Characterization of fatal blunt injuries using postmortem computed tomography.

BACKGROUND: Rapid triage of blunt agonal trauma patients is necessary to maximize survival, but autopsy is uncommon, slow, and rarely informs resuscitation guidelines. Postmortem computed tomography (PMCT) can serve as an adjunct to autopsy in guiding blunt agonal trauma resuscitation. METHODS: Retrospective cohort review of trauma decedents who died at or within 1 hour of arrival following blunt trauma and underwent noncontrasted PMCT. Primary outcome was the prevalence of mortal injury defined as potential exsanguination (e.g., cavitary injury, long bone and pelvic fractures), traumatic brain injury, and cervical spine injury. Secondary outcomes were potentially mortal injuries (e.g., pneumothorax) and misplacement airway devices. Patients were grouped by whether arrest occurred prehospital/in-hospital. Univariate analysis was used to identify differences in injury patterns including multiple-trauma injury patterns. RESULTS: Over a 9-year period, 80 decedents were included. Average age was 48.9 ± 21.7 years, 68% male, and an average ISS of 42.3 ± 16.3. The most common mechanism was motor vehicle accidents (67.5%) followed by pedestrian struck (15%). Of all decedents, 62 (77.5%) had traumatic arrest prehospital while 18 (22.5%) arrived with pulse. Between groups there were no significant differences in demographics including ISS. The most common mortal injuries were traumatic brain injury (40%), long bone fractures (25%), moderate/large hemoperitoneum (22.5%), and cervical spine injury (25%). Secondary outcomes included moderate/large pneumothorax (18.8%) and esophageal intubation rate of 5%. There were no significant differences in mortal or potentially mortal injuries, and no differences in multiple-trauma injury patterns. CONCLUSION: Fatal blunt injury patterns do not vary between prehospital and in-hospital arrest decedents. High rates of pneumothorax and endotracheal tube misplacement should prompt mandatory chest decompression and confirmation of tube placement in all blunt arrest patients. LEVEL OF EVIDENCE: Prognostic and Epidemiological; Level IV.

Traumatic abdominal wall hernias in the pediatric population: a 13-year institutional review.

BACKGROUND: Pediatric traumatic abdominal wall hernias are rare but potentially devastating injuries. Although classically considered to be caused by handlebar injuries from bicycle accidents, our anecdotal experience suggests pediatric traumatic abdominal wall hernias are far more likely to occur following road traffic accidents and have a high association with other significant intra-abdominal injuries. OBJECTIVE: The purpose of this study was to determine the frequency, mechanisms of injury, and associated injuries of traumatic abdominal wall hernias in the pediatric population. MATERIALS AND METHODS: This is a retrospective observational cohort study from two large urban level 1 trauma centers. Institutional trauma registries were queried from January 1, 2008, to December 31, 2020, for patients under 18 years of age diagnosed with traumatic abdominal wall hernias, excluding those without initial abdominopelvic CT imaging. Finalized CT reports and images were reviewed to confirm the presence of a traumatic abdominal wall hernia and document any associated secondary injuries. The medical record was reviewed to extract pertinent physical findings, interventions performed, and outcomes. Injury Severity Score (ISS) for each patient was calculated by the trauma registrar. RESULTS: A total of 19 patients with TAWH met inclusion criteria, with an overall frequency of 0.095% and a mean age of 10.6 years (range 3-17). Eleven patients were male (57.9%) with a mean ISS of 18.6 (range 1-48, including 63.2% with ISS > 15). The most common mechanism of injury was motor vehicle collision (N = 11, 57.9%) followed by bicycle accident (N = 3, 15.8%). A total of 17 (89.5%) had associated injuries, including 11 (57.9%) with intestinal injuries, 5 (26.3%) with pelvic fractures, 4 (21.1%) with femur fractures, 3 (15.8%) with splenic injuries, 3 (15.8%) with kidney injuries, and 3 (15.8%) with Chance fractures of the lumbar spine. All patients required surgery for the traumatic abdominal wall hernias and associated injuries. CONCLUSION: Pediatric traumatic abdominal wall hernias are more likely to be seen following motor vehicle collisions, with a majority (89.5%) having associated injuries, most frequently to the bowel (57.9%). Handlebar injuries were seen in a minority of patients (15.8%) and were less likely to be associated with additional injuries. CLINICAL IMPACT: Pediatric patients with a traumatic abdominal wall hernia on admission CT should be thoroughly evaluated for bowel injuries, especially in the setting of a motor vehicle collision.

Patient-Specific Precision Injury Signatures to Optimize Orthopaedic Interventions in Multiply Injured Patients (PRECISE STUDY).

SUMMARY: Optimal timing and procedure selection that define staged treatment strategies can affect outcomes dramatically and remain an area of major debate in the treatment of multiply injured orthopaedic trauma patients. Decisions regarding timing and choice of orthopaedic procedure(s) are currently based on the physiologic condition of the patient, resource availability, and the expected magnitude of the intervention. Surgical decision-making algorithms rarely rely on precision-type data that account for demographics, magnitude of injury, and the physiologic/immunologic response to injury on a patient-specific basis. This study is a multicenter prospective investigation that will work toward developing a precision medicine approach to managing multiply injured patients by incorporating patient-specific indices that quantify (1) mechanical tissue damage volume; (2) cumulative hypoperfusion; (3) immunologic response; and (4) demographics. These indices will formulate a precision injury signature, unique to each patient, which will be explored for correspondence to outcomes and response to surgical interventions. The impact of the timing and magnitude of initial and staged surgical interventions on patient-specific physiologic and immunologic responses will be evaluated and described. The primary goal of the study will be the development of data-driven models that will inform clinical decision-making tools that can be used to predict outcomes and guide intervention decisions.

American Society of Emergency Radiology Multicenter Blunt Splenic Trauma Study: CT and Clinical Findings.

Background Treatment of blunt splenic trauma (BST) continues to evolve with improved imaging for detection of splenic vascular injuries. Purpose To report on treatments for BST from 11 trauma centers, the frequency and clinical impact of splenic vascular injuries, and factors influencing treatment. Materials and Methods Patients were retrospectively identified as having BST between January 2011 and December 2018, and clinical, imaging, and outcome data were recorded. Patient data were summarized descriptively, both overall and stratified by initial treatment received (nonoperative management [NOM], angiography, or surgery). Regression analyses were used to examine the primary outcomes of interest, which were initial treatment received and length of stay (LOS). Results This study evaluated 1373 patients (mean age, 42 years ± 18; 845 men). Initial treatments included NOM in 849 patients, interventional radiology (IR) in 240 patients, and surgery in 284 patients. Rates from CT reporting were 22% (304 of 1373) for active splenic hemorrhage (ASH) and 20% (276 of 1373) for contained vascular injury (CVI). IR management of high-grade injuries increased 15.6%, from 28.6% (eight of 28) to 44.2% (57 of 129) (2011-2012 vs 2017-2018). Patients who were treated invasively had a higher injury severity score (odds ratio [OR], 1.04; 95% CI: 1.02, 1.05; P < .001), lower temperature (OR, 0.97; 95% CI: 0.97, 1.00; P = .03), and a lower hematocrit (OR, 0.96; 95% CI: 0.93, 0.99; P = .003) and were more likely to show ASH (OR, 8.05; 95% CI: 5.35, 12.26; P < .001) or CVI (OR, 2.70; 95% CI: 1.64, 4.44; P < .001) on CT images, have spleen-only injures (OR, 2.35; 95% CI: 1.45, 3.8; P < .001), and have been administered blood product for fewer than 24 hours (OR, 2.35; 95% CI: 1.58, 3.51; P < .001) compared with those chosen for NOM, after adjusting for key demographic and clinical variables. After adjustment, factors associated with a shorter LOS were female sex (OR, 0.84; 95% CI: 0.73, 0.96; P = .009), spleen-only injury (OR, 0.72; 95% CI: 0.6, 0.86; P < .001), higher admission hematocrit (OR, 0.98; 95% CI: 0.6, 0.86; P < .001), and presence of ASH at CT (OR, 0.74; 95% CI: 0.62, 0.88; P < .001). Conclusion Contained vascular injury and active splenic hemorrhage (ASH) were frequently reported, and rates of interventional radiologic management increased during the study period. ASH was associated with a shorter length of stay, and patients with ASH had eight times the odds of undergoing invasive treatment compared with undergoing nonoperative management. © RSNA, 2021 See also the editorial by Patlas in this issue.

Optimizing Electronic Release of Imaging Results through an Online Patient Portal.

Purpose To determine an optimal embargo period preceding release of radiologic test results to an online patient portal. Materials and Methods This prospective discrete choice conjoint survey with modified orthogonal design was administered to patients by trained interviewers at four outpatient sites and two institutions from December 2016 to February 2018. Three preferences for receiving imaging results associated with a possible or known cancer diagnosis were evaluated: delay in receipt of results (1, 3, or 14 days), method of receipt (online portal, physician's office, or phone), and condition of receipt (before, at the same time as, or after health care provider). Preferences (hereafter, referred to as utilities) were derived from parameter estimates (ß) of multinomial regression stratified according to study participant and choice set. Results Among 464 screened participants, the response and completion rates were 90.5% (420 of 464) and 99.5% (418 of 420), respectively. Participants preferred faster receipt of results (P < .001) from their physician (P < .001) over the telephone (P < .001). Each day of delay decreased preference by 13 percentage points. Participants preferred immediate receipt of results through an online portal (utility, -.57) if made to wait more than 6 days to get results in the office and more than 11 days to get results by telephone. Compared with receiving results in their physician's office on day 7 (utility, -.60), participants preferred immediate release through the online portal without physician involvement if followed by a telephone call within 6 days (utility, -0.49) or an office visit within 2 days (utility, -.53). Older participants preferred physician-directed communication (P < .001). Conclusion The optimal embargo period preceding release of results through an online portal depends on the timing of traditional telephone- and office-based styles of communication. © RSNA, 2018 Online supplemental material is available for this article. See also the editorial by Arenson et al in this issue.

Diagnostic Yield and Clinical Utility of Abdominopelvic CT Following Emergent Laparotomy for Trauma.

Purpose To determine the incidence of unexpected injuries that are diagnosed with computed tomography (CT) after emergent exploratory laparotomy for trauma and whether identification of such injuries results in additional surgery or angiography. Materials and Methods This HIPAA-compliant retrospective study was approved by the institutional review board, and the requirement for informed consent was waived. The trauma databases of two urban level 1 trauma centers were queried over a period of more than 5 years for patients who underwent abdominopelvic CT within 48 hours of emergent exploratory laparotomy for trauma. Comparisons were made between CT findings and those described in the surgical notes. Descriptive statistics were generated, and 95% confidence intervals (CIs) were determined by using an exact method based on a binomial distribution. Results The study cohort consisted of 90 patients, including both blunt and penetrating trauma victims with a median injury severity score of 17.5 (interquartile range, 9.25-34). Seventy-three percent (66 of 90) of patients sustained penetrating trauma, 82% (74 of 90) of whom were male. A total of 19 patients (21.1%; 95% CI: 13.2, 31.0) had additional injuries within the surgical field that were not identified during laparotomy. There were 17 unidentified solid organ injuries, and eight patients had active bleeding within the surgical field. Eight patients (8.9%; 95% CI: 3.9, 16.8) had unexpected injuries at CT that were substantial enough to warrant additional surgery or angiography. In addition, previously undiagnosed fractures were found in 45 patients (50%; 95% CI: 39.3, 60.7). Conclusion Performing CT after emergent exploratory laparotomy for trauma is useful in identifying unexpected injuries and confirming suspected injuries that were not fully explored at initial surgery. (©) RSNA, 2016.

Traumatic abdominal wall hernias: Location matters.

BACKGROUND: Because of its uncommon nature and a lack of comprehensive literature, abdominal wall hernias caused by blunt trauma continue to present a management dilemma. This study was performed to identify the incidence of associated injuries, the need for urgent operative intervention, and recurrence rates after hernia repair. METHODS: A retrospective review of patients diagnosed with a traumatic abdominal wall hernia from January 2002 to December 2014 was performed. Data were collected from the trauma registry and included patient demographics, location and type of hernia, associated injuries, operative interventions, complications, and length of stay. RESULTS: Eighty patients (64% male; median age, 36 years; mean Injury Severity Score [ISS], 22) were identified during the study period. A motor vehicle collision was the most frequent mechanism of injury (n = 58). Overall, 35 patients (44%) underwent urgent laparotomy or laparoscopy, and 10 of these (29%) were nontherapeutic excluding hernia repair. Of interest, 17 patients (49%) required bowel resection. Notably, the need for operative intervention and nontherapeutic rate differed depending on hernia location. Hernia repair was performed in 23 patients, the majority of whom (78.3%) underwent repair within 5 days of injury. There were six recurrences, four of which were repaired acutely (within 1 week of injury), with an overall first-time hernia recurrence rate of 26%. CONCLUSION: In the largest series to date, traumatic abdominal wall hernias were found to be associated with a high percentage of intra-abdominal injuries requiring urgent laparotomy or laparoscopy. Rates of therapeutic interventions varied by hernia location, with anterior abdominal hernias associated with the highest need for a therapeutic operation. Acute repair was associated with the majority of the recurrences. LEVEL OF EVIDENCE: Epidemiologic study, level III; therapeutic study, level IV.

Emergency radiology eponyms: part 1-Pott's puffy tumor to Kerley B lines.

An eponym is a name based on the name of a person, frequently as a means to honor him/her, and it can be used to concisely communicate or summarize a complex abnormality or injury. However, inappropriate use of an eponym may lead to potentially dangerous miscommunication. Moreover, an eponym may honor the incorrect person or a person who falls into disrepute. Despite their limitations, eponyms are still widespread in medicine. Many commonly used eponyms applied to extremity fractures should be familiar to most emergency radiologists and have been previously reported. Yet, a number of non-extremity eponyms can be encountered in an emergency radiology practice as well. This other group of eponyms encompasses a spectrum of traumatic and non-traumatic pathology. In this first part of a two-part series, the authors discuss a number of non-extremity emergency radiology eponyms, including relevant clinical and imaging features, as well biographical information of the eponyms' namesakes.

Imaging evaluation of penetrating neck injuries.

Penetrating neck injuries are a significant source of morbidity and mortality. Diagnostic imaging plays an integral role in the diagnosis and management of these injuries. Although clinical management of penetrating injuries to the neck remains controversial, many institutions have shifted away from mandatory surgical exploration of most penetrating neck injuries toward use of endoscopy, various imaging modalities, and selective surgery to manage specific injuries diagnosed with these techniques. Much of this shift can be attributed to computed tomographic (CT) angiography, a fast, reliable, and noninvasive procedure that provides a global assessment of the neck, thereby reducing the frequency of nontherapeutic surgical neck explorations and limiting the need for diagnostic conventional angiography. Therefore, radiologists interpreting images from CT angiography should be prepared to provide management recommendations on the basis of the CT angiographic findings. An appreciation of the value, roles, and limitations of multidetector CT angiography and other imaging modalities can position the radiologist as a vital participant in the care of patients with penetrating trauma to the neck.

Acute traumatic aortic injuries: posttherapy multidetector CT findings.

Acute traumatic aortic injury is a life-threatening entity that requires emergent treatment. Treatment was once performed with left thoracotomy, resection of the damaged aortic segment, and placement of an interposition graft. Within the past decade, endovascular therapy has gained increased acceptance, primarily because of a significant decrease in mortality and morbidity compared with those of surgery. The authors reviewed the experience with management of acute traumatic aortic injuries at their institution, as well as that reported in the literature. Complications after endovascular repair include endoleak, endograft collapse, stroke, upper extremity ischemia, paraplegia, graft infection, endograft structural failure, missed injury or stent migration, and access site complications. After surgical repair, paraplegia and ischemia to other organs, graft dehiscence, graft infection, and graft stenosis may occur. With the growing use of endovascular management of acute traumatic aortic injuries and the increased likelihood of patient survival, the radiologist will be expected to be familiar with the findings in these patients and is positioned to play a critical role in early recognition of potential complications. Early diagnosis of the complications of therapy for aortic injury is imperative for reduction of mortality and morbidity.

Handling of outside trauma studies: a survey of program directors.

OBJECTIVE: Many trauma transfer patients arrive after hours with imaging studies performed at the transferring institution. Little attention has been given to the impact on on-call radiology residents and the potential medicolegal consequences. The purpose of this study was to assess the impact of outside trauma studies on on-call radiology residents. METHODS: A 20-question survey using the Web site www.surveymonkey.com was created to focus on the handling of outside images on trauma transfers. An institutional review board exemption for consent was obtained. The survey was distributed to all radiology residency program directors throughout the United States. RESULTS: Sixty-four program directors responded to our survey. Eighty percent of program directors worked at Level 1 trauma centers, 94% of program directors were located in medium to large cities and had an average of 27 residents (range 8-74), and 69% of programs reported receiving between 1 and 5 outside trauma studies per day, most without radiologic reports from the transferring hospital. After hours (defined by periods of time when no attending staff is present), these studies are read only by radiology residents at 45% of institutions. Written documentation by residents is often lacking when they are the sole radiology interpreters, and in many of these cases, the only documentation of the interpretation is a note in the patient's chart written by the referring clinician. The issue of transfer study interpretation was deemed a "definite" issue in 45% of programs, with 78% of program directors having been approached at least once regarding this issue. CONCLUSION: Trauma patients are usually transferred to accepting teaching institutions without written radiologic reports, which generally do not meet either American College of Radiology or American Cancer Society guidelines. Approximately half of trauma transfer patients are managed solely on the basis of radiology resident interpretation, exposing residents to medicolegal liability. There is no consensus among programs regarding the optimal handling of these studies. This issue is in critical need of attention from the radiology community to enhance timeliness of communication and patient safety, and to protect radiology residents.

Acute abdomen: Added diagnostic value of coronal reformations with 64-slice multidetector row computed tomography.

RATIONALE AND OBJECTIVES: We sought to assess retrospectively the added value of coronal reformations from isotropic voxels obtained with 64-slice multidetector row computed tomography (CT) of the acute abdomen. MATERIALS AND METHODS: This retrospective study was approved by the institutional review board and informed consent was waived. Multidetector helical 64-section CT (section thickness, 0.6 mm; pitch 1.75; table speed 35 mm/sec) was performed in 100 patients (60 women and 40 men; age range, 9-/+85 years; mean age, 45.2 years) with acute nontraumatic abdominal pain who had been referred from the emergency department. Axial images were reconstructed with 5-mm-thick sections at 5-mm intervals. The second data set was reformatted coronally, with 3-mm-thick sections at 3-mm intervals. Four independent, blinded readers with various level of training interpreted first the axial scans alone and then followed immediately by the coronal scans. Confidence in the visualization of anatomy and pathology was scored on a 5-point scale. The final diagnosis was determined by surgical and pathologic reports and by clinical follow-up in those who did not undergo surgery. RESULTS: Based upon the individual patient's clinical history and other comorbid factors, 92 patients received intravenous contrast and 90 patients received oral contrast. In 45 patients, no CT abnormalities were detected for an explanation of the abdominal pain. Mean sensitivity and specificity of axial CT alone were 92.5% and 91%, respectively. No significant differences in sensitivity and specificity were observed for the use of combined axial and coronal images. For the most inexperienced reader, the coronal reformations were helpful in 95% of cases, while for the most experienced reader, the coronal reformations were helpful in 35% of the cases. The coronal images were deemed helpful in an average of 62.3% of the cases for the four readers. However, diagnosing subtle pathology in the abdominal wall was difficult on coronal reformations alone. Overall, coronal reformations improved diagnostic confidence and interobserver agreement over axial images alone for visualization of normal abdominal structures and in the diagnosis of abdominal pathology. CONCLUSION: Axial and coronal reformations of 64-section multidetector row CT have equal sensitivity and specificity for the diagnosis of acute abdominal pathology. However, coronal reformations improved the diagnostic confidence for all readers but most significantly for the least experienced. Therefore, radiology departments with residents should consider routinely generating coronal images in patients with acute abdominal pain.