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01-12-2019 | Original Article

Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation

Authors: Elisa Reitano, Laura Briani, Fabrizio Sammartano, Stefania Cimbanassi, Margherita Luperto, Angelo Vanzulli, Osvaldo Chiara

Published in: Emergency Radiology | Issue 6/2019

Abstract

Purpose

To determine whether torso CT can be avoided in patients who experience high-energy blunt trauma but have normal vital signs.

Methods

High-energy blunt trauma patients with normal vital signs were retrieved retrospectively from our registry. We reviewed 1317 patients (1027 men and 290 women) and 761 (57.8%) fulfilled the inclusion criteria. All patients were initially evaluated at the emergency room (ER), with a set of tests, part of a specific protocol. Patients with at least one altered exam at initial examination or after six-hour observation received a torso CECT. Sensitivity, specificity, accuracy, positive (PPV) and negative predictive values (NPV), and likelihood ratio (LH) of the protocol were evaluated.

Results

Of 761 patients, 354 (46.5%) received torso CECT because of the positive ER test, with 330 being true positive and 24 being false positive. The remaining 407 patients were negative at ER tests and did not receive torso CECT, showing a significantly (P < 0.001) lower Injury Severity Score (ISS). The positive and negative LH of the protocol to detect torso injuries were respectively 16.5 and 0.01 (overall accuracy of 0.96).

Conclusions

Torso CT can be avoided without adverse clinical outcomes in patients who experience high-energy blunt trauma, are hemodynamically stable, and have normal initial laboratory and imaging tests.

Sasser SM, Hunt RC, Faul M, Sugerman D, Pearson WS, Dulski T, et al. Guidelines for field triage of injured patients: recommendations of the National Expert Panel on Field Triage, 2011. MMWR Recomm Reports Morb Mortal Wkly Report Recomm Reports 2012. doi:https://doi.org/10.1542/peds.2009-0257,

Kortbeek JB, Brenneman F, Brink PR, Brohi K, Burris D, Burton RA et al (2008) Advanced Trauma Life Support, 8th edition, the evidence for change. J Trauma 64:1638–1650. https://doi.org/10.1097/TA.0b013e3181744b03 CrossRefPubMed

Singh A, Kumar A, Kumar P, Kumar S, Gamanagatti S (2017) “Beyond saving lives”: current perspectives of interventional radiology in trauma. World J Radiol 9:155. https://doi.org/10.4329/wjr.v9.i4.155 CrossRefPubMedPubMedCentral

Kim Y-J, Kim J-S, Cho S-H, Bae J-I, Sohn CH, Lee Y-S et al (2017) Characteristics of computed tomography in hemodynamically unstable blunt trauma patients: experience at a tertiary care center. Med (United States) 96:1–5. https://doi.org/10.1097/MD.0000000000009168 CrossRef

American College of Emergency Physicians (2001) ACEP emergency ultrasound guidelines–2001 American College of Emergency Physicians. Ann Emerg Med 38:470–481. https://doi.org/10.1016/S0196-0644(01)70030-3 CrossRef

Hoff WS, Holevar M, Nagy KK, Patterson L, Young JS, Arrillaga A et al (2002) Practice management guidelines for the evaluation of blunt abdominal trauma: the EAST Practice Management Guidelines Work Group. J Trauma 53:602–615. https://doi.org/10.1097/01.TA.0000025413.43206.97 CrossRefPubMed

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. https://doi.org/10.1186/s13049-018-0498-x

Van Rein EAJ, Houwert RM, Gunning AC, Lichtveld RA, Leenen LPH, Van Heijl M (2017) Accuracy of prehospital triage protocols in selecting severely injured patients: a systematic review. J Trauma Acute Care Surg. https://doi.org/10.1097/TA.0000000000001516 CrossRef

Moussavi N, Ghani H, Davoodabadi A, Atoof F, Moravveji A, Saidfar S, Talari H (2018) Routine versus selective chest and abdominopelvic CT-scan in conscious blunt trauma patients: a randomized controlled study. Eur J Trauma Emerg Surg. https://doi.org/10.1007/s00068-017-0842-2 CrossRef

10.

Grimes DA, Schulz KF (2005) Refining clinical diagnosis with likelihood ratios. Lancet. https://doi.org/10.1016/S0140-6736(05)66422-7 CrossRef

11.

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 76:1122–1130. https://doi.org/10.1097/TA.0000000000000178 CrossRefPubMed

12.

Van VR, Keus F, Kool D, Deunk J, Edwards M (2013) Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients. Cochrane Database Syst Rev. https://doi.org/10.1002/14651858.CD009743.pub2.

13.

Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury 2006;141

14.

Holmes JF, McGahan JP, Wisner DH (2012) Rate of intra-abdominal injury after a normal abdominal computed tomographic scan in adults with blunt trauma. Am J Emerg Med 30:575–579. https://doi.org/10.1016/j.ajem.2011.02.016 CrossRef

15.

Corwin MT, Sheen L, Kuramoto A, Lamba R, Parthasarathy S, Holmes JF (2014) Utilization of a clinical prediction rule for abdominal–pelvic CT scans in patients with blunt abdominal trauma. Emerg Radiol 21:571–576. https://doi.org/10.1007/s10140-014-1233-1 CrossRefPubMed

16.

Bettmann MA (2004) Frequently asked questions: iodinated contrast agents. Radiographics 24(Suppl 1):S3–S10. https://doi.org/10.1148/rg.24si045519 CrossRef

17.

Brenner DJ, Hall EJ (2012) Cancer risks from CT scans: now we have data, what next? Radiology 265:330–331. https://doi.org/10.1148/radiol.12121248 CrossRefPubMed

18.

Kocher KE, Meurer WJ, Fazel R, Scott PA, Krumholz HM, Nallamothu BK (2011) National trends in use of computed tomography in the emergency department. Ann Emerg Med 58. https://doi.org/10.1016/j.annemergmed.2011.05.020 CrossRef

19.

Poletti PA, Mirvis SE, Shanmuganathan K, Takada T, Killeen KL, Perlmutter D et al (2004) Blunt abdominal trauma patients: can organ injury be excluded without performing computed tomography? J Trauma 57:1072–1081. https://doi.org/10.1097/01.TA.0000092680.73274.E1 CrossRefPubMed

20.

Holmes JF, Wisner DH, McGahan JP, Mower WR, Kuppermann N (2009) Clinical prediction rules for identifying adults at very low risk for intra-abdominal injuries after blunt trauma. Ann Emerg Med 54:575–584. https://doi.org/10.1016/j.annemergmed.2009.04.007 CrossRefPubMed

21.

Beck D, Marley R, Salvator A, Muakkassa F (2004) Prospective study of the clinical predictors of a positive abdominal computed tomography in blunt trauma patients. J Trauma 57:296–300. https://doi.org/10.1097/01.TA.0000130612.60661.C3 CrossRefPubMed

22.

Self ML, Blake AM, Whitley M, Nadalo L, Dunn E (2003) The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries. Am J Surg 186:609–614. https://doi.org/10.1016/j.amjsurg.2003.08.003 CrossRefPubMed

23.

Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, Reiser M, Mutschler W, Kanz KG (2009) Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 373:1455–1461. https://doi.org/10.1016/S0140-6736(09)60232-4 CrossRefPubMed

24.

Fabian TC (2009) Whole-body CT in multiple trauma. Lancet 373:1408–1409. https://doi.org/10.1016/S0140-6736(09)60354-8 CrossRefPubMed

25.

Cimbanassi S, Chiara O, Leppaniemi A, Henry S, 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 84:517–531. https://doi.org/10.1097/TA.0000000000001774 CrossRefPubMed

26.

Belabbas D, Auger M, Lederlin M, Bonenfant J, Gandon Y, Aubé C, Paisant A (2019) Whole-body CT after motor vehicle crash: no benefit after high-energy impact and with normal physical examination. Radiology. https://doi.org/10.1148/radiol.2019182806 CrossRef

Title: Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation
Authors: Elisa Reitano
Laura Briani
Fabrizio Sammartano
Stefania Cimbanassi
Margherita Luperto
Angelo Vanzulli
Osvaldo Chiara
Publication date: 01-12-2019
Publisher: Springer International Publishing
Published in: Emergency Radiology / Issue 6/2019
Print ISSN: 1070-3004
Electronic ISSN: 1438-1435
DOI: https://doi.org/10.1007/s10140-019-01712-0

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Torso computed tomography in blunt trauma patients with normal vital signs can be avoided using non-invasive tests and close clinical evaluation

Abstract

Purpose

Methods

Results

Conclusions

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Purpose

Methods

Results

Conclusions

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