Traumatic injuries: role of imaging in the management of the polytrauma victim (conservative expectation)

Abstract

Abdominal US and CT play an important role in the initial management of blunt trauma in adults. Ultrasound is an excellent method for detection of free intra-abdominal fluid. It is the modality of choice for initial screening and enables selection of hemodynamically unstable trauma victims with severe hemoperitoneum for immediate surgery. However, even in experienced hands, US is not sufficient to rule out organ injuries reliably. Computed tomography, and particularly multislice CT (MSCT), has several major advantages over US and is currently unsurpassed for the detection of blunt visceral injuries in the abdomen. Computed tomography has a high sensitivity for the detection of parenchymal splenic and hepatic injuries. Injuries of the gastrointestinal tract may be detected with good sensitivity provided that adequate examination technique and careful diagnostic interpretation are combined. The value of CT-based injury-grading systems for predicting the outcome of conservative treatment remains unproven; however, demonstration of direct vascular injuries with CT, e.g., the intrasplenic "contrast blush" sign, may indicate a high likelihood that conservative treatment will fail, thus warranting angiographic embolization or surgery. Monitoring of conservatively treated trauma victims by means of repeat CT studies enables early detection of a variety of delayed, clinically silent complications of trauma, e.g., posttraumatic biloma or bowel devascularization. Catheter angiography may be reserved to selected cases with vascular injuries proven on CT.

The impact of clinically undiagnosed injuries on survival estimates

“…Although a well-known phenomenon in clinical medicine, the pattern and extent of missed injuries vary depending on the setting and the time period under study (7, 18 -24). It is likely that the proportion of missed injuries has decreased over time, as a result of implementation of structured clinical assessment of trauma victims (25) and improved diagnostic procedures (26). Nevertheless, in a study on traumarelated deaths in an intensive care unit by Ong et al (14), new major diagnoses were found in 19% of the autopsies.…”

Moderne CT-Diagnostik des akuten Thorax- und Abdominaltraumas

“…Unsere eigenen Erfahrungen an mehr als 500 Patienten bestätigen diese Annahme, da die diagnostische Sicherheit durch den Einsatz der MSCT erhöht wird und der Zeitaufwand für die diagnostische Abklärung erheblich verkürzt werden kann. Diese Einschätzung wird auch von anderen Autoren geteilt, wie jüngste Literaturberichte zeigen [7,26,39]. …”

Is Routine Spiral CT-Chest Justified in Evaluation of the Major Blunt Trauma Patients?

“…Furthermore, these injuries lead to a higher mortality in the multiple injured patients than isolated injuries of the same region [5]. In trauma patients, a clear history is rarely available as most patients are confused, unconscious or even anesthetized and the clinical findings have been shown to be equivocal or misleading in 20-50% of victims of blunt poly-trauma [6]. With the wide availability of Spiral computed tomography (CT) scanner overuse and perhaps overdependence on CT results for the management of patients with chest trauma has occurred.…”