A new screening model for quantitative risk assessment of blunt thoracic aortic injury.

PURPOSE: Early identification of blunt thoracic aortic injury is vital for preventing subsequent aortic rupture. However, risk factors for blunt thoracic aortic injury remain unclear, and a prediction rule remains to be established. We developed and internally validated a new nomogram-based screening model that allows clinicians to quantify blunt thoracic aortic injury risk. METHODS: Adult patients (age ≥ 18 years) with blunt injury were selected from a nationwide Japanese database (January 2004-May 2019). Patients were randomly divided into training and test cohorts. A new nomogram-based blunt thoracic aortic injury-screening model was constructed using multivariate logistic regression analysis to quantify the association of potential predictive factors with blunt thoracic aortic injury in the training cohort. RESULTS: Overall, 305,141 patients (training cohort, n = 152,570; test cohort, n = 152,571) were eligible for analysis. Median patient age was 65 years, and 60.9% were men. Multivariate analysis in the training cohort revealed that 13 factors (positive association: age ≥ 55 years, male sex, high-energy impact, hypotension on hospital arrival, Glasgow Coma Scale score < 9 on hospital arrival, diaphragmatic injuries, hepatic injuries, pulmonary injuries, cardiac injuries, renal injuries, sternum fractures, multiple rib fractures, and pelvic fractures) were significantly associated with blunt thoracic aortic injury and included in the screening model. In the test cohort, the new screening model had an area under the curve of 0.87. CONCLUSIONS: Our novel nomogram-based screening model aids in the quantitative assessment of blunt thoracic aortic injury risk. This model may improve tailored decision-making for each patient.

Geriatric Skiers: Active But Still at Risk, a National Trauma Data Bank Study.

BACKGROUND: Downhill skiing accounts for a large portion of geriatric sport-related trauma. We assessed the national burden of geriatric versus nongeriatric ski trauma. MATERIALS AND METHODS: Adults presenting to level 1/2 trauma centers after ski-associated injuries from 2011 to 2015 were identified from the National Trauma Data Bank by ICD-9 code. We compared demographics, injury patterns, and outcomes between geriatric (age ≥65 y) and nongeriatric adult skiers (age 18-64 y). A multiple regression analysis assessed for risk factors associated with severe injury (Injury Severity Score >15). RESULTS: We identified 3255 adult ski trauma patients, and 16.7% (543) were geriatric. Mean ages for nongeriatric versus geriatric skiers were 40.8 and 72.1 y, respectively. Geriatric skiers more often suffered head (36.7 versus 24.3%, P < 0.0001), severe head (abbreviated injury scale score >3, 49.0 versus 31.5%, P < 0.0001) and thorax injuries (22.2 versus 18.1%, P = 0.03) as compared with nongeriatric skiers. Geriatric skiers were also more often admitted to the ICU (26.5 versus 14.9%, P < 0.0001), discharged to a facility (26.7 versus 11.6%, P < 0.0001), and suffered higher mortality rates (1.3 versus 0.4%, P = 0.004). Independent risk factors for severe injury included being male (OR: 1.68, CI: 1.22-2.31), helmeted (OR: 1.41, CI: 1.07-1.85), and having comorbidities (OR: 1.37, CI: 1.05-1.80). Geriatric age was not independently associated with severe injury. CONCLUSIONS: At level 1/2 trauma centers, geriatric age in ski trauma victims was associated with unique injury patterns, higher acuity, increased rates of facility care at discharge, and higher mortality as compared with nongeriatric skiers. Our findings indicate the need for specialized care after high impact geriatric ski trauma.

Forced vital capacity assessment for risk stratification of blunt chest trauma patients in emergency settings: A preliminary study.

OBJECTIVE: The aim of this study was to assess the performance of Forced Vital Capacity (FVC) for prediction of secondary respiratory complications in blunt chest trauma patients. METHODS: During a 15-month period, all consecutive blunt chest trauma patients admitted in our emergency intensive care unit with more than 3 rib fractures were eligible, unless they required mechanical ventilation in the prehospital or emergency settings. FVC was measured at admission and at emergency discharge after therapeutic interventions. The main outcome was the occurrence of secondary respiratory complications defined by hospital-acquired pulmonary infection, secondary admission in the intensive care unit or mechanical ventilation for respiratory failure or death. The performance of FVC for prediction of secondary respiratory complications was assessed by receiver operating characteristic (ROC) curve and multivariate analysis after logistic regression. RESULTS: Sixty-two consecutive patients were included and 13 (21%) presented secondary respiratory complications. Only FVC measured at emergency discharge - not FCV at admission - was significantly lower in patients who developed secondary respiratory complications (44±15 vs. 61±20%, P=0.002). The area under the ROC curves for FCV in predicting secondary pulmonary complications was 0.79 [95% CI: 0.66-0.88], P=0.0001. An FVC at discharge≤50% was independently associated with the occurrence of secondary complications with an OR at 7.9 [1.9-42.1], P=0.004. CONCLUSION: The non-improvement of FVC≤50% at emergency discharge is associated with secondary respiratory complications and should prevent the under-triage of patients with no sign of respiratory failure at admission.

Importance of diagnostic laparoscopy in the assessment of the diaphragm after left thoracoabdominal stab wound: A prospective cohort study.

BACKGROUND: Stab wounds in the left thoracoabdominal region may cause diaphragmatic injury. The aim of the present study was to determine incidence of diaphragmatic injury and role of diagnostic laparoscopy in detection of injury in patients with left thoracoabdominal stab wound. METHODS: Total of 81 patients (75 male, 6 female; mean age 27.5±9.8 years; range 14 to 60 years) who presented with left thoracoabdominal stab wound between April 2009 and September 2014 were evaluated. Laparotomy was performed on patients who had hemodynamic instability, signs of peritonitis, or organ evisceration. Remaining patients were followed conservatively. After 48 hours, diagnostic laparoscopy was performed on patients without laparotomy indication to examine the left diaphragm for injury. Follow-up and treatment findings were prospectively evaluated. RESULTS: Thirteen patients underwent laparotomy while diagnostic laparoscopy was performed on remaining 68 patients. Left diaphragmatic injury was observed in 19 patients (23.5%) in the study group. Four injuries were diagnosed by laparotomy and 15 were diagnosed by laparoscopy. Presence of hemopneumothorax did not yield difference in incidence of diaphragmatic injury (p=0.131). No significant difference was detected in terms of diaphragmatic injury with respect to entry site of stab wound in the thoracoabdominal region (p=0.929). CONCLUSION: It is important to evaluate the diaphragm in left thoracoabdominal stab injuries, and diagnostic laparoscopy is still the safest and most feasible method.

[Assessment of thoracic trauma at the 1st Department of Surgery in Brno (1 January 2011 - 31 December 2015)]. / Poranení hrudníku na I. chirurgické klinice LF MU a FN USA v Brne (vyhodnocené období 1. 1. 2011 az 31. 12. 2015).

INTRODUCTION: The number of cases of thorax injury increased steadily between 2011 and 2015. This is probably related to a more active lifestyle of the younger generations and also to the increasing average age of citizens. The aim of the study was to show problems connected with thorax injury. METHOD: Our retrospective study evaluated a group of patients with thoracic injury (diagnosis codes S20-S29) in the period from 1 January 2011 to 31 December 2015 who were treated in our Department. RESULTS: We evaluated a group of 1,697 patients with thoracic injury were divided into five subgroups: 1) simple contusion of the thorax, 2) simple rib fractures, 3) contusion of the thorax with vertebral fractures, 4) serial, multiple rib fractures, 5) stab and gunshot injuries of the thorax. Each subgroup was analyzed independently and in detail. The number of thoracic injuries increased steadily, year on year. More than 40% of the patients were older than 60 years. In the group with simple rib fractures, the authors found 14 cases of pneumothorax (5.1%), which was drained in only 8 cases. The most common complications in the serial rib fractures group included pneumothorax (33 cases, 20%), hemothorax (28 cases, 16.9%) and lung contusion (15 cases, 9%). Stabilization of the thoracic wall was performed 16 times, out of the total of 26 multiple rib fracture cases (61.5%). CONCLUSIONS: Thorax injury is routinely encountered by surgeons. The authors recommend to pay particular attention not only to serious, but also to simple thorax injuries in very old patients, for instance those on anticoagulation therapy. Adequate caution also needs to be taken with serial rib fractures and flail chest and their treatment.Key words: thorax injury - rib fractures - hemothorax - pneumothorax.

Use of a Novel Accounting and Grouping Method for Major Trunk Injury-Analysis of Data from a Statewide Trauma Financial Survey.

Major trunk trauma is common and costly, but comparisons of costs between trauma centers (TCs) are rare. Understanding cost is essential to improve quality, manage trauma service lines, and to facilitate institutional commitment for trauma. We have used results of a statewide trauma financial survey of Levels I to IV TC to develop a useful grouping method for costs and clinical characteristics of major trunk trauma. The trauma financial survey collected billing and clinical data on 75 per cent of the state trauma registry patients for fiscal year 2012. Cost was calculated by separately accounting for embedded costs of trauma response and verification, and then adjusting reasonable costs from the Medicare cost report for each TC. The cost-to-charge ratios were then recalculated and used to determine uniform cost estimates for each patient. From the 13,215 patients submitted for the survey, we selected 1,094 patients with major trunk trauma: lengths of stay ≥ 48 hours and a maximum injury of AIS ≥3 for either thorax or abdominal trauma. These patients were then divided into three Injury Severity Score (ISS) groups of 9 to 15, 16 to 24, or 25+ to stratify patients into similar injury groups for analysis of cost and cost drivers. For abdominal injury, average total cost for patients with ISS 9 to 15 was $17,429. Total cost and cost per day increased with severity of injury, with $51,585 being the total cost for those with ISS 25. Similar trends existed for thoracic injury. Use of the Medicare cost report and cost-to-charge ratios to compute uniform costs with an innovative grouping method applied to data collected across a statewide trauma system provides unique information regarding cost and outcomes, which affects quality improvement, trauma service line management, and decisions on TC participation.

Torso Computed Tomography Can Be Bypassed after Thorough Trauma Bay Examination of Patients Who Fall from Standing.

Reliance on CT imaging in the evaluation of low-impact blunt trauma is a major source of radiation exposure, cost, and resource utilization. This study sought to determine if torso (chest and abdomen) CT could be avoided in patients with ground level falls. This was a retrospective chart review of patients admitted to the trauma service between January 2013 and April 2014. The mechanism of injury was ground level fall or fall from sitting. Patient demographics, physical examination (PE) findings, imaging results, length of stay, and complications were reviewed. History and physical data were based on chief resident or attending documentation. A significant thoracic injury was defined as a hemothorax, a pneumothorax, greater than three rib fractures, or aortic injury. A significant abdominal injury was defined as a solid organ injury, an intra-abdominal hematoma, a hollow viscus injury, aortic injury, or a urologic injury. The trauma service evaluated 156 patients. Nine patients were excluded for intubation or Glasgow Coma Scale (GCS) < 13. Of the 147 remaining, mean age was 69 years, mean GCS was 14.8. A chest CT was obtained in 111 (76%). Eight (7%) had a significant thoracic injury. All patients with significant thoracic injury had positive examination findings. No patient with a normal PE was found to have a significant thoracic injury (negative predictive value of 100%). An abdominal CT was obtained in 86 (59%). Five (6%) were found to have a significant abdominal injury. All patients who had a significant radiographic injury had an abnormal PE (negative predictive value of 100%). In conclusion, thorough history and physical in the trauma bay allow the clinician to obtain selective torso CT imaging. Routine torso CT warrants re-evaluation in low-impact injury mechanisms as there appears to be little benefit compared with the resource utilization and expense.

The effect of loss to follow-up on treatment of blunt traumatic thoracic aortic injury.

OBJECTIVE: Loss to follow-up (LTFU) can be a major difficulty for any clinical research study. The objective of this systematic review was to assess the extent of LTFU and its potential effect in studies of adult trauma patients with blunt thoracic aortic injuries (BTAIs). METHODS: Studies comparing management of BTAIs were systematically reviewed. Duplicate independent review was used for study selection, data abstraction, and critical appraisals. RESULTS: Thirty-six studies were included for synthesis, of which 94.1% applied a retrospective cohort design to prospective institutional databases. The mean LTFU at 1 year was 26.5% ± 31.6% for endovascular repair and 20.6% ± 34.2% for open repair groups. Not having a surgical/interventional specialist as a first or senior author was associated with a 39.7% higher LTFU at 1 year (P = .002). Studies with a higher risk of bias, later publication year, or North American origin were associated with a significantly higher risk for LTFU at 1 year (P ≤ .001). Nearly half of included studies assessed in-hospital outcomes exclusively. Only 38.2% explicitly reported LTFU data. Eight studies explicitly described the method of dealing with LTFU: eight used survival analysis and one used a national Social Security Death Index. Sensitivity analyses using plausible worst-case LTFU scenarios resulted in 14% to 17% of studies changing direction of effect. CONCLUSIONS: There is significant LTFU in trauma studies comparing operative methods for BTAIs. LTFU is generally handled and reported suboptimally, and sensitivity analyses suggest that study results are sensitive to differential LTFU. This has implications for the evidence-based choice of the operative method. Some protective factors that may aid in reducing LTFU were identified, one of which was involvement of a surgical or interventional specialist as a key author.

A new aortic injury score predicts early rupture more accurately than clinical assessment.

OBJECTIVE: The optimal timing for repair of a high-grade blunt thoracic aortic injury (BTAI) is uncertain. Delayed repair is common and associated with improved outcomes, but some lesions may rupture during observation. To determine optimal patient selection for appropriate management, we developed a pilot clinical risk score to evaluate aortic stability and predict rupture. METHODS: Patients presenting in stable condition with Society for Vascular Surgery grade III or IV BTAI diagnosed on computed tomography (CT) were retrospectively reviewed. To determine clinical and radiographic factors associated with aortic rupture, patients progressing to aortic rupture (defined by contrast extravasation on CT or on operative or autopsy findings) were compared with those who had no intervention ≤48 hours of admission. A model targeting 100% sensitivity for rupture was generated and internally validated by bootstrap analysis. Clinical utility was tested by comparison with clinical assessment by surgeons experienced in BTAI management who were provided with CT images and clinical data but were blinded to outcome. RESULTS: The derivation cohort included 18 patients whose aorta ruptured and 31 with stable BTAI. There was no difference in age, gender, injury mechanism, nonchest injury severity, blood pressure, or Glasgow Coma Scale on admission between patient groups. As dichotomous factors, admission lactate >4 mM, posterior mediastinal hematoma >10 mm, and lesion/normal aortic diameter ratio >1.4 on the admission CT were independently associated with aortic rupture. The model had an area under the receiver operator curve of .97, and in the presence of any two factors, was 100% sensitive and 84% specific for predicting aortic rupture. No aortic lesions ruptured in patients with fewer than two factors. In contrast, clinical assessment had lower accuracy (65% vs 90% total accuracy, P < .01). CONCLUSIONS: This novel risk score can be applied on admission using clinically relevant factors that incorporate patient physiology, size of the aortic lesion, and extent of the mediastinal hematoma. The model reliably identifies and distinguishes patients with high-grade BTAI who are at risk for early rupture from those with stable lesions. Although preliminary, because it is more accurate than clinical assessment alone, the score may improve patient selection for emergency or delayed intervention.

Ultrasonido torácico extendido en trauma (EFAST) / Thoracic ultrasound. extended focus assessment with sonography in trauma (EFAST)

Dentro del abordaje diagnóstico del trauma torácico se cuenta con múltiples auxiliares diagnósticos, entre ellos el ultrasonido FAST extendido a tórax (EFAST). Para la detección de hemo o neumotórax, la radiografía de tórax ha demostrado una sensibilidad de 69% y especificidad de 76%, con la tomografía la sensibilidad y especificidad se acercan al 100%. El EFAST ha demostrado una sensibilidad del 92-100%, aun realizado por médicos no radiólogos Objetvo: evaluar la sensibilidad y especifcidad del ultrasonido torácico extendido (EFAST) dentro de la práctca en la atención de emergencia en elservicio de emergencia en el Hospital Roosevelt Método: Se realizó un estudio descriptvo, tansversal de pacientes que ingresaron con trauma cerrado y penetrante en tórax a quienes se les realizóEFAST, radiografa de tórax y tomografa torácica Resultados: De 16 pacientes, 13 (81.25%) fueron hombres y tres (18.75%) mujeres. 11 (68.75%) con trauma contuso y 5 (31.25%) con trauma penetrante.El grupo de edad más afectado fue el comprendido entre los 18 a 45 años. De los 16 estudios realizados, nueve (56.25%) fueron califcados comopositvos para neumotórax, observándose el signo de la estratosfera en los nueve casos (100%); el resultado fue corroborado con radiografa de tórax ytomografa. Un paciente presentó alteraciones tomográfcas compatbles con hemoneumotórax que no fueron detectadas por ecografa; procediendoa colocación de tubo de toracostomía cerrada de manera inmediata. Los 7 pacientes restantes no tuvieron evidencia de lesión torácica por EFAST ni enlos estudios complementarios (radiografa, tomografa o EFAST de control) ni durante el seguimiento clínico. Conclusión: Durante la experiencia inicial el EFAST demostró ser sufcientemente sensible y específco para detectar neumotórax.

Background: The diagnosis of hemothorax or pneumothorax is established with chest radiography (sensitvity 69%, specifcity 76%) or computed tomography(sensitvity and specifcity near 100%). Studies have shown that EFAST has 92-100 % sensitvity even for non-radiologists. The aim of this studywas to determine sensitvity and specifcity of EFAST in the emergency department of Roosevelt Hospital.Methods: All patents admited from January to July 2015, with blunt or penetratng chest trauma were included in this study. They underwent EFAST,chest radiography and thoracic computed tomography.Results: Sixteen patents were analyzed, 13 (81.25%) were men, 11 (68.75%) presented blunt trauma and 5 (31.25%) penetratng trauma. The age groupwas from 18 to 45 years old. Of the 16 studies performed, 9 (56.25%) were classifed as positve for pneumothorax by EFAST, stratosphere positve signwas present in all of them; results were corroborated with chest radiography and tomography. One patent presented tomographic signs of hemo-pneumothoraxthat was not detected by ultrasound. The remaining 7 patents did not have evidence of thoracic injury with EFAST, chest radiography, thoracictomography or during clinical follow-up.Conclusions: During inital experience, EFAST demonstrates to be sensitve and specifc enough to detect pneumothorax.

Assessment of internal mammary artery injury after blunt chest trauma: a literature review.

The occurrence, bleeding, and treatment of internal mammary artery (IMA) injury after blunt chest trauma have not been well described in the literature. We reviewed articles published from July 1977 to February 2014 describing IMA injury after blunt chest trauma in 49 patients. There was a predominant incidence in males and on the left side. Blunt trauma to the IMA can cause anterior mediastinal hematoma, hemothorax, pseudoaneurysm, arteriovenous fistula, and extra-pleural hematoma. Of the 49 patients studied, 20 underwent embolization, 22 underwent surgical operation, 4 were managed by clinical observation, and 3 had undescribed treatment. Different parts and extents of IMA injury, adjacent vein injury, as well as the integrity of the pleura determined differences in bleeding modality. Prompt diagnosis, complete hemostasis, aggressive resuscitation, and multidisciplinary teams are recommended for patients with IMA injury.

Comparison of diagnostic peritoneal lavage and focused assessment by sonography in trauma as an adjunct to primary survey in torso trauma: a prospective randomized clinical trial.

BACKGROUND: Lately, Focused Assessment with Sonography in Trauma (FAST) is preferred over diagnostic peritoneal lavage (DPL) as adjunct to primary survey. However, this is not evidence-based as there has been no randomized trial. METHODS: In this study, 200 consecutive torso trauma patients meeting inclusion criteria were randomized to undergo either DPL or FAST. The results were then compared with either contrast enhanced computerized tomography (CECT) (in patients managed non-operatively) or laparotomy findings (in patients undergoing operative treatment). Outcome parameters were: result of the test, therapeutic usefulness, role in diagnosing bowel injury and time taken to perform the procedure. RESULTS: Two hundred patients with a mean age of 28.3 years were studied, 98 in FAST and 102 in DPL group. 104 sustained blunt trauma and 76 sustained penetrating trauma due to stabbing. In addition, 38 (38.7%) were FAST positive and 48 (47%) were DPL positive (p=0.237, not significant). As a guide to therapeutically beneficial laparotomy, negative DPL was better than negative FAST. For non-operative decisions, positive FAST was significantly better than positive DPL. DPL was significantly better than FAST in detecting as well as not missing the bowel injuries. DPL took significantly more time than FAST to perform. CONCLUSION: This study shows that DPL is better than FAST.

Ultrasound assessment of injury to the posterior ligamentous complex in patients with mild thoracolumbar fractures.

OBJECTIVE: To assess the value of ultrasonographic imaging of the posterior ligamentous complex (PLC) to diagnose ligamentous injuries, in patients with mild thoracolumbar fractures. METHODS: Patients with thoracolumbar fractures were included in this prospective study. Patients underwent palpation of the midline of the back, and ultrasonography was performed over the entire thoracolumbar region by an experienced sonographer. A team that included a musculoskeletal radiologist, an orthopaedic surgeon and a sonographer assessed the ultrasound results. Ultrasonographic and magnetic resonance imaging (MRI) findings were jointly evaluated in a subgroup of patients who were able to fund MRI analysis. Conflicts regarding the results were resolved by a majority vote. RESULTS: A total of 21 patients participated in the study, all of whom exhibited abnormal ultrasonographic echogenicity on the supraspinous or interspinous ligaments. Three patients were diagnosed with a rupture of the supraspinous ligament. In 15/17 (88.2%) patients, interspinous ligament injuries were detected caudally to the injured vertebrae. CONCLUSIONS: Ultrasound examination is a reliable complementary diagnostic tool to identify PLC injuries in patients with mild thoracolumbar fractures.

Video-assisted thoracoscopy as an important tool for trauma surgeons: a systematic review.

PURPOSE: Trauma patients frequently have serious chest injuries. Retained hemothoraces and persistent pneumothoraces are among the most frequent complications of chest injuries which may lead to major, long-term morbidity and mortality if these complications are not recognized and treated appropriately. Video-assisted thoracoscopy (VATS) is a well-established technique in surgical practice. The usefulness of VATS for treatment of complications after chest trauma has been demonstrated by several authors. However, there is an ongoing debate about the optimal timing of VATS. METHODS: A computerized search was conducted which yielded 450 studies reporting on the use of VATS for thoracic trauma. Eighteen of these studies were deemed relevant for this review. The quality of these studies was assessed using a check-list and the PRISMA guidelines. Outcome parameters were successful evacuation of the retained hemothorax or treatment of other complications as well as reduction of empyema rate, length of hospital stay, and hospital costs. RESULTS: There was only one randomized trial and two prospective studies. Most studies report case series of institutional experiences. VATS was found to be very successful in evacuation of retained hemothoraces and seems to reduce the empyema rate subsequently. Furthermore, the length of hospital stay and costs can be drastically reduced with the early use of VATS. CONCLUSION: Early VATS is an effective treatment for retained hemothoraces or other complications of chest trauma. We propose a clinical pathway, in which VATS is used as an early intervention in order to prevent serious complications such as empyemas or trapped lung.

Evolution of the incidence, management, and mortality of blunt thoracic aortic injury: a population-based analysis.

BACKGROUND: In the last decade, CT angiography has become the dominant diagnostic modality for blunt aortic injury and endovascular repair has become the leading aortic repair strategy. The impact of these shifts on incidence, aortic repair rate, and mortality remains poorly characterized. Our objective was to perform a population-based analysis of secular trends in the incidence, management, and in-hospital mortality of blunt thoracic aortic injury. STUDY DESIGN: From the population-based Canadian National Trauma Registry, we identified a cohort of all adults hospitalized between April 2002 and March 2010 with a diagnosis of thoracic aortic injury after blunt trauma. Trends over time in the incidence of hospitalization, frequency and type of aortic repair, as well as risk-adjusted in-hospital mortality, were evaluated. RESULTS: A total of 487 incident cases of blunt thoracic aortic injury were identified. During the study period, the incidence of hospitalization for blunt thoracic aortic injury remained stable (trend p = 0.16). Although the proportion of repairs undertaken via an endovascular approach increased (11% to 78% of repairs; trend p < 0.001), the frequency of any repair (endovascular or open) declined (55% to 36%; trend p = 0.003). Across all patients, when controlling for age, sex, mechanism of injury, and presence of severe extrathoracic injuries, mortality remained unchanged during the study period (odds ratio = 0.92 per 1 year; 95% CI, 0.82-1.03). However, in patients managed nonoperatively, risk-adjusted mortality decreased over time (odds ratio = 0.85 per 1 year; 95% CI, 0.80-0.98). CONCLUSIONS: The increasing frequency of patients managed nonoperatively and decreasing risk-adjusted mortality in these patients suggests that defining the evolving role of nonoperative management should be a major focus of research in the endovascular era.

Evaluation for intra-abdominal injury in children after blunt torso trauma: can we reduce unnecessary abdominal computed tomography by utilizing a clinical prediction model?

BACKGROUND: Blunt trauma is a leading cause of morbidity and mortality in children. Despite the potential for malignancy, increased cost, limited small bowel injury detection sensitivity, and the low incidence of injury requiring operative intervention, the use of computed tomographic (CT) scan in pediatric blunt trauma evaluation remains common. Previous studies suggest that a clinical model using examination and laboratory data may help predict intra-abdominal injuries (IAIs) and potentially limit unnecessary CT scans in children. METHODS: A retrospective chart review of all blunt "trauma alerts" for patients younger than 16 years during an 18-month period was performed at a Level I trauma center. Clinical factors, which might predict blunt IAI (hemodynamics, abdominal examination, serology, and plain radiographs), and potential limitations to performing a reliable abdominal examination (altered mental status, young age) were reviewed. A previously defined clinical prediction model based on six high-risk clinical variables for blunt IAI (hypotension, abnormal abdominal examination, elevated aspartate aminotransferase, elevated amylase, low hematocrit, and heme-positive urinalysis) was applied to each patient. RESULTS: Of the 125 "trauma alert" patients who sustained blunt trauma during the study period, 97 underwent abdominal CT scan, with only 15 identified as IAI. Our prediction rule would have identified 16 of 17 patients with IAI (SE, 94%) as high-risk and missed only 1 patient (grade I spleen laceration, which did not require operation) (negative predictive value, 99%). Of the 83 patients with no risk factors for IAI based on the prediction rule, 54 underwent a negative abdominal CT scan. Of these 54 patients, only 22 had a potential limitation to a reliable abdominal examination. Application of our prediction rule could have prevented unnecessary CT scan in at least 32 patients (33%) during an 18-month period. CONCLUSION: Use of a prediction model based on high-risk variables for IAI may decrease cost and radiation exposure by reducing the number of abdominal CT scans in children being evaluated for blunt abdominal trauma.

[Diagnostic assessment and treatment concepts for thoracic trauma]. / Diagnostik und Behandlungskonzepte beim Thoraxtrauma.

Most patients with chest trauma can be successfully treated with tube thoracostomy and appropriate pain medication. Initial care of these patients is usually straightforward and performed by an emergency doctor or an emergency room surgeon, e.g. a general surgeon. If more extensive therapy of these polytraumatized patients appears to be required, tertiary care should be done in specialized centers or clinics with network structures. An appropriate structured network of surgical centers guarantees sufficient and efficient care of patients with severe chest trauma. In a best-case scenario the specialist disciplines work in a rendezvous system with close cooperation. Early communication with a thoracic surgeon is essential to minimize mortality and long-term morbidity. Improvement in understanding the underlying molecular physiological mechanisms involved in the various traumatic pathological processes and the advancement of diagnostic techniques, minimally invasive approaches and pharmacologic therapy, will contribute to decreasing morbidity of these critically injured patients.

Sturdivan's formula revisited: MRI assessment of anterior chest wall thickness for injury risk prediction of blunt ballistic impact trauma.

BACKGROUND: The thickness and composition of the chest wall are important quantities in multiparametric trauma models for the assessment of injury severity due to blunt ballistic chest impact. While ballistic parameters of non-penetrating projectiles can routinely be measured with high accuracy, data on the thickness of the anterior chest wall is unreliable. Therefore, it is the aim of this work to provide data on the thickness and composition of the anterior chest wall based on MRI examinations of healthy volunteers and to compare these measurements with different empirical estimation rules for the chest wall thickness. METHODS: The study encompassed consecutive male patients from an ongoing population-based cohort study. Each subject underwent standardized whole-body MRI (1.5Tesla). Thickness of total chest wall (CWT) and of adipose tissue (AT) were measured by two independent readers at ten anatomic locations on two cross-sectional planes over the centre of the left ventricle and over the tracheal bifurcation. For each subject, chest wall thickness was estimated based on ten different empirical estimation rules and percent errors were calculated. RESULTS: The study encompassed 250 male volunteers (average age 55.5 years, range 21-84 years, SD 13.6 years). Mean intraclass correlation coefficient of the two readers was 0.90 (range 0.59-1.0, SD 0.08). Average CWT was 31.2mm (range 17.3-51.6mm, SD 5.8mm) while average thickness of AT was 13.1mm (range 3.6-26.7mm, SD 4.6mm). Relative adiposity was 0.41 on average (range 0.19-0.61, SD 0.09). There was significant correlation between CWT and body weight and between CWT and body mass index. Sturdivan's approximation formula showed strong correlation with the measured values (percent error 3.58%, SD 16.26%). CONCLUSION: In this population, Sturdivan's equation formula which is based on the individual's body weight provides valid approximation values for the chest wall thickness and may be used for the optimal design of protective devices and personal body armor as well as for the development of anthropomorphic based test methodologies.