The ability of computed tomography to diagnose placental abruption in the trauma patient.

BACKGROUND: Fetal demise following trauma remains a devastating complication largely owing to placental injury and abruption. Our objective was to determine if abdominopelvic computed tomographic (CT) imaging can assess for placental abruption (PA) when obtained to exclude associated maternal injuries. METHODS: Retrospective review of pregnant trauma patients of 20-week gestation or longer presenting to a trauma center during a 7-year period who underwent CT imaging as part of their initial evaluation. Radiographic images were reviewed by a radiologist for evidence of PA and classified based on percentage of visualized placental enhancement. Blinded to CT results, charts were reviewed by an obstetrician for clinical evidence of PA and classified as strongly positive, possibly positive, or no evidence. RESULTS: A total of 176 patients met inclusion criteria. CT imaging revealed evidence of PA in 61 patients (35%). As the percentage of placental enhancement decreased, patients were more likely to have strong clinical manifestations of PA, reaching statistical significance when enhancement was less than 50%. CT imaging evidence of PA was apparent in all patients who required delivery for nonassuring fetal heart tones. CONCLUSION: CT imaging evaluation of the placenta can accurately identify PA and therefore can help stratify patients at risk for fetal complications. The likelihood of requiring delivery increased as placental enhancement declined to less than 25%. LEVEL OF EVIDENCE: Diagnostic study, level III.

Incidence of blunt cerebrovascular injury in low-risk cervical spine fractures.

BACKGROUND: It has been suggested that specific cervical spine fractures (CSfx) (location at upper cervical spine [CS], subluxation, or involvement of the transverse foramen) are predictive of blunt cerebrovascular injury (BCVI). We sought to determine the incidence of BCVI with CSfx in the absence of high-risk injury patterns. METHODS: We performed a retrospective study in patients with CSfx who underwent evaluation for BCVI. The presence of recognized CS risk factors for BCVI and other risk factors (Glasgow coma score ≤ 8, skull-based fracture, complex facial fractures, soft-tissue neck injury) were reviewed. Patients were divided into 2 groups based on the presence/absence of risk factors. RESULTS: A total of 260 patients had CSfx. When screened for high-risk pattern of injury for BCVI, 168 patients were identified and 13 had a BCVI (8%). The remaining 92 patients had isolated low CSfx (C4-C7) without other risk factors for BCVI. In this group, 2 patients were diagnosed with BCVI (2%). Failure to screen all patients with CSfx would have missed 2 of 15 BCVIs (13%). CONCLUSIONS: We propose that all CS fracture patterns warrant screening for BCVI.

Use of computed tomography in the initial evaluation of anterior abdominal stab wounds.

BACKGROUND: The purpose of this study was to assess the ability of computed tomography (CT) to facilitate initial management decisions in patients with anterior abdominal stab wounds. METHODS: A retrospective review was conducted of patients with anterior abdominal stab wounds who underwent CT over 4.5 years. Any abnormality suspicious for intra-abdominal injury was considered a positive finding on CT. RESULTS: Ninety-eight patients met the study's inclusion criteria. Positive findings on CT were noted in 30 patients (31%), leading to operative intervention in 67%. Injuries were confirmed in 95% of cases, but only 70% were therapeutic. Ten patients had nonoperative management despite positive findings on CT, including 5 patients with solid organ injuries. One patient underwent operative intervention for clinical deterioration, with negative findings. No computed tomographic evidence of injury was noted in the remaining 68 patients (69%), but 1 patient was noted to have a splenic injury while undergoing operative evaluation of the diaphragm. All remaining patients were treated nonoperatively with success. CONCLUSIONS: In patients with anterior abdominal stab wounds, CT should be considered to facilitate initial management decisions, as it has the ability to delineate abnormalities suspicious for injury.

Risk factors for blunt cerebrovascular injury in children: do they mimic those seen in adults?

BACKGROUND: Eastern Association for the Surgery of Trauma guideline for the evaluation of blunt cerebrovascular injury (BCVI) states that pediatric trauma patients should be evaluated using the same criteria as the adult population. The purpose of our study was to determine whether adult criteria translate to the pediatric population. METHODS: Retrospective evaluation was performed at a Level I trauma center of blunt pediatric trauma patients (age <15 years) presenting over a 5-year period. Data obtained included patient demographics, presence of adult risk factors for BCVI (Glasgow coma scale ≤8, skull base fracture, cervical spine fracture, complex facial fractures, and soft tissue injury to the neck), presence of signs/symptoms of BCVI, method of evaluation, treatment, and outcome. RESULTS: A total of 1,209 pediatric trauma patients were admitted during the study period. While 128 patients met criteria on retrospective review for evaluation based on Eastern Association for the Surgery of Trauma criteria, only 52 patients (42%) received subsequent radiographic evaluation. In all, 14 carotid artery or vertebral artery injuries were identified in 11 patients (all admissions, 0.9% incidence; all screened, 21% incidence). Adult risk factors were present in 91% of patients diagnosed with an injury. Major thoracic injury was found in 67% of patients with carotid artery injuries. Cervical spine fracture was found in 100% of patients with vertebral artery injuries. Stroke occurred in four patients (36%). Stroke rate after admission for untreated patients was 38% (3/8) versus 0.0% in those treated (0/2). Mortality was 27% because of concomitant severe traumatic brain injury. CONCLUSION: Risk factors for BCVI in the pediatric trauma patient appear to mimic those of the adult patient.