Accuracy of Preoperative MDCT in Patients With Penetrating Abdominal and Pelvic Trauma

Purpose: This study aims to evaluate the overall diagnostic accuracy of preoperative multidetector computed tomography (MDCT) in penetrating abdominal and pelvic injuries (PAPI). Method and Materials: We used our hospitals’ trauma registry to retrospectively identify patients with PAPI from January 1, 2006, to December 31, 2016. Only patients who had a 64-MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in our study cohort. Each finding noted on MDCT was rated using a 5-point scale to indicate certainty of injury, with a score of 0 being definitive. Using surgical findings as the gold standard, the accuracy of radiology reports was analyzed in 2 ways. A κ statistic was calculated to evaluate each pair of values for absolute agreement, and ratings for all organ systems were analyzed using a repeated measures analysis of variance (ANOVA) to determine whether radiology and surgical findings were similar enough to be clinically meaningful. Qualitative review of the radiology and surgical reports focused on the gastrointestinal (GI) tract was conducted. Results: Our cohort consisted of 38 males and 4 females with a median age of 29 years and a median injury severity score of 15.6. For this study, 12 different organ groups were categorized and analyzed. Of those organ groups, absolute agreement between MDCT and surgical findings was found only for liver and spleen (κ values ranging from 0.2 to 0.5). Additionally, the ANOVA revealed an interaction between finding type and organ system ( F 1, 33 = 7.4, P < .001). The most clinically significant discrepancies between MDCT and surgical findings were for gallbladder, bowel, mesenteric, and diaphragmatic injuries. Qualitative review of the GI tract revealed that radiologists can detect significant findings such as presence of injury, however, localization and extent of injury pose a challenge. Conclusion: The detection of clinically significant injuries to solid organs in trauma patients with PAPI on 64-MDCT is adequate. However, detection of injury to the remaining organ groups on MDCT, especially bowel, mesentery, and diaphragm, remains a challenge.

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Are We Missing Traumatic Bowel and Mesenteric Injuries?

Canadian Association of Radiologists Journal ◽

10.1016/j.carj.2015.11.006 ◽

2016 ◽

Vol 67 (4) ◽

pp. 420-425 ◽

Cited By ~ 12

Author(s):

Bret A. Landry ◽

Michael N. Patlas ◽

Samir Faidi ◽

Angela Coates ◽

Savvas Nicolaou

Keyword(s):

Injury Severity ◽

Trauma Centre ◽

Preoperative Imaging ◽

Blunt Injury ◽

Study Cohort ◽

Trauma Patients ◽

Radiology Reports ◽

Bowel And Mesenteric Injury ◽

Ct Technology ◽

Imaging Signs

Purpose Traumatic bowel and mesenteric injury (TBMI), although an uncommon entity, can be lethal if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (MDCT) for the detection of TBMI in patients at our level 1 trauma centre. Methods We used our hospital's trauma registry to identify patients with a diagnosis of TBMI from January 1, 2006, to June 30, 2013. Only patients who had a 64-slice MDCT scan at presentation and subsequently underwent laparotomy or laparoscopy were included in the study cohort. Using the surgical findings as the gold standard, the accuracy of prospective radiology reports was analyzed. Results Of the 4781 trauma patients who presented to our institution, 44 (0.92%) had surgically proven TBMI. Twenty-two of 44 were excluded as they did not have MDCT before surgery. The study cohort consisted of 14 males and 8 females with a median age of 41.5 years and a median injury severity score of 27. In total 17 of 22 had blunt trauma and 5 of 22 had penetrating injury. A correct preoperative imaging diagnosis of TBMI was made in 14 of 22 of patients. The overall sensitivity of the radiology reports was 63.6% (95% confidence interval [CI]: 41%-82%), specificity was 79.6% (95% CI: 67%-89%), PPV was 53.9% (95% CI: 33%-73%), and the NPV was 85.5% (95% CI: 73%-94%). Accuracy was calculated at 75.3%. However, only 59% (10 of 17) of patients with blunt injury had a correct preoperative diagnosis. Review of the findings demonstrated that majority of patients with missed blunt TBMI (5 of 7) demonstrated only indirect signs of injury. Conclusion The detection of TBMI in trauma patients on 64-slice MDCT can be improved, especially in patients presenting with blunt injury. Missed cases in this population occurred because the possibility of TBMI was not considered despite the presence of indirect imaging signs. The prospective diagnosis of TBMI remains challenging despite advances in CT technology and widespread use of 64-slice MDCT.

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The self-assessment INTERMED predicts healthcare and social costs of orthopaedic trauma patients with persistent impairments

Clinical Rehabilitation ◽

10.1177/0269215520949170 ◽

2020 ◽

pp. 026921552094917

Author(s):

Cyrille Burrus ◽

Philippe Vuistiner ◽

Bertrand Léger ◽

Friedrich Stiefel ◽

Gilles Rivier ◽

...

Keyword(s):

Injury Severity ◽

Social Costs ◽

The Self ◽

Study Cohort ◽

Trauma Patients ◽

Orthopaedic Trauma ◽

Self Assessment ◽

Trauma Severity ◽

Education And Employment ◽

Fitness To Work

Objective: To use the self-assessment INTERMED questionnaire to determine the relationship between biopsychosocial complexity and healthcare and social costs of patients after orthopaedic trauma. Design: Secondary prospective analysis based on the validation study cohort of the self-assessment INTERMED questionnaire. Setting: Inpatients orthopaedic rehabilitation with vocational aspects. Subjects: In total, 136 patients with chronic pain and impairments were included in this study: mean (SD) age, 42.6 (10.7) years; 116 men, with moderate pain intensity (51/100); suffering from upper ( n = 55), lower-limb ( n = 51) or spine ( n = 30) pain after orthopaedic trauma; with minor or moderate injury severity (severe injury for 25). Main measures: Biopsychosocial complexity, assessed with the self-assessment INTERMED questionnaire, and other confounding variables collected prospectively during rehabilitation. Outcome measures (healthcare costs, loss of wage costs and time for fitness-to-work) were collected through insurance files after case settlements. Linear multiple regression models adjusted for age, gender, pain, trauma severity, education and employment contract were performed to measure the influence of biopsychosocial complexity on the three outcome variables. Results: High-cost patients were older (+3.6 years) and more anxious (9.0 vs 7.3 points at HADS-A), came later to rehabilitation (+105 days), and showed higher biopsychosocial complexity (+3.2 points). After adjustment, biopsychosocial complexity was significantly associated with healthcare (ß = 0.02; P = 0.003; expß = 1.02) and social costs (ß = 0.03; P = 0.006, expß = 1.03) and duration before fitness-to-work (ß = 0.04; P < 0.001, expß = 1.04). Conclusion: Biopsychosocial complexity assessed with the self-assessment INTERMED questionnaire is associated with higher healthcare and social costs.

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Application of a Geriatric Injury Protocol Demonstrates High Survival Rates for Geriatric Trauma Patients with High Injury Acuity

The American Surgeon ◽

10.1177/000313481708301022 ◽

2017 ◽

Vol 83 (10) ◽

pp. 1122-1126

Author(s):

Tigran Karamanukyan ◽

Andrea Pakula ◽

Maureen Martin ◽

Ashwitha Francis ◽

Ruby Skinner

Keyword(s):

Injury Severity ◽

Survival Rates ◽

Geriatric Trauma ◽

Study Cohort ◽

High Survival ◽

Trauma Patients ◽

Advanced Directives ◽

Severity Scores ◽

The Mean ◽

The Impact

Geriatric trauma has historically been associated with poor outcomes, particularly in the setting of severe polytrauma. Although geriatric trauma protocols are common, there are limited data on their impact in patients with high injury severity. In this study, we sought to investigate the impact of a geriatric injury protocol on outcomes in patients with severe trauma acuity. Ninety-eight geriatric patients (age ≥65) admitted to our trauma center with injury severity scores (ISS) ≥15 comprised the study cohort. The mean age was 75 ± 7.7 yrs. The mean ISS was 25 ± 9.2, and the mean geriatric trauma outcome score was 150 ± 3. Mortality was 17 per cent and 70 per cent were due to central nervous system injury. When patients with nonsurvivable injuries or advanced directives resulting in early care withdrawal were excluded, the mortality was 6 per cent. Extremes of age did not impact mortality [(>80 years, 21%) vs (65–79, 16%, P = 0.5)]. Most patients (53%) were discharged home. The application of our geriatric trauma protocol led to favorable results despite high injury acuity. These data suggest that even at the extremes of age, a large percentage of patients can be expected to survive. A prospective validation of these findings is warranted.

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Assessment of post-trauma complications in eight million trauma cases over a decade in the USA

Trauma Surgery & Acute Care Open ◽

10.1136/tsaco-2020-000667 ◽

2021 ◽

Vol 6 (1) ◽

pp. e000667

Author(s):

Rasmus Kirial Jakobsen ◽

Alexander Bonde ◽

Martin Sillesen

Keyword(s):

Multiple Regression ◽

Injury Severity ◽

Significant Risk ◽

Time Frame ◽

Trauma Patients ◽

Improvement Program ◽

Level Of Evidence ◽

Organ Systems ◽

The Usa ◽

Multiple Regression Modeling

BackgroundTrauma is associated with a significant risk of post-trauma complications (PTCs). These include thromboembolic events, strokes, infections, and failure of organ systems (eg, kidney failure). Although care of the trauma patient has evolved during the last decade, whether this has resulted in a reduction in specific PTCs is unknown. We hypothesize that the incidence of PTCs has been decreasing during a 10-year period from 2007 to 2017.MethodsThis is a descriptive study of trauma patients originating from level 1, 2, 3, and 4 trauma centers in the USA, obtained via the Trauma Quality Improvement Program (TQIP) database from 2007 to 2017. PTCs documented throughout the time frame were extracted along with demographic variables. Multiple regression modeling was used to associate admission year with PTCs, while controlling for age, gender, Glasgow Coma Scale score, and Injury Severity Score.ResultsData from 8 720 026 trauma patients were extracted from the TQIP database. A total of 366 768 patients experienced one or more PTCs. There was a general decrease in the incidence of PTCs during the study period, with the overall incidence dropping from 7.0% in 2007 to 2.8% in 2017. Multiple regression identified a slight decrease in incidence in all PTCs, although deep surgical site infection (SSI), deep venous thrombosis (DVT), and stroke incidences increased when controlled for confounders.DiscussionOverall the incidence of PTCs dropped during the 10-year study period, although deep SSI, DVT, stroke, and cardiac arrest increased during the study period. Better risk prediction tools, enabling a precision medicine approach, are warranted to identify at-risk patients.Level of evidenceIII.

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(A215) Delayed Diagnosis of Injury in Survivors of the February 2009 Crash of Flight TK 1951

Prehospital and Disaster Medicine ◽

10.1017/s1049023x11002056 ◽

2011 ◽

Vol 26 (S1) ◽

pp. s59-s60

Author(s):

I.L.E. Postma ◽

J. Winkelhagen ◽

T. Bijlsma ◽

F. Bloemers ◽

M. Heetveld ◽

...

Keyword(s):

Injury Severity ◽

Life Support ◽

Delayed Diagnosis ◽

Advanced Trauma Life Support ◽

Trauma Patients ◽

Emergency Intervention ◽

Plane Crash ◽

Tertiary Survey ◽

Clinically Significant ◽

The Uk

IntroductionIn 2009, a Boeing 737 crashed near Amsterdam, traumatically injuring 126 people. In trauma patients, some injuries initially escape detection. The aim of this study is to evaluate the incidence of Delayed Diagnosis of Injury (DDI) and the effects of tertiary survey on the victims of a plane crash.MethodsData collected included documentations of DDI, tertiary surveys, Injury Severity Scale (ISS) score, Glasgow Coma Scale score, number and type of injuries, and emergency intervention. Clinically significant injuries were separated from non-clinically significant injuries. Comparison was made to a crash in the UK (1989), before advanced trauma life support became practiced widely.ResultsAll 126 victims were evaluated in a hospital emergency department; 66 were admitted with a total of 171 clinically significant injuries. Twelve clinically significant DDIs were found in eight patients (12%). In 65%, a tertiary survey was documented. The DDI incidences differed for several risk factors. Eighty-one survivors of the UK crash had a total of 332 injuries. Of those with > 5 injuries, 5% had a DDI, versus 8% of those with ≤ 5 injuries.ConclusionsThe DDI incidence in this study was 7% of the injuries in 12% of the population. A tertiary survey was documented in 65%; ideally this should be 100%. In this study, a high ISS score, head injury, > 5 injuries, and emergency intervention were associated with DDI. The DDI incidence in the current study was lower than in the UK crash.

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Imaging of Traumatic Diaphragmatic Rupture: Evaluation of Diagnostic Accuracy at a Level 1 Trauma Centre

Canadian Association of Radiologists Journal ◽

10.1016/j.carj.2015.02.001 ◽

2015 ◽

Vol 66 (4) ◽

pp. 310-317 ◽

Cited By ~ 9

Author(s):

Vincent A. Leung ◽

Michael N. Patlas ◽

Susan Reid ◽

Angela Coates ◽

Savvas Nicolaou

Keyword(s):

Diagnostic Accuracy ◽

Predictive Value ◽

Trauma Centre ◽

Penetrating Injury ◽

Diaphragmatic Rupture ◽

Study Cohort ◽

Trauma Patients ◽

Traumatic Diaphragmatic Rupture ◽

Radiology Reports ◽

Level 1

PurposeTraumatic diaphragmatic rupture (TDR) is an uncommon injury that can be associated with significant morbidity if not detected and treated in a timely manner. The purpose of our study was to evaluate the diagnostic accuracy of 64-slice multidetector computed tomography (64-MDCT) for the detection of TDR in patients at our level 1 trauma centre.MethodsWe used our hospital's trauma registry to identify patients with a diagnosis of TDR from January 1, 2008, to December 31, 2012. Only patients with a 64-MDCT scan at presentation who subsequently underwent laparotomy/laparoscopy were included in the study cohort. Using surgical findings as the gold standard, the accuracy of the prospective radiology reports was analyzed.ResultsOf the 3225 trauma patients who presented to our institution, 38 (1.2%) had a TDR. Fourteen of the 38 were excluded as they did not have MDCT before surgery. The study cohort consisted of 20 males and 4 females with a median age of 34.5 years and a median Injury Severity Score (ISS90) of 26. Fifteen had blunt trauma while 9 had a penetrating injury. The overall sensitivity of the radiology reports was 66.7% (95% confidence interval [CI]: 46.7%-82.0%), specificity was 100% (95% CI: 94.1%-100%), positive predictive value was 100% (95% CI: 80.6%-100%), negative predictive value was 88.4% (95% CI: 78.8%-94.0%), and accuracy was 90.6% (95% CI: 82.5%-95.2%). However, only 3 of 9 patients with penetrating injury had a correct preoperative diagnosis. Two of the 6 missed penetrating trauma cases had only indirect signs of injury.ConclusionsThe detection of TDR in trauma patients on 64-MDCT can be improved, especially in patients presenting with penetrating injury. A careful search for subtle diaphragmatic defects and indirect evidence of injury is important to avoid missing the diagnosis.

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Relationship between the Injury Severity Score and the need for life-saving interventions in trauma patients in the UK

Emergency Medicine Journal ◽

10.1136/emermed-2019-209092 ◽

2020 ◽

pp. emermed-2019-209092

Author(s):

James Vassallo ◽

Gordon Fuller ◽

Jason E Smith

Keyword(s):

Injury Severity Score ◽

Severity Score ◽

Major Trauma ◽

Injury Severity ◽

Research Network ◽

Trauma Patients ◽

Traditional Definition ◽

Life Saving ◽

Clinically Significant ◽

The Uk

IntroductionMajor trauma is the third leading cause of avoidable mortality in the UK. Defining which patients require care in a major trauma centre is a critical component of developing, evaluating and enhancing regional major trauma systems. Traditionally, trauma patients have been classified using the Injury Severity Score (ISS), but resource-based criteria have been proposed as an alternative. The aim of this study was to investigate the relationship between ISS and the use of life-saving interventions (LSI).MethodsRetrospective cohort study using the Trauma Audit Research Network database for all adult patients (aged ≥18 years) between 2006 and 2014. Patients were categorised as needing an LSI if they received one or more interventions from a previously defined list determined by expert consensus.Results193 290 patients met study inclusion criteria: 56.9% male, median age 60.0 years (IQR 41.2–78.8) and median ISS 9 (IQR 9–16). The most common mechanism of injury was falls <2 m (52.1%), followed by road traffic collisions (22.2%). 15.1% received one or more LSIs. The probability of a receiving an LSI increased with increasing ISS, but only a low to moderate correlation was evident (0.334, p<0.001). A clinically significant number of cases (5.3% and 7.6%) received an LSI despite having an ISS ≤8 or <15, respectively.ConclusionsA clinically significant number of adult trauma patients requiring LSIs have an ISS below the traditional definition of major trauma. The traditional definition should be reconsidered and either lowered, or an alternative metric should be used.

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What's in the Box? the Effectiveness of a Low-Volume Massive Transfusion Protocol

The American Surgeon ◽

10.1177/000313481608200725 ◽

2016 ◽

Vol 82 (7) ◽

pp. 602-607 ◽

Cited By ~ 1

Author(s):

Katherine Baysinger ◽

Merry E. Barnett ◽

Mickey Ott ◽

William Bromberg ◽

Katherine McBride ◽

...

Keyword(s):

Trauma Patient ◽

Injury Severity ◽

Massive Transfusion ◽

Vital Signs ◽

Study Cohort ◽

Trauma Patients ◽

Packed Red Blood Cells ◽

Massive Transfusion Protocol ◽

Significant Difference ◽

Transfusion Protocol

Transfusion ratios approaching 1:1:1 of packed red blood cells (PRBCs) to fresh frozen plasma (FFP) to platelet have been shown to improve outcomes in trauma. There is little data available to describe in what quantity that ratio should be delivered. We hypothesized that lowering the total volume of products delivered in each protocol round would not adversely affect outcomes in the bleeding trauma patient. A retrospective review of 9732 trauma patients admitted to a rural Level I trauma center over a 3-year period was performed. Patients who received a massive transfusion (greater than 10 units of blood product transfused in the first 24 hours), between January 2012 and April 2015 were identified as the study cohort. In May of 2014, our institution switched from a massive transfusion protocol (MTP) that included 6 PRBCs:6 FFP:1 platelet to a lower volume massive transfusion protocol (LVMTP) that included 4 PRBG4 FFP:1 platelet. Data collected included patient demographics, vital signs, and outcomes. A total of 131 patients met study criteria. MTP was activated on 65 per cent of patients (57/88), receiving a massive transfusion during the 28 months before implementation of the new protocol. In contrast, LVMTP was activated in 100 per cent of patients (43/43) receiving a massive transfusion in the 12 months after implementation of the new protocol. There was no significant difference in age (36.6 vs 37.2, P = 0.87), injury severity score (29.8 vs 32.3, P = 0.45), or per cent penetrating mechanism (43.9 vs 37.2%, P = 0.503) when comparing MTP to LVMTP. In addition, there was no significant difference in mortality (47.4 vs 41.9%, P = 0.584), lengths of stay (13.5 vs 17.1, P = 0.258), or vent days (6.4 vs 8.2, P = 0.236) when comparing MTP to LVMTP. A LVMTP is safe and effective for the resuscitation of the trauma patient.

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The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury

The American Surgeon ◽

10.1177/000313481808401143 ◽

2018 ◽

Vol 84 (11) ◽

pp. 1825-1831 ◽

Cited By ~ 1

Author(s):

Andrew L. Plaster ◽

Mark E. Hamill ◽

Daniel I. Lollar ◽

Katie M. Love ◽

Emily R. Faulks ◽

...

Keyword(s):

Chart Review ◽

Injury Severity ◽

Treatment Plan ◽

Ct Imaging ◽

Trauma Patients ◽

Before And After ◽

Additional Imaging ◽

Level I ◽

Clinically Significant ◽

Trauma Surgeons

Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.

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Famotidine Use and Thrombocytopenia in the Trauma Patient

The American Surgeon ◽

10.1177/000313481107701225 ◽

2011 ◽

Vol 77 (12) ◽

pp. 1580-1583

Author(s):

John M. Compoginis ◽

Donald Gaspard ◽

Amal Obaid

Keyword(s):

Trauma Patient ◽

Retrospective Cohort ◽

Injury Severity ◽

Trauma Patients ◽

Similar Group ◽

Platelet Counts ◽

Severity Scores ◽

Clinically Significant ◽

Ulcer Prophylaxis ◽

Alternative Medications

The purpose of this study was to assess the incidence and clinical significance of famotidine-associated thrombocytopenia in the trauma patient population. A retrospective cohort study was performed between January 2003 and May 2009 comparing the consecutive platelet counts of trauma patients treated with intravenous famotidine with a similar group of trauma patients who were not. Patients were excluded if: 1) daily platelets counts for 48 hours were not drawn; 2) if platelet counts were less than 150 X 103/μL on admission or before initiation of famotidine treatment; 3) if patients received heparin or enoxaparin before or during the study period; and 4) if patients were taking famotidine before admission. Platelet counts were then recorded for the day of admission, the day famotidine was started if not on admission, and 24 hours and 48 hours during treatment. Seventy-two of 181 (39.8%) patients treated with famotidine developed thrombocytopenia compared with 23 of 126 (18.3%) untreated patients ( P < 0.001). Patients who developed thrombocytopenia were also more likely to have a longer length of stay and higher Injury Severity Scores. Intravenous famotidine therapy was the only variable found to be statistically significant after both univariate and multivariate analysis ( P < 0.001 and P = 0.003, respectively). Thrombocytopenia became clinically significant in eight of 181 (4.4%) famotidine-treated patients or 11.1 per cent of those who developed thrombocytopenia. Given these findings, we recommend the use of alternative medications for peptic ulcer prophylaxis in the critically ill trauma patient, especially those who are coagulopathic.

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