Decision Making by CT Grading in Blunt Hepatic Injury Patient

BACKGROUND: Because of increased number of traffic and industrial accidents, the incidence of blunt abdominal injury patients has increased. Recently, abdominal computed tomographic(CT) scans have been widely used in emergency departments for initial diagnostic workups on patients with blunt hepatic injuries. The purpose of this study is to analyze the correlation between abdominal CT scans and the clinical outcomes and to recommend a direction for the management of blunt hepatic injury. METHODS: A retrospective review was conducted of 66 patients with blunt hepatic injuries who underwent abdominal CT scans and were treated at the Department of Emergency Medicine of Dankook University Hospital during the period from January 1998 to December 2000. Statistical analysis was performed using the chi-square(x2) test, Spearman correlation test, Cochran-Mantel-Haenszel chi-square(x2) test and Fisher's exact test; a value of p<0.05 was considered significant. RESULTS: Based on CT scans, we graded the liver injuries by using the system of the Organ Injury Scaling Committee of American Association for the Surgery of Trauma. Grade II injuries(28 cases, 42.4%) were the most common in this study. Most patients with injuries above grade III were managed surgically, and CT grades correlated well with operative treatment and initial fluid resuscitation. Initial shock status correlated with the CT grade, but did not correlate with operative management. For nonoperative management, as the CT grade increased, the amount of blood transfusion also increased. Increasing liver enzyme did not correlate with CT grade. The mortality rate was 9.1%, and the most common cause of death were hypovolemic shock due to massive bleeding. CONCLUSION: Non-operative management is the first choice of treatment in low grade blunt hepatic injury(CT grade I, II, and III). For cases above grade IV hepatic injury, the key points of operative management were the hepatic injury itself and it's complication.

Nontraumatic Disorders in Mediastinum and Thoracic Aorta: Chest RadiographicFindings

BACKGROUND: Rupture of thoracic aortic aneurysm and dissection into the chest space results in the death of the patient from uncontrolled hemorrhage. The purpose of our study is to evaluate chest radiographic findings that may assist in the rapid detection of nontraumatic disorder in mediastinum and thoracic aorta. MATERIAL AND METHOD: Thirteen consecutive chest radiographs obtained at emergency room of patients with hemorrhage from ruptured thoracic aortic aneurysms or aortic dissections were randomized with radiographs of 8 subjects with nonruptured thoracic aortic aneurysms, 11 subjects with nonruptured aortic dissections, and 20 control subjects. Diagnoses were confirmed by computed tomography(CT) and transesophageal echocardiography(TEE). A retrospective study was performed by assessment of 14 parameters on each of these 52 radiographs to screen the mediastinum and thoracic aortic disorder. RESULTS: Significant difference between patients with mediastinum and thoracic aortic disorder(aneurysm and dissection) and normal subjects occurred in mediastinal/chest ratio>0.25, aortic knob width>4cm, tracheal shift to right loss of paratracheal stripe & azygos vein, and left pleural & extrapleural fluid of chest radiographs(p<0.05). The most useful predictors of mediastinum and thoracic disorder were aortic knob widening above 4cm and combining signs of mediastinum/chest ratio above 0.25 and abnormal aortic arch. These plain radiographic signs had a sensitivity of 9.1~96.9% and a specificity of 40~100% for mediastinum and thoracic aortic disorder. CONCLUSION: The chest radiograph obtained at emergency room remains the best available screening test for mediastinum and thoracic aortic disorder and can be used effectively, though not perfectively, to eliminate unnecessary CT or TEE.

Clinical Difference Between a Thoracic Aortic Dissection and an Acute Myocardial Infarction

BACKGROUND: Acute dissection of the thoracic aorta can mimic the symptoms of myocardial infarction with pain, elevated serum creatinine kinase levels, and electrocardiographic abnormalities suggesting myocardial ischemia. Therefore, this study was designed to assess the clinical differences between a thoracic aortic dissection and an acute myocardial infarction. METHODS: The cases of 72 patients who visited the Emergency Department, Dankook University Hospital, from January 1996 to December 1998 were retrospectively reviewed. Of the 72 patients, 32 were thoracic aortic dissections and 40 were acute myocardial infarctions. The parameters analyzed were epidemiology, pain character and associated symptoms, simple X-rays, EKGs on arrival. RESULTS: This study demonstrated that 1) there were significant differences in the nature, location, and duration of pain, the radiation, the neurologic symptoms, the chest X-rays, and the EKGs between the two groups and that 2) there were no significant differences in pain severity and abrupt onset. CONCLUSION: This study suggests that patients with suspected acute myocardial infarction should be provided an appropriate, accurate technique, such as CT, MRI, or TEE, if the nature, location, and duration of pain, the radiation, the neurologic symptoms, the chest X-ray, and the EKG are consistent with a thoracic aortic dissection.

Traumatic Acute Subdural Hematoma: Prognosis and Operative Timing

BACKGROUND: Traumatic acute subdural hematoma remains one of the most lethal of all head injuries. It has been strongly held that the critical factor in the overall outcome from acute subdural hematoma is the timing of operative intervention for clot removal; those operated on within 4 hours of injury may have a marked decrease in mortality and morbidity. METHODS: Data were reviewed for 79 patients with a traumatic acute subdural hematoma during 2 years between January 1997 and December 1998. Treatment protocol included rapid operative intervention and aggressive postoperative control of intracranial pressure. RESULTS: The overall mortality rate was 63.3%, and 21.5% had functional recovery. The following variables statistically correlated(p

Analysis of CT findings in patients with Diffuse Axonal Injury

BACKGROUND: Diffuse axonal injury(DAI) occurring in almost in half of severely head-injured patients is a severe farm of primary brain damage, and is associated with immediate prolonged coma. This study was designed to investigate the brain computerized tomography(CT) findings and prognostic factors of patients with DAI to provide some valuable guidlines in evaluation and management. METHOD: A series of 71 patients of DAI diagnosed with CT and magnetic resonance imaging(MRI) between January 1996 to December 1997 were studied retrospectively. Inclusion criteria were severe head injury patients of GCS below 8 and whose CT scan demonstrated characteristic punctuate hemorrhage of <20mm in diameter at deep white marrer, basal ganglia, corpus callosum and upper brainstem, and intraventricular hemorrhage. We analyzed data with t-test and regression methods for statistical significance. RESULT: The lesions on CT were classified according to the modified Adams staging as follows, staging 0 : no lesion identified(25 cases, 35.2%), stage 1 : lesions confined to deep white matter or basal ganglia(32 cases, 45.2%) ; stage 2 : lesions in the corpus callosum(9 cases, 12.7%) ; stage 3 : focal lesions in the corpus callosum and rostral brainstem(5 cases,7.0%). A moderate or good recovery at discharge was achieved by 42 patients(59.2%), but 29 patients had a poor outcome(severe disability in 13, vegetative state in 7, and death in 9). The modified Adams staging in patients with DAI was not associated with Gennarelli's neurological grade, Glasgow coma scale(GCS), and outcome. The CT findings associated with visible hemorrhagic lesions, subarachnoid hemorrhage(SAH), or generalized brain swelling in patients with DAI carried poor outcome. CONCLUSION: The nonhemorrhagic DAI is not detected by Cf. Patient with decreased conscious level and normal brain CT in head injury should be suspected the DAI. The hemorrhagic DAI had worse prognosis than nonhemorrhagic DAI. Prognosis of the patient with CT findings of SAH or generalized brain swelling in DAI was poor.

Acute Traumatic Intracranial Hematoma: Mortality and Operative timing

To discover the effects of the time from injury to operative evacuation of the acute intracranial hematoma in the regard to improve outcome mortality, we reviewed the records 90 traumatic patients with acute intracrainal hematoma treated at our hospital between 1996 and 1997. The overall mortality late was 50%. The important prognostic variables included Glasgow coma scale(GCS), age, degree of midline shift in computerized tomography(CT), and lesional type of hematoma. Outcome was not significantly improved by rapid surgical decompression and no benefit revealed when surgery was performed within fast 4 hours. The mean interval from injury to surgery was 411 minutes for patient who died and 404 minutes for patients with functional recovery, but it was statistically insignificant. the mortality rate for those patients operated on within 4 hours of injury was 44% versus 52.3% for those operated on after 4 hours, and it was also statistically insignificant. In our opinion impart brain damage may be substantial and will affect recovery from intracranial hematoma and the operative timing-within the first 4 hours-may not be critical as has been commonly held.

Clinical Analysis of Delayed Intracranial Hemorrhage in Head Injury

Experinece in the management of 74 patients with delayed traumatic intracranial hemorrhage(DTICH) of 474 head injury from January 1996 to December 1996 is poresented with emphasis on the incidence, occurring time, risk factors and outcome. The incidence of DTICH was 15.6% of all hospitalized head-injury patients. After an injury, every patient had an immediate computerized tomography(CT) scan to diagnose intracranial pathology and then CT follow-up was carried out according to intial CT finding and reurological deficit. The lesion was almost occurred in patients with initial abnormal CT finding(85.1%). 82.4% of DTICH were noted within 72 hours after injury. The delayed epidural hematoma and intracerebral hemorrhage were almost noted in first 72 hours(>90%), but the delayed subdural hemorrhage was found after a time interval varying from 6 hours to 10 days. So we strongly recommend CT follow-up in 4-8hour, 24-72hour, and then 7th day after head injury, especially in patients with initial abnormal CT findings. The risk factor of the delayed lesion was not hypotension, hypoxia, and consciousness level, but age of patients and the initial CT finding. The development of DTICH was not heralded by neurological deterioration. The prognosis of DTICH was not worse than non-DTICH. The patient with delayed subdural hemorrhage was better than the patient with non-delayed lesion(including hemorrhage and normal CT finding).