[Interdisciplinary shock room management: personnel, equipment and spatial logistics in 3 trauma centers in Europe]. / Interdisziplinäre Schockraumversorgung: Personelle, apparative und räumlich-logistische Konzepte in 3 Traumakrankenhäusern in Europa.

OBJECTIVE: To analyse common and divergent features of staff-related, equipmental and spatial/logistical concepts of three large trauma centers of highest health care level. METHODS: The health care mandate as well as the staff management, the organisational and the constructional-spacial structure of trauma room diagnostics and therapy of the trauma centers of the Universities of Leiden and Munich (Innenstadt) and the Zentralklinikum Augsberg are described. In particular the technical equipment and the process of the radiological diagnostic procedures in the trauma room are outlined. RESULTS: Staff availability and basic technical equipment of the trauma rooms are comparable between the three hospitals. Divergent concepts exist concerning the complexity of the initial radiologic examination protocols. Spacial connection and importance of computed tomography are also discussed controversially. Urgent interventional procedures are increasingly performed within the trauma room. Magnetic-resonance-tomography does not play a role in early care from multiple injured patients. CONCLUSION: Trauma centers have to meet certain personnel and technical prerequisites to guarantee a temporally optimised care for multiple injured patients. Differences between the three centers concerning the logistic sequence and the radiologic examination techniques used are mainly due to variable emphasis put on CT in the initial phase of patient care.

Routine cervical spine radiography for trauma victims: Does everybody need it?

OBJECTIVE: The purpose of this study was to evaluate the indication for routine cervical spine radiography in trauma patients. METHODS: Prospective analysis of radiologic and clinical findings was performed during a 5-year period. Patients suitable for a clinical decision rule were reviewed separately. RESULTS: Of the 1,757 consecutive patients included in the study, 38 were diagnosed with a cervical spine injury. Of the 599 patients suitable for the clinical decision rule, 62 had midline cervical tenderness, including 2 with cervical spine injury. No additional cervical spine injuries were found during follow-up. CONCLUSION: It is within good practice, and it is also cost-effective, to obtain a cervical spine radiograph only on clinical parameters in trauma patients with no apparent bodily trauma and optimal parameters. With this clinical decision rule, 30.6% of all cervical spine series were redundant, and no (occult) spinal fractures would have been undetected.

Sonography in a clinical algorithm for early evaluation of 1671 patients with blunt abdominal trauma.

OBJECTIVE: The purpose of this study was to evaluate the efficacy of sonography in our algorithm when differentiating patients with blunt abdominal trauma who need immediate surgery from patients who would benefit from further diagnostic workup or who need no treatment. SUBJECTS AND METHODS: We performed abdominal sonography as the primary screening tool in 1671 consecutive patients in our prospective study. Radiologists performed sonography in the trauma room within minutes of the arrival of each patient. Hemodynamic instability in conjunction with positive sonographic findings led to emergency laparotomy. Otherwise, positive sonographic findings warranted additional diagnostic tests. Observing free fluid or organ injury caused us to categorize sonographic findings as positive. RESULTS: Sonography correctly identified all patients requiring emergency laparotomy. No inconclusive laparotomies were performed in this group. The sensitivity of sonography for revealing intraabdominal injury was 88%, the specificity was 100%, and the accuracy was 99%. In 132 patients (8%), abdominal CT was performed. CT revealed relevant posttraumatic abnormalities in 61% of all patients. Four hundred seventy patients with negative sonographic findings were discharged approximately 12 hr after admission; two of these patients (0.4%) were mistakenly discharged. Trauma scores did not influence the efficacy of sonography. CONCLUSION: Our algorithm that uses sonography as the primary diagnostic tool provides accurate, fast, cost-effective, and noninvasive initial management of patients with blunt abdominal trauma. Our test characteristics were excellent indicators of the need for emergency laparotomy. Sonography also achieves high values in revealing relevant injury. Our algorithm produced medically satisfactory and economically prudent management of patients with blunt abdominal trauma.

Abdominal aortic aneurysm measurements for endovascular repair: intra- and interobserver variability of CT measurements.

OBJECTIVES: to evaluate the intra- and interobserver variability in measurements of the aorta and iliac arteries in patients with abdominal aortic aneurysms (AAAs) considered for endovascular repair using computed tomography angiography (CTA). METHODS: the diameter of the neck, aneurysm, right and left iliac artery were measured by 5 observers in 10 consecutive patients. Measurements were performed on hard copy using a ruler and on a workstation using an electronic caliper. RESULTS: the intraobserver variability showed a decrease going from hard copy to workstation in the standard deviation of the differences of the paired observations for the neck from 3.54 mm to 1.18 mm; for the aorta from 4.16 to 1.72 mm; for the right iliac from 1.87 to 1.01 mm; for the left iliac from 2.07 to 0.87 mm. The interobserver variability showed a similar decrease for the neck in all ten pairs of observers; for the aorta in two, for the right iliac and left iliac in five. However, the difference between observers regularly exceeded 2 mm. CONCLUSION: the use of a workstation and electronic calipers results in lower intra- and interobserver variability. However, the results still show a clinically relevant difference between the observers. Therefore, it is necessary to develop an automatic observer-independent measurement technique.

The value of physical examination in the diagnosis of patients with blunt abdominal trauma: a retrospective study.

Between 1 January 1993 and 1 January 1994, 204 consecutive patients with possible blunt abdominal injury were analysed retrospectively. All patients underwent a standardized diagnostic approach on admission to the emergency room. Abdominal ultrasound (AUS) was performed in all cases. If there was evidence of intra-abdominal injury on physical examination or AUS, without signs of persistent hypovolaemia after initial assessment, contrast-enhanced computed tomographic scanning (CECT) of the abdomen was carried out without exception. Physical examination was equivocal in 13 and 3 per cent, respectively, of patients with 'isolated' abdominal trauma (N = 23) or with fractures of lower ribs 7-12 as a sole diagnosis (N = 30). In multiple injury patients (N = 95) or those with suspected 'isolated' head injury (N = 56), these figures reached 45 and 84 per cent, respectively. AUS (N = 204) revealed intra-abdominal injury in 20 per cent of patients, and CECT (N = 43) resulted in additional information in 49 per cent. Patients with 'isolated' head injury showed 9 per cent abnormalities on abdominal evaluation versus 32 per cent in multiple injury patients. In lower rib fractures (7-12) in multiple injury patients abdominal injury was diagnosed in 67 per cent of the cases. We conclude that: (1) negative findings following reliable physical examination of patients with 'isolated' head injury show very high values (NPV 100 per cent), but reliable physical examination is very infrequent (16 per cent); (2) NPV in lower rib fractures due to low energy impact is very high (100 per cent), with a reliable physical examination in most patients (97 per cent); (3) in patients with isolated abdominal trauma 87 per cent have a reliable physical examination with a moderately high NPV (71 per cent); (4) almost half the multiple injury patients have an unequivocal physical examination (45 per cent), with a high NPV following reliable physical examination for abdominal injury (85 per cent); (5) abdominal ultrasonography should be the first step in the radiological assessment of all patients with possible blunt abdominal injury; (6) in multiply injured patients with fractures of their lower ribs (7-12) due to high energy impact the incidence of abdominal injury is very high and CECT might be indicated even in the case of normal AUS findings.

Degenerative changes at the knee and ankle related to malunion of tibial fractures. 15-year follow-up of 88 patients.

We re-examined clinically and radiologically 88 patients with a fracture of the lower leg at a mean follow-up of 15 years. Forty-three fractures (49%) had healed with malalignment of at least 5 degrees. More arthritis was found in the knee and ankle adjacent to the fracture than in the comparable joints of the uninjured leg. Malaligned fractures showed significantly more degenerative changes. Eighteen patients (20%) had symptoms in the fractured leg. There was a significant correlation between symptoms in the knee and arthritis but not between symptoms and ankle arthritis or malalignment. We conclude that fractures of the lower leg should be managed so that the possibility of angular deformity and thereby late arthritis is minimised.

Ultrasound in the diagnosis of injury.

Ultrasound is one of several modalities useful in the work-up of an injured patient. It is a bedside technique which is quick, economical and highly reliable in filtering out the patients who are in urgent need of laparotomy. For the moment, this is the prime and only function of this modality. The US examination can and should be repeated with a very low threshold. Apart from the complication rate, which is zero for US, it shares many virtues with DPL. Ultrasonography in a badly injured victim is a challenging investigation which should be done by an expert. In most situations, this will be a radiologist whose presence in the emergency room could further be used for expert film reading and development as well as the unhampered implementation of a rational follow-up imaging strategy. Follow-up modalities, however impressive, should not be compared with first-line investigations. In expert hands, accuracy figures between DPL and US do not differ decisively but one must bear in mind that DPL spans only one compartment while US gives information about much more vital areas. DPL is complementary to US; it is of paramount importance to understand that DPL spoils the US examination (and CT as well) but is not hindered by repeated US. DPL can and should be used to investigate the nature of free intra-peritoneal fluid when the amount does not warrant laparotomy. Neither US nor DPl are substitutes for sound clinical judgement.

The trauma emergency room: a concept for handling and imaging the polytrauma patient.

Polytrauma is a life-threatening entity that requires immediate action by all specialties involved. Upon arrival in the hospital, the patient will be seen and managed primarily by three groups of medical personnel: (a) surgeons (trauma specialists), (b) intensive care specialists, and (c) radiologists. The usual medical approach within the first minutes to hours will consist of four important steps: (1) primary survey, (2) resuscitation and stabilization, (3) secondary survey, and (4) definitive care. Survey, with regard to polytrauma, means quick and comprehensive evaluation of the patient's situation, clinically as well as by imaging. To fulfill these requirements, an interdisciplinary trauma emergency room with appropriate equipment, infrastructure and environment is necessary. Immediately after the patient's arrival and within a short time span, a limited number of plain radiographs of the spine, chest, pelvis, and abdomen (and extremities and skull, if necessary) should be obtained without turning, moving, or repositioning the patient. Sonography will be applied simultaneously to visualize or exclude: free fluid collections within the pleural spaces and/or peritoneal cavity and in other compartments (retroperitoneum, pelvis, soft tissues). Organ lesions (such as lacerations of liver, spleen or kidneys) and posttraumatic pathology of large vessels (tears, occlusion, aneurysm) can be evaluated or detected by sonography. These basic imaging studies (plain films and sonography) together with the clinical findings may be conclusive, or at least serve as decision makers for further action which may include: (a) more detailed plain radiography examinations, (b) tailored computed tomography examinations, invasive/interventional procedures (angiography or image-guided punctures), or (c) immediate surgical intervention. This concept is a challenge for the medical groups involved. Unlimited interdisciplinary cooperation and mutual exchange of information are the fundamental principles for successful trauma care and management.

Changes in the diagnosis and treatment of traumatic splenic rupture: a retrospective analysis of 99 consecutive cases.

From January 1986 to January 1995, 99 consecutive cases with a ruptured spleen were analysed retrospectively. Diagnostic peritoneal lavage was replaced by abdominal ultrasound as a routine screening investigation in blunt abdominal trauma after 1991. An abdominal computed tomography scan carried out in stable circulatory conditions provided additional information in 80% of the cases. The choice of treatment was related to the extent of the splenic damage and associated injuries. Even in degree IV ruptures splenorrhaphy was carried out successfully in 38% (five out of 12). The Hospital Trauma Index-Injury Severity Score (HTI-ISS) was significantly lower (17.7; n = 43) in conservative treatment than in cases treated by splenorrhaphy (27.6; n = 25) or splenectomy (33.6; n = 31). Conservative treatment (n = 43) resulted in a secondary intervention in 19%, whereas primary splenorrhaphy (n = 25) failed once (4%). Clinical morbidity was 26%, with no significant differences between conservative treatment, splenorrhaphy and splenectomy. Early mortality (0-30 days post-trauma) reached 14%, and was related to extensive injuries in all cases. The mean HTI-ISS in patients with a fatal outcome was 50.5. Overall, 62% of the injured spleens were saved, with the rate of splenic preservation improving throughout the study period. A conservative policy was increasingly treatment of first choice in patients with stable circulatory parameters with major concomitant injuries.

Percutaneous computed-tomography-guided thermocoagulation for osteoid osteomas.

Current treatment for osteoid osteomas is usually surgical excision of the nidus. We treated 18 patients with osteoid osteoma by percutaneous thermocoagulation of the nidus under computed-tomography guidance. The procedure was technically successful in all cases and there were no complications. Patients were discharged on the following morning and resumed normal activities immediately. All patients but one remained pain free during follow-up (range 3-15 months). A second thermocoagulation treatment relieved the recurrent symptoms in this patient. Percutaneous thermocoagulation appears to be effective for osteoid osteomas, and is a minimally invasive alternative to surgical resection.

Unstable pelvic fractures: a retrospective analysis.

Thirty-nine patients with unstable pelvic fractures were analysed retrospectively. The mean age of the group was 41 years (range 15-77). Of these cases 35 had sustained high energy trauma. The mean Hospital Trauma Index-Injury Severity Score of the population was 32 (16-66). Nine cases were haemodynamically unstable on admission. The type of unstable pelvic fracture was classified according to Tile. Sixteen patients had a type B fracture and 23 had a vertical instability (type C) fracture. In two patients, an open fracture was seen. Directly associated injuries were diagnosed in 11 patients, of which eight showed damage of the urogenital system, three of the rectum and three of the peripheral nerve system. In seven cases the fracture was treated non-operatively; in the remaining 32 patients the pelvic ring was stabilized operatively. Additional therapy for hypovolaemic shock due to pelvic bleeding was necessary in six cases. The overall mortality in this series was 13 per cent. Early and aggressive resuscitation and standardized treatment in well-equipped and staffed injury centres is mandatory in these severely traumatized patients to achieve optimal results and to minimize the risk of fatal outcome.

Ureteric obstruction after radical hysterectomy.

Two patients with invasive carcinoma of the cervix treated with radical hysterectomy developed total unilateral ureteric obstruction postoperatively. A temporary percutaneous nephrostomy was inserted. Because both patients needed adjuvant radiotherapy, intended reimplantation of the ureter was postponed. During this period spontaneous passage through the ureter was observed after 5 and 14 weeks, respectively. It is emphasized that a 'wait and see' policy may be justifiable in the case of ureteric obstruction of unclear etiology after radical hysterectomy for at least 3 months, as long as renal function is preserved by percutaneous nephrostomy drainage of the affected kidney side.

Posterolateral dislocation of the elbow with concomitant fracture of the lateral humeral condyle: case report.

We describe a case of a 6-year-old girl with a posterolateral elbow dislocation and a concomitant fracture of the lateral humeral condyle. After reduction of the dislocation, the fracture was diagnosed and treated by open reduction and fixation, with a good functional result. In doubtful cases, oblique, heterolateral, and varus stress films, or even arthrography may be necessary.

Pancreatic graft survival after arterial thrombosis in simultaneous renal-pancreatic transplantation.

Vascular thrombosis following pancreas transplantation is one of the main causes of early graft loss. Successful thrombectomy after pancreatic graft thrombosis has not been reported yet. A patient with arterial graft thrombosis in whom the graft survived after thrombectomy is described. Different varieties of pancreatic graft thrombosis are discussed.

Abdominal ultrasound as a reliable indicator for conclusive laparotomy in blunt abdominal trauma.

The purpose of this study was to evaluate the ability of abdominal ultrasound (US) to detect intra-abdominal injuries that required surgical repair. We therefore retrospectively reviewed 353 patients with nontrivial blunt abdominal trauma. All patients underwent abdominal evaluation as part of our routine trauma protocol within the first minutes of arrival at our emergency center. Hemoperitoneum and intraperitoneal parenchymal damage were correctly identified by US with a sensitivity of 92.8%, and a specificity of 100%. Accuracy was 99.4%, the positive predictive value was 100%, and the negative predictive value was 99.4% (prior probability of disease was 7.65%). We believe that abdominal US should be considered an important tool and an integral part in the work-up of major trauma victims.