Stable Blunt Trauma Patients Research Articles

Role of Laparoscopy in Evaluation of Various Blunt Abdominal Trauma

Introduction with Objective: The aim of the present study was to assess the role of laparoscopy in evaluation of various Blunt abdominal trauma (BTA) in tertiary care teaching hospital. Materials and Methods: A prospective observational study was conducted from 21st June 2016 to 21st December 2017 among 50 abdominal blunt trauma patients attending at Casualty Block, Dhaka Medical College Hospital, Dhaka, after obtaining requisite consent from the patients attendant. Data were collected through the assessment and investigation report of abdominal blunt trauma patients in the Casualty Department. The collected data were entered into the computer and analyzed by using SPSS (version 20.1) to assess the role of laparoscopy in evaluation of various blunt abdominal trauma. Results: Most of the patients were from 21-30 years (36%) of age group followed by 11-20 years (32%). The median age of this study population is 27 years. Of the study population, 84% (n=42) were male and 16% (n=8) were female. Male-female ratio was 84:16. In this study, 62% (n=31) of patients underwent only laparoscopy and 38% of patients (n=19%) underwent laparoscopy followed by laparotomy. Perforation of gas containing hollow viscus (94.73%) is responsible for conversion of laparoscopy into laparotomy in patients with blunt abdominal trauma. Among 50 patients 14 patients (28%) developed post operative complications. Rate of wound infection was higher laparoscopy followed by laparotomy (n=11). One patient developed post operative collection following laparoscopy. The accuracy rate is 100% in laparoscopic evaluation of BTA in this study. Conclusion: laparoscopy is a useful modality for evaluating and managing hemodynamically stable blunt abdominal trauma patients. Medicine Today 2024, Vol.36 (2): 95-98

Incidence of intra-abdominal injuries in hemodynamically stable blunt trauma patients with a normal computed tomography scan admitted to the emergency department

ObjectivesBlunt abdominal trauma is a common cause of emergency department admission. Computed tomography (CT) scanning is the gold standard method for identifying intra-abdominal injuries in patients experiencing blunt trauma, especially those with high-energy trauma. Although the diagnostic accuracy of this imaging technique is very high, patient admission and prolonged observation protocols are still common practices worldwide. We aimed to evaluate the incidence of intra-abdominal injury in hemodynamically stable patients with high-energy blunt trauma and a normal abdominal CT scan at a Level-1 Trauma Center in Colombia, South America, to assess the relevance of a prolonged observation period.MethodsWe performed a retrospective study of patients admitted to the emergency department for blunt trauma between 2021 and 2022. All consecutive patients with high-energy mechanisms of trauma and a normal CT scan at admission were included. Our primary outcomes were the incidence of intra-abdominal injury identified during a 24-hour observation period or hospital stay, ICU admission, and death.ResultsWe included 480 patients who met the inclusion criteria. The median age was 33 (IQR 25.5, 47), and 74.2% were male. The most common mechanisms of injury were motor vehicle accidents (64.2%), falls from height (26%), and falls from bikes (3.1%). A total of 99.2% of patients had a Revised Trauma Score of 8. Only 1 patient (0.2%) (95% CI: 0.01–1.16) presented with an abdominal injury during the observation period. No ICU admissions or deaths were reported.ConclusionThe incidence of intra-abdominal injury in patients with hemodynamically stable blunt trauma and a negative abdominal CT scan is extremely low, and prolonged observation may not be justified in these patients.

Clinical utility of performing FAST scan in hemodynamically stable patients presenting with blunt abdominal trauma in level one trauma center

Background: Focused assessment with sonography for trauma (FAST) has a role in the rapid screening of hemodynamically unstable patients to decide on management, however, its role in hemodynamically stable patients remains equivocal. Objectives: This study aimed to determine the sensitivity and specificity rate of FAST for intra-abdominal injury (IAI) in hemodynamically stable blunt abdominal trauma patients. Secondary outcomes like Glasgow coma score, length of hospital stays (LOS), head injury, and mortality were also examined for their association with FAST scan results. Settings and Design: A retrospective cross-sectional study was conducted in level-one trauma center in Bahrain. Methods: This study was conducted from January 2019 to October 2020. A total of 191 trauma codes were activated during this period, however, only 112 patients were included based on the inclusion criteria. Results: FAST scan in hemodynamically stable patients was found to have a higher specificity (96.7%) than sensitivity (30%) in this study. A higher negative predictive value (NPV) (86.4%) compared to a positive predictive value (66.6%) and a high accuracy rate (84.8%) was observed. LOS showed significant association only with FAST diagnostic accuracy. Conclusion: In hemodynamically stable patients; FAST is better at ruling in intra IAI when compared to ruling out and its high NPV supports it being a good screening tool. The results do not support the use of FAST as the sole diagnostic tool without performing computed tomography scan.

Usefulness of ultrasonography in diagnosing abdominal trauma compared to computed tomography scan

Background: Abdominal trauma following road traffic accident is a leading cause of morbidity and mortality among all age groups. Imaging such as ultrasonography (USG) and computed tomography (CT) scan plays a critical role in the evaluation of these patients. The accuracy of CT scan in hemodynamically stable blunt trauma patients has been well-established. Aims and Objectives: Assessment of usefulness of USG in diagnosing abdominal trauma with reference to involvement of different organs in terms of sensitivity, specificity, and predictive accuracy compared to CT scan. Materials and Methods: It is a hospital-based cross-sectional study was conducted on 87 patients in imaging and sonology room under the Department of Radiodiagnosis, Bankura Sammilani Medical College and Hospital, Bankura, West Bengal with a time frame of years. Results: In this study, the sensitivity of USG in detecting hemoperitoneum as compared to CT was found out to be 88.8%. USG had sensitivity – 79.3%, specificity – 98.2%, positive predictive value (PPV) – 95.8%, negative predictive value (NPV) – 90.4%, and predictive accuracy – 91.9% for splenic injury. For liver injury, USG had a sensitivity – 80%, specificity – 98.5%, PPV – 94.1 %, NPV – 94.2 %, and predictive accuracy – 94.25%. For renal injury, USG had sensitivity – 83.3%, specificity – 98.6%, PPV – 90.9%, NPV – 97.3%, and predictive accuracy – 96.5%. The sensitivity, specificity, PPV, NPV, and predictive accuracy of USG for pancreatic injury in comparison to CT were 100%. Conclusion: When the findings of abdominal injury on USG were compared to CT scan, which was taken to be the gold standard, it was observed that USG was fairly sensitive in detecting hemoperitoneum and solid organ injury (especially when the grades of injury was higher), but it showed less sensitivity in detecting lower grades of solid organ injuries and hollow visceral injuries (such as injury to the bowel and bladder). These cases, which were missed on USG were detected on CT scan and CT scan also helped in better grading of the visceral injuries. CT also helped in better detection of other associated findings such as pelvic fractures and pneumoperitoneum.

Do signs of abdominal wall injury on computed tomography predict intra-abdominal injury in trauma patients with a seatbelt sign?

BackgroundA seatbelt sign in patients with blunt abdominal injury is associated with both abdominal wall and intra-abdominal injuries. This study aimed to assess the association between signs of abdominal wall injury on computed tomography (CT) and rates of intra-abdominal injury in patients with a blunt abdominal injury and a clinical seatbelt sign. MethodsThis study includes hemodynamically stable trauma patients with blunt abdominal injury and a clinical seatbelt sign who were hospitalized in two regional trauma centers in Israel, during 2014–2019. All data were collected via the medical center's trauma registry in both centers. ResultsWe identified 123 stable blunt abdominal trauma patients with a seatbelt sign, of which 101 (82.1%) and 22 (17.9%) had a low-grade and high-grade abdominal wall injury according to CT findings, respectively. Laparotomy rates were significantly higher in patients with signs of high-grade abdominal wall injury (p<0.0001). No differences in the timing of laparotomy between low and high-grade injuries were found. ConclusionsIn stable patients with blunt abdominal trauma and a clinical seatbelt sign, the severity of abdominal wall injury, as represented by CT findings, may predict a need for surgical treatment.

Vascular plugs are associated with reduced fluoroscopy times compared to endovascular coils in proximal splenic artery embolization in trauma.

Purpose:Proximal splenic artery embolization plays an important role in the treatment of hemodynamically stable blunt splenic trauma patients with medium- to high-grade injuries. Proximal splenic artery embolization is most often performed utilizing endovascular coils or vascular plugs. The objective of this study was to compare technical and clinical outcomes of proximal splenic artery embolization using either endovascular coils or vascular plugs in patients with traumatic splenic injuries.Materials and methods:A single-institution retrospective review of all proximal splenic artery embolizations for trauma over a 5-year period was performed. Patients who underwent embolization using both endovascular coils and vascular plugs were excluded. Baseline characteristics, including patient age, sex, and grade of splenic injury, were recorded. Complication rates, rates of splenic salvage, and total fluoroscopy time were recorded and compared.Results:A total of 26 patients were included in the analysis (17 males, 9 females, median age: 50 years). Of these, 15 patients were treated with vascular plugs (57.7%), while 11 patients (42.3%) were treated with endovascular coils. Mean grade of injury was 3.5 and 4.1 in the vascular plug and endovascular coils groups, respectively. There were no differences between the groups regarding these baseline characteristics. Splenic salvage was 100% in both groups. No major complications were identified in either group. Mean fluoroscopy time was significantly lower in the vascular plug group (14.5 versus 34.0 min; p < 0.0001).Conclusion:Proximal splenic artery embolization for splenic trauma can be satisfactorily achieved with either vascular plugs or endovascular coils with no differences in splenic salvage or complication rates in this retrospective study. However, embolization utilizing vascular plugs had significantly reduced fluoroscopy times.

Selective Computed Tomography (CT) Imaging is Superior to Liberal CT Imaging in the Hemodynamically Normal Pediatric Blunt Trauma Patient

The optimal imaging strategy in hemodynamically stable pediatric blunt trauma remains to be defined. The purpose of this study was to determine the differences between selective and liberal computed tomography (CT) strategy in a pediatric trauma population with respect to radiation exposure and outcomes. We performed a retrospective analysis of hemodynamically stable blunt pediatric trauma patients (≤16 y) who were admitted to a Level I trauma center between 2013-2016. Patients were stratified into selective and liberal imaging cohorts. Univariate and multivariate regression analyses were used to compare outcomes between the groups. Outcomes included radiation dose, hospital and ICU length of stay, complications and mortality. Of the 485 patients included, 176 underwent liberal and 309 selective CT imaging. The liberal cohort were more likely to be severely injured (ISS>15: 34.1 versus 8.4%, P< 0.001). The odds of exposure to a radiation dose of >15 mSv were higher with liberal scanning in patients with both ISS > 15 (OR 2.78, 95% CI 1.76-5.19, P< 0.001) and ISS ≤ 15 (OR 3.41, 95% CI 2.19-8.44, P < 0.001). Adjusted outcomes regarding mortality, ICU length of stay, and complications were similar between the cohorts. Selective CT imaging in hemodynamically stable blunt pediatric trauma patients was associated with reduced radiation exposure and similar outcomes when compared to a liberal CT strategy.

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.

Renal ultrasound to evaluate for blunt renal trauma in children: A retrospective comparison to contrast enhanced CT imaging

The standard imaging modality for hemodynamically stable blunt abdominal trauma patients is a contrast enhanced CT scan, which is reflected in the current AUA urotrauma guidelines. This comes, however, with radiation exposure and the potential sequalae of IV contrast administration in the pediatric patient. We hypothesize that ultrasound imaging would be able to diagnose and rule out clinically significant renal injuries when compared to the gold standard of CT scan in the setting of pediatric blunt abdominal trauma. All children <18 years of age who were evaluated for blunt abdominal trauma who had a CT scan and ultrasound imaging of kidneys were identified. The ultrasound images were reviewed by four reviewers who were blinded to CT results and all clinical information. The ability of ultrasound to diagnose and rule out clinically significant renal injury was evaluated by diagnostic test performance characteristics including sensitivity, specificity, negative predictive value and positive predictive value. There were 76 patients identified, 24 of which had a renal injury (1 bilateral) diagnosed by CT scan for a total of 25 injuries in 152 renal units. There were six grade I-II injuries and 19 grade III-V injuries. The sensitivity of the four blinded reviewers by ultrasound alone to detect the 19 grade III-V injuries ranged from 79 to 100% with NPV between 97 and 100%. Three of the four reviewers identified all 19 grade III-V injuries by ultrasound. When combined with significant hematuria, all 19 grade III-IV injuries were identified. Of note, all patients with a grade III-V injury of the kidney had significant hematuria. Of the grade I-II renal injuries, all reviewers identified 1/5 or 2/5 by ultrasound alone. The limitations of this study include: its retrospective nature, limited number of patients and reviewers, quality of the ultrasound machine. and experience of technologist, radiologist and urologist. A major limitation is the inability to assess other solid organ injuries during this initial study. When compared to a CT scan as the gold standard, kidney ultrasound images had a sensitivity of 79-100% to detect grade III-V injuries and NPV of 97-100% by four blinded reviewers. All grade III-V injuries had either an episode of gross hematuria or microscopic hematuria >50 RBC/hpf. A prospective study that includes full abdominal imaging is needed to confirm that ultrasound can safely be used in place of CT scan for evaluation of hemodynamically stable blunt trauma patients.

The emergency department length of stay: Is the time running out?

PurposeTo examine the relationships between emergency department length of stay (EDLOS) with hospital length of stay (HLOS) and clinical outcome in hemodynamically stable trauma patients. MethodsProspective data collected for 2 years from consecutive trauma patients admitted to the trauma resuscitation bay. Only stable blunt trauma patients with appropriate trauma triage criteria requiring trauma team activation were included in the study. EDLOS was determined short if patient spent less than 2 h in the emergency department (ER) and long for more than 2 h. ResultsA total of 248 patients were enrolled in the study. The mean total EDLOS was 125 min (range 78–180). Injury severity score (ISS) were significantly higher in the long EDLOS group (17 ± 13 versus 11 ± 9, p < 0.001). However, when leveled according to ISS, there were no differences in mean in diagnostic workup, admission rate to intensive care unit (ICU) or HLOS between the short and long EDLOS groups. ConclusionEDLOS is not a significant parameter for HLOS in stable trauma patients.

Contrast-enhanced ultrasound performance in predicting blunt splenic injuries requiring only observation and monitoring.

To assess contrast enhanced ultrasound (CEUS) performance in the prediction of non-operatively managed bluntspleen injuries requiring only observation and monitoring during follow-up and to evaluate if CEUS accuracy was higher thanconventional ultrasound (US) in this field. In 112 hemodynamic stable blunt spleen trauma patients,CEUS was performed for follow-up after computed tomography evaluation in the emergency department. CEUS and US performancewere assessed considering as true negative cases patients that had not underwent interventional or surgical treatmentduring follow-up and were assessed as negative for splenic complications respectively by CEUS or US examinations. CEUS showed sensitivity of 100%, specificity of 96.1%, positive predictive value of 69.2%, negative predictive value of100.0% and accuracy of 96.4%. CEUS showed a significantly higher accuracy than conventional US (p=0.013). CEUS is a very useful imaging modality during follow-up of blunt splenic trauma non-operatively managed, allowing an efficientprediction of splenic injuries requiring only observation and monitoring during follow-up.

Contrast-enhanced ultrasound in the evaluation of splenic injury healing time and grade

To assess mean healing time of blunt spleen injuries managed nonoperatively using CEUS (contrast-enhanced ultrasound); to analyze whether spleen injury grade, subcapsular hematoma (SCH) presence, SCH grade and spleen infarct after spleen artery angioembolization could be related to healing time; and to evaluate CEUS sensitivity in diagnosing spleen injury and to assess CEUS performance in classifying spleen injury grade compared to CT. After CT evaluation in the Emergency Department, 101 hemodynamic stable blunt spleen trauma patients (73 males; 28 females; mean age 46.4years, range 18-92) underwent serial CEUS follow-up examinations at pre-established intervals (1, 3, 8, 15, 30, 60, 90 and 180days after trauma), until spleen injury became no more identifiable. Mean CEUS examinations performed before spleen injury healing were 4.5; mean spleen injury healing time was 22.6days. Spleen injury healing time was significantly related to spleen injury grade, subcapsular hematoma (SCH) presence, SCH grade and spleen infarct. CEUS spleen injury diagnostic sensitivity was 96.9% and, according to the American Association for the Surgery of Trauma (AAST)-spleen injury scale (SIS), CEUS-CT concordance was 95.8%. Spleen injury healing time in blunt abdominal trauma nonoperatively managed is significantly related to AAST-SIS grade, SCH presence and grade, and spleen infarct development, and CEUS can be used in order to evaluate spleen injury grade.

Conservative Versus Operative Management of Blunt Splenic Injuries

Background: The spleen is the most frequently injured organ in blunt abdominal trauma, mainly because of its highly vascularized parenchyma and its anatomic location. In the past the management of blunt splenic injuries was splenectomy, but high rate of operative complications caused paradigm shift from operative to non-operative management (NOM) in hemodynamically stable blunt abdominal trauma patients. Now, nonoperative management of hemodynamically stable patients with blunt splenic injuries is the standard of care and has been proven to be safe and successful in the acute setting. The advent of newer imaging techniques with high resolution CT scanners has enabled the clinicians to exactly diagnose the extent of intra-abdominal organ injury. Objective: This work aim to compare between operative and conservative management of splenic trauma. Methodology: Total numbers of patients in this study were 20 patients classified in two groups, the first group contained12 patients and the other group contained 8 patients. The First group was managed conservative and the second was managed operative with splenectomy and splenoraphy. The first group of patients consisted of 9 males (75%) and 3 female (25%). The second group of patients consisted of 6 males (75%) and 2 females (25%). Results: In this study, bunt splenic injury was found to be more common in males because of their risky and hard work. RTA and Falling from a height were found to be the most common causes of blunt abdominal injuries. According to CT, grade one and two of splenic injury are more common than other grades of splenic injury. As regard complication the operative management has more complication as postoperative wound infection and postoperative chest infection. So, NOM of splenic injury is the management of choice in haemodynamically stable patients. Conclusion: The nonoperative management is considered the ideal management for blunt splenic injuries due to less complication, less blood transfusion, less hospital stay and less mortality than operative management.

Operative versus conservative management of splenic trauma in pediatric patients

Objective The aim of this study was to compare between operative and conservative management of splenic trauma in pediatric patients. Background In the past the management of blunt splenic injuries was carried out using splenectomy. However, the high rate of operative complications caused a paradigm shift from operative to nonoperative management in hemodynamically stable blunt abdominal trauma patients. Patients and methods This prospective study included a total of 40 patients. The patients were managed conservatively or operatively. Nonoperative management criteria included hemodynamic stability and absence of other injuries requiring laparotomy. Unstable patients were operated using splenectomy. Results Road traffic accident was the most common mechanism of trauma in this study (55%) in the patients who were managed conservatively and (60%) in the patients who were managed operatively (χ2 = 1.507; P = 1.000). Computed tomography was performed for stable patients only; grade I and grade II splenic injury comprised 70% of cases. The incidence of complications was 5% in the patients who were managed conservatively and 10% in the patients who were managed operatively (χ2 = 0.360; P = 1.000). The incidence of blood transfusion was less in the patients who were managed conservatively (25%) than in the patients who were managed operatively (100%) (χ2 = 24.000; P < 0.001). There was no mortality in the patients who were managed conservatively, whereas in the patients who were managed operatively the incidence of mortality was 5% (χ2 = 1.026; P = 1.000). All these tests were used as tests of significance at P less than 0.05. Conclusion The nonoperative management is considered the ideal management for blunt splenic injuries in pediatric patients because of fewer complications, lower blood transfusion rate, shorter hospital stay, and less mortality compared with operative management.

Routine pelvic X-rays in asymptomatic hemodynamically stable blunt trauma patients: A meta-analysis

IntroductionThere is no consensus on how pelvic X-rays should be ordered selectively in blunt trauma patients which may save time, reduce radiation exposure and costs. The aim of this systematic review and meta-analysis was to assess the need for routine pelvic X-rays in awake, respiratory and hemodynamically (HD) stable blunt trauma patients without signs of pelvic fracture. Criteria to identify patients who could safely forgo pelvic X-ray were evaluated. MethodsA literature search was performed for prospective comparative cohort studies. Inclusion criteria were: blunt force trauma, hemodynamically and respiratory stable and awake patients, physical examination (PE) for pelvic fractures was adequately described, and the reliability of negative PE findings could be evaluated. Primary outcome was the negative predictive value (NPV) of PE for all and for clinically relevant pelvic fractures. Additionally sensitivity, specificity and positive predictive value (PPV) were calculated. ResultsTen studies were included; yielding a total of 11,423 patients. The NPV of PE for all pelvic fractures ranged from 0.96 to 1.00 with a median of 0.996. Combining studies, total NPV was 0.991. For clinically relevant fractures, the NPV of PE ranged from 0.996 to 1.00 with a median of 1.00. In patients with negative findings during PE, 0.9% had fractures, and 0.1% had clinically relevant fractures, none requiring surgical management. ConclusionsIn awake, hemodynamically and respiratory stable blunt trauma patients, PE could identify those patients who could safely forgo pelvic X-ray. Selective ordering of pelvic X-ray may lead to a decrease in patient work-up time, lower radiation exposure, and reduce costs. A decision making flow chart is proposed..

The combined utility of extended focused assessment with sonography for trauma and chest x-ray in blunt thoracic trauma.

Portable chest x-ray (CXR) and extended focused assessment with sonography for trauma (EFAST) screen patients for thoracic injury in the trauma bay. It is unclear if one test alone is sufficient, if both are required, or if the two investigations are complementary. Study objectives were to define the combined diagnostic yield of EFAST and CXR among stable blunt thoracic trauma patients and to determine if a normal EFAST and CXR might obviate the need for computed tomography (CT) scan of the chest. All blunt trauma patients 15 years or older presenting to LAC+USC Medical Center in 2016 were screened. Only patients who underwent CT thorax were included. Patients were excluded if they presented more than 24 hours after injury, were transferred, or if they did not undergo EFAST and CXR. Demographics, physical examination (PEx) of the thorax, injury data, investigations, procedures, and outcomes were collected. The EFAST, CXR, and PEx findings were compared to the gold standard CT thorax to calculate the diagnostic yield of each investigation and combinations thereof in the assessment for clinically significant thoracic injury. One thousand three hundred eleven patients met inclusion/exclusion criteria. Most common mechanisms of injury were motor vehicle collision (n = 385, 29%) and auto versus pedestrian trauma (n = 379, 29%). Mean Injury Severity Score was 11 (1-75), with mean Abbreviated Injury Scale chest score of 1.6 (1-6). The sensitivities of EFAST, CXR, and PEx, either individually or in combination, were less than 0.73 in the detection of clinically significant thoracic injury. The most common missed clinically significant injuries were sternal fractures, scapular fractures, clavicular fractures, and pneumothoraces. Motorcycle collisions and auto versus pedestrian traumas resulted in the highest rates of missed injury. Even in conjunction with the physical examination, the sensitivity of EFAST+CXR in the detection of clinically significant thoracic injury is low. Therefore, if clinical suspicion for injury exists after blunt thoracic trauma, a normal EFAST+CXR is insufficient to exclude injury and CT scan of the chest should be performed. Diagnostic tests/criteria, level III.

Analysis of incidence of traumatic brain injury in blunt trauma patients with Glasgow Coma Scale of 12 or less

PurposeEarly diagnosis of traumatic brain injury (TBI) is important for improving survival and neurologic outcome in trauma victims. The purpose of this study was to assess whether Glasgow Coma Scale (GCS) of 12 or less can predict the presence of TBI and the severity of associated injuries in blunt trauma patients. MethodsA retrospective cohort study including 303,435 blunt trauma patients who were transferred from the scene to hospital from 1998 to 2013. The data was obtained from the records of the National Trauma Registry maintained by Israel's National Center for Trauma and Emergency Medicine Research, in the Gertner Institute for Epidemiology and Health Policy Research. All blunt trauma patients with GCS 12 or less were included in this study. Data collected in the registry include age, gender, mechanism of injury, GCS, initial blood pressure, presence of TBI and incidence of associated injuries. Patients younger than 14 years old and trauma victims with GCS 13–15 were excluded from the study. Statistical analysis was performed by using Statistical Analysis Software Version 9.2. Statistical tests performed included Chi-square tests. A p-value less than 0.05 was considered statistically significant. ResultsThere were 303,435 blunt trauma patients, 8731 (2.9%) of them with GCS of 3–12 that including 6351 (72%) patients with GCS of 3–8 and 2380 (28%) patient with GCS of 9–12. In these 8731 patients with GCS of 3–12, 5372 (61.5%) patients had TBI. There were total 1404 unstable patients in all the blunt trauma patients with GCS of 3–12, 1256 (89%) patients with GCS 3–8, 148 (11%) patients with GCS 9–12. In the 5095 stable blunt trauma patients with GCS 3–8, 32.4% of them had no TBI. The rate in the 2232 stable blunt trauma patients with GCS 9–12 was 50.1%. In the unstable patients with GCS 3–8, 60.5% of them had TBI, and in subgroup of patients with GCS 9–12, only 37.2% suffered from TBI. ConclusionThe utility of a GCS 12 and less is limited in prediction of brain injury in multiple trauma patients. Significant proportion of trauma victims with low GCS had no TBI and their impaired neurological status is related to severe extra-cranial injuries. The findings of this study showed that using of GCS in initial triage and decision making processes in blunt trauma patients needs to be re-evaluated.

The Predictive Value of Repeated Abdominal Ultrasonography in Patients with Multiple Trauma and Decreased Level of Consciousness: The Experience of a Resource-Limited Centre.

To determine the predictive value of repeated abdominal ultrasonography in patients with multiple trauma and decreased level of consciousness (LOC). This prospective cross-sectional study was conducted over a six-month period at Shahid Rajaee Trauma Hospital, Shiraz, Iran. We included hemodynamically stable blunt abdominal trauma patients with a decreased LOC (Glasgow Coma Scale ≤ 13) who were referred to the neurosurgery ICU ward. Included cases underwent 1 contrast-enhanced CT scan and two-time ultrasonographic study of the abdomen with an interval of 48 hours. The diagnostic accuracy of the ultrasonography was determined according to the CT-scan results. Overall 80 patients with mean age of 37.75 ± 18.67 years were included. There were 17 (21.3%) women and 63 (78.8%) men among the patients. Compared with the CT-Scan, the first ultrasonography showed a sensitivity of 60%, specificity of 80%, PPV of 16.60%, NPV of 96.80%, and a diagnostic accuracy of 70%. The same values for the second ultrasonographic study were 80%, 79%, 20%, 98%, and 79%, respectively. In 4 (5%) patients whose first ultrasonography and CT scan results were negative, the second ultrasonography was positive for injury. In patients with blunt trauma to the abdomen, when the only indication of abdominal CT scan is a decreased LOC, two ultrasonographic studies can replace a CT imaging.

Routine Versus Selective Use of Chest and Abdominopelvic CT-Scan in Blunt Trauma: A Randomized Controlled Study

Background: Whole body CT-scan (WBCT) is increasingly used in the setting of severe blunt trauma due higher sensitivity for detecting occult injuries in comparison to conventional radiography and ultrasound. But the real impact of routine CT-scan on patient outcome is still unclear. Considering the high radiation exposure due to routine CT-scan, this study was conducted to assess the effect of performing routine chest and abdominopelvic CT-scan on patient admission time and complications in blunt trauma. Methods: One hundred and forty conscious and hemodynamically stable blunt trauma patients were included in this randomized controlled study. For seventy patients, routine chest and abdominopelvic CT-scan was requested in addition to conventional radiography and ultrasound. For the other 70 patients, selective CT-scan was ordered according to the clinical presentation. Patient admission times in the emergency room and surgery ward, complications and surgical procedures were assessed. Missed injuries defined as additional findings on CT-scan which were not evident on radiography or ultrasound were assessed. Results: Admission time in the emergency ward was significantly shorter in the intervention group with 3.7 0.9 hours in comparison to 4.9 0.8 hours in the control group. Also mean admission time in hospital was only 5.4 2.4 in the intervention group in comparison to 7 3.3 days in the control group. On abdominopelvic CT-scan, 9 (7.8%) additional injuries were detected. All these 9 patients had a positive clinical examination. Chest CT-scan in the intervention group led to additional diagnoses in 17 patients (24.28%) leading to tube thoracostomy insertion in 13 patients (18.57%). Conclusions: Performing routine chest and abdominopelvic CT-scan in conscious blunt trauma patients decreases the hospitalization time but has no effect on patient complications and final outcome. Using a selective approach and performing CT-scan only for symptomatic patients, would be an appropriate option to decrease radiation dose and facility overuse. Nevertheless, the concern of missing occasionally a life threatening injury still remains. Each trauma center should make the decision whether to perform CT-scan or not according to all the pros and contras of this imaging modality.

Vascular and Interventional Radiology in Blunt Abdominopelvic Trauma‐ Institutional Practice and Review of the Literature

Trauma is the leading cause of mortality among Americans 1-44 years old and is responsible for 193,000 deaths annually. One third of these patients die from exsanguination. Current practice guidelines emphasizing nonoperative management (NOM) of most hemodynamically stable blunt trauma patients and advances in endovascular equipment and techniques have led to an established role for adjunctive endovascular therapy in the arrest of traumatic hemorrhage.