Checklist: Neck computed tomography in non-traumatic emergencies.

Patients attending the emergency department (ED) with cervical inflammatory/infectious symptoms or presenting masses that may involve the aerodigestive tract or vascular structures require a contrast-enhanced computed tomography (CT) scan of the neck. Its radiological interpretation is hampered by the anatomical complexity and pathophysiological interrelationship between the different component systems in a relatively small area. Recent studies propose a systematic evaluation of the cervical structures, using a 7-item checklist, to correctly identify the pathology and detect incidental findings that may interfere with patient management. As a conclusion, the aim of this paper is to review CT findings in non-traumatic pathology of the neck in the ED, highlighting the importance of a systematic approach in its interpretation and synthesis of a structured, complete, and concise radiological report.

Cervical spine trauma.

Cervical spine trauma encompasses a wide of injuries, ranging from stable, minor lesions to unstable, complex lesions that can lead to neurologic sequelae or vascular involvement. The Canadian C-Spine Rule and the NEXUS criteria aim to identify individuals with a low risk of cervical spine trauma who can safely forgo imaging tests. In high-risk patients, an imaging test is indicated. In adult patients the imaging test of choice is multidetector computed tomography. Complementary imaging tests such as CT angiography of the supra-aortic vessels and/or magnetic resonance imaging are occasionally necessary. It can be challenging for radiologists to diagnose and classify these lesions, because some of them can be subtle and difficult to detect. This paper aims to describe the most important imaging findings and the most widely used classification systems.

Psychological symptoms in difficult-to-sedate critical care survivors.

BACKGROUND: Critical care survivors often experience symptoms of anxiety, depression, or post-traumatic stress disorder (PTSD). AIMS: To determine the prevalence and severity of psychological symptoms during the first 6 months after discharge from the intensive care unit (ICU) and to evaluate its association with patients who are difficult to sedate during admission. DESIGN: Descriptive, prospective analysis of psychological symptoms in survivors from medicosurgical ICU over a 2-year period. METHODS: All ICU survivors who required mechanical ventilation (MV) for more than 24 hours were followed for 6 months after their ICU discharge. ICU outcome and complications as well as the presence of psychological symptoms, 1 to 3 to 6 months after discharge were prospectively evaluated through phone interviews comparing the incidence and intensity of patients who were difficult to sedate during their ICU stay with those who were not. Descriptive analysis and multivariate logistic regression were performed. RESULTS: Data were obtained for 195 patients, of whom 30% experienced difficult sedation (DS). Difficult-to-sedate patients were younger (P = .001), less critically ill (APACHE II score P = .002), and more likely to engage in harmful use of alcohol (P = .001) and psychoactive/psychotropic drug abuse. They also spent longer times on MV and in the ICU (P = .001). Anxiety incidence at 1 to 3 to 6 months post-discharge was significantly higher in DS patients than in those who were not (87.7% vs 45.4%, 75.5% vs 29.0%, and 70.8% vs 23.7%; P < .01), respectively. Depression incidence was also significantly higher in the DS group (82.4% vs 43.1%, 66% vs 33.9%, and 60.4% vs 27.2%; [P = .001]) at 1 to 3 to 6 months, respectively. A higher percentage of patients in the DS group reported symptoms of PTSD at 1 month (28.1% vs 11.5%) (P = .007) when compared with non-DS group. CONCLUSIONS: Critical care survivors who are difficult to sedate during their ICU stay are more likely to present psychological sequelae. Early identification of at-risk patients is necessary to implement appropriate preventive strategies. RELEVANCE TO CLINICAL PRACTICE: Patients who are difficult to sedate in the ICU may develop psychological disorders upon discharge, which may negatively affect their recovery. The prevention of DS and the early detection of psychological disorders are essential to minimize its subsequent impact.

[Consensus document for sepsis code implementation and development in the Community of Madrid]. / Documento de consenso para la implantación y desarrollo del Código Sepsis en la Comunidad de Madrid.

The consensus paper for the implementation and development of the sepsis code, finished in April 2017 is presented here. It was adopted by the Regional Office of Health as a working document for the implementation of the sepsis code in the Community of Madrid, both in the hospital setting (acute, middle and long-stay hospitals) and in Primary Care and Out-of-Hospital Emergency Services. It is now published without changes with respect to the original version, having only added the most significant bibliographical references. The document is divided into four parts: introduction, initial detection and assessment, early therapy and organizational recommendations. In the second to fourth sections, 25 statements or proposals have been included, agreed upon by the authors after several face-to-face meetings and an extensive "online" discussion. The annex includes nine tables that are intended as a practical guide to the activation of the sepsis code. Both the content of the recommendations and their formal writing have been made taking into account their applicability in all areas to which they are directed, which may have very different structural and functional characteristics and features, so that we have deliberately avoided a greater degree of concretion: the objective is not that the sepsis code is organized and applied identically in all of them, but that the health resources work in a coordinated manner aligned in the same direction.

Neutrophil-to-lymphocyte ratio and mesenteric ischemia: can it predict the etiology of mesenteric ischemic at computed tomography?

OBJECTIVES: To assess the usefulness of the neutrophil-to-lymphocyte ratio (NLR) as a predictive factor of acute mesenteric ischemia (AMI) in patients presenting at the emergency department (ED) with acute abdominal pain. METHODS: This is a retrospective case-control study of patients older than 16 years admitted to the ED with acute abdominal pain with CT and histologic confirmation. The study group corresponded to patients with abdominal CT with radiological signs of AMI. The control group corresponded to patients with non-AMI findings in abdominal CT. Association measurements of NLR with radiological signs were compared with a paired-sample t test, and multivariate regression performed to analyze potential correlations. To assess the diagnosis capacity of NLR, ROC curves were calculated. RESULTS: A total of 61 patients were included (32 cases and 29 controls). The cases of AMI showed higher mortality (43.8% vs 6.9%, p < 0.01) and higher NLR on the limit of statistical significance (13.8 vs 8.7, p = 0.053). Patients with AMI due to occlusion of the superior mesenteric artery (SMA) showed a higher NLR (8.3 vs 22.3, p < 0.001). The area under the curve (AUC) of the NLR for AMI due to occlusion of the SMA was 0.88 (95% CI 0.7-1.0, p = 0.001). No patient with NLR < 5 presented AMI due to occlusion of the SMA. An NLR of 12.8 showed a sensitivity of 92% and a specificity of 74% for AMI due to occlusion of SMA. CONCLUSIONS: The NLR is a useful parameter of AMI of arterial origin due to occlusion of the SMA; it can help the clinician to raise suspicion of this diagnosis and the interpreting radiologist in the acquisition protocol for the CT study and would alert for an early surgical treatment.

Patología traumática de peñascos, un diagnóstico complejo. Claves para el informe / Traumatic injury of the petrous part of the temporal bone: keys for reporting a complex diagnosis

La fractura de peñascos constituye una lesión común de la base del cráneo, y la mayoría son el resultado de traumatismos de alta energía. Su reconocimiento en politraumatizados puede realizarse en las tomografías computarizadas de cráneo y cervicales. Los hallazgos directos e indirectos suelen ser suficientes para establecer el diagnóstico. Su identificación es importante debido a que el hueso temporal contiene estructuras críticas, y es posible errar debido a la complejidad de esta región, y su insuficiente vigilancia. Este trabajo revisa los puntos clave anatómicos, la sistematización de los hallazgos radiológicos y las clasificaciones usadas en fracturas de hueso temporal. Cobra relevancia la identificación y descripción de los hallazgos relativos a estructuras importantes de esta región, la búsqueda de fracturas no visibles sospechadas por signos indirectos, y la identificación de estructuras anatómicas que pueden simular fracturas. Pierden valor las clasificaciones clásicas, aunque siguen condicionando el manejo terapéutico

Fractures of the petrous part of the temporal bone are a common lesion of the base of the skull; most of these fractures result from high-energy trauma. In patients with multiple trauma, these injuries can be detected on CT scans of the head and neck, where the direct and indirect signs are usually sufficient to establish the diagnosis. It is important to these fractures because the temporal bone has critical structures and the complexity of this region increases the risk of error unless special care is taken. This article reviews the key anatomical points, the systematization of the imaging findings, and the classifications used for temporal bone fracture. We emphasize the usefulness of identifying and describing the findings in relation to important structures in this region, of looking for unseen fractures suspected through indirect signs, and of identifying anatomical structures that can simulate fractures. We point out that the classical classifications of these fractures are less useful, although they continue to be used for treatment decisions

Traumatic Injury of the Petrous Part of the Temporal Bone: Keys for Reporting a Complex Diagnosis. / Patología traumática de peñascos, un diagnóstico complejo. Claves para el informe.

Fractures of the petrous part of the temporal bone are a common lesion of the base of the skull; most of these fractures result from high-energy trauma. In patients with multiple trauma, these injuries can be detected on CT scans of the head and neck, where the direct and indirect signs are usually sufficient to establish the diagnosis. It is important to these fractures because the temporal bone has critical structures and the complexity of this region increases the risk of error unless special care is taken. This article reviews the key anatomical points, the systematization of the imaging findings, and the classifications used for temporal bone fracture. We emphasize the usefulness of identifying and describing the findings in relation to important structures in this region, of looking for unseen fractures suspected through indirect signs, and of identifying anatomical structures that can simulate fractures. We point out that the classical classifications of these fractures are less useful, although they continue to be used for treatment decisions.

¿Es necesario realizar una angiografía por tomografía computarizada urgente en la hemorragia digestiva baja aguda? Proyecto MAPAC-IMAGEN / Is urgent CT angiography necessary in cases of acute lower gastrointestinal bleeding?

La hemorragia digestiva baja aguda se presenta en forma de hematoquecia, rectorragia o melenas, y constituye el 1-2% de los motivos de consulta en los servicios de urgencia. La mortalidad alcanza el 30-40%, en relación con la gravedad y la comorbilidad. La mayoría de las guías de práctica clínica incluyen la colonoscopia en algún momento del proceso diagnóstico-terapéutico (precoz en las graves y programada en las leves), y buscan factores predictores de gravedad. En los últimos años se han publicado numerosos estudios en los que queda patente la relevancia y la complementariedad diagnóstica de las técnicas de imagen avanzadas, incorporadas paulatinamente como alternativa o de segundo escalón en los casos graves. Por ello, hemos realizado una revisión de la evidencia científica actual que permita establecer una regla de predicción clínica para la óptima indicación de la angiografía por tomografía computarizada en estos pacientes. Son necesarios, no obstante, futuros estudios que aporten mayor robustez y nivel de evidencia (AU)

Acute lower gastrointestinal bleeding usually presents as hematochezia, rectal bleeding or melena and represents 1-2% of the medical appointments in the Emergency Services. Mortality reaches the 30-40% and it is highly related with the severity and associated comorbidity. Most clinical practice guidelines include colonoscopy at some point in the diagnostic and therapeutic process (urgent for severe cases and ambulatory for mild ones) and look for predictors of severity. In the last years, there have been numerous studies where is clear the relevance and complementarity of advanced diagnostic imaging techniques, gradually incorporated as an alternative or second step in severe cases. Therefore, we have made a review of current scientific evidence to establish a clinical prediction rule for optimal indication of CT angiography in these patients. However, future studies providing greater robustness and level of evidence are necessary (AU)

Is urgent CT angiography necessary in cases of acute lower gastrointestinal bleeding? / ¿Es necesario realizar una angiografía por tomografía computarizada urgente en la hemorragia digestiva baja aguda? Proyecto MAPAC-IMAGEN.

Acute lower gastrointestinal bleeding usually presents as hematochezia, rectal bleeding or melena and represents 1-2% of the medical appointments in the Emergency Services. Mortality reaches the 30-40% and it is highly related with the severity and associated comorbidity. Most clinical practice guidelines include colonoscopy at some point in the diagnostic and therapeutic process (urgent for severe cases and ambulatory for mild ones) and look for predictors of severity. In the last years, there have been numerous studies where is clear the relevance and complementarity of advanced diagnostic imaging techniques, gradually incorporated as an alternative or second step in severe cases. Therefore, we have made a review of current scientific evidence to establish a clinical prediction rule for optimal indication of CT angiography in these patients. However, future studies providing greater robustness and level of evidence are necessary.

Non-Heart-Beating Donor Kidney Transplantation Survival Is Similar to Donation After Brain Death: Comparative Study With Controls in a Regional Program.

Non-heart-beating donors (NHBD) are an increasing source of organs for kidney transplantation (KT) compared with donation after brain death (DBD), but the results in each regional transplantation program require local analysis. We compared 164 KT from NHBD (83 Maastrich type II A-B [T2] and 81 type III [T3]) with 328 DBD controls. NHBD kidneys were implanted with less cold ischemia, mean time on renal replacement therapy for NHBD recipients before transplantation was less too, and a higher proportion of thymoglobulin was also used. Besides NHBD-T2 more frequently showing the A group and patients being younger (48.9 ± 11 vs DBD 55.2 ± 15 years old; P < .001), there was a lower proportion of retransplant recipients and HLA sensitization; HLA-DR compatibility was slightly worse. Proportion of nonfunctioning allograft and necessity of dialysis after transplantation for NHBD were 4.9 and 68.3% versus DBD 4.3 and 26.9% (P < .001); renal function after a year was significantly less in NHBD (serum creatinine 1.79 ± 0.9 mg/dL vs 1.46 ± 0.5 in DBD; P < .001). NHBD recipient survival rates were 96% and 96% for the 1st and 3rd years, respectively, versus 96% and 94% for DBD, respectively (not significant [NS]). Graft survival rates censored by death were 91% and 89% (1st and 3rd years, respectively) versus 95% and 94% for DBD, respectively (NS). We did not find significant differences about survival between NHBD-T2 and T3. In the multivariable survival study (Cox, covariables with statistical significance demonstrated previously in our region), NHBD is not a prognosis factor for recipient or graft survival. Regarding current criteria for choosing donors and the graft allocation applied in Andalusia, short-term survival for NHBD transplantation is similar to DBD. Renal function in the short term is slightly worse, which is why it is important to monitor results over a long term, especially those from NHBD-T2.

Radiografía del abdomen en Urgencias. ¿Una exploración para el recuerdo? / Routine abdominal X-rays in the emergency department: a thing of the past?

La escasa rentabilidad diagnóstica de la radiografía de abdomen en patología urgente contrasta con el elevado número de exploraciones que se realizan. La mayoría arroja hallazgos normales o inespecíficos, lo que cuestiona la idoneidad de su indicación. Suele considerarse un procedimiento rutinario o incluso una herramienta 'defensiva' de cribado, cuya utilidad real se desconoce. Desde hace más de 30 años, se recomienda en la literatura científica reducir tanto el número de exploraciones como el de proyecciones realizadas, en aras a disminuir dosis de radiación, molestias innecesarias para los pacientes y costes. Radiólogos y clínicos deben conocer las importantes limitaciones de la radiografía de abdomen en el manejo diagnóstico de la patología abdominal aguda y restringir su empleo. Para ello, es imprescindible una adecuada selección clínica de los pacientes candidatos a estudio de imagen, que permite un empleo ágil de técnicas alternativas más rentables como la ecografía o la tomografía computarizada (AU)

The large number of abdominal X-ray examinations done in the emergency department is striking considering the scant diagnostic yield of this imaging test in urgent disease. Most of these examinations have normal or nonspecific findings, bringing into question the appropriateness of these examinations. Abdominal X-ray examinations are usually considered a routine procedure or even a 'defensive' screening tool, whose real usefulness is unknown. For more than 30 years, the scientific literature has been recommending a reduction in both the number of examinations and the number of projections obtained in each examination to reduce the dose of radiation, unnecessary inconvenience for patients, and costs. Radiologists and clinicians need to know the important limitations of abdominal X-rays in the diagnostic management of acute abdomen and restrict the use of this technique accordingly. This requires the correct clinical selection of patients that can benefit from this examination, which would allow better use of alternative techniques with better diagnostic yield, such as ultrasonography or computed tomograph (AU)

Routine abdominal X-rays in the emergency department: a thing of the past?

The large number of abdominal X-ray examinations done in the emergency department is striking considering the scant diagnostic yield of this imaging test in urgent disease. Most of these examinations have normal or nonspecific findings, bringing into question the appropriateness of these examinations. Abdominal X-ray examinations are usually considered a routine procedure or even a "defensive" screening tool, whose real usefulness is unknown. For more than 30 years, the scientific literature has been recommending a reduction in both the number of examinations and the number of projections obtained in each examination to reduce the dose of radiation, unnecessary inconvenience for patients, and costs. Radiologists and clinicians need to know the important limitations of abdominal X-rays in the diagnostic management of acute abdomen and restrict the use of this technique accordingly. This requires the correct clinical selection of patients that can benefit from this examination, which would allow better use of alternative techniques with better diagnostic yield, such as ultrasonography or computed tomography.

Radiología e imagen en el traumatismo grave / Radiology and imaging techniques in severe trauma

No disponible

Fractura de cuerpo cavernoso: la ecografía en el diagnóstico de urgencia / Corpus cavernosum fracture: the ultrasound in the emergency diagnosis

Objetivo. Valorar la utilidad de los hallazgos ecográficos en la sospecha de fractura de pene. Material y métodos. Se revisan las ecografías de pene realizadas en urgencias entre julio de 2007 y agosto de 2009 por sospecha clínica de fractura del cuerpo cavernoso, comparando los hallazgos ecográficos (hematoma subcutáneo, hematoma perialbugínea, rotura de la albugínea y rotura de la fascia de Buck) con los quirúrgicos, y la evolución a medio plazo. Se calculan sensibilidad (S), especificidad (E), valor predictivo positivo (VPP) y valor predictivo negativo (VPN) de los hallazgos ecográficos para el diagnóstico de fractura del cuerpo cavernoso. Recogemos datos epidemiológicos de los casos revisados. Resultados. Se estudiaron a 12 pacientes, con edad media de 35,75 años. El origen más frecuente de la lesión es el traumatismo durante el acto sexual. Ecográficamente, presentaron un hematoma subcutáneo 9 pacientes, perialbugínea 11 sujetos y discontinuidad de la albugínea 6 pacientes. No se visualizaron roturas de la fascia de Buck. Siete fueron operados. En los 5 sujetos restantes se realizó manejo conservador. La evolución fue siempre satisfactoria. La identificación mediante ecografía de la discontinuidad de la albugínea mostró una S de 0, 83, E de 1, VPP de 1 y VPN de 0,83. Conclusión. Consideramos la ecografía como un procedimiento útil para diagnosticar la fractura de cuerpo cavernoso y que se puede proponer como de elección para confirmar la sospecha clínica. La identificación del punto exacto de rotura dirige y facilita la cirugía(AU)

Objective. The main objective of this work is to study usefulness of ultrasound (US) for the emergency diagnosis of the penile fracture. Material and methods. We reviewed all the penile US studies registered in our Emergency Department between July 2007 and August 2009 with suspicion of a corpus cavernosum fracture. We compared US findings (subcutaneous haematoma, peri-albuginea haematoma, albuginea rupture and Buck¿s fascia rupture), and the clinical progress, with those of the surgery. We studied sensitivity, specificity, positive predictive value and negative predictive value of US in the diagnosis of rupture of the tunica albuginea. The epidemiological data of all the cases reviewed were collected. Results. Twelve patients with a mean age of 37.8 years were reviewed. The most common cause of injury was sexual intercourse. A subcutaneous haematoma was found in nine patients, a peri-albuginea hematoma in eleven of the cases, and an albuginea rupture was seen in six of them. We found no Buck¿s fascia rupture. Seven patients underwent surgical treatment and in the remaining five patients, treatment was conservative. Clinical progress was good in all cases. US, as an emergency test to diagnose albuginea fracture gave 0.83 sensitivity, 1 specificity, 1 positive predictive value and 0.83 negative predictive value. Conclusion. We believe that US is a useful procedure in the diagnosis of acute penile fracture and that it could be proposed as the diagnostic method of choice to confirm the clinical suspicion of penile fracture. Identifying the exact site of a tear in the tunica albuginea facilitates the surgical procedure(AU)

[Corpus cavernosum fracture: the ultrasound in the emergency diagnosis]. / Fractura de cuerpo cavernoso: la ecografía en el diagnóstico de urgencia.

OBJECTIVE: The main objective of this work is to study usefulness of ultrasound (US) for the emergency diagnosis of the penile fracture. MATERIAL AND METHODS: We reviewed all the penile US studies registered in our Emergency Department between July 2007 and August 2009 with suspicion of a corpus cavernosum fracture. We compared US findings (subcutaneous haematoma, peri-albuginea haematoma, albuginea rupture and Bucks fascia rupture), and the clinical progress, with those of the surgery. We studied sensitivity, specificity, positive predictive value and negative predictive value of US in the diagnosis of rupture of the tunica albuginea. The epidemiological data of all the cases reviewed were collected. RESULTS: Twelve patients with a mean age of 37.8 years were reviewed. The most common cause of injury was sexual intercourse. A subcutaneous haematoma was found in nine patients, a peri-albuginea hematoma in eleven of the cases, and an albuginea rupture was seen in six of them. We found no Bucks fascia rupture. Seven patients underwent surgical treatment and in the remaining five patients, treatment was conservative. Clinical progress was good in all cases. US, as an emergency test to diagnose albuginea fracture gave 0.83 sensitivity, 1 specificity, 1 positive predictive value and 0.83 negative predictive value. CONCLUSION: We believe that US is a useful procedure in the diagnosis of acute penile fracture and that it could be proposed as the diagnostic method of choice to confirm the clinical suspicion of penile fracture. Identifying the exact site of a tear in the tunica albuginea facilitates the surgical procedure.