The validity of abdominal examination in blunt trauma patients with distracting injuries

Rostas, Jack W.; Cason, Benton; Simmons, Jon D.; Frotan, Mohammad Amin; Brevard, Sidney B.; Gonzalez, Richard P.

doi:10.1097/ta.0000000000000650

Cited by 20 publications

(7 citation statements)

References 22 publications

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“…Our opinion has been supported by other researchers performing physical assessments in trauma patients with GCS scores of 14 and 15. 17 18 If our rule had indicated cervical CT for all patients with GCS scores less than 15, the specificity of Rule 2 would have decreased substantially.…”

Section: Discussionmentioning

confidence: 92%

Development of a new clinical decision rule for cervical CT to detect cervical spine injury in patients with head or neck trauma

Inagaki

Kimura

et al. 2018

Emerg Med J

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ObjectivePrevious cervical spine imaging decision rules have been based on positive findings on plain X-ray and are limited by lack of specificity, age restrictions and complicated algorithms. We previously derived and validated a clinical decision rule (Rule 1) for detecting cervical spine injury (CSI) on CT in a single-centre study. This recommended CT for patients with (1) GCS score <14, (2) GCS 14–15 and posterior cervical tenderness or neurological deficit, (3) age ≥60 years and fall down stairs, or (4) age <60 and injured in a motorcycle collision or fallen from height. This study assessed the accuracy and reliability of this rule and refined the rule.MethodsWe conducted a prospective, dual-centre study at two Japanese EDs between August 2012 and March 2014. Patients with head or neck injury ≥16 years of age were included. Clinical data were collected from medical records. Imaging was at the discretion of the treating physician. CSI was diagnosed as a fracture or dislocation seen on CT; patients who were not imaged were followed for 14 days. We analysed the sensitivity and specificity of Rule 1 and refined it post hoc using recursive partitioning.Results1192 patients were enrolled. 927 completed follow-up. Of these, 584 (63.0%) underwent CT imaging and 38 had CSI. Sensitivity and specificity of Rule 1 were 92.1% (95% CI 79.2% to 97.3%) and 58.6% (95% CI 55.4% to 61.9%). A second rule (Rule 2) was derived recommending CT for those with any of the following: GCS <14, cervical tenderness, neurological deficit or mechanism of injury (fall down stairs, motorcycle collision or fall from height) without age limits. Sensitivity and specificity were 100% (95% CI 90.8% to 100%) and 51.9% (95% CI 48.6% to 55.2%), respectively.ConclusionsOur initial CT decision rule had lower sensitivity than in our initial validation study. A refined decision rule based on GCS, neck tenderness, neurological deficit and mechanism of injury showed excellent sensitivity with a small loss of specificity. Rule 2 will now need validation in an independent cohort.

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Section: Discussionmentioning

confidence: 92%

Development of a new clinical decision rule for cervical CT to detect cervical spine injury in patients with head or neck trauma

Inagaki

Kimura

et al. 2018

Emerg Med J

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“…The management of patients with BAT poses significant challenges to the treating physicians. Only 5%–10% of blunt trauma patients will have significant intra-abdominal injuries requiring surgical intervention, and 10% of them will present with negative clinical examination (16). Severe “occult” intra-abdominal injuries requiring specific treatment were described in BAT patients even without distracting injuries and abdominal pain (17).…”

Section: Discussionmentioning

confidence: 99%

Laparoscopy for blunt abdominal trauma: a challenging endeavor

et al. 2018

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Background and Aims: Laparoscopy in blunt abdominal trauma is challenging because of multiple associated injuries, higher trauma score values and higher morbidity and mortality, as compared with patients with penetrating abdominal trauma. The aim of this study was to investigate the role of laparoscopy in the management of blunt abdominal trauma patients and to highlight related challenges. Material and Methods: Over a 4-year period, patients managed laparoscopically for blunt abdominal trauma were retrospectively analyzed. Perioperative details, indications for laparoscopy and conversion, complications, and length of hospital stay were discussed. Results: A total of 35 stable patients underwent laparoscopy. The mean Injury Severity Score was 12 (4–38). Therapeutic laparoscopy was performed in 15 (56%) and diagnostic in 12 (44%) patients. Eight (23%) patients were converted to therapeutic laparotomy. Intraoperative bleeding, complex injuries, visualization problem, and equipment failure necessitated conversion. Three (30%) patients with negative computed tomography scan had therapeutic laparoscopy for mesenteric injuries. There were no missed injuries. The mean length of hospital stay was 11 days in both groups. Conclusion: Laparoscopy for stable patients is feasible and safe. Multiple injuries make laparoscopy more difficult, and advanced laparoscopic skills are required. The conversion rate is high; however, the non-therapeutic laparotomies were completely eliminated in this study.

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“…The other unsuspected injuries depicted were one sternal and acetabular fracture. No CT scans for conscious patients with extra-abdominal injuries after blunt trauma and a normal physical examination of the abdomen were needless (24,25). Those results are concordant with ours.…”

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confidence: 99%

Whole-Body CT after Motor Vehicle Crash: No Benefit after High-Energy Impact and with Normal Physical Examination

Belabbas¹,

Auger²,

Léderlin³

et al. 2019

Radiology

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outine use of whole-body CT in the initial assessment of patients with severe trauma following a motor vehicle crash (MVC) is widely accepted and recommended by Advanced Trauma Life Support guidelines (1). It enables accurate diagnosis of injuries, even those not suspected at physical examination (2-4). Several retrospective studies have suggested that whole-body CT could reduce mortality in comparison to standard x-rays plus selective CT (5-9). However, in a prospective randomized trial, the REACT -2 study group (10) recently reported no reduction in mortality by using immediate whole-body CT in comparison to conventional imaging plus selective CT for patients suspected of having severe or life-threatening injuries. Nevertheless, many patients with an injury severity score lower than 16 were included. Furthermore, whole-body CT is responsible for a higher amount of radiation dose delivered to patients (10-12). In view of the known risks of injected CT (radiation exposure, renal and allergy risks, time, and cost) (13,14), debate continues about the risk-to-benefit ratio of systematic whole-body CT when no injury is clinically suspected. Indications for whole-body CT in France are based on the Vittel criteria. These criteria include physiologic variables, kinetic components (mechanism of injury), anatomic injuries, and resuscitation prior to admission (15). Vittel criteria were initially used for field triage and were later adopted for whole-body CT indications, which is performed when at least one criterion is present. An initial study (2) reported that 30% of wholebody CT examinations showed clinically unsuspected injuries when systematically performed for presence of one or more Vittel criterion. Only 15% of these wholebody CT-depicted injuries were considered to change patient treatment. Moreover, 64% of whole-body CT demonstrated no abnormalities. These findings underline the lack of specificity of the Vittel criteria as applied to whole-body CT for trauma.

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The validity of abdominal examination in blunt trauma patients with distracting injuries

Abstract: Diagnostic study, level III.

Cited by 20 publications

References 22 publications

Development of a new clinical decision rule for cervical CT to detect cervical spine injury in patients with head or neck trauma

Development of a new clinical decision rule for cervical CT to detect cervical spine injury in patients with head or neck trauma

Laparoscopy for blunt abdominal trauma: a challenging endeavor

Whole-Body CT after Motor Vehicle Crash: No Benefit after High-Energy Impact and with Normal Physical Examination

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