Unstable Without a Source: The Non-Diagnostic Triad in Hypotensive Blunt Trauma Victims

Background: Current algorithms for resuscitation in blunt trauma patients rely on chest x-ray, FAST, and pelvic x-ray to quickly elicit a source of major bleeding in the trauma bay. There are currently no good recommendations for the patient in whom all three of these imaging studies are negative. Methods: We identified blunt trauma victims who presented with a systolic blood pressure below 100mmHg. Chest x-ray, FAST, and pelvic x-ray obtained in the trauma bay were reviewed, and patients who had all three studies negative underwent thorough chart review and characterization of injuries. Results: Of the total hypotensive blunt trauma victims (n=649), we found 47 who had a “non-diagnostic triad” (NDT). Of the NDT group, 31.9% (n=15) were found to have a major injury contributing to hypotension, while 61% (n=29) were not diagnosed with a severe injury that could have contributed to hypotension. Of the NDT group with severe injury, 40% (n=6) were found to have retroperitoneal bleeding, 40% (n=6) were found to have intraperitoneal bleeding despite negative fast, 13% (n=2) were thought to have spinal shock, and one patient had a blunt cardiac injury. Conclusions: Most of the NDT group patients in this study were not diagnosed with a serious injury. However, a significant minority (31%) were found to have a major injury contributing to hypotension. Of these patients, retroperitoneal and/or intra-abdominal bleeding were found in 80%, with neurogenic and cardiogenic shock less common. We feel these sicker NDT patients may benefit from REBOA, although more study is warranted before formal algorithms and recommendations are made.

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

World Journal of Emergency Surgery ◽

10.1186/s13017-019-0287-5 ◽

2020 ◽

Vol 15 (1) ◽

Author(s):

Gregory J. Roberts ◽

Lewis E. Jacobson ◽

Michelle M. Amaral ◽

Courtney D. Jensen ◽

Louis Cooke ◽

...

Keyword(s):

Blunt Trauma ◽

Chest Ct ◽

Physical Exam ◽

Trauma Patients ◽

Cross Sectional ◽

X Ray ◽

Cross Sectional Imaging ◽

Normal Chest ◽

Chest X Ray ◽

Sectional Imaging

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

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Optimizing Chest X-ray Indication in Blunt Trauma Patients using Clinical Criteria

Panamerican Journal of Trauma, Critical Care & Emergency Surgery ◽

10.5005/jp-journals-10030-1169 ◽

2017 ◽

Vol 6 (1) ◽

pp. 30-34

Author(s):

Luca GA Pivetta ◽

Cristiano Below ◽

Giovanna Z Rondini ◽

Jacqueline AG Perlingero ◽

José C Assef ◽

...

Keyword(s):

Blunt Trauma ◽

Thoracic Injury ◽

Trauma Patients ◽

X Rays ◽

Chest Drainage ◽

X Ray ◽

Clinical Criteria ◽

Chest X Ray ◽

Low Probability ◽

Excessive Number

ABSTRACT Background There is an excessive number of unnecessary chest X-rays (CXRs) in minor blunt trauma patients. Objective To identify, using routine clinical criteria, a subgroup of blunt trauma patients that do not require CXR for assessment. Materials and methods This was a retrospective analysis of trauma registry data collected over a 24-month period. Adult blunt trauma patients undergoing CXR on admission were analyzed. The following clinical criteria were assessed: Normal neurologic examination on admission (NNEx), hemodynamic stability (HS), normal physical examination of the chest on admission (NCEx), age ≤ 60 years, and absence of distracting injuries (Abbreviated Injury Scale >2 in head, abdomen, and extremities). These clinical criteria were progressively merged to select a group with lowest risk of exhibiting abnormal CXR on admission. Results Out of 4,647 patients submitted to CXR on admission, 268 (5.7%) had abnormal findings on scans. Of 2,897 patients admitted with NNEx, 116 (4.0%) had abnormal CXR. Of 2,426 patients with NNEx and HS, 74 (3.0%) had abnormal CXR. Of 1,698 patients with NNEx, HS, and NCEx, 24 (1.4%) had abnormal CXR. Of 1,347 patients with NNEx, HS, NCEx, and age < 60 years, 12 had thoracic injury (0.9% of total individuals receiving CXR). A total of 4 patients underwent chest drainage. Among 1,140 cases with all clinical criteria, 8 had confirmed thoracic injuries and 2 underwent chest drainage. Conclusion A subgroup of blunt trauma patients with low probability of exhibiting abnormalities on CXR at admission was identified. The need for CXR in this subgroup should be reviewed. How to cite this article Pivetta LGA, Parreira JG, Below C, Rondini GZ, Perlingero JAG, Assef JC. Optimizing Chest X-ray Indication in Blunt Trauma Patients using Clinical Criteria. Panam J Trauma Crit Care Emerg Surg 2017;6(1):30-34.

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Young and Aged Blunt Trauma Patients Display Major Differences in Circulating Inflammatory Mediator Profiles after Severe Injury

Journal of the American College of Surgeons ◽

10.1016/j.jamcollsurg.2018.10.019 ◽

2019 ◽

Vol 228 (2) ◽

pp. 148-160.e7 ◽

Cited By ~ 12

Author(s):

Ashley J. Lamparello ◽

Rami A. Namas ◽

Othman Abdul-Malak ◽

Yoram Vodovotz ◽

Timothy R. Billiar

Keyword(s):

Blunt Trauma ◽

Inflammatory Mediator ◽

Severe Injury ◽

Trauma Patients

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08. Missed Diagnosis of Pneumothorax During Aeromedical Transport

Prehospital and Disaster Medicine ◽

10.1017/s1049023x00045829 ◽

1996 ◽

Vol 11 (S2) ◽

pp. S38-S38

Author(s):

SH Thomas ◽

P DeVellis ◽

T Harrison ◽

SK Wedel

Keyword(s):

Trauma Center ◽

Air Transport ◽

Trauma Patients ◽

X Ray ◽

Chest X Ray ◽

Missed Diagnosis ◽

Level I ◽

Aeromedical Transport ◽

One Year ◽

Needle Decompression

Purpose: Difficulties with physical assessment inherent to the helicopter environment have led to suggestion that aeromedical crews may be unable to identify hemo- or pneumothorax (HTX/PTX) while in-flight. This study was conducted to determine the frequency of missed HTX/PTX in trauma patients undergoing air transport.Methods: One year (1994) of an air medical service's trauma transports to a Level I trauma center were analyzed to identify patients undergoing tube thoracostomy (TT) within 2 hours of trauma center arrival. Patients who had received intra-transport needle thoracostomy were excluded. Records were reviewed to determine how HTX/PTX was diagnosed at the trauma center.Results: Only 11 patients who had not received aeromedical needle decompression underwent TT at the receiving center. Two of the 11 were trauma arrests and received TT as part of thoracotomy, without air or blood return on TT. None of the remaining 9 patients had TT on clinical suspicion alone. Four had normal physical examination and underwent TT after chest X-ray (CXR). Remaining patients had no HTX/PTX clues on exam or CXR; one had a small HTX identified on chest computed tomography and the other four received intra-operative TT because of rib fractures in the setting of multisystem trauma.

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Ultrasound Detection of Pneumothorax Compared with Chest X-Ray and Computed Tomography Scan

The American Surgeon ◽

10.1177/000313481107700427 ◽

2011 ◽

Vol 77 (4) ◽

pp. 480-483 ◽

Cited By ~ 29

Author(s):

Khanjan Nagarsheth ◽

Stanley Kurek

Keyword(s):

Ct Scan ◽

Negative Predictive Value ◽

Predictive Value ◽

Chest Ct ◽

Trauma Patients ◽

X Rays ◽

Thoracic Ultrasound ◽

X Ray ◽

Chest X Ray ◽

Chest Ct Scan

Pneumothorax after trauma can be a life threatening injury and its care requires expeditious and accurate diagnosis and possible intervention. We performed a prospective, single blinded study with convenience sampling at a Level I trauma center comparing thoracic ultrasound with chest X-ray and CT scan in the detection of traumatic pneumothorax. Trauma patients that received a thoracic ultrasound, chest X-ray, and chest CT scan were included in the study. The chest X-rays were read by a radiologist who was blinded to the thoracic ultrasound results. Then both were compared with CT scan results. One hundred and twenty-five patients had a thoracic ultrasound performed in the 24-month period. Forty-six patients were excluded from the study due to lack of either a chest X-ray or chest CT scan. Of the remaining 79 patients there were 22 positive pneumothorax found by CT and of those 18 (82%) were found on ultrasound and 7 (32%) were found on chest X-ray. The sensitivity of thoracic ultrasound was found to be 81.8 per cent and the specificity was found to be 100 per cent. The sensitivity of chest X-ray was found to be 31.8 per cent and again the specificity was found to be 100 per cent. The negative predictive value of thoracic ultrasound for pneumothorax was 0.934 and the negative predictive value for chest X-ray for pneumothorax was found to be 0.792. We advocate the use of chest ultrasound for detection of pneumothorax in trauma patients.

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Factors Associated with Chest Tube Placement in Blunt Trauma Patients with an Occult Pneumothorax

Critical Care Research and Practice ◽

10.1155/2019/9274697 ◽

2019 ◽

Vol 2019 ◽

pp. 1-6

Author(s):

Michael Paplawski ◽

Swapna Munnangi ◽

Jody C. Digiacomo ◽

Edwin Gonzalez ◽

Ashley Modica ◽

...

Keyword(s):

Blunt Trauma ◽

Chest Tube ◽

Rib Fractures ◽

Tube Placement ◽

Chest Tubes ◽

Chest Tube Placement ◽

X Ray ◽

Factors Associated ◽

Occult Pneumothorax ◽

Chest X Ray

Background. An occult pneumothorax is identified by computed tomography but not visualized by a plain film chest X-ray. The optimal management remains unclear. Methods. A retrospective review of an urban level I trauma center’s trauma registry was conducted to identify patients with occult pneumothorax over a 2-year period. Factors predictive of chest tube placement were identified using univariate and multivariate logistic regression analysis. Results. A total of 131 patients were identified, of whom 100 were managed expectantly with an initial period of observation. Ultimately, 42 (32.0%) patients received chest tubes and 89 did not. The patients who received chest tubes had larger pneumothoraces at initial assessment, a higher incidence of rib fractures, and an increased average number of rib fractures, of which significantly more were displaced. Conclusions. Displaced rib fractures and moderate-sized pneumothoraces are significant factors associated with chest tube placement in a victim of blunt trauma with occult pneumothorax. The optimal timing for the first follow-up chest X-ray remains unclear.

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eFAST for Pneumothorax: Real-Life Application in an Urban Level 1 Center by Trauma Team Members

The American Surgeon ◽

10.1177/000313481808400228 ◽

2018 ◽

Vol 84 (2) ◽

pp. 220-224 ◽

Cited By ~ 3

Author(s):

Steven Maximus ◽

Cesar Figueroa ◽

Matthew Whealon ◽

Jacqueline Pham ◽

Eric Kuncir ◽

...

Keyword(s):

Real Life ◽

Standard Of Care ◽

Trauma Team ◽

Tube Thoracostomy ◽

Trauma Patients ◽

Team Members ◽

X Ray ◽

Chest X Ray ◽

Level 1 ◽

Clinically Significant

The focused assessment with sonography for trauma (FAST) examination has become the standard of care for rapid evaluation of trauma patients. Extended FAST (eFAST) is the use of ultra-sonography for the detection of pneumothorax (PTX). The exact sensitivity and specificity of eFAST detecting traumatic PTX during practical “real-life” application is yet to be investigated. This is a retrospective review of all trauma patients with a diagnosis of PTX, who were treated at a large level 1 urban trauma center from March 2013 through July 2014. Charts were reviewed for results of imaging, which included eFAST, chest X-ray, and CT scan. The requirement of tube thoracostomy and mechanism of injury were also analyzed. A total of 369 patients with a diagnosis of PTX were identified. A total of 69 patients were excluded, as eFASTwas either not performed or not documented, leaving 300 patients identified with PTX. A total of 113 patients had clinically significant PTX (37.6%), requiring immediate tube thoracostomy placement. eFAST yielded a positive diagnosis of PTX in 19 patients (16.8%), and all were clinically significant, requiring tube thoracostomy. Chest X-ray detected clinically significant PTX in 105 patients (92.9%). The literature on the utility of eFAST for PTX in trauma is variable. Our data show that although specific for clinically significant traumatic PTX, it has poor sensitivity when performed by clinicians with variable levels of ultrasound training. We conclude that CT is still the gold standard in detecting PTX, and clinicians performing eFAST should have adequate training.

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