Admission or Observation Is Not Necessary after a Negative Abdominal Computed Tomographic Scan in Patients with Suspected Blunt Abdominal Trauma: Results of a Prospective, Multi-institutional Trial
01 Feb 1998-Journal of Trauma-injury Infection and Critical Care (J Trauma)-Vol. 44, Iss: 2, pp 273-282
TL;DR: Data indicate that abdominal tenderness is not predictive of an abdominal injury and that patients with a negative CT scan after suspected blunt abdominal trauma do not benefit from hospital admission and prolonged observation.
Abstract: Objectives: Hospitalization for observation is the current standard of practice for patients who have sustained blunt abdominal trauma and who do not require emergent operation, despite having undergone diagnostic studies that exclude the presence of an intra-abdominal injury. The reasons for this practice are multifactorial and include the perceived false-negative rate of all standard diagnostic tests, the belief that hospitalization will allow for the prompt diagnosis of occult injuries, and medicolegal considerations about the risk of early discharge. The focus of this study was to determine whether hospitalization for observation is necessary after a negative diagnostic evaluation after blunt abdominal trauma, to determine the negative predictive value of abdominal computed tomographic (CT) scanning in a prospective series of patients, and to identify which patients can be safely released from the emergency department without observation or hospitalization after blunt abdominal trauma. Methods: In a prospective, multi-institutional study over 22 months at four Level I trauma centers, all patients with blunt abdominal trauma suspected by either physical examination or mechanism of injury were evaluated using the following protocol : physical examination in the emergency department, followed by abdominal CT scanning, followed by hospitalization for observation. The standardized physical examination was repeated between 4 and 8 hours. Outcomes were measured at 20 hours and at discharge and included clinical deterioration, the need for celiotomy, and mortality. Other data collected included demographics, mechanism of injury, and findings on physical examination and abdominal CT scanning. Results: Three thousand eight hundred twenty-two consecutive patients with suspected abdominal trauma presented to the four trauma centers. Two thousand seven hundred seventy-four of these met study eligibility criteria and were prospectively enrolled. Of these, 2299 fulfilled the entire study protocol. CT scan was negative in 1,809 patients, positive for organ injury or abdominal fluid in 389 patients, and nondiagnostic in 78 patients. Abdominal tenderness or bruising was present in 1,380 patients (61%), but only 22% had a positive CT scan. Nineteen percent of patients with a positive CT scan had no tenderness. Computed tomography detected 22 of the 25 blunt intestinal injuries in this series. Free intraperitoneal fluid without solid visceral injury was present in 90 patients, and but only 7 patients had intestinal injuries. There were nine celiotomies in patients whose CT scan was initially interpreted as negative: six were therapeutic (intestine in three, bladder in one, kidney in one, and diaphragm in one), two were nontherapeutic, and one was negative. The negative predictive power of an abdominal CT scan based on the preliminary reading and as defined by the subsequent need for a celiotomy in the population fully satisfying the protocol was 99.63% (lower 95 and 99% confidence bounds of 99.31 and 99.16%, respectively). Conclusion: These data indicate that abdominal tenderness is not predictive of an abdominal injury and that patients with a negative CT scan after suspected blunt abdominal trauma do not benefit from hospital admission and prolonged observation.
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TL;DR: The use of pan scan based on mechanism in awake, evaluable patients is warranted, and Clinically significant abnormalities are not uncommon, resulting in a change in treatment in nearly 19% of patients.
Abstract: Hypothesis The use of liberal whole body imaging (pan scan) in patients based on mechanism is warranted, even in evaluable patients with no obvious signs of chest or abdominal injury. Design Prospective observational study. Setting Academic level I trauma center. Patients All patients admitted following blunt multisystem trauma. Intervention Pan scan, including computed tomography (CT) of the head, cervical spine, chest, abdomen, and pelvis, with the following inclusion criteria: (1) no visible evidence of chest or abdominal injury, (2) hemodynamically stable, (3) normal abdominal examination results in a neurologically intact patient or unevaluable abdominal examination results secondary to a depressed level of consciousness, and (4) significant mechanisms of injury. Radiological findings and changes in treatment based on these findings were recorded. Main Outcome Measure Any alteration in the normal treatment plan as a direct result of CT scan findings. These alterations include early hospital discharge, admission for observation, operative intervention, and additional diagnostic studies or interventions. Results One thousand patients underwent pan scan during the 18-month observation period, of which 592 were evaluable patients with no obvious signs of abdominal injury. Clinically significant abnormalities were found in 3.5% of head CT scans, 5.1% of cervical spine CT scans, 19.6% of chest CT scans, and 7.1% of abdominal CT scans. Overall treatment was changed in 18.9% of patients based on abnormal CT scan findings. Conclusions The use of pan scan based on mechanism in awake, evaluable patients is warranted. Clinically significant abnormalities are not uncommon, resulting in a change in treatment in nearly 19% of patients.
325 citations
TL;DR: Triple-contrast helical CT accurately demonstrates peritoneal violation and visceral injury in patients with penetrating torso wounds.
Abstract: PURPOSE: To assess the accuracy of computed tomography (CT) in demonstrating the presence or absence of peritoneal violation and type of intraperitoneal organ injury, if any, in hemodynamically stable patients with penetrating torso trauma but without definite peritoneal signs or radiographic evidence of free intraperitoneal air. MATERIALS AND METHODS: During a 29-month period, helical CT with oral, rectal, and intravenous contrast material (triple-contrast) was performed in 200 hemodynamically stable patients, including 169 men (age range, 15–85 years; mean age, 31 years) and 31 women (age range, 17–45 years; mean age, 28 years) with penetrating torso trauma. The study group included 86 patients with gunshot wounds, 111 with stab wounds, and three impaled by sharp objects. CT scans were evaluated prospectively by three trauma radiologists for evidence of peritoneal violation to determine injury to intra- or retroperitoneal solid organs, bowel, mesentery, vascular structures, diaphragm, and urinary tract....
229 citations
TL;DR: The primary purpose of this study was to develop an evidence-based, systematic diagnostic approach to BAT using the three major diagnostic modalities: DPL, CT scanning, and FAST.
Abstract: I. STATEMENT OF THE PROBLEM Evaluation of patients who have sustained blunt abdominal trauma (BAT) may pose a significant diagnostic challenge to the most seasoned trauma surgeon. Blunt trauma produces a spectrum of injury from minor, single-system injury to devastating, multisystem trauma. Trauma surgeons must have the ability to detect the presence of intra-abdominal injuries across this entire spectrum. Although a carefully performed physical examination remains the most important method to determine the need for exploratory laparotomy, there is little Level I evidence to support this tenet. In fact, several studies have highlighted the inaccuracies of the physical examination in BAT. The effect of altered level of consciousness as a result of neurologic injury, alcohol, or drugs is another major confounding factor in assessing BAT. Because of the recognized inadequacies of physical examination, trauma surgeons have come to rely on a number of diagnostic adjuncts. Commonly used modalities include diagnostic peritoneal lavage (DPL) and computed tomographic (CT) scanning. Although not available universally, focused abdominal sonography for trauma (FAST) has recently been included in the diagnostic armamentarium. Diagnostic algorithms outlining appropriate use of each of these modalities individually have been established. Several factors influence the selection of diagnostic testing: type of hospital (i.e., trauma center vs. “nontrauma” hospital); access to a particular technology at the surgeon’s institution; and the surgeon’s individual experience with a given diagnostic modality. As facilities evolve, technologies mature, and surgeons gain new experience, it is important that any diagnostic strategy constructed be dynamic. The primary purpose of this study was to develop an evidence-based, systematic diagnostic approach to BAT using the three major diagnostic modalities: DPL, CT scanning, and FAST. This diagnostic regimen would be designed such that it could be reasonably applied by all general surgeons performing an initial evaluation of BAT.
225 citations
Cites background from "Admission or Observation Is Not Nec..."
...63%) of CT scanning was sufficiently high to permit safe discharge of BAT patients after a negative CT scan.(42) CT scanning is notoriously inadequate for the diagnosis of mesenteric injuries and may also miss hollow visceral injuries....
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TL;DR: Improvements in diagnostic methods and approaches are needed to ensure the prompt diagnosis of this uncommon but potentially devastating injury.
Abstract: Objectives Blunt SBI is infrequent and its diagnosis may be difficult, especially in the face of confounding variables. The purpose of this study was to evaluate methods for making the diagnosis of blunt SBI.Methods Patients with blunt small bowel injury (SBI) were identified from the registries of
219 citations
TL;DR: Screening the TLS on truncal helical CT scanning performed for the evaluation of visceral injuries is more accurate than TLS imaging by standard radiography and should replace plain radiographs in high-risk trauma patients who require screening.
Abstract: Objective: Concern for thoracolumbar spine (TLS) injuries after major trauma mandates immobilization pending radiographic evaluation. Current protocols use standard posteroanterior and lateral radiographs of the thoracolumbar spine (XR/TLS), but many patients also undergo abdominal or thoracic computed tomographic (CT) scanning. We sought to evaluate whether helical truncal CT scanning performed to evaluate visceral trauma images the spine as well as dedicated XR/TLS. Methods: We prospectively studied 222 consecutive patients sustaining high-risk trauma requiring TLS screening because of clinical findings or altered mentation. The chest, abdomen, and pelvis were imaged with one intravenous contrast infusion. All patients had CT scan of the chest, abdomen, and pelvis (CT/CAP) and XR/TLS. Initial radiologic diagnoses were compared with the discharge diagnosis of acute fractures confirmed by thin-cut CT scan and/or clinical examination of the patient when alert. Results: Of 222 patients studied, 215 were fully evaluated. Thirty-six (17%) had acute TLS fractures. The accuracy of CT/CAP for TLS fractures was 99% (95% confidence interval [CI], 96-100%). The accuracy of XR/TLS was 87% (95% CI, 82-92%). Sensitivity, specificity, and positive and negative predictive values were better for CT/CAP than for XR/ TLS. CT/CAP found acute fractures XR/ TLS missed, and correctly classified old fractures XR/TLS read as "possibly" acute. The total XR/TLS misclassification rate was 12.6% (95% Cl, 8.4-19%); for CT/CAP it was 1.4% (95% CI, 0.3-3.3%). No fractures were missed by CT/CAP. No unstable fracture was missed by either technique. Conclusion: CT/CAP diagnoses TLS fractures more accurately than XR/TLS. Neither misses unstable fractures, but CT scanning finds small fractures that benefit by treatment and identifies chronic disease better. CT screening is far faster and shortens time to removal of spine precautions. CT scan-based diagnosis does not result in greater radiation exposure and improves resource use. Screening the TLS on truncal helical CT scanning performed for the evaluation of visceral injuries is more accurate than TLS imaging by standard radiography. CT/CAP should replace plain radiographs in high-risk trauma patients who require screening.
180 citations
References
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TL;DR: There is a substantial amount of injury to patients from medical management, and many injuries are the result of substandard care.
Abstract: Background As part of an interdisciplinary study of medical injury and malpractice litigation, we estimated the incidence of adverse events, defined as injuries caused by medical management, and of the subgroup of such injuries that resulted from negligent or substandard care. Methods We reviewed 30,121 randomly selected records from 51 randomly selected acute care, nonpsychiatric hospitals in New York State in 1984. We then developed population estimates of injuries and computed rates according to the age and sex of the patients as well as the specialties of the physicians. Results Adverse events occurred in 3.7 percent of the hospitalizations (95 percent confidence interval, 3.2 to 4.2), and 27.6 percent of the adverse events were due to negligence (95 percent confidence interval, 22.5 to 32.6). Although 70.5 percent of the adverse events gave rise to disability lasting less than six months, 2.6 percent caused permanently disabling injuries and 13.6 percent led to death. The percentage of adverse events...
4,580 citations
TL;DR: The high proportion that are due to management errors suggests that many others are potentially preventable now, and reducing the incidence of these events will require identifying their causes and developing methods to prevent error or reduce its effects.
Abstract: Background In a sample of 30,195 randomly selected hospital records, we identified 1133 patients (3.7 percent) with disabling injuries caused by medical treatment. We report here an analysis of these adverse events and their relation to error, negligence, and disability. Methods Two physician-reviewers independently identified the adverse events and evaluated them with respect to negligence, errors in management, and extent of disability. One of the authors classified each event according to type of injury. We tested the significance of differences in rates of negligence and disability among categories with at least 30 adverse events. Results Drug complications were the most common type of adverse event (19 percent), followed by wound infections (14 percent) and technical complications (13 percent). Nearly half the adverse events (48 percent) were associated with an operation. Adverse events during surgery were less likely to be caused by negligence (17 percent) than nonsurgical ones (37 percent). The proportion of adverse events due to negligence was highest for diagnostic mishaps (75 percent), noninvasive therapeutic mishaps ("errors of omission") (77 percent), and events occurring in the emergency room (70 percent). Errors in management were identified for 58 percent of the adverse events, among which nearly half were attributed to negligence. Conclusions Although the prevention of many adverse events must await improvements in medical knowledge, the high proportion that are due to management errors suggests that many others are potentially preventable now. Reducing the incidence of these events will require identifying their causes and developing methods to prevent error or reduce its effects.
3,734 citations
TL;DR: The attributable lengths of stay and costs of hospitalization for ADEs are substantial and an ADE is associated with a significantly prolonged length of stay, increased economic burden, and an almost 2-fold increased risk of death.
Abstract: Objective. —To determine the excess length of stay, extra costs, and mortality attributable to adverse drug events (ADEs) in hospitalized patients. Design. —Matched case-control study. Setting. —The LDS Hospital, a tertiary care health care institution. Patients. —All patients admitted to LDS Hospital from January 1, 1990, to December 31,1993, were eligible. Cases were defined as patients with ADEs that occurred during hospitalization; controls were selected according to matching variables in a stepwise fashion. Methods. —Controls were matched to cases on primary discharge diagnosis related group (DRG), age, sex, acuity, and year of admission; varying numbers of controls were matched to each case. Matching was successful for 71% of the cases, leading to 1580 cases and 20197 controls. Main Outcome Measures. —Crude and attributable mortality, crude and attributable length of stay, and cost of hospitalization. Results. —ADEs complicated 2.43 per 100 admissions to the LDS Hospital during the study period. The crude mortality rates for the cases and matched controls were 3.5% and 1.05%, respectively (P Conclusion. —The attributable lengths of stay and costs of hospitalization for ADEs are substantial. An ADE is associated with a significantly prolonged length of stay, increased economic burden, and an almost 2-fold increased risk of death.
1,622 citations
TL;DR: Current data would suggest that 50 to 80% of all adult patients with blunt hepatic injuries are candidates for nonoperative management, irrespective of grade of injury or degree of hemoperitoneum, and thus merit constant re-evaluation and close observation in critical care units.
Abstract: Introduction Nonoperative management is presently considered the treatment modality of choice in over 50% of adult patients sustaining blunt hepatic trauma who meet inclusion criteria. A multicenter study was retrospectively undertaken to assess whether the combined experiences at level I trauma cen
372 citations
TL;DR: This review traces the evolution of the preventable death concept, discusses its influence on trauma care systems development, and proposes future research directions.
Abstract: ACCIDENTAL death, characterized as the neglected disease of modern society, 1 is the leading mortality cause for persons 1 through 39 years of age and the third for those of all ages. 2 Because of the medical, social, and economic implications of trauma, attention is increasingly focusing on a systems approach to reducing traumatic death and disability through prevention, treatment, and research. 3-5 Regional trauma care systems have not been universally implemented, however, because of concerns about need, efficacy, and cost. This review traces the evolution of the preventable death concept, discusses its influence on trauma care systems development, and proposes future research directions. HISTORICAL REVIEW The American College of Surgeons first addressed trauma care in 1922 by forming the Committee on Treatment of Fractures, now the Committee on Trauma. 6 Excepting the military experience, 7 however, care quality for the multiply injured received relatively little attention during the next
353 citations