Search

Abstract: Introduction: Total-body Computed Tomography (CT) scans are increasingly used in trauma care. Herewith the observation of incidental findings, trauma unrelated findings, is also increased. The aim of this study was to evaluate the number of incidental findings in adult trauma patients. Patients and methods: All consecutive trauma patients that underwent total-body CT scanning between January 2009 and December 2011 were analysed. Incidental findings were divided in three categories: category I (potentially severe condition, further diagnostic work-up is required), category II (diagnostic work-up dependent on patients’ symptoms) and category III (findings of minor concern, no diagnostic work-up required). Results: There were 2248 trauma room presentations; 321 patients underwent a total-body CT scan (14.3%). In 143 patients (44.5%), 186 incidental findings were reported. There were 13 category I findings (7.0%), 45 category II findings (24.2%) and 128 category III incidental findings (68.8%). Overall, 18 patients (5.6%) required additional diagnostic work-up. Four patients underwent work-up by additional radiologic imaging. Three patients required further invasive work-up or treatment. Three patients were transferred to another hospital, no extended follow-up was performed. In three patients, there was no documentation of follow-up. Five patients deceased before diagnostic work-up of the incidental finding could start. Conclusion: Total-body CT scanning as part of the evaluation of trauma patients leads to a substantial amount of incidental findings. Documentation of incidental findings and their clinical consequences was incomplete. Therefore, the findings of this study have prompted us to add an item to our electronic trauma room report that obliges residents to report whether or not incidental findings are found during trauma imaging. [Copyright &y& Elsevier]

Abstract: Introduction: Despite the presence of diagnostic guidelines for the initial evaluation in trauma, the reported incidence of missed injuries is considerable. The aim of this study was to assess the missed injuries in a large cohort of trauma patients originating from two European Level-1 trauma centres. Methods: We analysed the 1124 patients included in the randomised REACT trial. Missed injuries were defined as injuries not diagnosed or suspected during initial clinical and radiological evaluation in the trauma room. We assessed the frequency, type, consequences and the phase in which the missed injuries were diagnosed and used univariate analysis to identify potential contributing factors. Results: Eight hundred and three patients were male, median age was 38 years and 1079 patients sustained blunt trauma. Overall, 122 injuries were missed in 92 patients (8.2%). Most injuries concerned the extremities. Sixteen injuries had an AIS grade of ≥3. Patients with missed injuries had significantly higher injury severity scores (ISSs) (median of 15 versus 5, p <0.001). Factors associated with missed injuries were severe traumatic brain injury (GCS≤8) and multitrauma (ISS≥16). Seventy-two missed injuries remained undetected during tertiary survey (59%). In total, 31 operations were required for 26 initially missed injuries. Conclusion: Despite guidelines to avoid missed injuries, this problem is hard to prevent, especially in the severely injured. The present study showed that the rate of missed injuries was comparable with the literature and their consequences not severe. A high index of suspicion remains warranted, especially in multitrauma patients. [Copyright &y& Elsevier]

Abstract: Background: Monitoring the quality of trauma care is frequently done by analysing the preventability of trauma deaths and errors during trauma care. In the Academic Medical Center trauma deaths are discussed during a monthly Morbidity and Mortality meeting. In this study an external multidisciplinary panel assessed the trauma deaths and errors in management of a Dutch Level-1 trauma centre for (potential) preventability. Methods: All patients who died during or after presentation in the trauma resuscitation room in a 2-year period were eligible for review. All information on trauma evaluation and management was summarised by an independent research fellow. An external multidisciplinary panel individually evaluated the cases for preventability of death. Potential errors or mismanagements during the admission were classified for type, phase and domain. Overall agreement on (potential) preventability was compared between the external panel and the internal M&M consensus. Results: Of the 62 evaluated trauma deaths one was judged as preventable and 17 were judged as potentially preventable by the review panel. Overall agreement on preventability between the review panel and the internal consensus was moderate (Kappa 0.51). The external panel judged one death as preventable compared with three from the internal consensus. The interobserver agreement between the external panel members was also moderate (Kappa 0.43). The panel judged 31 errors to have occurred in the (potential) preventable death group and 23 errors in the non-preventable death group. Such errors included choice or sequence of diagnostics, rewarming of hypothermic patients, and correction of coagulopathies. Conclusions: The preventable death rate in the present study was comparable to data in the available literature. Compared to internal review, the external, multidisciplinary review did not find a higher preventable death rate, although it provided several insights to optimise trauma care. [Copyright &y& Elsevier]

Abstract: [-] Patients with a (potential) cervical spine injury can be subdivided into low-risk and high-risk patients. [-] With a detailed history and physical examination the cervical spine of patients in the ‘low-risk’ group can be ‘cleared’ without further radiographic examinations. [-] X-ray imaging (3-view series) is currently the primary choice of imaging for patients in the ‘low-risk’ group with a suspected cervical spine injury after blunt trauma. [-] For patients in the ‘high-risk’ group because of its higher sensitivity a computed tomography scan is primarily advised or, alternatively, the cervical spine is immobilised until the patient can be reliably questioned and examined again. [-] For the imaging of traumatic soft tissue injuries of the cervical spine magnetic resonance imaging is the technique of choice. [Copyright &y& Elsevier]

Introduction: Evaluation of immediate total-body CT (iTBCT) scouts during primary trauma care could be clinically relevant for early detection and treatment of specific major injuries. The aim of this study was to determine the diagnostic usefulness of TBCT scouts in detecting life-threatening chest and pelvic injuries.Methods: All patients who underwent an iTBCT during their primary trauma assessment in one trauma center between April 2011 and November 2014 were retrospectively included. Two experienced trauma surgeons and two emergency radiologists evaluated iTBCT scouts with structured questionnaires. Inter-observer agreement and diagnostic properties were calculated for endotracheal tube position and identification of pneumo- and/or hemothorax and pelvic fractures. Diagnostic properties of iTBCT scouts for indication for chest tube placement and pelvic binder application were calculated in comparison to decision based on iTBCT.Results: In total 220 patients with a median age of 37 years (IQR 26-59) were selected with a median Injury Severity Score of 18 (IQR 9-27). There was moderate to substantial inter-observer agreement and low false positive rates for pneumo- and/or hemothorax and for severe pelvic fractures by iTBCT scouts. For 19.8%-22.5% of the endotracheal intubated patients trauma surgeons stated that repositioning of the tube was indicated. Positive predictive value and sensitivity were respectively 100% (95%CI 52%-100%) and 50% (95%CI 22%-78%) for decisions on chest tube placement by trauma surgeon 1 and 67% (95%CI 13%-98%) and 22% (95%CI 4%-60%) for decisions by trauma surgeon 2. Only in one of 14 patients the pelvic binder was applied after iTBCT acquisition.Conclusions: iTBCT scouts can be useful for early detection of pneumo- and/or hemothorax and severe pelvic fractures. Decision for chest tube placement based on iTBCT scouts alone is not recommended. [ABSTRACT FROM AUTHOR]