Increased and unjustified CT usage in paediatric C-spine clearance in a level 2 trauma centre.

PURPOSE: Cervical spine injury after blunt trauma in children is rare but can have severe consequences. Clear protocols for diagnostic workup are, therefore, needed, but currently not available. As a step in developing such a protocol, we determined the incidence of cervical spine injury and the degree of protocol adherence at our level 2 trauma centre. METHODS: We analysed data from all patients aged < 16 years suspected of cervical spine injury after blunt trauma who had presented to our hospital during two periods: January 2010 to June 2012, and January 2017 to June 2019. In the intervening period, the imaging protocol for diagnostic workup was updated. Outcomes were the incidence of cervical spine injury and protocol adherence in terms of the indication for imaging and the type of imaging. RESULTS: We included 170 children in the first study period and 83 in the second. One patient was diagnosed with cervical spine injury. Protocol adherence regarding the indication for imaging was > 80% in both periods. Adherence regarding the imaging type decreased over time, with 45.8% of the patients receiving a primary CT scan in the second study period versus 2.9% in the first. CONCLUSION: Radiographic imaging is frequently performed when clearing the paediatric cervical spine, although cervical spine injury is rare. Particularly CT scan usage has wrongly been emerging over time. Stricter adherence to current protocols could limit overuse of radiographic imaging, but ultimately there is a need for an accurate rule predicting which children really are at risk of injury.

Split bolus technique in polytrauma: a prospective study on scan protocols for trauma analysis.

BACKGROUND: For the evaluation of severely injured trauma patients a variety of total body computed tomography (CT) scanning protocols exist. Frequently multiple pass protocols are used. A split bolus contrast protocol can reduce the number of passes through the body, and thereby radiation exposure, in this relatively young and vitally threatened population. PURPOSE: To evaluate three protocols for single pass total body scanning in 64-slice multidetector CT (MDCT) on optimal image quality. MATERIAL AND METHODS: Three total body CT protocols were prospectively evaluated in three series of 10 consecutive trauma patients. In Group A unenhanced brain and cervical spine CT was followed by chest-abdomen-pelvis CT in portovenous phase after repositioning of the arms. Group B underwent brain CT followed without arm repositioning by a one-volume contrast CT from skull base to the pubic symphysis. Group C was identical to Group A, but the torso was scanned with a split bolus technique. Three radiologists independently evaluated protocol quality scores (5-point Likert scale), parenchymal and vascular enhancement and artifacts. RESULTS: Overall image quality was good (4.10) in Group A, more than satisfactory (3.38) in Group B, and nearly excellent (4.75) in Group C (P < 0.001). Interfering artifacts were mostly reported in Group B in the liver and spleen. CONCLUSION: In single pass total body CT scanning a split bolus technique reached the highest overall image quality compared to conventional total body CT and one-volume contrast CT.

A case-matched series of immediate total-body CT scanning versus the standard radiological work-up in trauma patients.

BACKGROUND: In recent years computed tomography (CT) has become faster and more available in the acute trauma care setting. The aim of the present study was to compare injured patients who underwent immediate total-body CT (TBCT) scanning with patients who underwent the standard radiological work-up with respect to 30-day mortality. METHODS: Between January 2009 and April 2011, 152 consecutive patients underwent immediate TBCT scanning as part of a prospective pilot study. These patients were case-matched by age, gender, and Injury Severity Score (ISS) category with control patients from a historical cohort (July 2006-November 2007) who had undergone X-rays and focused assessment with sonography for trauma, followed by selective CT scanning. RESULTS: Despite comparable demographics, TBCT patients had a lower median Glasgow Coma Score (GCS) than controls (10 vs. 15; p < 0.001) and on-scene endotracheal intubation was performed more often (33 vs. 19 %; p = 0.004). 30-day mortality was 13 % in the TBCT patient group versus 13 % in the control group (p = 1.000). A generalized linear mixed model analysis showed that a higher in-hospital GCS [odds ratio (OR) 0.8, 95 % confidence interval (CI) 0.745-0.86; p < 0.001] and immediate TBCT scanning (OR 0.46, 95 % CI 0.236-0.895; p = 0.022) were associated with decreased 30-day mortality, while a higher ISS (OR 1.054, 95 % CI 1.028-1.08) p < 0.001) was associated with increased 30-day mortality. CONCLUSIONS: Trauma patients who underwent immediate TBCT scanning had similar absolute 30-day mortality rates compared to patients who underwent conventional imaging and selective CT scanning. However, immediate TBCT scanning was associated with a decreased 30-day mortality after correction for the impact of differences in raw ISS and in-hospital GCS.

A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2).

BACKGROUND: Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients. METHODS/DESIGN: The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness. DISCUSSION: The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group. TRIAL REGISTRATION: ClinicalTrials.gov: (NCT01523626).

Impact of secondary transfer on patients with severe traumatic brain injury.

BACKGROUND: Within a trauma network in the Netherlands, neurosurgical facilities are usually limited to Level I hospitals. Initial transport to a district hospital of patients who are later found to require neurosurgical intervention may cause delay. The purpose of this study was to assess the influence on outcome and time intervals of secondary transfer in trauma patients requiring emergency neurosurgical intervention. METHODS: In a 3-year period, all patients who sustained a severe traumatic brain injury and underwent a neurosurgical intervention within 6 hours after admission to a Level I trauma center were included. Patients were classified into two groups: direct presentation to the Level I trauma center (TC) group or requiring secondary transport after having been diagnosed for neurosurgical intervention in other hospitals (transfer group). RESULTS: Eighty patients were included for analyses. Twenty-four patients in the transfer group had a better Glasgow Coma Scale on-scene but a higher 30-day mortality compared with patients who were primarily presented to the Level I trauma center (33% vs. 27%; p = 0.553). In the transfer group, time to operation was 304 minutes compared with 151 minutes in the TC group (p < 0.001). Most delay occurred during the initial trauma evaluation and the interval between the first computed tomography and the transfer ambulance departure at the referring hospital. CONCLUSION: Patients requiring an emergency neurosurgical intervention appear to have a clinically relevant worse outcome after secondary transfer to a neurosurgical service. Therefore, patient care can probably be improved by better triage on-scene and standardized procedures in case of a secondary transfer.

Improved outcomes in the non-operative management of liver injuries.

OBJECTIVES: Non-operative management has become the treatment of choice in the majority of liver injuries. The aim of this study was to assess the changes in primary treatment and outcomes in a single Dutch Level 1 trauma centre with wide experience in angio-embolisation (AE). METHODS: The prospective trauma registry was retrospectively analysed for 7-year periods before (Period 1) and after (Period 2) the introduction of AE. The primary outcome was the failure rate of primary treatment defined as liver injury-related death or re-bleeding requiring radiologic or operative (re)interventions. Secondary outcomes were liver injury-related intra-abdominal complications. RESULTS: Despite an increase in high-grade liver injuries, the incidence of primary non-operative management more than doubled over the two periods, from 33% (20 of 61 cases) in Period 1 to 72% (84 of 116 cases) in Period 2 (P < 0.001). The failure rate of primary treatment in Period 1 was 18% (11/61), compared with 11% (13/116) in Period 2 (P= 0.21). Complication rates were 23% (14/61) and 16% (18/116) in Periods 1 and 2, respectively (P= 0.22). Liver-related mortality rates were 10% (6/61) and 3% (4/116) in Periods 1 and 2, respectively (P= 0.095). The increase in the frequency of non-operative management was even higher in high-grade injuries, in which outcomes were improved. In high-grade injuries in Periods 1 and 2, failure rates decreased from 45% (9/20) to 20% (11/55) (P= 0.041), liver-related mortality decreased from 30% (6/20) to 7% (4/55) (P= 0.019) and complication rates fell from 60% (12/20) to 27% (15/55) (P= 0.014). Liver infarction or necrosis and abscess formation seemed to occur more frequently with AE. CONCLUSIONS: Overall, liver-related mortality, treatment failure and complication rates remained constant despite an increase in non-operative management. However, in high-grade injuries outcomes improved after the introduction of AE.

Is a maximum Revised Trauma Score a safe triage tool for Helicopter Emergency Medical Services cancellations?

INTRODUCTION: The Revised Trauma Score is used worldwide in the prehospital setting and provides a snapshot of patient's physiological state. Several studies have shown that the reliability of the RTS is high in trauma outcomes. In the Netherlands, Helicopter Emergency Medical Services (HEMS) are mostly used for delivery of specialized trauma teams on-scene and occasionally for patient transportation. In our trauma system, the Emergency Medical Services crew performs triage after arrival on-scene and cancels the HEMS-dispatch if deemed unnecessary. In this study we assessed the ability of a maximum on-scene Revised Trauma Score (RTS=12) to be used as a triage tool for HEMS cancellation. METHODS: All patients with a maximum on-scene RTS after blunt trauma (with or without receiving HEMS care) who were presented in the trauma resuscitation room of two Level-1 trauma centers during a period of 6 months, were included. Information concerning prehospital and in-hospital vital parameters, severity and localization of the injuries, and the in-hospital course were analyzed. Major trauma patients were classified using the following parameters: Injury Severity Score of at least 16, emergency intervention, Intensive Care Unit admission, and in-hospital death. RESULTS: Four-hundred and forty blunt trauma patients having a maximum RTS were included between 1 July and 31 December 2006. Eighty patients received on-scene HEMS care. Almost 16% of the total population concerned major trauma patients, of which only 25 (36%) received HEMS care. In 17 patients (3.9%), the RTS deteriorated during transportation. Major trauma patients sustained more injuries to the chest, abdomen, and lower extremities. CONCLUSION: The RTS alone is not a reliable triage tool for HEMS cancellations in our trauma system and will lead to a considerable rate of undertriage with one in every six cancellations being incorrect. Other criteria based on patient's vital signs, combined with anatomical and mechanism of injury parameters should be developed to safely minimize triage errors.

[Transfusion policy in trauma involving massive blood loss]. / Transfusiebeleid bij trauma met massaal bloedverlies.

Severe haemorrhage is a significant cause of death in trauma patients. In the case of massive blood loss a combination of coagulation defects, acidosis and hypothermia arise, which are accompanied by high morbidity and mortality rates unless properly corrected. Research in wounded military showed that a high ratio of fresh frozen plasma to packed red blood cells (FFP:PRBC) seemed to have a positive effect on survival. These studies do not provide a definition of the ideal ratio FFP:PRBC; the ratio in which a positive effect is seen varies from 1:1 to 1:3. Unnecessary FFP transfusions in trauma patients without imminent severe haemorrhage increase the risk of complications such as multi-organ failure and acute respiratory distress syndrome. Additional research is required into the accuracy of diagnosis of acute coagulation disorders.

The association of mobile medical team involvement on on-scene times and mortality in trauma patients.

OBJECTIVES: Mobile medical teams (MMTs) provide specialized care on-scene with the purpose to improve outcome. However, this additional care could prolong the on-scene time (OST), which is related to mortality. The purpose of this study was to assess the effects of MMT involvement on the mortality rate and on the OST, in a Dutch consecutive cohort of Level I trauma patients. METHODS: All patients who required presentation in the trauma resuscitation room in an urban Level I trauma center were included in this prospective study during the period of November 2005 till November 2007. For data collection, we used both pre- and in-hospital registration systems. Outcome measures were 30-day mortality and OST. RESULTS: In total, 1,054 patients were analyzed. In 172 (16%) patients, the MMT was involved. Mortality was significantly higher in the MMT group compared with patients treated without MMT involvement; 9.9% versus 2.7%, respectively (p < 0.001). Significantly higher Injury Severity Scores, intervention rates, and a significantly lower Triage Revised Trauma Score were found in patients treated by MMT. After adjustment for patient and injury characteristics, no association could be found between MMT involvement and higher mortality (95% CI, 0.581-3.979; p = 0.394). In patients with severe traumatic brain injury (GCS score ≤ 8) in whom a MMT was involved, the mortality was 25.5%, compared with 32.7% in those without MMT involvement (p = 0.442). The mean OST was prolonged (2.7 minutes) when MMT was involved (26.1 vs. 23.4 minutes; p = 0.003). CONCLUSIONS: In this study, OSTs were long compared with PHTLS recommendations. MMT involvement slightly prolonged the OST. Trauma patients with MMT involvement had a high mortality, but after correction for patient and injury characteristics, the mortality rate did not significantly differ from patients without MMT involvement.

Frequent computed tomography scanning due to incomplete three-view X-ray imaging of the cervical spine.

BACKGROUND: Conventional C-spine imaging (3-view series) is still widely used in trauma patients, although the utilization of computed tomography (CT) scanning is increasing. The aim of this study was to analyze the value of conventional radiography and the frequency of subsequent CT scanning due to incompleteness of three-view series of the C-spine in adult blunt trauma patients. METHODS: We analyzed the data of a prospectively collected database including all patients between November 2005 and November 2007 treated in the trauma resuscitating room. We assessed the reasons for subsequent CT scanning after the three-view series according to the following classification: inevaluability, incompletion, evaluation of findings on three-view series or evaluation of unexplained, and persistent clinical symptoms. Furthermore, we evaluated possible predictors for incompleteness. RESULTS: Of 1,283 blunt trauma patients, 88 C-spine injuries were diagnosed with an overall incidence of 6.9%. One hundred fifty-nine patients (12%) had their C-spine cleared based on the NEXUS criteria and 12 died before C-spine imaging could be performed. A total of 717 patients were primarily evaluated with three-view series and 395 patients primarily with CT scanning. Within the population with primarily three-view series, 249 (35%) were repeatedly incomplete and 16 (2%) were inevaluable. In the majority of the incomplete three-view series, no apparent reason could be determined. However, the presence of clavicular fractures (resulting in incomplete radiographs in 68% vs. 34% without a fracture; p < 0.001) and rib fractures (56% vs. 34%; p = 0.008) were associated with incomplete three-view series. CONCLUSION: In more than one third of the patients primarily assessed with three-view X-ray series of the C-spine, the results are incomplete or inevaluable necessitating CT scanning. Although the majority of the incomplete series remain unexplained, we advise CT scanning in patients having clavicular and rib fractures because this increases the likelihood of obtaining incomplete three-view series.

[Total body CT scan as the primary diagnostic modality in multi-trauma patients]. / Primaire totale lichaams-CT bij multitraumapatiënten.

Radiological imaging is highly protocolized during initial assessment of severely injured trauma patients. After an initial examination, radiography and ultrasound are performed. Imaging is frequently supplemented by CT scan of selective body areas. Technical features of CT scanners have improved drastically and the number of CT scanners located near or in trauma resuscitation rooms is increasing. These developments enable early CT scanning in trauma patients. Currently there is an ongoing discussion as to whether 'total body' CT scan (TBCT) should be used as a primary and sole diagnostic imaging tool during workup of trauma patients. Recent research on TBCT in multi-trauma patients shows promising results and several large European trauma centers have already protocolized this strategy. These studies lack a good study design, so more prospective research on clinical outcomes, cost effectiveness and radiation exposure is necessary. As part of a pilot study in preparation for a randomized multicenter study, the University Medical Centre in Amsterdam in the Netherlands is performing TBCT in severely injured trauma patients.