Blunt Trauma Victims Research Articles

311: Do Chest Radiography Miss Significant Intrathoracic Injury In Blunt Trauma Patients?

Using chest computed tomography (CT) as the gold standard, we sought to determine the frequency of missed significant intrathoracic injuries (SITI) of ED chest radiography (CXR) in blunt trauma patients. At 3 Level I trauma centers, adult blunt trauma victims older than 14 years who received ED chest imaging [CXR and CT (when performed)] were evaluated. SITI was defined as any of the following injuries: pneumothorax, hemothorax, sternal fracture, aortic injury, ruptured diaphragm, 2 or more rib fractures, or pulmonary contusion on radiology reports. Of the 2598 patients evaluated, 271 (10.4%) patients had SITI. 2001 (77%) patients had CXR alone and 597 (23%) had CXR and CT. Approximately half of all injuries were missed by CXR, including all sternal fractures, 75% of hemothoraces, and 60% of pulmonary contusions. Of the 2 patients who had aortic injury determined by CT, 1 had a widened mediastinum on CXR and 1 did not.Table 1Frequency of missed injuries on CXR in patients with CT When compared to CT, CXR misses a high proportion of SITI in blunt trauma patients, especially pulmonary contusion, hemothorax, and sternal fractures. Of the 2 patients with aortic injury, 1 had a normal mediastinum and no indication of injury on CXR.

418: Survival of Apneic Patients: Better Than You Might Assume

418: Survival of Apneic Patients: Better Than You Might Assume

A Comparison of the Diagnostic Performances of Visceral Organ-Targeted Versus Spine-Targeted Protocols for the Evaluation of Spinal Fractures Using Sixteen-Channel Multidetector Row Computed Tomography: Is Additional Spine-Targeted Computed Tomography Necessary to Evaluate Thoracolumbar Spinal Fractures in Blunt Trauma Victims?

It remains to be determined whether spine-targeted computed tomography (thoracolumbar spine computed tomography [TLS-CT]) images and visceral organ-targeted CT (abdominopelvic [AP]-CT) images are comparable for the evaluation of thoracolumbar spinal fractures using 16-channel multidetector row CT. The elimination of an additional spine-targeted CT protocol would substantially reduce time, the storage burden, and potential patient radiation exposure. A total of 420 vertebrae in 72 consecutive patients who underwent AP-CT to assess blunt traumatic injury and an additional CT examination using a TLS-CT protocol to evaluate spinal fractures were retrospectively evaluated. The AP-CT set (set A, reconstructed with using a wide display field of view [FOV] and a soft algorithm) and the TLS-CT set (set S, reconstructed using a narrow display FOV and a hard algorithm) were composed of axial plus reformatted sagittal or coronal images or both. Three radiologists independently reviewed all CT data retrospectively. Performances for detecting and typing fractures were compared by using areas under receiver operating characteristic curves and by determining concordance rates. The overall areas under the curves for sets S and A for fracture detection were 0.996 and 0.995, respectively; no significant difference was found between the two sets. Concordance rates for typing performance also showed no statistical significance between the two sets for any of the three observers. Sixteen-channel multidetector row CT images reconstructed using a soft algorithm and a wide display FOV that cover the entire abdomen using a visceral organ-targeted protocol with 1.5-mm collimation are sufficient for the evaluation of spine fractures in trauma patients, given that multiplanar-reformatted images are provided.

Occipitocervical dissociative injuries: common in blunt trauma fatalities and better detected with objective computed tomography-based measurements

Background context Occipitocervical injuries (OCIs) are generally not common in blunt trauma victims, but autopsy studies of blunt trauma fatalities consistently report a high prevalence of these injuries. New computed tomography (CT)-based quantitative criteria have recently been developed for use in assessing the occipitocervical spine. The efficacy of these new criteria for detecting OCI would be supported if the high prevalence of OCI in blunt trauma fatalities can also be detected using these objective CT-based criteria. Purpose To test the hypothesis that the prevalence of OCI in blunt trauma fatalities, determined using objective CT-based measurements and reliable reference data, will be similar to the prevalence reported in prior autopsy studies. Study design/setting Retrospective assessment of the CT examinations of blunt trauma fatalities at a Level 1 trauma center. Patient sample Seventy-four consecutive patients who died within 21 days of blunt trauma and had a CT examination of the cervical spine. Outcome measures Quantitative measurements from CT examinations of the occiput–C1 and C1–C2 levels. Methods Measurements were made on a Picture Archiving and Communication System (PACS) from the CT images that were originally used for diagnosis and also using imaging software that allowed for precisely reoriented slices that correct for variations in the alignment of the upper cervical spine. The prevalence of abnormal measurements found by each method and the interobserver reliability of the measurements were assessed. Results At least one abnormal measurement was found in 50% of cases based on measurements made on the PACS, and in 34% of cases using measurements from carefully reoriented images. At least three abnormal measurements were found in 22% and 14% of patients, respectively. Only one of the patients had been diagnosed as having an OCI before death. Interobserver reliability measurements of more than 80% were found for most measurements. Conclusions Using precise CT-based measurements and reliable reference data for diagnosis of occipitocervical dissociative injuries, the prevalence of injuries in severely injured blunt trauma patients was close to the levels reported in prior autopsy studies (approximately 30%). This supports that with careful measurements, both soft- and hard-tissue OCI can be detected by CT. This study is limited by the fact that a gold standard was not available to confirm the injuries.

Mesenteric thrombosis in patient victim of blunt abdominal trauma with fatal outcome

BACKGROUND: Mesenteric thrombosis related to trauma is an uncommon entity and has poor prognosis when have low flow and hemorrhagic shock. It usually presents with a challenging diagnosis and high mortality rates, despite appropriate treatment. CASE REPORT: Patient with blunt trauma was admitted and initial treatment, complementary exams showed ribs and humerus fractures. Computerized tomography showed aerial distension in small bowels along with gastric stasis and hidropneumothorax. The patient had hypotension during clinical observation and cardiopulmonary arrest, responding to reanimation. Taken to surgery for damage control, it was found extensive necrosis of right colon, which was excised and performed primary anastomosis. He was admitted in the intensive care unit, evolving with oliguria, miosis, convulsion, and pulseless electric activity, dying three days after hospital admission. CONCLUSION: Although uncommon, mesenteric ischemia with venous thrombosis might be secondary to systemic hypotension, frequently followed by fatal outcomes.

Splenic Artery Embolization in Blunt Abdominal Trauma: Creating a Mathematical Model to Predict ICU Length of Stay

Objectives: Splenic artery embolization (SAE) has been adopted in many trauma centers as a form of non-operative management (NOM) in blunt trauma victims. It has been routine practice that after embolization these patients be transferred to an intensive care unit (ICU) for continuous monitoring and close observation. The aim of this work is to create a mathematical model that can be utilized to predict ICU length of stay in these trauma patients that undergo SAE. Methods: A retrospective analysis of all patients in our trauma registry that arrived with splenic injury between January 1999 and December 2008.

Computed tomographic screening for thoracic and lumbar fractures: is spine reformatting necessary?

Introduction Patients who sustain traumatic vertebral fractures often have multiple other associated injuries. Because of the mechanisms of injury, many of these patients routinely undergo chest computed tomographic (CCT) and/or abdominal/pelvic computed tomographic (APCT) scans to diagnose intrathoracic or intra-abdominal injuries. These scans are routinely reformatted to provide more detailed imaging of the spine. Although the patient does not incur more radiation, the charges associated with this are significant. This study compared the sensitivity of these CT modalities in detecting thoracolumbar spine fractures. Methods A retrospective chart review identified blunt trauma victims, admitted through the emergency department, with a discharge diagnosis of thoracic or lumbar spine fracture that received (1) a chest and T-spine CT, (2) an abdominal/pelvic and lumbar spine CT, or both. Final radiologic readings of these patients' CT scans were obtained, and the sensitivities of the different imaging methods were compared. Discharge diagnosis of spine fracture was considered the gold standard. Results One hundred seventy-six APCT scans with reformatting and 175 CCT scans with reformatting were available for comparison. There were 9 of 176 false-negative APCT scans vs 3/176 false-negative lumbar spine CT scans. There were 14/175 false-negative CCT scans vs 2/175 false-negative thoracic spine CT scans. The differences in sensitivity were significant ( P < .001) for both comparisons. Conclusions Reformatting of CCT and APCT scans gives improved sensitivity in the detection of thoracic and lumbar spine fractures in trauma patients. Future study looking at clinically significant fractures or those that change clinical management decisions may find that the reformatted images are not routinely needed as a screening tool.

Application of a New Resource-Constrained Triage Method to Military-Age Victims

Evaluate the resource-constrained, evidence-based, and outcome-driven Sacco Triage method (STM) for military-age victims of blunt, penetrating, and blast overpressure-like trauma. STM is based on a mathematical model of resource-constrained triage. Its objective is to maximize expected survivors given constraints on transport and treatment resources. STM uses estimates of time-dependent victim survival probabilities and expected deteriorations. A respiration, pulse, and best motor response (RPM) score predicts survivability. Logistic function-generated survival probability estimates from 99,369 military-age victims were assessed using calibration and discrimination statistics. The consensus building Delphi method was used to provide aggregate expert opinion on victim deterioration rates. The models were solved using linear programming. Rule-based (not requiring software) protocols were determined using a greedy algorithm for Iraqi combat scenarios, and simulations enabled comparison of STM to the widely known Simple Triage and Rapid Treatment (START) method. RPM was an accurate predictor of survival probability, equivalent to the Revised Trauma Score and exceeding the Injury Severity Score. In 18 simulations, STM and STM rule-based protocols increased survivorship over START from 20% to an 18-fold increase. STM offers lifesaving and operational advantages for military-age victims of blunt, penetrating, and blast overpressure-like trauma.

Blunt Cardiac Trauma: Lessons Learned From the Medical Examiner

The objective of this study was to analyze autopsy findings after blunt traumatic deaths to identify the incidence of cardiac injuries and describe the patterns of associated injuries. All autopsies performed by the Los Angeles County Forensic Medicine Division for blunt traumatic deaths in 2005 were retrospectively reviewed. Only cases that underwent a full autopsy including internal examination were included in the analysis. The study population was divided into two groups according to the presence or absence of a cardiac injury and compared for differences in baseline characteristics and types of associated injuries. Of the 881 fatal victims of blunt trauma received by the Los Angeles County Forensic Medicine Division, 304 (35%) underwent a full autopsy with internal examination and were included in the analysis. The mean age was 43 years +/- 21 years, patients were more often men (71%) and were intoxicated in 39% of the cases. The most common mechanism was motor vehicle collision (50%), followed by pedestrian struck by auto (37%), and 32% had a cardiac injury. Death at the scene was significantly more common in patients with a cardiac injury (78% vs. 65%, p = 0.02). The right chambers were the most frequently injured (30%, right atrium; 27%, right ventricle). Among the 96 patients with cardiac injuries, 64% had transmural rupture. Multiple chambers were ruptured in 26%, the right atrium in 25%, and the right ventricle in 20% of these patients. Patients with cardiac injuries were significantly more likely to have other associated injuries: thoracic aorta (47% vs. 27%, p = 0.001), hemothorax (81% vs. 59%, p < 0.001), rib fractures (91% vs. 71%, p < 0.001), sternum fracture (32% vs. 13%, p < 0.001), and intra-abdominal injury (77% vs. 48%, p < 0.001) compared with patients without cardiac injury. Of the 96 patients with a cardiac injury, 78% died at the scene of the crash and 22% died en route or at the hospital. Cardiac injury is a common autopsy finding after blunt traumatic fatalities, with the majority of deaths occurring at the scene. Patients with cardiac injuries are at significantly increased risk for associated thoracic and intra-abdominal injuries.

Western Trauma Association Critical Decisions in Trauma: Screening for and Treatment of Blunt Cerebrovascular Injuries

This is a recommended management algorithm from the Western Trauma Association addressing the diagnostic evaluation and management of blunt cerebrovascular injuries (BCVI) in adult patients. Because there are no published prospective randomized clinical trials that have generated class I data, the recommendations herein are based on published observational studies and expert opinion of Western Trauma Association members. The algorithm (Fig. 1) and accompanying comments represent a safe and sensible approach that could be followed at most trauma centers. We recognize that there will be patient, personnel, institutional, and situational factors that may warrant or require deviation from the recommended algorithm. We encourage institutions to use this guideline to formulate their own local protocols. The algorithm contains letters at decision points; the corresponding paragraphs in the text elaborate on the thought process and cite the pertinent literature. The annotated algorithm is intended to (a) serve as a quick bedside reference for clinicians; (b) foster more detailed patient care protocols that will allow for prospective data collection and analysis to identify best practices; and (c) generate research projects to answer specific questions concerning decision making in the management of adults with BCVI.

Is the Use of Pan-Computed Tomography for Blunt Trauma Justified? A Prospective Evaluation

Many trauma centers use the pan-computed tomography (CT) scan (head, neck, chest, and abdomen/pelvis) for the evaluation of blunt trauma. This prospective observational study was undertaken to determine whether a more selective approach could be justified. We evaluated injuries in blunt trauma victims receiving a pan-CT scan at a level I trauma center. The primary outcome was injury needing immediate intervention. Secondary outcome was any injury. The perceived need for each scan was independently recorded by the emergency medicine and trauma surgery service before patients went to CT. A scan was unsupported if at least one of the physicians deemed it unnecessary. Between July, 1, 2007, and December, 28, 2007, 284 blunt trauma patients (average Injury Severity Score = 11) underwent a pan-CT after the survey form was completed. A total of 311 CT scans were judged to be unnecessary in 143 patients (27%), including scans of the head (62), neck (50), chest (116), and abdomen/pelvis (83). Of the 284 patients, 48 (17%) had injuries on 52 unsupported CT scans. An immediate intervention was required in 2 of the 48 patients (4%). Injuries that would have been missed included 5 of 62 unsupported head scans (8%), 2 of 50 neck scans (4%), 33 of 116 chest scans (28%), and 12 of 83 abdominal scans (14%). These missed injuries represent 5 of the 61 patients with closed head injuries (8%) in the series, 2 of the 23 with C-spine injuries (9%), 33 of the 112 with chest injuries (29%), and 12 of the 86 with abdominal injuries (14%). In 19 patients, none of the four CT scans was supported; nine of these had an injury identified, and six were admitted to the hospital (1 to the intensive care unit). Injuries that would have been missed included intraventricular and intracerebral hemorrhage (4), subarachnoid hemorrhage (2), cerebral contusion (1), C1 fracture (1), spinous and transverse process fractures (3), vertebral fracture (6), lung lacerations (1), lung contusions (14), small pneumothoraces (7), grade II-III liver and splenic lacerations (6), and perinephric or mesenteric hematomas (2). In this small sample, physicians were willing to omit 27% of scans. If this was done, two injuries requiring immediate actions would have been missed initially, and other potentially important injuries would have been missed in 17% of patients.

Normal presenting vital signs are unreliable in geriatric blunt trauma victims

Heffernan, Daithi S. MD; Thakkar, Rajan MD; Ravindran, Radhika BA; Adams, Charles MD; Kozloff, Matthew MD; Gregg, Shea MD; Cioffi, William G. Jr MD, FACS Author Information

Ventilator-associated pneumonia in pediatric trauma patients

Ventilator-associated pneumonia (VAP) is a significant cause of secondary morbidity and mortality in adult trauma patients. No study has characterized VAP in pediatric trauma patients. We determined the rates of and potential risk factors for VAP in pediatric trauma patients. A countywide trauma registry identified all pediatric trauma patients with potential VAP treated at a Regional Trauma Center. After a structured chart review, descriptive statistics were used to characterize the population. One hundred fifty-eight trauma patients younger than 16 years requiring intubation and mechanical ventilation were identified in 3388 pediatric trauma admissions from the period 1995-2006. Drownings and poisonings were excluded. The registry identified 14 potential VAPs, of which, on detailed review, 7 were true cases. The VAP rate for pediatric trauma patients was 0.2% overall or 4.4% of those mechanically ventilated. In addition, ventilator days were available in the registry from 2003 forward and the rate in ventilator days was found to be 13.83/1000. Although higher than the overall pediatric intensive care unit VAP rate (5.93/1000 ventilator days), the pediatric trauma VAP rate was substantially lower than the VAP rate in adult trauma patients (58.25/1000 ventilator days). On chart review, six of the seven patients were male and older than 10 years (mean age, 11.9 years). All seven patients with VAP were blunt trauma victims with head injury (mean initial Glasgow Coma Score, 5.6) with Injury Severity Scores over 25 (mean, 32.1). Pulmonary contusion was present in four of the seven. Although the in-hospital mortality rate of ventilated pediatric trauma patients was 17.1%, there was no mortality in those with VAP. The rate of VAP in pediatric trauma patients is substantially lower than in similar adults. Age older than 10 years, blunt trauma, head injury, and Injury Severity Score >25 may be risk factors. VAP is not associated with increased mortality in pediatric trauma patients.

Geriatric Literature Review: Revisited

Geriatric Literature Review: Revisited

Protocol compliance and time management in blunt trauma resuscitation

To study advanced trauma life support (ATLS) protocol adherence prospectively in trauma resuscitation and to analyse time management of daily multidisciplinary trauma resuscitation at a level 1 trauma centre, for both moderately and severely injured patients. All victims of severe blunt trauma were consecutively included. Patients with a revised trauma score (RTS) of 12 were resuscitated by a "minor trauma" team and patients with an RTS of less than 12 were resuscitated by a "severe trauma" team. Digital video recordings were used to analyse protocol compliance and time management during initial assessment. From 1 May to 1 September 2003, 193 resuscitations were included. The "minor trauma" team assessed 119 patients, with a mean injury severity score (ISS) of 7 (range 1-45). Overall protocol compliance was 42%, ranging from 0% for thoracic percussion to 93% for thoracic auscultation. The median resuscitation time was 45.9 minutes (range 39.7-55.9). The "severe team" assessed 74 patients, with a mean ISS of 22 (range 1-59). Overall protocol compliance was 53%, ranging from 4% for thoracic percussion to 95% for thoracic auscultation. Resuscitation took 34.8 minutes median (range 21.6-44.1). Results showed the current trauma resuscitation to be ATLS-like, with sometimes very low protocol compliance rates. Timing of secondary survey and radiology and thus time efficiency remains a challenge in all trauma patients. To assess the effect of trauma resuscitation protocols on outcome, protocol adherence needs to be improved.

Injury to the Thoracic Aorta Following Fatal Blunt Trauma: An Autopsy Study.

Transection of the thoracic aorta (TTA) remains a leading cause of death after blunt trauma. In this autopsy study, the natural history of this injury is reviewed. All blunt trauma deaths that occurred in the Milano urban area over a period of one year were collected. Autopsies were available in all cases. Incidence, mechanisms, anatomical locations of TTA, deaths due to TTA or coexisting injuries, and times of death were reviewed. Cause of death was established. Death was attributed to TTA if its abbreviated injury score was six (hemorrhage not confined to the mediastinum). 199 cases of fatal blunt trauma were included, 72% of which were males; mean age 53 ± 21. A TTA was observed in 53 subjects (27%), with a significantly higher incidence between the ages of 45 and 64 years and after falls from height. The aorta was transected at the isthmus in 36% of cases. Victims with TTA had a higher pre-hospital mortality and more injuries to chest organs, the chest wall and pelvis. In victims with TTA, injury to the aorta was the cause of death in 58%. Only five patients with TTA survived more than 1 h, reaching the hospital alive; four of these died due to the rupture of a mediastinal hematoma during the first hours of in-hospital care. This study demonstrates that TTA is a frequent cause of immediate deaths among blunt trauma victims. Patients with risk factors for TTA who reach the hospital alive need to be promptly investigated with a contrast CT scan. Evidence of mediastinal hematoma is suggestive for possible rapid evolution.

A treatment protocol including vasopressin and hydroxyethyl starch solution is associated with increased rate of return of spontaneous circulation in blunt trauma patients with pulseless electrical activity

BackgroundSurvival after cardiopulmonary resuscitation (CPR) using standard vasopressor therapy is disappointing. Vasopressin is a potent vasopressor that could become a useful therapeutic alternative in the treatment of cardiac arrest.AimsThe aim of this prehospital prospective cohort study was to assess the influence of treatment with vasopressin and hydroxyethyl starch solution (HHS) on outcome in resuscitated blunt trauma patients with pulseless electrical activity (PEA) cardiac arrest.MethodsTwo treatment groups of resuscitated trauma patients in cardiac arrest were compared: in the epinephrine group patients received epinephrine 1 mg IV every 3 min only; in the vasopressin group patients first received hypertonic HHS and arginine vasopressin 40 units IV only or followed by epinephrine 1 mg every 3 min until cessation of CPR. Medical trauma care was provided according to advanced trauma life support (ATLS) guidelines.ResultsThe study included 31 patients and there were no significant demographic or clinical differences between the treatment groups. Significantly more circulatory restorations [11/13 (85%) vs 3/18 (17%); P < 0.01] and better 24-h survival rates [8/13 (62%) vs 2/18 (11%); P = 0.001] were observed in the vasopressin group. Average mean arterial pressure (100.4 ± 11.4 mmHg vs 80.3 ± 12.4 mmHg) and final end-tidal partial pressure of carbon dioxide (PETCO2) at admission (4.5 ± 0.9 kPa vs 2.8 ± 0.4 kPa) were also higher in the vasopressin group.ConclusionOur results suggest that victims of severe blunt trauma with PEA should be initially treated with vasopressin in combination with HHS volume resuscitation followed by standard resuscitation therapy and other procedures when appropriate. Vasopressin might be potentially lifesaving in blunt trauma cardiac arrest compared to standard treatment with epinephrine.

Is the Grading of Liver Injuries a Useful Clinical Tool in the Initial Management of Blunt Trauma Patients?

Computed tomography (CT) has become the preferred method for evaluation of the abdomen for victims of blunt trauma. Grading of liver injuries, primarily by CT, has been advocated as a measure of severity and, by implication, the likelihood for intervention or complications. We have sought to determine if grading of liver injuries, as a clinical tool, affects immediate or extended management of patients. We have retrospectively reviewed all patients sustaining blunt liver injuries as diagnosed by CT over a five-year period at a Level I trauma center to determine if grading of injury influenced management. The AAST organ scaling system was utilized (major grade 4-5, minor grade 1-3), as well as the ISS, AIS, mortality, morbidity, and treatment. There were 133 patients available for review. The patients were grouped into major (n = 20) and minor (n = 113) liver injuries and operative (n = 12) and nonoperative (n = 121) management. Major liver injuries had a higher ISS (39 + 13 vs. 27 + 15, p = 0.001) and were more likely to require operative intervention (5/20 vs. 7/113, p = 0.02). Mortality in this group was not different (major vs. minor), and there were no differences in the incidence of complications. Twelve patients (9%) required operation, all for hemodynamic instability, all within 24 h, and 11/12 within 6 h. At operation 8/12 patients had other sources of bleeding beside the liver injury, and 7/12 had minor hepatic injuries. The operative patients had higher ISS and AIS scores (head/neck, chest, abdomen, extremities) than those managed nonoperatively. More patients died in the operative group (6/12 vs. 8/121, p = 0.0003). There were more pulmonary (6/12 vs. 16/121, p = 0.005), cardiovascular (6/12 vs. 19/121, p = 0.01), and infectious (5/12 vs. 20/121, p = 0.049) complications in the operative group. There were 14 deaths overall; 13/14 were due to traumatic brain injury, and 8/14 required urgent operation for hemorrhage. In conclusion, grading of liver injuries does not seem to influence immediate management. Physiologic behavior dictated management and need for operative intervention, as well as prognosis. However, both major hepatic injuries and need for early operation reflected overall severity and the possibility of associated injuries.

Congenital Aberrant Vessel as a Source of Massive Hemothorax in Blunt Trauma

A congenital aberrant vessel in the pleural cavity has rarely been described in the literature. It has been known to be a source of bleeding in spontaneous hemopneumothorax. As a result of the lack of pleural adhesions around the vessel, a congenital aberrant vessel is prone to deceleration injury. This is a case of massive hemothorax caused by a ruptured aberrant congenital vessel in a blunt trauma victim who sustained a two meter fall.

Prehospital interventions: time wasted or time saved? An observational cohort study of management in initial trauma care

Objective:Preclinical actions in the primary assessment of victims of blunt trauma may prolong the time to definitive clinical care. The aim of this study was to examine the duration of...