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Study objective: We evaluated the importance of microscopic and gross hematuria and the role of retrograde cystography and computed tomography (CT) in the diagnosis of blunt traumatic bladder rupture. Design: All cases at a Level I trauma center between January 1, 1986, and March 31, 1989, were reviewed retrospectively. Setting: Level I trauma center, university hospital. Type of participants: All patients with acute blunt abdominal trauma admitted to this Level I trauma center. Interventions: The patients' charts were reviewed with emphasis on mode of diagnosis, treatment, and outcome. Measurements and main results: Twenty-one patients had bladder rupture. All 21 had hematuria with more than 50 RBCs/high-power field, 17 gross and four microscopic. Twenty patients underwent retrograde cystography, which accurately identified bladder rupture, and one was found at laparotomy for other injuries. Seven patients had CT of the abdomen and pelvis, which failed to demonstrate bladder rupture. There were no associated urethral injuries in any of the patients with bladder rupture. Conclusion: Significant (more than 50 RBCs/high-power field) hematuria is the principal indication for evaluation for blunt bladder injury, and retrograde cystography is the diagnostic procedure of choice. CT is neither sensitive nor specific enough as primary diagnostic modality.

Study objective: To determine indications for thoracolumbar radiography. Design: Case series with prospective data collection. Setting: Level I trauma center. Participants: Blunt-trauma victims more than 12 years old who underwent routine thoracic and lumbar radigraphy according to institutional protocol. Patients were classified as group 1, not able to be evaluated clinically (Glasgow Coma Scale score of less than 13, intoxication, intubation, or cervical neurologic deficit); and group 2, able to be evaluated clinically. Results: Twenty-four of 319 patients sustained 25 thoracic or lumbar fractures. Seven of 136 group 1 patients and 17 of 183 group 2 patients had fractures. Eight of 17 patients with pain and 9 of 17 with tenderness had fractures ( P =.001). No group 2 patients without pain, tenderness, thoracic or lumbar neurodeficit, or major distracting injury, including cervical fracture, had fractures. The negative predictive value of pain and tenderness was 95%. Five of 46 patients with spinal fractures at any level had multiple fractures. Conclusion: Blunt-trauma victims who cannot be evaluated clinically should undergo thoracolumbar radiography. Routine radiography may be unnecessary in asymptomatic patients who can be evaluated clinically and who do not have neurologic deficits or distracting injuries. Spinal fracture at any level mandates complete spinal radiography. [Terregino CA, Ross SE, Lipinski MF, Foreman J, Hughes R: Selective indications for thoracic and lumbar radiography in blunt trauma. Ann Emerg Med August 1995;26:126-129.]

Objective: To compare relative costs of treating mildly head-injured patients by routine admission or by using skull radiographs or cranial computed tomography (CT) scanning to screen patients for admission. Design: Retrospective record review, hypothetical costs based on actual patient course and requirements. Setting: Southern New Jersey Regional trauma Center at Cooper Hospital/University Medical Center. Participants: 658 consecutive mildly head-injured patients admitted from 1986 to 1988. All were given cranial CT scans. Measurements: Records were reviewed retrospectively and hypothetical costs were calculated based on actual length of hospitalization, surgical intervention, etc. These costs were compared for different treatment protocols. Main results: The average cost if every patient had been admitted for observation given skull radiographs, with CT scans done on those exhibiting skull fracture or later deterioration, was $1,207, If the CT scan had been used to identify patients with intracranial lesions and the others had been discharged, costs would have been almost 10% less. Had skull radiography been used to screen admissions, costs would have been 22% below those of routine CT scanning. However, these small savings are likely to be reduced by additional expenses related to missed intracranial lesions. Conclusions: Every patient with loss of consciousness or post-traumatic amnesia should have routine CT scanning. If the scan is normal and there are no other reasons for admission, the patients can be discharged safely from the emergency department. This represents optimal care from a medical standpoint and is justified from a cost-effectiveness point of view.

Study objective: To investigate the necessity of intensive evaluation of the intoxicated patient with normal mentation for intra-abdominal injury after blunt torso trauma. Design: Retrospective study; trauma registry and medical records. Setting: Level I regional trauma center serving a population of 2.3 million. Participants: Adult victims of blunt trauma more than 17 years old, admitted between January 1, 1986, and December 31, 1989, with suspected blunt abdominal injury and serum ethanol of more than 100 mg/dL and Glasgow Coma Score of 15. Intervention: All patients had serum ethanol levels measured in mg/dL and computed tomography (CT) scan of the abdomen and/or diagnostic peritoneal lavage (DPL). Results: Criteria were met by 92 patients. Eighty-nine underwent CT scans, two had DPL, and one had both. Of 17 patients complaining of abdominal pain and/or tenderness on palpation, six (35.3%) had blood in the peritoneal cavity demonstrated by CT scan or DPL and underwent celiotomy All 75 patients without abdominal pain or tenderness had negative CT scan or DPL, with no missed injury. Conclusion: In the intoxicated blunt trauma patient with normal mentation, the physical examination is a reliable indicator of abdominal injury. Elevated alcohol level; per se , should not be considered an absolute indication for DPL or abdominal CT.

To evaluate the hypothesis that all victims of severe blunt trauma require a pelvic radiograph, we prospectively studied all such patients admitted to the Southern New Jersey Regional Trauma Center during a seven-month period. All patients were classified as unconscious; impaired; awake, alert, and symptomatic; or alert, oriented, and asymptomatic for pelvic fracture on admission. All underwent a plain anterior-posterior radiograph of the pelvis. A total of 265 patients were studied and 26 pelvic fractures were identified. These occurred in seven of 36 unconscious patients, 11 of 96 impaired patients, and eight of 23 symptomatic patients. No fractures were identified in 110 awake, alert, oriented, and asymptomatic patients (P less than .0001). We conclude that pelvic radiographs are required in unconscious or impaired victims of severe blunt trauma and those with signs or symptoms of pelvic fractures but are not required in the awake, alert, and asymptomatic patient.

Unstable injury of the cervical spine must be considered in all victims of blunt trauma. To evaluate the role of limited, directed computed tomography (CT) in the initial evaluation of the cervical spine, a one-year study involving 104 high-risk patients was undertaken. Sensitivity was 0.78 overall, but in the group of patients scanned after inadequate plain radiographs, CT had a sensitivity of 1.0 for unstable cervical injury. All false-negative studies involved atlantoaxial rotary subluxation. We conclude that limited, directed CT of the cervical spine is appropriate in the initial evaluation of patients at risk, particularly if plain radiographs are inadequate, but is of limited value in the evaluation of ligamentous injury of the upper cervical spine.