Implementation of a standardized protocol to manage elderly patients with low energy pelvic fractures: can service improvement be expected?

PURPOSE: The incidence of low energy pelvic fractures (FPFs) in the elderly is increasing. Comorbidities, decreased bone-quality, problematic fracture fixation and poor compliance represent some of their specific difficulties. In the absence of uniform management, a standard operating procedure (SOP) was introduced to our unit, aiming to improve the quality of services provided to these patients. METHODS: A cohort study was contacted to test the impact of (1) using a specific clinical algorithm and (2) using different antiosteoporotic drugs. Multivariate regression analysis was used to determine prognostic factors. Study endpoints were the time-to-healing, length-of-stay, return to pre-injury mobility, union status, mortality and complications. RESULTS: A total of 132 elderly patients (≥65 years) admitted during the period 2012-2014 with FPFs were enrolled. High-energy fractures, acetabular fractures, associated trauma affecting mobility, pathological pelvic lesions and operated FPFs were used as exclusion criteria. The majority of included patients were females (108/132; 81.8%), and the mean age was 85.8 years (range 67-108). Use of antiosteoporotics was associated with a shorter time of healing (p = 0.036). Patients treated according to the algorithm showed a significant protection against malunion (p < 0.001). Also, adherence to the algorithm allowed more patients to return to their pre-injury mobility status (p = 0.039). CONCLUSIONS: The use of antiosteoporotic medication in elderly patients with fragility pelvic fractures was associated with faster healing, whilst the adherence to a structured clinical pathway led to less malunions and non-unions and return to pre-injury mobility state.

A nurse-initiated pain protocol in the ED improves pain treatment in patients with acute musculoskeletal pain.

While acute musculoskeletal pain is a frequent complaint, its management is often neglected. An implementation of a nurse-initiated pain protocol based on the algorithm of a Dutch pain management guideline in the emergency department might improve this. A pre-post intervention study was performed as part of the prospective PROTACT follow-up study. During the pre- (15 months, n = 504) and post-period (6 months, n = 156) patients' self-reported pain intensity and pain treatment were registered. Analgesic provision in patients with moderate to severe pain (NRS ≥4) improved from 46.8% to 68.0%. Over 10% of the patients refused analgesics, resulting into an actual analgesic administration increase from 36.3% to 46.1%. Median time to analgesic decreased from 10 to 7 min (P < 0.05), whereas time to opioids decreased from 37 to 15 min (P < 0.01). Mean pain relief significantly increased to 1.56 NRS-points, in patients who received analgesic treatment even up to 2.02 points. The protocol appeared to lead to an increase in analgesic administration, shorter time to analgesics and a higher clinically relevant pain relief. Despite improvements, suffering moderate to severe pain at ED discharge was still common. Protocol adherence needs to be studied in order to optimize pain management.

Trauma team activation varies across Dutch emergency departments: a national survey.

BACKGROUND: Tiered trauma team response may contribute to efficient in-hospital trauma triage by reducing the amount of resources required and by improving health outcomes. This study evaluates current practice of trauma team activation (TTA) in Dutch emergency departments (EDs). METHODS: A survey was conducted among managers of all 102 EDs in the Netherlands, using a semi-structured online questionnaire. RESULTS: Seventy-two questionnaires were analysed. Most EDs use a one-team system (68 %). EDs with a tiered-response receive more multi trauma patients (p < 0.01) and have more trauma team alerts per year (p < 0.05) than one-team EDs. The number of trauma team members varies from three to 16 professionals. The ED nurse usually receives the pre-notification (97 %), whereas the decision to activate a team is made by an ED nurse (46 %), ED physician (30 %), by multiple professionals (20 %) or other (4 %). Information in the pre-notification mostly used for trauma team activation are Airway-Breathing-Circulation (87 %), Glasgow Coma Score (90 %), and Revised Trauma Score (85 %) or Paediatric Trauma Score (86 %). However, this information is only available for 75 % of the patients or less. Only 56 % of the respondents were satisfied with their current in-hospital trauma triage system. CONCLUSIONS: Trauma team activation varies across Dutch EDs and there is room for improvement in the trauma triage system used, size of the teams and the professionals involved. More direct communication and more uniform criteria could be used to efficiently and safely activate a specific trauma team. Therefore, the implementation of a revised national consensus guideline is recommended.

Pain management in the emergency chain: the use and effectiveness of pain management in patients with acute musculoskeletal pain.

OBJECTIVE: While acute musculoskeletal pain is a frequent complaint in emergency care, its management is often neglected, placing patients at risk for insufficient pain relief. Our aim is to investigate how often pain management is provided in the prehospital phase and emergency department (ED) and how this affects pain relief. A secondary goal is to identify prognostic factors for clinically relevant pain relief. DESIGN: This prospective study (PROTACT) includes 697 patients admitted to ED with musculoskeletal extremity injury. Data regarding pain, injury, and pain management were collected using questionnaires and registries. RESULTS: Although 39.9% of the patients used analgesics in the prehospital phase, most patients arrived at the ED with severe pain. Despite the high pain prevalence in the ED, only 35.7% of the patients received analgesics and 12.5% received adequate analgesic pain management. More than two-third of the patients still had moderate to severe pain at discharge. Clinically relevant pain relief was achieved in only 19.7% of the patients. Pain relief in the ED was higher in patients who received analgesics compared with those who did not. Besides analgesics, the type of injury and pain intensity on admission were associated with pain relief. CONCLUSIONS: There is still room for improvement of musculoskeletal pain management in the chain of emergency care. A high percentage of patients were discharged with unacceptable pain levels. The use of multimodal pain management or the implementation of a pain management protocol might be useful methods to optimize pain relief. Additional research in these areas is needed.

Outcome prediction in moderate and severe traumatic brain injury: a focus on computed tomography variables.

BACKGROUND: With this study we aimed to design validated outcome prediction models in moderate and severe traumatic brain injury (TBI) using demographic, clinical, and radiological parameters. METHODS: Seven hundred consecutive moderate or severe TBI patients were included in this observational prospective cohort study. After inclusion, clinical data were collected, initial head computed tomography (CT) scans were rated, and at 6 months outcome was determined using the extended Glasgow Outcome Scale. Multivariate binary logistic regression analysis was applied to evaluate the association between potential predictors and three different outcome endpoints. The prognostic models that resulted were externally validated in a national Dutch TBI cohort. RESULTS: In line with previous literature we identified age, pupil responses, Glasgow Coma Scale score and the occurrence of a hypotensive episode post-injury as predictors. Furthermore, several CT characteristics were associated with outcome; the aspect of the ambient cisterns being the most powerful. After external validation using Receiver Operating Characteristic (ROC) analysis our prediction models demonstrated adequate discriminative values, quantified by the area under the ROC curve, of 0.86 for death versus survival and 0.83 for unfavorable versus favorable outcome. Discriminative power was less for unfavorable outcome in survivors: 0.69. CONCLUSIONS: Outcome prediction in moderate and severe TBI might be improved using the models that were designed in this study. However, conventional demographic, clinical and CT variables proved insufficient to predict disability in surviving patients. The information that can be derived from our prediction rules is important for the selection and stratification of patients recruited into clinical TBI trials.

Development and external validation of a new PTA assessment scale.

BACKGROUND: Post-traumatic amnesia (PTA) is a key symptom of traumatic brain injury (TBI). Accurate assessment of PTA is imperative in guiding clinical decision making. Our aim was to develop and externally validate a short, examiner independent and practical PTA scale, by selecting the most discriminative items from existing scales and using a three-word memory test. METHODS: Mild, moderate and severe TBI patients and control subjects were assessed in two separate cohorts, one for derivation and one for validation, using a questionnaire comprised of items from existing PTA scales. We tested which individual items best discriminated between TBI patients and controls, represented by sensitivity and specificity. We then created our PTA scale based on these results. This new scale was externally evaluated for its discriminative value using Receiver Operating Characteristic (ROC) analysis and compared to existing PTA scales. RESULTS: The derivation cohort included 126 TBI patients and 31 control subjects; the validation cohort consisted of 132 patients and 30 controls. A set of seven items was eventually selected to comprise the new PTA scale: age, name of hospital, time, day of week, month, mode of transport and recall of three words. This scale demonstrated adequate discriminative values compared to existing PTA scales on three consecutive administrations in the validation cohort. CONCLUSION: We introduce a valid, practical and examiner independent PTA scale, which is suitable for mild TBI patients at the emergency department and yet still valuable for the follow-up of more severely injured TBI patients.

Incidental Findings on Routine Thoracoabdominal Computed Tomography in Blunt Trauma Patients.

BACKGROUND:: Thoracoabdominal MultiDetector-row Computed Tomography (MDCT) is frequently used as a diagnostic tool in trauma patients. One potential side-effect of performing MDCT is the detection of incidental findings and their subsequent consequences on medical treatment. The objective was to evaluate frequency and effects of incidental findings in trauma patients. METHODS:: The reports of 1,047 consecutive blunt trauma patients (mean age, 40 years) who underwent routine contrast-enhanced thoracoabdominal MDCT were evaluated. Incidental findings were categorized by a trauma radiologist into four hierarchic categories based on their clinical consequences. We recorded additional diagnostic workup and treatment performed in conjunction with these incidental findings. RESULTS:: Of the 1,047 patients, 372 (mean age, 56 years; 61% male) had one or more incidental findings on thoracoabdominal MDCT. Complementary investigation or therapy was performed in 72 of these 372 patients; 29 of these patients required additional invasive evaluation or treatment. Nineteen patients underwent surgery due to an incidental finding. Nine patients were diagnosed with a not previously identified malignancy. CONCLUSIONS:: Routine thoracoabdominal MDCT in the evaluation of trauma patients revealed a significant number of incidental findings. Based on radiologic findings it is possible to decide whether additional follow-up or treatment is necessary.

A hinged external fixator for complex elbow dislocations: a multicenter prospective cohort study.

BACKGROUND: Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures of the radial head, olecranon, or coronoid process. The majority of patients with these complex dislocations are treated with open reduction and internal fixation (ORIF), or arthroplasty in case of a non-reconstructable radial head fracture. If the elbow joint remains unstable after fracture fixation, a hinged elbow fixator can be applied. The fixator provides stability to the elbow joint, and allows for early mobilization. The latter may be important for preventing stiffness of the joint. The aim of this study is to determine the effect of early mobilization with a hinged external elbow fixator on clinical outcome in patients with complex elbow dislocations with residual instability following fracture fixation. METHODS/DESIGN: The design of the study will be a multicenter prospective cohort study of 30 patients who have sustained a complex elbow dislocation and are treated with a hinged elbow fixator following fracture fixation because of residual instability. Early active motion exercises within the limits of pain will be started immediately after surgery under supervision of a physical therapist. Outcome will be evaluated at regular intervals over the subsequent 12 months. The primary outcome is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford Elbow Score, pain level at both sides, range of motion of the elbow joint at both sides, radiographic healing of the fractures and formation of periarticular ossifications, rate of secondary interventions and complications, and health-related quality of life (Short-Form 36). DISCUSSION: The outcome of this study will yield quantitative data on the functional outcome in patients with a complex elbow dislocation and who are treated with ORIF and additional stabilization with a hinged elbow fixator. TRIAL REGISTRATION: The trial is registered at the Netherlands Trial Register (NTR1996).

Prevalence and relief of pain in trauma patients in emergency medical services.

OBJECTIVES: The aim of this study was to give insight in the prevalence of pain, and the (effect of) pain management according to the national emergency medical services analgesia protocol in trauma patients in the Netherlands. METHODS: The retrospective document study included adult and alert trauma patients. Data collection concerned patient characteristics, prevalence of pain, and the (effect of) pain management. Actual pain management was compared with the national emergency medical services analgesia protocol for paramedics. Pain relief was defined as a decrease on the Numeric Rating Scale. RESULTS: One thousand four hundred and seven trauma patients were included. A report on pain was missing in 28% of the patients (n=393), 2% of the patients (n=34) reported no pain, and the prevalence of pain was reported by 70% of the patients (n=980). Of the patients in pain, 31% (n=311) had a systematic pain assessment (Numeric Rating Scale) at the scene of accident and the median pain score was 6 (interquartile range=3 to 8). Pharmacological pain treatment was administered to 42% of the patients in pain (n=410), and consisted mainly of intravenous fentanyl. Nonpharmacological pain treatments were cleaning of wounds (n=189), and application of splints or immobilizing bandages (n=130). Pain relief on arrival in the emergency department could only be evaluated in 15% of the patients in pain (n=149). DISCUSSION: Prevalence of pain in trauma was high, and without consistent "objective" reporting of pain it is difficult to evaluate the effectiveness of pain management, despite the adherence to clinical practice guideline or protocol. Paramedics need to elicit and report validated pain measurements.

Functional treatment versus plaster for simple elbow dislocations (FuncSiE): a randomized trial.

BACKGROUND: Elbow dislocations can be classified as simple or complex. Simple dislocations are characterized by the absence of fractures, while complex dislocations are associated with fractures. After reduction of a simple dislocation, treatment options include immobilization in a static plaster for different periods of time or so-called functional treatment. Functional treatment is characterized by early active motion within the limits of pain with or without the use of a sling or hinged brace. Theoretically, functional treatment should prevent stiffness without introducing increased joint instability. The primary aim of this randomized controlled trial is to compare early functional treatment versus plaster immobilization following simple dislocations of the elbow. METHODS/DESIGN: The design of the study will be a multicenter randomized controlled trial of 100 patients who have sustained a simple elbow dislocation. After reduction of the dislocation, patients are randomized between a pressure bandage for 5-7 days and early functional treatment or a plaster in 90 degrees flexion, neutral position for pro-supination for a period of three weeks. In the functional group, treatment is started with early active motion within the limits of pain. Function, pain, and radiographic recovery will be evaluated at regular intervals over the subsequent 12 months. The primary outcome measure is the Quick Disabilities of the Arm, Shoulder, and Hand score. The secondary outcome measures are the Mayo Elbow Performance Index, Oxford elbow score, pain level at both sides, range of motion of the elbow joint at both sides, rate of secondary interventions and complication rates in both groups (secondary dislocation, instability, relaxation), health-related quality of life (Short-Form 36 and EuroQol-5D), radiographic appearance of the elbow joint (degenerative changes and heterotopic ossifications), costs, and cost-effectiveness. DISCUSSION: The successful completion of this trial will provide evidence on the effectiveness of a functional treatment for the management of simple elbow dislocations. TRIAL REGISTRATION: The trial is registered at the Netherlands Trial Register (NTR2025).

The clinical outcome of occult pulmonary contusion on multidetector-row computed tomography in blunt trauma patients.

BACKGROUND: Multidetector-row computed tomography (MDCT) is a more sensitive modality as compared with conventional radiography (CR) in detecting pulmonary injuries. MDCT often detects pulmonary contusion that is not visualized by CR, defined as occult pulmonary contusion (OPC). The aim of this study was to investigate whether OPC on MDCT has implications for the outcome in blunt trauma patients. METHODS: We used prospectively collected data from 1,040 adult high-energy blunt trauma patients who were primarily presented at our emergency department and who underwent CR and MDCT of the chest. All patients with pulmonary contusion were identified and divided into two groups: The "CR/computed tomography (CT) group" consisted of patients with pulmonary contusion visible on both CR and MDCT. The "CT-only" group consisted of patients with OPC, visible exclusively on MDCT. The control group consisted of blunt trauma patients without pulmonary contusion. These groups were compared with respect to difference in mortality and other outcome measures. In addition, a multivariate analysis was performed. RESULTS: Two hundred fifty-five patients suffered pulmonary contusion: The CT-only group consisted of 157 and the CR/CT group of 98 patients. The CT-only group did not differ from the control group with respect to mortality rate and other outcome measures. However, compared with the CR/CT group, mortality rate was significantly lower (8% versus 16%, p = 0.039) and most other outcome measures were significantly better in the CT-only group. CONCLUSION: OPC on MDCT is not associated with a worse outcome as compared with patients without pulmonary contusion. OPC has a better outcome as compared with pulmonary contusion visible on both CR and MDCT.

Predictors for the selection of patients for abdominal CT after blunt trauma: a proposal for a diagnostic algorithm.

OBJECTIVE: To select parameters that can predict which patients should receive abdominal computed tomography (CT) after high-energy blunt trauma. SUMMARY BACKGROUND DATA: Abdominal CT accurately detects injuries of the abdomen, pelvis, and lumbar spine, but has important disadvantages. More evidence for an appropriate patient selection for CT is required. METHODS: A prospective observational study was performed on consecutive adult high-energy blunt trauma patients. All patients received primary and secondary surveys according to the advanced trauma life support, sonography (focused assessment with sonography for trauma [FAST]), conventional radiography (CR) of the chest, pelvis, and spine and routine abdominal CT. Parameters from prehospital information, physical examination, laboratory investigations, FAST, and CR were prospectively recorded for all patients. Independent predictors for the presence of > or =1 injuries on abdominal CT were determined using a multivariate logistic regression analysis. RESULTS: A total of 1040 patients were included, 309 had injuries on abdominal CT. Nine parameters were independent predictors for injuries on CT: abnormal CR of the pelvis (odds ratio [OR], 46.8), lumbar spine (OR, 16.2), and chest (OR, 2.37), abnormal FAST (OR, 26.7), abnormalities in physical examination of the abdomen/pelvis (OR, 2.41) or lumbar spine (OR 2.53), base excess <-3 (OR, 2.39), systolic blood pressure <90 mm Hg (OR, 3.81), and long bone fractures (OR, 1.61). The prediction model based on these predictors resulted in a R of 0.60, a sensitivity of 97%, and a specificity of 33%. A diagnostic algorithm was subsequently proposed, which could reduce CT usage with 22% as compared with a routine use. CONCLUSIONS: Based on parameters from physical examination, laboratory, FAST, and CR, we created a prediction model with a high sensitivity to select patients for abdominal CT after blunt trauma. A diagnostic algorithm was proposed.

Effect of a new pelvic stabilizer (T-POD®) on reduction of pelvic volume and haemodynamic stability in unstable pelvic fractures.

BACKGROUND: Pelvic fractures, often the result of high energy blunt trauma, are associated with severe morbidity and mortality. A new pelvic stabilizer (T-POD®) provides secure and effective simultaneous circumferential compression of the pelvis. METHODS: In this study we describe 15 patients with a prehospital untreated unstable pelvic fracture with signs of hypovolaemic shock with the T-POD®. Before and 2 min after applying the T-POD®, heart rate and blood pressure were measured. An X-ray before and directly after applying the T-POD® was made to measure the effect on reduction in symphyseal diastasis. RESULTS: Application of the T-POD® reduced the symphyseal diastasis with 60% (p = 0.01). The mean arterial pressure (MAP) increased significant from 65.3 to 81.2 mm Hg (p = 0.03) and the heart rate declined from 107 beats per minute to 94 (p = 0.02). Out of ten patients in whom the circulatory response before and after the T-POD® was recorded, seven were good responders, one had a transient response and two responded poor. CONCLUSION: In the acute setting, the T-POD® device has a clear compressive effect on the pelvic volume in unstable pelvic fractures. The T-POD® is therefore an effective and easy to use device in (temporarily) stabilizing the pelvic ring in haemodynamically unstable patients.

Criteria for the selective use of chest computed tomography in blunt trauma patients.

PURPOSE: The purpose of this study was to derive parameters that predict which high-energy blunt trauma patients should undergo computed tomography (CT) for detection of chest injury. METHODS: This observational study prospectively included consecutive patients (>or=16 years old) who underwent multidetector CT of the chest after a high-energy mechanism of blunt trauma in one trauma centre. RESULTS: We included 1,047 patients (median age, 37; 70% male), of whom 508 had chest injuries identified by CT. Using logistic regression, we identified nine predictors of chest injury presence on CT (age >or=55 years, abnormal chest physical examination, altered sensorium, abnormal thoracic spine physical examination, abnormal chest conventional radiography (CR), abnormal thoracic spine CR, abnormal pelvic CR or abdominal ultrasound, base excess <-3 mmol/l and haemoglobin <6 mmol/l). Of 855 patients with >or=1 positive predictors, 484 had injury on CT (95% of all 508 patients with injury). Of all 192 patients with no positive predictor, 24 (13%) had chest injury, of whom 4 (2%) had injuries that were considered clinically relevant. CONCLUSION: Omission of CT in patients without any positive predictor could reduce imaging frequency by 18%, while most clinically relevant chest injuries remain adequately detected.

Outcome prediction in mild traumatic brain injury: age and clinical variables are stronger predictors than CT abnormalities.

Mild traumatic brain injury (mTBI) is a common heterogeneous neurological disorder with a wide range of possible clinical outcomes. Accurate prediction of outcome is desirable for optimal treatment. This study aimed both to identify the demographic, clinical, and computed tomographic (CT) characteristics associated with unfavorable outcome at 6 months after mTBI, and to design a prediction model for application in daily practice. All consecutive mTBI patients (Glasgow Coma Scale [GCS] score: 13-15) admitted to our hospital who were age 16 or older were included during an 8-year period as part of the prospective Radboud University Brain Injury Cohort Study (RUBICS). Outcome was assessed at 6 months post-trauma using the Glasgow Outcome Scale-Extended (GOSE), dichotomized into unfavorable (GOSE score 1-6) and favorable (GOSE score 7-8) outcome groups. The predictive value of several variables was determined using multivariate binary logistic regression analysis. We included 2784 mTBI patients and found CT abnormalities in 20.7% of the 1999 patients that underwent a head CT. Age, extracranial injuries, and day-of-injury alcohol intoxication proved to be the strongest outcome predictors. The presence of facial fractures and the number of hemorrhagic contusions emerged as CT predictors. Furthermore, we showed that the predictive value of a scheme based on a modified Injury Severity Score (ISS), alcohol intoxication, and age equalled the value of one that also included CT characteristics. In fact, it exceeded one that was based on CT characteristics alone. We conclude that, although valuable for the identification of the individual mTBI patient at risk for deterioration and eventual neurosurgical intervention, CT characteristics are imperfect predictors of outcome after mTBI.

[Acute pelvic fractures]. / Acute behandeling van bekkenfracturen.

Two patients were involved in a high-energy trauma that resulted in an unstable pelvic fracture. The first patient, a 51-year-old woman, was trapped between two boats. At our hospital she received a traumatic pelvic orthotic device (T-POD), followed by angiography with embolisation. Three days post-trauma she went to the operating room for definitive surgical treatment of her Tile C pelvic fracture. The second patient, a 19-year-old man, was in a car that collided with a tree. He also received a T-POD, but remained haemodynamically unstable. He went to the operating room for damage control surgery, followed by an angiography with embolisation. Two days later, definitive surgical treatment of the Tile C pelvic fracture took place. These cases illustrate the variety of possible treatments for patients with unstable pelvic fractures. Choice of treatment depends on the character of the attending injuries and the haemodynamic situation. Fast consultation should take place with a hospital experienced in the initial care and treatment of unstable pelvic fractures.

Is a pelvic fracture a predictor for thoracolumbar spine fractures after blunt trauma?

BACKGROUND: Discussion still remains which polytraumatized patients require radiologic thoracolumbar spine (TL spine) screening. The purpose of this study is to determine whether pelvic fractures are associated with TL spine fractures after a blunt trauma. Additionally, the sensitivity of conventional TL spine radiographs and pelvic radiographs (PXRs) is evaluated. METHODS: We prospectively studied 721 consecutive patients who had sustained a high-energy blunt trauma. The diagnostic workup in these patients included routine conventional radiographs of the pelvis and TL spine followed by a computed tomography (CT) analysis. All patients with pelvic fractures and TL spine fractures identified on conventional radiographs and CT were analyzed. A relative risk (RR) was calculated for the association between pelvic fractures and TL spine fractures. The sensitivity for conventional TL spine radiographs and PXRs in identifying fractures was calculated. RESULTS: Of the 721 patients studied, 620 were included in our diagnostic high-energy trauma protocol. Of these 620 included patients, 86 (14%) suffered a pelvic fracture and 126 (20%) suffered a TL spine fracture. Thirty-three patients (5%) suffered both a pelvic fracture and a TL spine fracture. The RR for a TL spine fracture in the presence of a pelvic fracture identified on PXR is 2.14 (95% confidence interval, 1.54-2.98) and identified on CT this RR is 2.20 (95% confidence interval, 1.59-3.05). However, this association diminishes to a nonsignificant level when the transverse process and spinous process fractures are excluded. Overall sensitivity for conventional TL spine radiographs and PXRs is 22% and 69%, respectively. CONCLUSION: Our data suggest that a pelvic fracture is not a predictor for clinically relevant TL spine fractures. Furthermore, our data confirm the superior sensitivity of CT for detecting TL spine injury and pelvic fractures.

Routine versus selective multidetector-row computed tomography (MDCT) in blunt trauma patients: level of agreement on the influence of additional findings on management.

INTRODUCTION: This study was performed to determine the agreement between and within surgeons concerning the influence on treatment plan of routine versus selective multidetector-row computed tomography (MDCT) findings in blunt trauma patients. PATIENTS: For this study, 50 patients were randomly selected from a customized database that was originally used to compare a diagnostic algorithm with a selective use of MDCT with an algorithm with routine MDCT of the spine, chest, and abdomen within the same population. In all 50 patients, routine MDCT found additional diagnoses as compared with the selective MDCT algorithm. Of all patients, paper cases were created with detailed information on clinical parameters, findings by physical examination, and radiologic findings. The cases were independently presented to three different trauma surgeons. First, the surgeons were asked for their treatment plan based upon diagnoses found by physical examination, conventional radiography, and selective MDCT alone. Subsequently they were asked for their treatment plan with knowledge of the injuries additionally found by routine MDCT. This procedure was repeated after 3 months. The agreement between and within surgeons was determined for the change of patient management because of additional findings by routine MDCT. RESULTS: The agreement on the influence of routine MDCT findings on patient management between surgeons was moderate ([kappa] = 0.46) in the first procedure and substantial in the second ([kappa] = 0.67). The agreement within surgeons ranged from moderate ([kappa] = 0.60) to excellent ([kappa] = 0.87). CONCLUSION: All surgeons agreed that the traumatic injuries additionally found by routine MDCT, frequently resulted in a change of treatment plan. There was a moderate-to-excellent agreement between and within surgeons that these additional findings resulted in a change of treatment plan.

Routine versus selective computed tomography of the abdomen, pelvis, and lumbar spine in blunt trauma: a prospective evaluation.

BACKGROUND: Discussion still remains whether computed tomography (CT) of the abdomen, pelvis, and lumbar spine should be performed routinely after blunt trauma with high energy impact or only in restricted situations. The purpose of this study was to evaluate the additional value of a routine CT algorithm as compared with a more restricted, selective CT algorithm. MATERIALS: This prospective study consisted of 465 patients that met the inclusion criteria of our high-energy trauma protocol. All patients underwent physical examination, abdominal ultrasound (AUS), and conventional radiography (CR) of the pelvis and lumbar spine and subsequently routine CT of the abdomen, pelvis, and lumbar spine. Before CT, a subgroup of patients with abnormal physical examination or CR or AUS was prospectively defined as the selective CT group. Type and extent of injuries and impact on treatment were recorded for both the routine CT group and the selective CT subgroup. RESULTS: Of all patients, 42 received selective CT of the abdomen, 71 of the pelvis, and 48 of the lumbar spine. Compared with the algorithm with selective CT, routine CT revealed additional traumatic injuries in 15% of the patients in the abdomen, in 2.4% in the pelvis and in 8.2% in the lumbar spine. This resulted in an overall change of treatment in 6.4% (95% confidence interval, 3.7-9.0) of the patients who would not have received CT in a selective CT algorithm. CONCLUSIONS: Compared with an algorithm with selective CT, an algorithm with routine CT finds substantially more clinically relevant diagnoses, even in patients with unsuspicious clinical examination, normal CR, and normal AUS.