Trauma CT Research Articles

Head injury burden in a major referral hospital emergency centre in Botswana.

IntroductionThis study describes the demographics, aetiology, emergency centre diagnosis and severity indicators of patients with head injuries presenting to the largest referral hospital emergency centre in Botswana.MethodsCross-sectional retrospective data was collected from July 2015 to September 2015 for all emergency centre head injury presentations at Princess Marina Hospital. Information was extracted from emergency centre records regarding patient demographics, mechanism of injury, clinical observations, diagnosis, and treatment.ResultsThree-hundred and sixty head injury patients presented to the emergency centre in the three months, averaging four per day. 80% were less than 40 years of age and males accounted for 69% of all presentations. 58% of injuries were listed as being accidental, 39% recorded from assaults and 38% from road traffic accidents. The most common emergency centre clinical diagnosis was concussion and the most common radiological diagnosis skull fracture. The median Glasgow Coma Scale was 15 with a range from 3 to 15; and, among patients for whom Revised Trauma Score could be calculated, 79% scored the lowest probability of death in the Revised Trauma Score.DiscussionHead injury disproportionately overburdened males in this study, and head injury aetiology and demographic picture was similar to regional data. Severity scoring using the Glasgow Coma Scale was only available among 66% of patients and Revised Trauma Score calculable in half of presentations. Only 55% of head injury patients were discharged from the emergency centre, despite the preponderance of low severity scores. Head CTs appear to have been over-utilised and implementation of a Traumatic Head CT guideline for our setting is proposed. This study improves understanding of the burden of head injury in Botswana and advocates for national referral guidelines for patients with head injury in Botswana.

Assessment of sensitivity of whole body CT for major trauma

Whole body computed tomography has become standard practice in many centres in the management of severely injured trauma patients, however, the evidence for it's diagnostic accuracy is limited. To assess the sensitivity of whole body CT in major trauma. Retrospective review of all patients with injury severity score (ISS) > 15 presenting with blunt trauma to a UK Major Trauma Centre between May 2012 and April 2014. Injuries were classified as per ISS score-1 = head and neck 2 = face 3 = chest 4 = abdomen. The authors reviewed patient's electronic charts, radiological results; interventional procedure records, discharge letters and outpatient follow up documentation and referenced this with Trauma Audit and Research Network data. 407 patients with ISS > 15 presented to the Trauma centre during May 2012 and April 2014. Of these, 337 (82.8%) had a whole body CT scan. 246 pts were male, 91 were female. 74 (21.9%) were due to a fall from > 2m, 41 (12.2%) due to a fall from < 2m, 208 (61.7%) were due to motor vehicle crashes, 1 (0.3%) due to a blast injury, 5 (1.5%) due to blows, and 8 (2.4%) due to crush injuries. Sensitivity for Region 1 was 0.98, Region 2 = 0.98, Region 3 = 0.98 and Region 4 was 0.95. Overall sensitivity was 0.98. 15 injuries (2.4%) were not identified on initial CT (false -ve). These injuries were: colonic perforation = 1, splenic contusion = 1, pneumothorax = 1, liver laceration = 1, intracranial haemorrhage = 1, cerebral contusions = 1, spinal injuries = 7, canal haemorrhage = 1, maxilla fracture = 1. These results show that whole body CT in trauma has a high sensitivity and a low rate of missed injuries (2.4%). However, our study only evaluated a subgroup of patients with ISS > 15 and further work is required to assess the use of this investigation for all major trauma patients.

Utility of MRI for cervical spine clearance in blunt trauma patients after a negative CT.

To determine the utility of cervical spine MRI in blunt trauma evaluation for instability after a negative non-contrast cervical spine CT. A review of medical records identified all adult patients with blunt trauma who underwent CT cervical spine followed by MRI within 48 h over a 33-month period. Utility of subsequent MRI was assessed in terms of findings and impact on outcome. A total of 1,271 patients with blunt cervical spine trauma underwent both cervical spine CT and MRI within 48 h; 1,080 patients were included in the study analysis. Sixty-six percent of patients with a CT cervical spine study had a negative study. Of these, the subsequent cervical spine MRI had positive findings in 20.9%; 92.6% had stable ligamentous or osseous injuries, 6.0% had unstable injuries and 1.3% had potentially unstable injuries. For unstable injury, the NPV for CT was 98.5%. In all 712 patients undergoing both CT and MRI, only 1.5% had unstable injuries, and only 0.42% had significant change in management. MRI for blunt trauma evaluation remains not infrequent at our institution. MRI may have utility only in certain patients with persistent abnormal neurological examination. • MRI has limited utility after negative cervical CT in blunt trauma. • MRI is frequently positive for non-specific soft-tissue injury. • Unstable injury missed on CT is infrequent.

Comparative Study of CT and Ultrasonography in Blunt Abdominal Trauma

Comparative Study of CT and Ultrasonography in Blunt Abdominal Trauma

Diagnostic Imaging for Blunt Abdominal Trauma

Background: Blunt abdominal trauma is a common cause of morbidity and mortality among patients encountering traumatic injuries, especially motor vehicle accidents, which are the leading cause of injury worldwide. Focused abdominal sonogram for trauma, computed tomography with or without contrast, and laparotomy are the most common ways of diagnosis and treatment. With advancement of diagnostic medicine, the physicians are making use of non-operative methods to achieve quick results quicker and with fewer complications. Methodology: We conducted this review using a comprehensive search of MEDLINE, PubMed, and EMBASE, January 2001, through February 2017. The following search terms were used: blunt abdominal injury, FAST scan, US in abdominal trauma, CT for abdominal trauma, trauma management Aim: In this review, we aimed at evaluating the various methods of diagnosis using imaging for blunt abdominal trauma. Conclusion: The growing tendency of non-operative management necessitates early identification of the injury sites, which is aided by the increasing sophistication of the CT techniques. Additionally, CT also provides a very significant method for following up the patients and for detecting complications which were not diagnosed initially.

Two Cases of Pneumorrhachis with Different Causes

We present two interesting and rare cases of pneumorrhachis (intraspinal air). The first patient is a 43- year-old male patient who had a road traffic accident and trauma CT showed impressive pneumocephalus and pneumorrhachis within the cervical canal. Treatment was conservative and the patient improved the following weeks with reabsorption of the air. Another 60-year-old female patient had known diverticulitis and developed paraparesis of her legs with associated fever. MRI of her spine showed extensive intraspinal air in the thoracolumbar space. She was operated combined with neurosurgeons and abdominal surgeons with colostomy and laminectomy. After a long treatment on ICU and rehab center 6 months after surgery she was able to walk with help.

Incidental Pelvic Schwannoma: A Case Report

Introduction: Incidental findings are identified on 35% to 45% of trauma CT scans. Most commonly, they are found on CT scans of the abdomen/pelvis in female patients older than age 60. Multiple studies show that the majority of these findings are benign and do not require urgent intervention. Many patients are discharged without notification of their findings or sufficient follow-up care. Case description: A 28-year-old male presented as a trauma alert after a rollover motor vehicle collision. He was assessed according to ATLS protocol and underwent CT scans of his head, neck, chest, abdomen, and pelvis. Imaging showed a fracture of his C1 vertebrae, so the patient was placed in an Aspen collar by neurosurgery and admitted to the hospital. The CT scan also showed an incidental 11 cm × 9.5 cm × 12.6 cm solid mass containing areas of calcification and hemorrhage displacing the bladder and the right external iliac vein. A CT guided biopsy of this mass was preformed and sent for pathological evaluation. Results returned as a spindle cell lesion, positive for S-100 and negative for desmin and vimentin. Decision was made to respect the mass based on its large size and potential for obstructive or compressive symptoms. Pathology was positive for a schwannoma. Discussion and Conclusion: Our case describes a rare benign neoplasm found incidentally after a work-up for trauma. Schwannomas account for 5% of benign soft tissue neoplasms, occurring primarily as solitary, slow-growing lesions in patients 20 to 40 years of age. They are rarely symptomatic unless their size results in compression of surrounding structures. They appear as heterogenous encapsulated masses with degenerative and cystic cavitations on imaging. They will routinely stain positive for S-100 on histological examination.

To scan or not to scan - a service improvement project for CT in facial trauma

Introduction and Aims: Facial trauma patients often receive CTs to exclude head injury, but these rarely include the orbits or facial bones. As CT is useful in managing orbital fractures, this service improvement project aims to examine practice and streamline the process for patients with likely fractures, already receiving a CT.

Indicators of Radiographic Progression after Positive Initial Head CT in Trauma: A Multi-Institutional Retrospective Review

Indicators of Radiographic Progression after Positive Initial Head CT in Trauma: A Multi-Institutional Retrospective Review

Management of hemodynamically unstable patients with fracture pelvis Mafraq Hospital experience, UAE

Background: Multidisciplinary team and multiple approaches were introduced to improve the outcome after significant pelvic trauma. In present study, we are evaluating our institutional management modalities for unstable patients with unstable pelvic fractures using angio-embolization, pelvic packing with or without angio-embolization and conservative management with surgical intensive care unit (SICU) admission.Methods: We reviewed 108 patients admitted with pelvic fractures from January 2013 to September 2014, 19 patients (17.5%) were hemodynamically unstable with pelvic fracture. Massive transfusion protocol was activated in all patients. FAST scan was done. Level 1 trauma CT for the responder and transient responder patients.Results: Out of 19 patients, 7 patients (36.8%) were good responders to resuscitation with maintaining of their hemoglobin stable, with no extravasation of dye, admitted to SICU for conservative management. 4 patients (21%) were responders with CT trauma revealed dye leak so they underwent angio-embolization, SICU admission. 8 patients (42.1%) were non-responders underwent preperitoneal packing, one of them had additional angio-embolization.Conclusions: Preperitoneal packing is an excellent choice for non-responder patients, while angio-embolization can be done for responder and transient responder patients with evident dye extravasation. This study needs more evaluation on a wider clinical scale.

Emergency CT of blunt abdominal trauma: experience from a large urban hospital in Southern China.

Trauma is one of the leading causes of death for men and women under the age of 45 years old, and abdominal injuries contribute to a large number of these deaths. Prompt diagnosis is very important for treatment decision making and can be life-saving. CT has become an essential imaging modality in emergency medicine. In this pictorial review, we present our experience of CT in blunt abdominal trauma and describe CT findings of common injuries, including hemoperitoneum, solid viscera, hollow viscera, mesenteric and diaphragmatic injuries. Unenhanced CT is routinely used, tailored protocols should be reserved for patients with questionable or subtle findings at unenhanced CT, especially for bowel and mesenteric injuries. The decision can be made by radiologists based on initial findings or by referring clinicians based by clinical presentations or deterioration of patients' condition.

Compliance with evidence-based guidelines for computed tomography of children with head and abdominal trauma.

Recently, two large prospective clinical trials developed and validated prediction rules for children at very low risk for clinically important traumatic brain injuries (ciTBI) or abdominal injury for whom CT is unnecessary. Specific criteria/guidelines were identified which if met would obviate the need for CT scanning. The purpose of this study was to assess compliance at a level one pediatric center with these guidelines as a tool for quality improvement. Records of children admitted to our pediatric trauma center one year before and two years after publication of head (Kuppermann '09) and abdominal trauma (Holmes '13) CT imaging guidelines were reviewed. Data collected included demographics, Glasgow coma score, (GCS), injury severity score (ISS), mechanism of injury, and indication for imaging based on criteria/guidelines from the prediction rule including history, symptoms, and physical exam findings. There were 296 total patients identified. Demographic data, GCS, ISS, and mechanism of injury were similar between both groups before and after guideline publication. Prior to publication of head trauma imaging guidelines, 20.7% of head trauma patients had no indication for head CT prior compared with 19.5% after publication of imaging guideline (p=0.85). Prior to publication of abdominal trauma imaging guidelines, 28.9% of patients had no indication for abdominal CT compared with 31.5% after publication of imaging guidelines (0.76). The rate of ciTBI requiring intervention was 4.6% before and 1.1% after guideline publication (p=0.4). The rate of abdominal injury requiring intervention was 7.9% before and 1.8% post guideline publication (p=0.2). None of the children at very low risk for ciTBI or abdominal injury required surgical intervention. At our institution compliance with evidence-based guidelines for CT of children with head and abdominal trauma is poor with a significant number of patients undergoing unnecessary imaging. This provides an opportunity for quality improvement with evidence based methods to reduce unnecessary imaging for trauma. III TYPE OF STUDY: Clinical Research Paper.

Implementation of clinical effectiveness guidelines for solid organ injury after trauma: 10-year experience at a level 1 pediatric trauma center.

Diagnostic imaging of pediatric blunt abdominal trauma is evolving in light of increased attention to radiation exposure. We hypothesize that the implementation of imaging guidelines has reduced total CT scans without missing clinically significant injury. We retrospectively reviewed blunt trauma patients age 0-17 with solid organ injury who underwent CT scan at our academic level 1 pediatric trauma center between 2005 and 2014. Variables including total annual trauma admissions and CT scans, demographics, injury characteristics, and procedures were recorded. Descriptive statistics, Fisher exact and rank sum testing were performed. p<0.05 defined significance. Overall percentage of abdominal CT scans decreased significantly after protocol implementation. There were 498 solid organ injuries in 403 subjects. There was a significant decrease in the median percentage of low grade injuries (1.3% versus 0.6%; p=0.019) but no difference in high grade injuries (1.3% versus 1.1%; p=0.394). No patient had death, readmission or delayed diagnosis of injury requiring intervention. Implementation of imaging guidelines for blunt abdominal trauma decreased the incidence of low grade solid organ injuries at our institution, but did not inhibit diagnosis and safe management of high grade injuries. Selective imaging of trauma patients decreases childhood radiation exposure and does not result in delayed bleeding or death. Level III, retrospective study.

Radiologic head CT interpretation errors in pediatric abusive and non-abusive head trauma patients.

Pediatric head trauma, including abusive head trauma, is a significant cause of morbidity and mortality. The purpose of this research was to identify and evaluate radiologic interpretation errors of head CTs performed on abusive and non-abusive pediatric head trauma patients from a community setting referred for a secondary interpretation at a tertiary pediatric hospital. A retrospective search identified 184 patients <5years of age with head CT for known or potential head trauma who had a primary interpretation performed at a referring community hospital by a board-certified radiologist. Two board-certified fellowship-trained neuroradiologists at an academic pediatric hospital independently interpreted the head CTs, compared their interpretations to determine inter-reader discrepancy rates, and resolved discrepancies to establish a consensus second interpretation. The primary interpretation was compared to the consensus second interpretation using the RADPEER™ scoring system to determine the primary interpretation-second interpretation overall and major discrepancy rates. MRI and/or surgical findings were used to validate the primary interpretation or second interpretation when possible. The diagnosis of abusive head trauma was made using clinical and imaging data by a child abuse specialist to separate patients into abusive head trauma and non-abusive head trauma groups. Discrepancy rates were compared for both groups. Lastly, primary interpretations and second interpretations were evaluated for discussion of imaging findings concerning for abusive head trauma. There were statistically significant differences between primary interpretation-second interpretation versus inter-reader overall and major discrepancy rates (28% vs. 6%, P=0.0001; 16% vs. 1%, P=0.0001). There were significant differences in the primary interpretation-second interpretation overall and major discrepancy rates for abusive head trauma patients compared to non-abusive head trauma patients (41% vs 23%, P=0.02; 26% vs. 12%, P=0.03). The most common findings resulting in major radiologic interpretation errors were fractures and subdural hemorrhage. Differences in the age of the patient and the percentage of patients with hemorrhage were statistically significant between the abusive head trauma versus non-abusive head trauma groups, while no statistical difference was identified for skull fractures, ischemia, head CT radiation dose, or presence of multiplanar or 3-D reformatted images. The second interpretation more frequently indicated potential for abusive head trauma compared to the primary interpretation (P=0.0001). MRI and/or surgical findings were in agreement with the second interpretation in 29/29 (100%) of patients with discrepancies. A high incidence of radiologic interpretation errors may occur in pediatric trauma patients at risk for abusive head trauma who are referred from a community hospital. This suggests value for second interpretations of head CTs at a tertiary pediatric hospital for this patient population.

A new low-dose multi-phase trauma CT protocol and its impact on diagnostic assessment and radiation dose in multi-trauma patients

PurposeComputed tomography (CT) examinations, often using high-radiation dosages, are increasingly used in the acute management of polytrauma patients. This study compares a low-dose polytrauma multi-phase whole-body CT (WBCT) protocol on a latest generation of 16-cm detector 258-slice multi-detector CT (MDCT) scanner with advanced dose reduction techniques to a single-phase polytrauma WBCT protocol on a 64-slice MDCT scanner.MethodsBetween March and September 2015, 109 polytrauma patients (group A) underwent acute WBCT with a low-dose multi-phase WBCT protocol on a 258-slice MDCT whereas 110 polytrauma patients (group B) underwent single-phase trauma CT on a 64-slice MDCT. The diagnostic accuracy to trauma-related injuries, radiation dose, quantitative and semiquantitative image quality parameters, subjective image quality scorings, and workflow time parameters were compared.ResultsIn group A, statistically significantly more arterial injuries (p = 0.04) and arterial dissections (p = 0.002) were detected. In group A, the mean (±SD) dose length product value was 1681 ± 183 mGy*cm and markedly lower when compared to group B (p < 0.001). The SDs of the mean Houndsfield unit values of the brain, liver, and abdominal aorta were lower in group A (p < 0.001). Mean signal-to-noise ratios (SNRs) for the brain, liver, and abdominal aorta were significantly higher in group A (p < 0.001). Group A had significantly higher image quality scores for all analyzed anatomical locations (p < 0.02). However, the mean time from patient registration until completion of examination was significantly longer for group A (p < 0.001).ConclusionsThe low-dose multi-phase CT protocol improves diagnostic accuracy and image quality at markedly reduced radiation. However, due to technical complexities and surplus electronic data provided by the newer low-dose technique, examination time increases, which reduces workflow in acute emergency situations.

Intra-abdominal insufflation as a diagnostic modality for penetrating anterior abdominal wall trauma in a busy urban center: a retrospective case-series

Background: The optimal algorithm for evaluating patients with anterior abdominal stab wounds (AASW) is not clear and has been a long standing controversy. Currently, the workup and management of penetrating anterior abdominal wall trauma may involve the decision to proceed immediately to surgery based on the presentation of the patient, or the work up may involve local wound exploration (LWE), focused abdominal sonography for trauma (FAST) exam, CT scan, or serial abdominal exams. Here we discuss an observational sign utilizing the Veress needle intra-abdominal insufflation test that can be used in conjunction with the current AASW algorithm, to rule in peritoneal violation. Methods: Eight patients admitted to our level 1 trauma center with penetrating AASW were evaluated using LWE, FAST, or CT scan followed by Veress needle insufflation and DL for suspected intra-abdominal injuries. These cases were retrospectively evaluated for the efficacy of Veress needle insufflation as an observational test for peritoneal violation. Results: Eight hemodynamically stable patients from December 2013 to June 2014 presented to our level one trauma center after sustaining penetrating AASW. All eight patients went to the operating room for Veress needle insufflation and DL. Upon intra-abdominal insufflation using a Veress needle to a target pressure of 15 mmHg, all patients with peritoneal violations [5] were found to have CO2 escape from their wounds. The remaining three patients with no violation to the peritoneum did not have any appreciable CO 2 escape. Conclusions: Utilizing our technique of intra-abdominal insufflation combined with monitoring for CO 2 escape, we were able to successfully identify all patients with peritoneal violation and rule out violation in those without peritoneal injuries. With further research, our technique can be used to safely, accurately and in a timely manner stratify patients for the need of further diagnostic and interventional procedures.

Time to CT and Surgery for HPB Trauma in Scotland Prior to the Introduction of Major Trauma Centres

To assess the time taken to CT and emergency surgery for trauma patients with an injury to liver, spleen or pancreas prior to the introduction of major trauma centres (MTCs) in Scotland. A search was performed of the Scottish Trauma Audit Group database for any patient with relevant injuries over a 2-year period. Primary outcome measures were time to CT and emergency surgery. Patient demographics were also recorded. A total of 211 patients were identified of whom 23 had more than one organ affected. There were a total of 234 injuries (123 liver, 99 splenic and 12 pancreatic) in these patients. A total of 160 injuries (75.8%) suffered blunt trauma. Of 211 patients, 157 underwent emergency CT with a median time to scan of 73min (range 4-474). Hospitals provisionally designated as MTCs were 9min faster than non-MTCs in time to CT. There was no difference in time of day. Ninety-nine patients had surgery within 24h at a median time of 200min. Twenty-five patients with hypotension on presentation took a median time of 130min. Only 44 patients (27%) had a CT or emergency surgery within the expected MTC target of 1h. Thirty-nine patients required transfer to another centre. Current management of patients with abdominal trauma and haemodynamic instability remains sub-optimal in Scotland when compared to recognized performance indicators of CT and emergency surgery within 1h. Implementation of a major trauma network in Scotland should improve access to emergency radiology and surgery and efforts to shorten current timelines should improve patient outcomes.

ECMO for a polytrauma patient without systemic anticoagulation

Background: ECMO has been successfully used to support patients with trauma-induced respiratory failure. Here, we present the successful application of ECMO in a patient with life-threatening polytrauma following a road traffic accident complicated by severe acute respiratory failure. 1 Methods: This is a retrospective case report, and approval for presentation has been obtained from the department and can be submitted upon request. The patient was 20 years old and found at the roadside after being hit by a vehicle. The patient was rushed into the ED by an ambulance, where the trachea was intubated due to the low Glasgow Coma Score. A trauma CT scan revealed severe head injury with possible diffuse axonal injury. The scan also confirmed fractures of the mandible, left transfers process of L3,4,5 and first sacral vertebrae, pelvis and comminuted fracture of the right tibia and fibula. The patient was admitted to the Trauma Intensive Care Unit (TICU). A subsequent head CT scan showed multiple hemorrhagic co...

Impact and publishing: your journals need you!

The impact of a paper can be, and is, measured in many ways. This month in 360 we feature a paper from The Lancet which should be read by every orthopaedic surgeon involved in trauma care.1 This is potentially a game-changing article, a randomised control trial suggesting that one of the major “advances” in trauma care may in fact not be an advance at all. The authors conducted a technically and logistically challenging study, and randomised patients to either ATLS standard of care or immediate trauma CT scanning. It is a miraculous study with an interesting result. Whole-body CT scanning trauma patients is no better than ATLS-directed imaging in experienced hands, yet it poses a significant radiation risk. But who will read it? The paper is published in The Lancet , where only a handful …

Non-traumatic incidental findings in patients undergoing whole-body computed tomography at initial emergency admission

ObjectiveTo evaluate the number, localisation and importance of non-traumatic incidental findings (IFs) in patients with suspected or obvious multiple trauma undergoing whole-body CT (WBCT) in a level-1 trauma centre.MethodsBetween January...