIF and arthroscopy. Patients were evaluated by NRS and AO-FAS score for at least of 1-year of follow-up. Results: The mean follow-up was 2.7 years; all fractures fully healed. The mean age at the time of surgery was 33.5 years. A single complication was recorded (complex regional pain syndrome, healed 6 months after surgery). All subjects reported satisfaction with improvements of the scores and return to their daily life activities. Discussion: Occult injuries associated with ankle fractures should be suspected and ruled out by a CT scan at the emergency room. Probably many occult injuries are underestimated because CT scan is not commonly performed, explaining cases of bone healing but poor functional results. In case of confirmation, these alterations should be treated in association with ORIF; arthroscopy may represent a valid and minimally invasive procedure, with low rates of complications.

Understanding Abusive Head Trauma: A Primer for the General Pediatrician.

Abusive head trauma (AHT) refers to a well-recognized constellation of injuries caused by the direct application of force to an infant or young child, resulting in trauma to the head, intracranial contents, and/or neck, with potentially devastating health outcomes. Mechanisms of AHT include impulsive injurious acts, such as violent shaking and impact, often due to caregiver frustration or exhaustion. Subdural and retinal hemorrhage, and associated extracranial injury (fractures, abdominal trauma), are common. Suspected victims require laboratory/diagnostic testing and occult injury screening, as well as protective measures by investigative authorities to ensure safety. Medicolegal controversies persist around AHT diagnosis, including alternative hypotheses proffered in court by skeptics despite advances in scientific understanding, biomechanical research, neuroimaging techniques, and perpetrator confessions. Pediatricians play a key role in prevention and reduction of AHT morbidity and mortality through anticipatory guidance and caregiver education about the risks of shaking, normal infant development and behavior, and encouragement of stress reduction strategies. [Pediatr Ann. 2020;49(8):e347-e353.].

Computed tomographic indications for occult skull fractures in paediatric head trauma diagnosed at the time of wound closure under general anaesthesia

Children with head injuries commonly present to the emergency department with forehead lacerations, and are frequently referred to the oral and maxillofacial team. Assessing the Glasgow coma scale (GCS) and neurological status of these patients is particularly challenging and there remains marked ambiguity regarding the use of computed tomographic (CT) imaging in children who have no obvious signs of traumatic brain injury. We present a case series of three patients who presented to our unit with forehead lacerations following a fall. All had a normal GCS, no obvious neurological signs, and all were listed for wound closure under general anaesthesia. Intraoperatively they were found to have underlying skull fractures that necessitated emergency CT whilst under general anaesthesia. Retrospective analysis was performed. Current guidelines and the literature were reviewed to identify factors that may help to identify occult skull fractures in the context of paediatric head trauma. Despite the subsequent discovery of skull fractures under general anaesthesia, none of our patients would have satisfied the present absolute indications for CT in the current guidelines. A number of helpful factors are not common in the UK guidelines but are present in others, including the presence of an appreciable haematoma and lacerations greater than 5 cm, amongst others. The assessment of paediatric patients with head trauma often remains a challenge when assessing for features such as headache, focal neurology, and amnesia. A high index of suspicion, formal examination under anaesthesia, and communication with the radiology department, are imperative if we are to avoid missing an occult injury that could potentially result in brain injury.

Streamlining Definitive Care for Occult Scaphoid Fractures: A Retrospective Review of the Workup of Scaphoid Nonunions and Applying Lessons Learned.

The process for working up scaphoid fractures from frontline providers to the specialty care clinic is variable. Initial imaging can often be negative and the management algorithm is not clearly defined. Delays in diagnosis are a contributing factor to scaphoid nonunion. Fractures may not be identified by frontline providers on initial presentation because of radiographically occult injuries. If not treated promptly, scaphoid fractures may be complicated by nonunion, avascular necrosis, and osteoarthritis. Retrospective review of scaphoid nonunions from 2017 to 2018 in a single tertiary care institution after internal review board approval was obtained (NMCSD.QI.2019.0003). Cases were identified using an ICD 10 search for "scaphoid (navicular) fracture non-union" and subtypes. Charts were examined for time between injury and presentation, injury and diagnosis, initial radiologic workup, and limited duty (LIMDU). Nonparametric statistical analysis for linear and categorical data was conducted using SPSS. A subgroup of patients who had a delay in diagnosis of greater than 30 days upon entering the medical system was further analyzed and identified as the "delayed diagnosis" cohort. In total, 30 patients with scaphoid nonunion were identified. Overall, 35% of patients had negative initial X-rays and averaged 42.1days until diagnosis. In total, 100% of patients required at least one LIMDU period, averaging 1.4 periods, for a total of 6,404days and 16% went on to a physical evaluation board (PEB). In 9 (30%) of these patients, injury was initially not identified upon entering the medical system resulting in average of 139.7days until diagnosis; this became known as the delayed diagnosis subgroup. Further analysis of the delayed diagnosis subgroup demonstrated significantly more initial negative X-rays (P<.005) at a rate of 77% (7/9). A delay in diagnosis was significantly associated with PEB (R=0.4, P=.031) with 33% of these patients going on to a PEB. Delayed diagnosis of a scaphoid fracture is a contributing factor for excessive light duty, high rates of LIMDU utilization, and ultimately medical separation of service members. Overall, in all patients who had scaphoid nonunions, the average time to diagnosis was 42.1days with 35% of patients presenting with negative initial imaging. A delayed diagnosis subgroup was identified and notable for a higher rate of initial negative X-rays, an average of 139.7days until diagnosis, and a 33% PEB rate. In total, 77% of patients with a delay in diagnosis of more than 30 days had an initial negative X-ray. An evidence-based algorithm for diagnosing occult scaphoid fractures may prevent delays in diagnosis, thus increasing the readiness of active duty service members.

Emergent Comprehensive Imaging of the Major Trauma Patient: A New Paradigm for Improved Clinical Decision-Making.

Modern advances in the medical imaging layered onto sophisticated trauma resuscitation strategies in highly organized regionalized trauma systems have created a paradigm shift in the management of severely injured patients. Although immediate exploratory surgery to identify and control life-threatening injuries still has its place, accelerated image acquisition and interpretation procedures now make it rare for trauma surgeons in major centers to venture into damage control surgery unaided by computed tomography (CT) or other imaging, particularly in cases of blunt trauma. Indeed, because of the high incidence of clinically occult injuries associated with major mechanism trauma, and even lower energy trauma in frail or elderly patients, CT imaging has become as invaluable as physical examination, if not more so, in critical decision-making in support of optimal outcomes. In particular, whole-body computed tomography (WBCT) completed promptly after initial assessment of a major trauma provides a quick, comprehensive survey of injuries that enables better surgical planning, obviates the need for multiple subsequent studies, and permits specialized reconstructions when needed. For those at risk for problematic occult injury after modest trauma, WBCT facilitates safer discharge planning and simplified follow-up. Through standardized guidelines, streamlined protocols, synoptic reporting, accessible web-based platforms, and active collaboration with clinicians, radiologists dedicated to trauma and emergency imaging enable clearer understanding of complex injuries in high-risk patients which leads to superior clinical decision-making. Whereas dated dogma has long warned that the CT scanner is the last place to take a challenging trauma patient, modern practice suggests that, more often than not, early comprehensive imaging can be done safely and efficiently and is in the patient's best interest. This article outlines how the role of diagnostic imaging for major trauma has evolved considerably in recent years.

Occult Injuries Commonly Identified on Torso CT After Mild Trauma

Computed tomography (CT) identifies more injuries than physical examination and plain radiography alone, although there is no proven clinical benefit

The Role of Ultrasound for Detecting Occult Penetrating Cardiac Wounds in Hemodynamically Stable Patients.

There is evidence in favor of using the ultrasound as the primary screening tool in looking for an occult cardiac injury. We report on a prospective single-center study to determine the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac wounds in a low-resource hospital from a middle-income country. Data were collected prospectively. We included all consecutive patients 14years and older who presented to the Emergency Trauma Unit with (1) penetrating injuries to the precordial area and (2) a systolic blood pressure ≥ 90mmHg (hemodynamically stable). The main outcome measures were sensitivity, specificity, and positive and negative predictive values of ultrasound compared with those of the pericardial window, which was the standard test. A total of 141 patients met the inclusion criteria. Our results showed that for diagnosing an occult cardiac injury, the sensitivity of the chest ultrasonography was 79.31%, and the specificity was 92.86%. Of the 110 patients with a normal or negative ultrasound, six had a positive pericardial window. All of these patients had left hemothoraces. None of them required further cardiac surgical interventions. We found that ultrasound was 79% sensitive and 92% specific for the diagnosis of occult penetrating cardiac wounds. However, it should be used with caution in patients with injuries to the cardiac zone and simultaneous left hemothorax.

Cross-sectional imaging of the torso reveals occult injuries in asymptomatic blunt trauma patients

BackgroundHigh morbidity and mortality rates of trauma injuries make early detection and correct diagnosis crucial for increasing patient’s survival and quality of life after an injury. Improvements in technology have facilitated the rapid detection of injuries, especially with the use of computed tomography (CT). However, the increased use of CT imaging is not universally advocated for. Some advocate for the use of selective CT imaging, especially in cases where the severity of the injury is low. The purpose of this study is to review the CT indications, findings, and complications in patients with low Injury Severity Scores (ISS) to determine the utility of torso CT in this patient cohort.MethodsA retrospective review of non-intubated, adult blunt trauma patients with an initial GCS of 14 or 15 evaluated in an ACS verified level 1 trauma center from July 2012 to June 2015 was performed. Data was obtained from the hospital’s trauma registry and chart review, with the following data included: age, sex, injury type, ISS, physical exam findings, all injuries recorded, injuries detected by torso CT, missed injuries, and complications. The statistical tests conducted in the analysis of the collected data were chi-squared, Fischer exact test, and ANOVA analysis.ResultsThere were 2306 patients included in this study, with a mean ISS of 8. For patients with a normal chest exam that had a chest CT, 15% were found to have an occult chest injury. In patients with a negative chest exam and negative chest X-ray, 35% had occult injuries detected on chest CT. For patients with a negative abdominal exam and CT abdomen and pelvis, 16% were found to have an occult injury on CT. Lastly, 25% of patients with normal chest, abdomen, and pelvis exams with chest, abdomen, and pelvis CT scans demonstrated occult injuries. Asymptomatic patients with a negative CT had a length of stay 1 day less than patients without a corresponding CT. No incidents of contrast-induced complications were recorded.ConclusionsA negative physical exam combined with a normal chest X-ray does not rule out the presence of occult injuries and the need for torso imaging. In blunt trauma patients with normal sensorium, physical exam and chest X-ray, the practice of obtaining cross-sectional imaging appears beneficial by increasing the accuracy of total injury burden and decreasing the length of stay.

Animal Injuries; a Case Series of Bull Induced Injuries in India.

Introduction:Bull injuries are common in India. An injury by a bull is more common in rural and agriculture dependent regions of the country. The incident causing injury by a bull can be sports related or work related. Work related injuries are almost mostly seen in farmers.Case presentation:We would like to present six cases of bull injury over a period of three years who reported to our EM. All six patients were admitted. Five out of six patients survived the hospital stay.Conclusion:Trauma sustained due to being hit by a large animal should be treated akin to a high velocity trauma and such a patient definitely warrants a period of observation even if the injuries are not life threatening. A high index of suspicion is needed for suspecting occult injuries. Fluid resuscitation and age of the patient are important considerations.

Usefulness of CT-scan in the management of chest stab trauma: a prospective observational study

The management of chest stab wounds necessitates to perform an efficient imaging strategy. Compared to chest X-ray, computed tomography (CT) scan has a higher sensitivity. Nevertheless, the utility of diagnosing occult injuries remains controversial. Previous studies reported very different rates of management modifications induced by CT-scan. Indeed, no study specifically addressed the issue of ruling out traumatic diaphragmatic injury (TDI) in the specific population of chest stab trauma. The aim of the study was to evaluate the rate of thoracic procedures induced or guided by the results of thoracic CT-scan in the specific population of chest stab wounds. Secondary objective was to evaluate the utility of CT-scan for the diagnosis of TDI. We conducted a prospective observational study. All consecutive patients referred to the acute care unit were included. We recorded the general characteristics of patients, the localization of wounds, all imaging tests, the final injury diagnosis, and the patients' management. We compared patients with modifications of management induced by CT-scan results to other patients. We evaluated the performance of CT-scan for the diagnosis of TDI by calculating its sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV). 153 patients were included. There were 92 patients with normal chest X-ray. 67 of them received a CT-scan. 34 (51%) patients had an abnormal CT-scan, including 19 (21%) patients with thoracic new findings, with 3 (4.5%) modification of management. There were 50 patients who had an abnormal chest X-ray. 31 of them received a CT-scan, and 31 (100%) had an abnormal CT-scan, including 19 thoracic new findings, with 11 (36%) modifications of management. The diagnostic performance of CT-scan for TDI was: sensitivity 50%; specificity 95%; NPV 72%; PPV 88%. In chest stab trauma, CT-scans may be unnecessary outside the thoracoabdominal zone when chest X-ray is normal. In other cases, CT-scan seems to have an impact on the decision-making. In case of thoracoabdominal wounds, CT-scan helps to detect intra-abdominal injuries. The performance of CT-scan to diagnose TDI is not high enough to reliably rule out all TDI.

Chest tube output, duration, and length of stay are similar for pneumothorax and hemothorax seen only on computed tomography vs. chest radiograph

Whole-body computed tomography (CT) for blunt trauma patients is common. Chest CT (CCT) identifies "occult" pneumo- (PTX) and hemothorax (HTX) not seen on chest radiograph (CXR), one-third of whom get chest tubes, while CXR identifies "non-occult" PTX/HTX. To assess chest tube value for occult injury vs. expectant management, we compared output, duration, and length of stay (LOS) for chest tubes placed for occult vs. non-occult (CXR-visible) injury. We compared chest tube output and duration, and patient length of stay for occult vs. non-occult PTX/HTX. This was a retrospective analysis of 5451 consecutive Level I blunt trauma patients, from 2010 to 2013. Of these blunt trauma patients, 402patients (7.4%) had PTX, HTX or both, and both CXR and CCT. One third (n = 136, 33.8%) had chest tubes placed in 163 hemithoraces (27 bilateral). Non-occult chest tube output for all patients was 1558 ± 1919cc (n = 54), similar to occult at 1123 ± 1076cc (n = 109, p = 0.126). Outputs were similar for HTX-only patients, with non-occult (n = 34) at 1917 ± 2130cc, vs. occult (n = 54) at 1449 ± 1131cc (p = 0.24). Chest tube duration for all patients was 6.3 ± 4.9days for non-occult vs. 5.0 ± 3.3 for occult (p = 0.096). LOS was similar between all occult injury patients (n = 46) and non-occult (n = 90, 17.0 ± 15.8 vs. 13.7 ± 11.9days, p = 0.23). Mature clinical judgment may dictate which patients need chest tubes and explain the similarity between groups.