nach oben

Erschienen in:

10.01.2022 | Original Article

Avoiding immediate whole-body trauma CT: a prospective observational study in stable trauma patients

verfasst von: Elisa Reitano, Stefano Granieri, Fabrizio Sammartano, Stefania Cimbanassi, Miriam Galati, Shailvi Gupta, Angelo Vanzulli, Osvaldo Chiara

Erschienen in: Updates in Surgery | Ausgabe 1/2022

Einloggen, um Zugang zu erhalten

Abstract

High energy blunt trauma patients with normal vital signs are usually investigated with a Contrast Enhanced Computed Tomography (CECT) for torso injuries. CECT involves high levels of radiations, often showing no injuries in patients over-triaged to the trauma center. The aim of our study was to suggest an alternative diagnostic protocol based on Emergency Room (ER) tests (physical exam, blood tests, extended FAST, Chest and Pelvis X-ray) to avoid CECT in selected patients. A prospective cohort study was conducted from September 2018 to September 2019. Five hundred patients fulfilled the inclusion criteria. Patients received torso-CECT scan only if they had at least one positive ER test. The validity of the single component of the protocol and the global validity of the ER tests to detect torso injuries was assessed through sensitivity, specificity, positive (PPV) and negative (NPV) predictive value, positive (+ LR) and negative (− LR) likelihood ratio. Multivariate analysis was performed to identify independent predictors of torso injuries. One hundred and seventy patients received a torso-CECT scan because of positive ER tests. ER tests showed a global sensitivity for torso injuries of 86.96% (95% CI 80.17–92.08) specificity of 83.98%(95% CI 79.79–87.60), PPV of 67.42% (95% CI 61.83–72.54), NPV of 94.41% (95% CI 91.63–96.30) + LR of 5.43 (95% CI 4.25–6.93), − LR of 0.16 (95% CI 0.10–0.24). ER tests in an experienced center seem to be able to identify more severe blunt trauma patients needing CECT. Further studies are advisable to confirm these results.

Nur mit Berechtigung zugänglich

Van Rein EAJ, Houwert RM, Lichtveld GAC, RA, Leenen LP, Van Henijl M. (2017) Accuracy of prehospital triage protocols in selecting severely injured patients: A systematic review. J Trauma Acute Care Surg 83(2):328–339. https://doi.org/10.1097/TA.0000000000001516CrossRefPubMed

MacKenzie EJ, Rivara FP, Jurkovich GJ,Nathens AB, Frey KP, Egleston BL et al. (2006). A National Evaluation of the Effect of Trauma-Center Care on Mortality. N Engl J Med 26;354(4):366–78. doi: https://doi.org/10.1056/NEJMsa052049.

Weninger P, Mauritz W, Fridrich P, Spitaler R, Figl M, Kern B et al (2007) Emergency room management of patients with blunt major trauma: Evaluation of the multislice computed tomography protocol exemplified by an urban trauma center. J Trauma - Inj Infect Crit Care 62(3):584–591. https://doi.org/10.1097/01.ta.0000221797.46249.eeCrossRef

Wurmb TE, Quaisser C, Balling H, Kredel M, Muellenbach R, Kenn W et al (2011) Whole-body multislice computed tomography (MSCT) improves trauma care in patients requiring surgery after multiple trauma. Emerg Med J 28(4):300–304. https://doi.org/10.1136/emj.2009.082164CrossRefPubMed

Gordic S, Alkadhi H, Hodel S, Simmen HP, Brueesch M, Frauenfelder T et al (2015) Whole-body CT-based imaging algorithm for multiple trauma patients: Radiation dose and time to diagnosis. Br J Radiol 88(1047):20140616. https://doi.org/10.1259/bjr.20140616CrossRefPubMedPubMedCentral

Galvagno SM, Nahmias JT, Young DA. (2019). Advanced Trauma Life Support® Update 2019: Management and Applications for Adults and Special Populations. Anesthesiology Clinics. W.B. Saunders; doi:https://doi.org/10.1016/j.anclin.2018.09.009

Huber-Wagner S, Kanz KG, Hanschen M, van Griensven M, Biberthaler P, Lefering R (2018) Whole-Body computed tomography in severely injured patients. Curr Opin Crit Care 24(1):55–61. https://doi.org/10.1097/MCC.0000000000000474CrossRefPubMed

Brenner DJ, Hall EJ (2007) Computed tomography - An increasing source of radiation exposure. N Engl J Med 357(22):2277–2284. https://doi.org/10.1056/NEJMra072149CrossRefPubMed

Reitano E, Briani L, Sammartano F, Cimbanassi S, Luperto M, Vanzulli A et al. (2Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation. Emerg Radiol. 26(6):655–661. doi: https://doi.org/10.1007/s10140-019-01712-0.

10.

Kumar S, Prakash P, Joshi MK, Rathi V (2017) Selective Non-operative Management of Patients with Abdominal Trauma—Is CECT Scan Mandatory? Indian J Surg 79(5):396–400. https://doi.org/10.1007/s12262-016-1494-xCrossRefPubMed

11.

Steenburg SD, Ravenel JG, Ikonomidis JS, Schonholz C, Reeves S (2008) Acute traumatic aortic injury: Imaging evaluation and management. Radiology 248(3):748–762. https://doi.org/10.1148/radiol.2483071416CrossRefPubMed

12.

Alonso RC, Nacenta SB, Martinez PD, Guerrer AS, Fuentes CG (2009) Kidney in danger: CT findings of blunt and penetrating renal trauma. Radiographics 29(7):2033–2053. https://doi.org/10.1148/rg.297095071CrossRefPubMed

13.

Rowell SE, Biffl WL, Brasel K, Moore EE, Albrecht A, DeMoya M et al (2017) Western trauma association (WTA) critical decisions in trauma: Management of adult blunt splenic trauma. Journal of Trauma - Injury, Infection and Critical Care 82(4):787–793. https://doi.org/10.1097/TA.0000000000001323CrossRef

14.

Italian Ministry of Health SI of H (ISS). (2020) Italian Guidelines on management of major trauma form the scene to the definitive cure. https://snlg.iss.it/?p=2533 .

15.

Canadian CT Head and C-Spine (CCC) Study Group (2002) Canadian C-Spine Rule study for alert and stable trauma patients: I. Background and rationale CJEM 4(2):84–90

16.

Hanley JA, McNeil BJ (1982) The meaning and use of the area under a receiver operating characteristic (ROC) curve. Radiology 143(1):29–36. https://doi.org/10.1148/radiology.143.1.7063747CrossRefPubMed

17.

Kumar S, Sagar S, Subramanian A, Albert V, Pandey RM, Kapoor N (2012) Evaluation of amylase and lipase levels in blunt trauma abdomen patients. J Emergencies, Trauma Shock 5(2):135–142. https://doi.org/10.4103/0974-2700.96482CrossRef

18.

Tan KK, Bang SL, Vijayan A, Chiu MT (2009) Hepatic enzymes have a role in the diagnosis of hepatic injury after blunt abdominal trauma. Injury 40(9):978–983. https://doi.org/10.1016/j.injury.2009.02.023CrossRefPubMed

19.

Régnier MA, Raux M, Le Manach Y, Asencio Y, Gaillard J, Devillers C et al (2012) Prognostic significance of blood lactate and lactate clearance in trauma patients. Anesthesiology 117(6):1276–1288. https://doi.org/10.1097/ALN.0b013e318273349dCrossRefPubMed

20.

Simundic AM (2009) Measures of Diagnostic Accuracy: Basic Definitions. Ejifcc 19(4):203–211PubMedPubMedCentral

21.

Lee YH, Bang H, Kim DJ (2016) How to establish clinical prediction models. Endocrinol Metab 31(1):38–44CrossRef

22.

Altman, Douglas G., Machin D, Bryant TN GM. (2000). Statistics with confidence, 2nd ed. 2nd ed.

23.

Von Elm E, Altman DG, Egger M, Pocock SJ, Gøtzsche PC, Vandenbroucke JP; STROBE Initiative. The Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies. Epidemiology; 18(6):800–4. doi: https://doi.org/10.1097/EDE.0b013e3181577654.

24.

Surendran A, Mori A, Varma DK, Gruen RL (2014) Systematic review of the benefits and harms of whole-body computed tomography in the early management of multitrauma patients: Are we getting the whole picture. J Trauma Acute Care Surg 76(4):1122–1130. https://doi.org/10.1097/TA.0000000000000178CrossRefPubMed

25.

Cimbanassi S, Chiara O, Leppaniemi A, Hnery SM, Scalea TM, Shanmuganathan K et al (2018) Nonoperative management of abdominal solid-organ injuries following blunt trauma in adults: Results from an International Consensus Conference. J Trauma Acute Care Surg 84(3):517–531. https://doi.org/10.1097/TA.0000000000001774CrossRefPubMed

26.

Botelho Filho Fm Oliveira e Silva RX, Starling SV, Pereirra Zille D, Drumond DAF. (2015). Complementary exams in blunt torso trauma. Perform only radiographs and fast: is it safe? Rev Col Bras Cir. 42(4):220–3. doi: https://doi.org/10.1590/0100-69912015004005.

27.

Sierink JC, Treskes K, Edwards MJR, Beuker BJA, den Hartog D, Hohmann J et al (2016) Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet 388(10045):673–683. https://doi.org/10.1016/S0140-6736(16)30932-1CrossRefPubMed

28.

Pacanowski JP, Waack M, Miller C, Daley BJ. (1999). Sensitivity of non-contrast radiography for intra-abdominal injuries. J Trauma Inj Infect Crit Care. 47(1)219.

29.

Kaewlai R, Avery LL, Asrani AV, Novelline RA (2008) Multidetector CT of blunt thoracic trauma. Radiographics 28(6):1555–1570. https://doi.org/10.1148/rg.286085510CrossRefPubMed

30.

Rubin GD (2014) Computed tomography: Revolutionizing the practice of medicine for 40 years. Radiology 273(2 Suppl):S45-74. https://doi.org/10.1148/radiol.14141356CrossRefPubMed

31.

Sierink JC, Saltzherr TP, Reitsma JB, Van Delden OM, Luitse JSK, Gosling JC (2012) Systematic review and meta-analysis of immediate total-body computed tomography compared with selective radiological imaging of injured patients. BJS 99(Suppl 1):52–58. https://doi.org/10.1002/bjs.7760CrossRef

32.

Healy DA, Hegarty A, Feeley I, Moloney MC, Grace PA, Walsh SR (2014) Systematic review and meta-analysis of routine total body CT compared with selective CT in trauma patients. Emerg Med J 31(2):101–108. https://doi.org/10.1136/emermed-2012-201892CrossRefPubMed

33.

Van Vugt R, Kool DR, Deunk J, Edwards MJR (2012) Effects on mortality, treatment, and time management as a result of routine use of total body computed tomography in blunt high-energy trauma patients. J Trauma Acute Care Surg 72(3):553–559. https://doi.org/10.1097/TA.0b013e31822dd93bCrossRefPubMed

34.

Caputo ND, Stahmer C, Lim G, Shah K (2014) Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: A systematic review and meta-analysis. J Trauma Acute Care Surg 77(4):534–539. https://doi.org/10.1097/TA.0000000000000414CrossRefPubMed

35.

Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Z et al (2014) Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: A meta-analysis. Scand J Trauma Resusc Emerg Med 22:54. https://doi.org/10.1186/s13049-014-0054-2CrossRefPubMedPubMedCentral

36.

Yeguiayan JM, Yap A, Freysz M, Garrigue D, Jacquot C, Martin C et al. (2012). Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma. Crit Care. 11;16(3):R101.doi: https://doi.org/10.1186/cc11375.

37.

Huber-Wagner S, Lefering R, Qvick LM, Korner M, VìKay MV, Pfeifer KJ et al (2009) Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 373:1455–1461CrossRefPubMed

38.

Braken P, Amsler F, Gross T (2018) Simple modification of trauma mechanism alarm criteria published for the TraumaNetwork DGU®may significantly improve overtriage - A cross sectional study. Scand J Trauma Resusc Emerg Med 26(1):32. https://doi.org/10.1186/s13049-018-0498-xCrossRefPubMedPubMedCentral

39.

Wirth S, Hebebrand J, Basilico R, Berger FH, Blanco A, Calli C et al (2020) European Society of Emergency Radiology: guideline on radiological polytrauma imaging and service. Insights Imaging 11(1):135. https://doi.org/10.1186/s13244-020-00947-7CrossRefPubMedPubMedCentral

40.

Sweetman SJ, Bernard J (2020) Patient Knowledge and Perception of Radiation Risk in Diagnostic Imaging: A Cross-Sectional Study. J Patient Exp 7(1):110–115. https://doi.org/10.1177/2374373518825118CrossRefPubMed

41.

Nelson TR (2014) Practical strategies to reduce pediatric CT radiation dose. J Am Coll Radiol 11(3):292–299. https://doi.org/10.1016/j.jacr.2013.10.011CrossRefPubMed

42.

Vaiserman AM (2010) Radiation hormesis: Historical perspective and implications for low-dose cancer risk assessment. Dose-Response 8(2):172–191. https://doi.org/10.2203/dose-response.09-037.VaisermanCrossRefPubMedPubMedCentral

43.

Chen J, Majercik S, Bledsoe J, Connor K, Morris B, Gardner S et al (2015) The prevalence and impact of defensive medicine in the radiographic workup of the trauma patient: a pilot study. Am J Surg 210(3):462–467. https://doi.org/10.1016/j.amjsurg.2015.03.016CrossRefPubMed

44.

van Vugt R, Kool DR, Brink M, Dekker HM, Deunk J, Edwards MJ (2014) Thoracoabdominal computed tomography in trauma patients: a cost-consequences analysis. Trauma Mon 19(3):e19219. https://doi.org/10.5812/traumamon.19219CrossRefPubMedPubMedCentral

45.

Hipp A, Desai S, Lopez C, Sinert R (2008) The incidence of contrast-induced nephropathy in trauma patients. Eur J Emerg Med 15(3):134–139. https://doi.org/10.1097/MEJ.0b013e328270367dCrossRefPubMed

46.

McGillicuddy EA, Schuster KM, Kaplan LJ, Maung AA, Lui FY, Maerz LL et al (2010) Contrast-induced nephropathy in elderly trauma patients. J Trauma 68(2):294–297. https://doi.org/10.1097/TA.0b013e3181cf7e40CrossRefPubMed

47.

STARSurg Collaborative. (2020) Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study. Br J Surg 107(8):1023–1032. https://doi.org/10.1002/bjs.11453CrossRef

48.

Kelemen JA, Kaserer A, Jensen KO, Stein P, Seifert B, Simmen HP et al (2020) Prevalence and outcome of contrast-induced nephropathy in major trauma patients. Eur J Trauma Emerg Surg 19:1–7. https://doi.org/10.1007/s00068-020-01496-wCrossRef

49.

Leung V, Sastry A, Jones WTD, HR. (2015) Implementation of a split-bolus single-pass CT protocol at a UK major trauma centre to reduce excess radiation dose in trauma pan-CT. Clin Radiol 70(10):1110–1115. https://doi.org/10.1016/j.crad.2015.05.014CrossRefPubMed

50.

Beenen LFM, Sierink JC, Kolkman S, Nio CY, Saltzherr TP, Dikgraaf MGW et al (2015) Split bolus technique in polytrauma: A prospective study on scan protocols for trauma analysis. Acta radiol 56(7):873–880. https://doi.org/10.1177/0284185114539319CrossRefPubMed

51.

Godt JC, Eken T, Schulz A, Johansen CK, Aarsnes A, Dormagen JP (2018) Triple-split-bolus versus single-bolus CT in abdominal trauma patients: a comparative study. Acta radiol 59(9):1038–1044. https://doi.org/10.1177/0284185117752522CrossRefPubMed

52.

Difino M, Bini R, Reitano E, Faccincani R, Sammartano F, Briani L, Cimbanassi S, Chiara O (2021) Epidemiology of trauma admission in a level one trauma center in northern Italy: a nine years study. Updates Surg. https://doi.org/10.1007/s13304-021-00991-yCrossRefPubMedPubMedCentral

53.

Uleberg O, Vinjevoll P, Eriksson U, Aadahl P, Skogvoll E (2007) Overtriage in trauma – what are the cuses? Acta Anaesthesiol Scand 51(9):1178–1183. https://doi.org/10.1111/j.1399-6576.2007.01414.xCrossRefPubMed

Titel: Avoiding immediate whole-body trauma CT: a prospective observational study in stable trauma patients
verfasst von: Elisa Reitano
Stefano Granieri
Fabrizio Sammartano
Stefania Cimbanassi
Miriam Galati
Shailvi Gupta
Angelo Vanzulli
Osvaldo Chiara
Publikationsdatum: 10.01.2022
Verlag: Springer International Publishing
Erschienen in: Updates in Surgery / Ausgabe 1/2022
Print ISSN: 2038-131X
Elektronische ISSN: 2038-3312
DOI: https://doi.org/10.1007/s13304-021-01199-w

Strong impact of sarcopenia as a risk factor of survival in resected gastric cancer patients: first Italian report of a Bicentric study

Original Article

Laparoscopic ultrasound guided wedge resection of the stomach: a novel procedure for gastric submucosal tumor

Technical Note

Laparoscopic right hemicolectomy with complete mesocolic excision plus D3 lymphadenectomy (CME + D3): a new medial approach for central vascular ligation

Original Article

Major hepatectomy for perihilar cholangiocarcinoma in elderly patients: is it reasonable?

Open Access
Original Article

Combined liver transplantation with sleeve gastrectomy: a pioneer case series from Brazil

Original Article

Management of endocrine surgical disorders during COVID-19 pandemic: expert opinion for non-surgical options

Zur Zeit gratis
COVID-19
Original Article

Neu im Fachgebiet Chirurgie

Mit Lidocain kommt der Darm nicht schneller in Schwung

13.01.2025
Kolektomie
Nachrichten

Verzögertes Wiederanspringen der Darmfunktion ist ein Hauptfaktor dafür, wenn Patientinnen und Patienten nach einer Kolonresektion länger als geplant im Krankenhaus bleiben müssen. Ob man diesem Problem mit Lidocain vorbeugen kann, war Thema einer Studie.

Kein Unterschied bei inadäquaten Schocks zwischen ICD-Typen

24.12.2024
Implantierbarer Kardioverter-Defibrillator
Nachrichten

Inadäquate Schockabgaben sind ein unerwünschter Effekt der Therapie mit implantierbaren Kardioverter-Defibrillatoren. Subkutanen Geräten haftet dabei der Ruf an, dafür besonders anfällig zu sein. Die PRAETORIAN-Forschungsgruppe ist dem nachgegangen.

DCIS: Ist ein Verzicht auf eine Operation möglich?

Mammakarzinom
Nachrichten

Die COMET-Studie zeigt, dass aktives Monitoring bei Patientinnen mit duktalem Carcinoma in situ (DCIS) hinsichtlich der kumulativen Zwei-Jahres-Rate an ipsilateralen invasiven Karzinomen der leitliniengerechten Standardbehandlung nicht unterlegen ist. Dennoch wird von einem Verzicht auf eine Operation abgeraten, wie in einem begleitenden Editorial betont wird.

Soll man bei Cholezystektomie routinemäßig cholangiografieren?

18.12.2024
Cholezystektomie
Nachrichten

Eine US-Studie scheint den Befürwortern einer routinemäßigen intraoperativen Cholangiografie im Rahmen einer Cholezystektomie Recht zu geben. Die Studienkommentatoren in JAMA Surgery sparen jedoch nicht mit Kritik.

Update Chirurgie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.

Newsletter bestellen

Springer Medizin

Avoiding immediate whole-body trauma CT: a prospective observational study in stable trauma patients

Abstract

Weitere Artikel der Ausgabe 1/2022

Strong impact of sarcopenia as a risk factor of survival in resected gastric cancer patients: first Italian report of a Bicentric study

Laparoscopic ultrasound guided wedge resection of the stomach: a novel procedure for gastric submucosal tumor

Laparoscopic right hemicolectomy with complete mesocolic excision plus D3 lymphadenectomy (CME + D3): a new medial approach for central vascular ligation

Major hepatectomy for perihilar cholangiocarcinoma in elderly patients: is it reasonable?

Combined liver transplantation with sleeve gastrectomy: a pioneer case series from Brazil

Management of endocrine surgical disorders during COVID-19 pandemic: expert opinion for non-surgical options

Neu im Fachgebiet Chirurgie

Mit Lidocain kommt der Darm nicht schneller in Schwung

Kein Unterschied bei inadäquaten Schocks zwischen ICD-Typen

DCIS: Ist ein Verzicht auf eine Operation möglich?

Soll man bei Cholezystektomie routinemäßig cholangiografieren?

Update Chirurgie

Springer Medizin

Abstract

Bitte loggen Sie sich ein, um Zugang zu diesem Inhalt zu erhalten