Trends in utilization of whole-body computed tomography in blunt trauma after MVC: Analysis of the Trauma Quality Improvement Program database.

BACKGROUND: The use of whole-body computed tomography (WBCT) in awake, clinically stable injured patients is controversial. It is associated with unnecessary radiation exposure and increased cost. We evaluate use of computed tomography (CT) imaging during the initial evaluation of injured patients at American College of Surgeons Levels I and II trauma centers (TCs) after blunt trauma. METHODS: We identified adult blunt trauma patients after motor vehicle crash (MVC) from the American College of Surgeons Trauma Quality Improvement Program (TQIP) database between 2007 and 2016 at Level I or II TCs. We defined awake clinically stable patients as those with systolic blood pressure of 100 mm Hg or higher with a Glasgow Coma Scale score of 15. Computed tomography imaging had to have been performed within 2 hours of arrival. Whole-body computed tomography was defined as simultaneous CT of the head, chest and abdomen, and selective CT if only one to two aforementioned regions were imaged. Patients were stratified by Injury Severity Score (ISS). RESULTS: There were 217,870 records for analysis; 131,434 (60.3%) had selective CT, and 86,436 (39.7%) had WBCT. Overall, there was an increasing trend in WBCT utilization over the study period (p < 0.001). In patients with ISS less than 10, WBCT was utilized more commonly at Level II versus Level I TCs in patients discharged from the emergency department (26.9% vs. 18.3%, p < 0.001), which had no surgical procedure(s) (81.4% vs. 80.3%, p < 0.001) and no injury of the head (53.7% vs. 52.4%, p = 0.008) or abdomen (83.8% vs. 82.1%, p = 0.001). The risk-adjusted odds of WBCT was two times higher at Level II TC vs. Level I (odds ratio, 1.88; 95% confidence interval 1.82-1.94; p < 0.001). CONCLUSION: Whole-body computed tomography utilization is increasing relative to selective CT. This increasing utilization is highest at Level II TCs in patients with low ISSs, and in patients without associated head or abdominal injury. The findings have implications for quality improvement and cost reduction. LEVEL OF EVIDENCE: Care management, Level IV.

Bringing to Light Symptoms and Treatments of Effort Thrombosis (Paget-Schroetter Syndrome) in the Military Population, a Case Study.

BACKGROUND: Effort thrombosis, or Paget-Schroetter Syndrome, is an activity-induced upper extremity deep vein thrombosis affecting the axillary and/or subclavian vein. It is a rare disorder affecting 2 per 100,000 person years and mainly occurring in young, active individuals after repetitive upper extremity exertion. Effective diagnosis and management of this disorder has been difficult to study given the syndrome's rarity. METHODS: We discuss and evaluate the case of a 38-year-old muscular male Marine who presented to the primary care clinic following an incorrect diagnosis during an emergency room visit where he was evaluated and treated for a right pectoralis muscle strain while having symptoms suggestive of upper extremity vascular congestion, including pain and edema. FINDINGS: Given this presentation in a concentrated population such as the military, the primary care provider's suspicion of effort thrombosis was heightened. This patient was directed for lab and radiology examination followed by vascular surgery evaluation to be treated with catheter-directed thrombolysis, anticoagulation, and a first rib resection. DISCUSSION: Though rare, effort thrombosis is of particular importance in our relatively young, athletic population. A missed or delayed diagnosis could lead to lifelong disability. Awareness of this condition's presentation, inciting factors, and potential sequelae is important to minimize mortality and morbidity.