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.

Changes in scapular bone density vary by region and are associated with age and sex.

BACKGROUND: Decreases in bone density of the scapula due to age and disease can make orthopedic procedures such as arthroplasty and fracture fixation challenging. There is limited information in the literature regarding the effect of age and sex on the patterns of these density changes across the bone. Characterizing these changes could assist the surgeon in planning optimal instrumentation placement. METHODS: Ninety-seven 3-dimensional models of the scapula were segmented from routine clinical computed tomography scans, and an opportunistic quantitative computed tomography approach was used to obtain detailed calibrated bone density measurements for each bone model. The effects of age and sex on cortical and trabecular bone density were assessed for the entire scapula. Specific regions (eg, scapular spine) where these factors had a significant effect were identified. Three-dimensional models were generated to allow clear visualization of the changes in density patterns. RESULTS: Cortical bone loss averaged 1.0 mg/cm3 and 0.3 mg/cm3 per year for female and male subjects, respectively, and trabecular bone loss averaged 1.6 mg/cm3 and 1.2 mg/cm3, respectively. However, several regions had loss rates several times greater. Areas that were significantly affected by age included the acromion, scapular spine, base of the coracoid, inferior glenoid neck, and glenoid vault. Areas that were significantly affected by sex were the scapular spine and body. CONCLUSIONS: These findings provide evidence that the bone density distribution across the scapula changes non-uniformly because of factors including sex and age. Despite overall trends of bone loss, there remains significant variability between individuals, and subject-specific tools for planning surgical procedures in which scapular fixation is required may be beneficial.

Policies and Guidelines for COVID-19 Preparedness: Experiences from the University of Washington.

The coronavirus disease 2019 (COVID-19) pandemic initially manifested in the United States in the greater Seattle area and has rapidly progressed across the nation in the past 2 months, with the United States having the highest number of cases in the world. Radiology departments play a critical role in policy and guideline development both for the department and for the institutions, specifically in planning diagnostic screening, triage, and management of patients. In addition, radiology workflows, volumes, and access must be optimized in preparation for the expected surges in the number of patients with COVID-19. In this article, the authors discuss the processes that have been implemented at the University of Washington in managing the COVID-19 pandemic as well in preparing for patient surges, which may provide important guidance for other radiology departments who are in the early stages of preparation and management.

Policies and Guidelines for COVID-19 Preparedness: Experiences from the University of Washington.

The coronavirus disease 2019 (COVID-19) pandemic initially manifested in the United States in the greater Seattle area and has rapidly progressed across the nation in the past 2 months, with the United States having the highest number of cases in the world. Radiology departments play a critical role in policy and guideline development both for the department and for the institutions, specifically in planning diagnostic screening, triage, and management of patients. In addition, radiology workflows, volumes, and access must be optimized in preparation for the expected surges in the number of patients with COVID-19. In this article, the authors discuss the processes that have been implemented at the University of Washington in managing the COVID-19 pandemic as well in preparing for patient surges, which may provide important guidance for other radiology departments who are in the early stages of preparation and management.

Core curriculum illustration: epiploic appendagitis.

This is the 45th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC.

Repeat CT Performed Within One Month of CT Conducted in the Emergency Department for Abdominal Pain: A Secondary Analysis of Data From a Prospective Multicenter Study.

OBJECTIVE: The purpose of this study is to determine both the frequency of repeat CT performed within 1 month after a patient visits the emergency department (ED) and undergoes CT evaluation for abdominal pain and the frequency of worsened or new CT-based diagnoses. SUBJECTS AND METHODS: Secondary analysis was performed on data collected during a prospective multicenter study. The parent study included patients who underwent CT in the ED for abdominal pain between 2012 and 2014, and these patients constituted the study group of the present analysis. The proportion of patients who underwent (in any setting) repeat abdominal CT within 1 month of the index CT examination was calculated. For each of these patients, results of the index and repeat CT scans were compared by an independent panel and categorized as follows: no change (group 1); same process, improved (group 2); same process, worse (group 3); or different process (group 4). The proportion of patients in groups 1 and 2 versus groups 3 and 4 was calculated, and patient and ED physician characteristics were compared. RESULTS: The parent study included 544 patients (246 of whom were men [45%]; mean patient age, 49.4 years). Of those 544 patients, 53 (10%; 95% CI, 7.5-13%) underwent repeat abdominal CT. Patients' CT comparisons were categorized as follows: group 1 for 43% of patients (23/53), group 2 for 26% (14/53), group 3 for 15% (8/53), and group 4 for 15% (8/53). New or worse findings were present in 30% of patients (16/53) (95% CI, 19-44%). When patients with findings in groups 1 and 2 were compared to patients with findings in groups 3 and 4, no significant difference was noted in patient age (p = 0.25) or sex (p = 0.76), the number of days between scans (p = 0.98), and the diagnostic confidence of the ED physician after the index CT scan was obtained (p = 0.33). CONCLUSION: Short-term, repeat abdominal CT was performed for 10% of patients who underwent CT in the ED for abdominal pain, and it yielded new or worse findings for 30% of those patients.

Core curriculum case illustration: cardiac tamponade complicating proximal aortic dissection.

This is the 39th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.erad.org/page/CCIP_TOC .

Placental abruption and hemorrhage-review of imaging appearance.

Placental and periplacental bleeding are common etiologies for antepartum bleeding. Placental abruption complicates approximately 1% of pregnancies and is associated with increased maternal, fetal, and neonatal morbidity and mortality. This article reviews the normal placental appearance on ultrasound, computed tomography (CT), and magnetic resonance imaging (MRI) and then discusses the different morphological appearance of placental and periplacental hematomas along with their mimics. Hematomas are classified based on the location as retroplacental, marginal subchorionic, preplacental (subamniotic), or intraplacental. Placenta-related bleeding is a common finding during first trimester ultrasound and its detection can help triage the pregnant females into low- and high-risk groups. This article reviews placenta related bleeding in the setting of trauma. Trauma can complicate pregnancy with potential severe maternal and fetal outcomes. CT is usually performed as part of the trauma workup and it can be challenging for placental evaluation. MRI can characterize the age of the hematomas and can differentiate hematomas from tumors.

Use of whole body CT to detect patterns of CPR-related injuries after sudden cardiac arrest.

AIMS AND OBJECTIVES: We have recently implemented a dedicated sudden cardiac arrest (SCA) - whole-body computed tomography (WBCT) protocol to evaluate SCA patients with return of spontaneous circulation (ROSC) following cardiopulmonary resuscitation (CPR). The aim of this study is to evaluate the number and pattern of CPR-related injuries in ROSC patients with SCA-WBCT. METHODS AND MATERIALS: Single-centre retrospective review of 39 patients (13 female; 20 male, mean age 51.8 years) with non-traumatic, out-of-hospital SCA and ROSC and evaluation with dedicated SCA-WBCT over a 10-month period. RESULTS: In-hospital mortality was 54%. CPR-related injuries were detected in 85% (33/39). Chest injuries were most common on WBCT: 85% (33) subjects had rib fractures (mean of 8.5 fractures/subject); 31% (12) sternal fractures; 13% (5) mediastinal haematoma; 10% (4) pneumothorax; 8% (3) pneumomediastinum and 3% (1) haemothorax. Three subjects (8%) had abdominal injuries on WBCT, including one hepatic haematoma with active haemorrhage. CONCLUSION: CPR-related injuries on WBCT after ROSC are common, with serial rib fractures detected most commonly. An unexpectedly high rate of abdominal injuries was detected on SCA-WBCT. Radiologists need to be attuned to the spectrum of CPR-related injuries in WBCT, including abdominal injuries and subtle rib fractures. KEY POINTS: • CPR frequently causes injuries. • Radiologists should be aware of the spectrum of CPR related injuries. • Rib fractures are frequent and radiologic findings often subtle. • Clinically unexpected abdominal injuries may be present.

Core curriculum illustration: orbital blow out fracture.

This is the 32nd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC.

Core curriculum case illustration: placental abruption.

This is the 33rd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at: http://www.erad.org/page/CCIP_TOC .

Accuracy of outside radiologists' reports of computed tomography exams of emergently transferred patients.

PURPOSE: Growing numbers of patient with advanced imaging being transferred to trauma centers has resulted in increased numbers of outside CT scans received at trauma centers. This study examines the degree of agreement between community radiologists' interpretations of the CT scans of transferred patients and trauma center radiologists' reinterpretation. METHODS: All CT scans of emergency transfer patients received over a 1 month period were reviewed by an emergency radiologist. Patients were classified as trauma or non-trauma and exams as neuro or non-neuro. Interpretive discrepancies between the emergency radiologist and community radiologist were classified as minor, moderate, or major. Major discrepancies were confirmed by review of a second emergency radiologist. Discrepancy rates were calculated on a per-patient and per exam basis. RESULTS: Six hundred twenty-seven CT scans of 326 patients were reviewed. Major discrepancies were encountered in 52 (16.0%, 95% CI 12.2-20.5) patients and 53 exams (8.5%, 95% CI 6.5-10.5). These were discovered in 46 trauma patients (21.6%, 95% CI 16.4-27.9) compared to six non-trauma patients (5.3%, 95% CI 2.2-11.7) (P < 0.001). A significant difference in the major discrepancy rate was also found between non-neuro and neuro exams (12.4 vs 3.3%, respectively, P < 0.001), primarily due to discrepancies in trauma patients, rather than non-trauma patients. CONCLUSIONS: Potentially management-changing interpretive changes affected 16% of transferred patients and 8.5% of CT exams over a 1 month period. Trauma center reinterpretations of community hospital CT scans of transferred patients provide valuable additional information to the clinical services caring for critically ill patients.

Role of CT in the Diagnosis of Nonspecific Abdominal Pain: A Multicenter Analysis.

OBJECTIVE: The objective of our study was to determine whether specific patient and physician factors-known before CT-are associated with a diagnosis of nonspecific abdominal pain (NSAP) after CT in the emergency department (ED). MATERIALS AND METHODS: We analyzed data originally collected in a prospective multicenter study. In the parent study, we identified ED patients referred to CT for evaluation of abdominal pain. We surveyed their physicians before and after CT to identify changes in leading diagnoses, diagnostic confidence, and admission decisions. In the current study, we conducted a multiple regression analysis to identify whether the following were associated with a post-CT diagnosis of NSAP: patient age; patient sex; physicians' years of experience; physicians' pre-CT diagnostic confidence; and physicians' pre-CT admission decision if CT had not been available. We analyzed patients with and those without a pre-CT diagnosis of NSAP separately. For the sensitivity analysis, we excluded patients with different physicians before and after CT. RESULTS: In total, 544 patients were included: 10% (52/544) with a pre-CT diagnosis of NSAP and 90% (492/544) with a pre-CT diagnosis other than NSAP. The leading diagnoses changed after CT in a large proportion of patients with a pre-CT diagnosis of NSAP (38%, 20/52). In regression analysis, we found that physicians' pre-CT diagnostic confidence was inversely associated with a post-CT diagnosis of NSAP in patients with a pre-CT diagnosis other than NSAP (p = 0.0001). No other associations were significant in both primary and sensitivity analyses. CONCLUSION: With the exception of physicians' pre-CT diagnostic confidence, the factors evaluated were not associated with a post-CT diagnosis of NSAP.

Scary gas: pathways in the axial body for soft tissue gas dissection (part I).

Gas is often encountered in abnormal locations in the torso, including within soft tissue compartments, vessels, and bones. The clinical significance of this gas ranges from incidental, benign, and self-limited to aggressive infection requiring immediate surgery. As a result of fascial interconnectivity and pressure differences between compartments, gas can dissect distant from its source. Gas can easily dissect between spaces of the extrapleural thorax, subperitoneal abdomen, deep cervical spaces, and subcutaneous tissues. The pleural and peritoneal cavities are normally isolated but may communicate with the other spaces in select situations. Dissection of gas may cause confusion as to its origin, potentially delaying treatment or prompting unnecessary and/or distracting workup and therapies. The radiologist might be the first to suggest and identify a remote source of dissecting gas when the clinical manifestation alone might be misleading. The purpose of this paper, the first in a three-part series on soft tissue gas, is to explore the various pathways by which gas dissects through the superficial and deep compartments of the torso.

Scary gas: a spectrum of soft tissue gas encountered in the axial body (part II).

Ectopic gas in the mediastinum, subperitoneal abdomen, and superficial soft tissues is concerning and can be seen in the setting of trauma, iatrogenic injuries, infection, and inflammation. It can spread along different dissection pathways and may present remotely from the involved organ as described in part one. Recognition of ectopic gas on imaging and differentiating it from other causes of benign gas is very important as these conditions associated with ectopic gas can lead to rapid patient deterioration and usually require urgent surgery. In part two, the different causes of ectopic and benign gas in the torso are reviewed as well as the imaging features that can help to narrow the differential diagnosis.

Scary gas: intravascular, intracranial, and intraspinal ectopic gas (part III).

While ectopic gas can be a sign of dangerous disease requiring immediate medical or surgical intervention, it can also be an incidental and benign finding. Intravenous gas and spinal vacuum gas are common and almost always benign. Intravascular gas is most often related to instrumentation and, if intraarticular, can cause end-organ ischemia; however, treatment is usually supportive. Pneumocephalus arises from a communication with paranasal sinuses or mastoids more often than from meningeal infection and can usually be managed nonoperatively. In part 3 of this series, the different causes of ectopic gas in the vessels, skull, and spine are reviewed, as are the imaging features that can help to narrow the differential diagnosis.

ASER core curriculum illustration project: aortic intramural hematoma (IMH).

This is the 23rd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Core curriculum illustration: blunt trauma to the bowel.

This is the 22nd installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

Core curriculum illustration: rib fractures.

This is the 24th installment of a series that will highlight one case per publication issue from the bank of cases available online as part of the American Society of Emergency Radiology (ASER) educational resources. Our goal is to generate more interest in and use of our online materials. To view more cases online, please visit the ASER Core Curriculum and Recommendations for Study online at http://www.aseronline.org/curriculum/toc.htm .

CT in the Emergency Department: A Real-Time Study of Changes in Physician Decision Making.

PURPOSE: To determine how physicians' diagnoses, diagnostic uncertainty, and management decisions are affected by the results of computed tomography (CT) in emergency department settings. MATERIALS AND METHODS: This study was approved by the institutional review board and compliant with HIPAA. Data were collected between July 12, 2012, and January 13, 2014. The requirement to obtain patient consent was waived. In this prospective, four-center study, patients presenting to the emergency department who were referred for CT with abdominal pain, chest pain and/or dyspnea, or headache were identified. Physicians were surveyed before and after CT to determine the leading diagnosis, diagnostic confidence (on a scale of 0% to 100%), alternative "rule out" diagnosis, and management decisions. Primary measures were the proportion of patients for whom the leading diagnosis or admission decision changed and median changes in diagnostic confidence. Secondary measures addressed alternative diagnoses and return-to-care visits (eg, to emergency department) at 1-month follow-up. Regression analysis was used to identify associations between primary measures and site and participant characteristics. RESULTS: Both surveys were completed for 1280 patients by 245 physicians. The leading diagnosis changed in 235 of 460 patients with abdominal pain (51%), 163 of 387 with chest pain and/or dyspnea (42%), and 103 of 433 with headache (24%). Pre-CT diagnostic confidence was inversely associated with the likelihood of a diagnostic change (P < .0001). Median changes in confidence were substantial (increases of 25%, 20%, and 13%, respectively, for patients with abdominal pain, chest pain and/or dyspnea, and headache; P < .0001); median post-CT confidence was high (95% for all three groups). CT helped confirm or exclude at least 95% of alternative diagnoses. Admission decisions changed in 116 of 457 patients with abdominal pain (25%), 72 of 387 with chest pain and/or dyspnea (19%), and 81 of 426 with headache (19%). During follow-up, 70 of 450 patients with abdominal pain (15%), 53 of 387 with chest pain and/or dyspnea (14%), and 49 of 433 with headache (11%) returned for the same indication. In general, changes in leading diagnosis, diagnostic confidence, and admission decisions were not well explained with site or participant characteristics. CONCLUSION: Physicians' diagnoses and admission decisions changed frequently after CT, and diagnostic uncertainty was alleviated.