Torso Trauma Update

1. Torso Trauma Update Michael D McGonigal MD Regions Hospital

2. Objectives • Discuss new developments in FAST exam of the torso • Review the diagnosis of abdominal and pelvic vascular injury with imaging techniques • Examine the link between mortality and number of abdominal operations performed at trauma centers

3. FAST And Penetrating Trauma • FAST was originally developed for diagnosis in blunt trauma • Sens: 46-85% • Spec: 52-89% • NPV: 60-98% • Accuracy: 98-90%

4. FAST And Penetrating Trauma • Traditionally used in penetrating trauma, just for practice • The question: • Is FAST able to ruleout peritoneal orcardiac injury frompenetrating trauma?

5. FAST And Penetrating Trauma • Studies selected for meta-analysis • 148 studies identified • Selection criteria • Age >12 • Hemodynamically stable • Had confirmatory test • Only 8 left for review!

6. FAST And Penetrating Trauma • Only four of the 8 papers were useful • Results • Specificity >94% • PPV > 75 • Likelihood ratio >8

7. FAST And Penetrating Trauma • A hemodynamically stable patient with penetrating torso trauma and a positive FAST should undergo exploratory laparotomy

8. FAST And Penetrating Trauma • A hemodynamically stable patient with penetrating torso trauma and a positive FAST should undergo exploratory laparotomy • Patients with a negative FAST are stable enough to undergo further diagnostic studies

9. CT In Abdominal and Pelvic Vascular Injury • CT offers a non-invasive technique for providing high quality images in torso trauma • New technology = delayed imaging • Vascular injury presents in two different ways • End organ anomaly • Vascular abnormality • Calling it a “blush” is nolonger enough!

10. CT In Abdominal and Pelvic Vascular Injury • End organ anomaly - hypoenhancement

11. CT In Abdominal and Pelvic Vascular Injury • Vascular abnormality • Persistent hyperattenuation

12. CT In Abdominal and Pelvic Vascular Injury • Vascular abnormality • Expanding hyperattenu-ation

13. CT In Abdominal and Pelvic Vascular Injury • Vascular abnormality • Expanding hyperattenu-ation

14. CT In Abdominal and Pelvic Vascular Injury • Vascular abnormality • Vessel irregularity

15. CT In Abdominal and Pelvic Vascular Injury • Vascular abnormality • Vessel irregularity

16. CT In Abdominal and Pelvic Vascular Injury • So what is a contrast blush anyway? • Contrast extravasation

17. CT In Abdominal and Pelvic Vascular Injury • So what is a contrast blush anyway? • Contrast extravasation • Pseudoaneurysm

18. CT In Abdominal and Pelvic Vascular Injury • So what is a contrast blush anyway? • Contrast extravasation • Pseudoaneurysm • Contrast washes away

19. CT In Abdominal and Pelvic Vascular Injury • So what is a contrast blush anyway? • Contrast extravasation • Pseudoaneurysm • What’s the difference?

20. CT In Abdominal and Pelvic Vascular Injury • So what is a contrast blush anyway? • Contrast extravasation • Pseudoaneurysm • What’s the difference? • Both are bad!

21. CT In Abdominal and Pelvic Vascular Injury • So what is a contrast blush anyway? • Contrast extravasation • Pseudoaneurysm • What’s the difference? • Both are bad! • Pseudoaneurysm

22. CT In Abdominal and Pelvic Vascular Injury • So what is a contrast blush anyway? • Contrast extravasation • Pseudoaneurysm • What’s the difference? • Both are bad! • Pseudoaneurysm • Extravasation

23. CT In Abdominal and Pelvic Vascular Injury • Bottom Line • If you diagnose a pseudoaneurysm, obtain a surgical consult and consider IR soon • If you see extravasation, order blood first, consult surgery and prepare patient for IR ASAP

24. Mortality and Operations • Started with • Development of trauma centers

25. Mortality and Operations • Started with • Development of trauma centers • Moved to • Development of trauma systems

26. Mortality and Trauma Operations • Started with • Development of trauma centers • Moved to • Development of trauma systems • Found that • Trauma center care decreased mortality • Don’t know about • How care is delivered at trauma centers

27. Mortality and Trauma Operations • Your patient is bleeding to death until proven otherwise • Trauma centers are good at operative management of bleeding

28. Mortality and Trauma Operations • Your patient is bleeding to death until proven otherwise • Trauma centers are good at operative management of bleeding • Trauma centers that operate a lot tostop bleeding have lower mortality

29. Mortality and Trauma Operations • ACS TQIP project allows calculation of observed to expected mortality rates • Calculate O/E mortality rates • Calculate procedure rates for specific operations • Examine the association betweennumbers 1 and 2

30. Mortality and Trauma Operations • Study population of 135,666 patients obtained from the NTDB • Level I or II centers • No DOA • No minor injuries • Complete data record

31. Mortality and Trauma Operations

32. Mortality and Trauma Operations

33. Mortality and Trauma Operations • How can this be? • More reliance on nonop management, less experience with operative control • No good guidelines as to when patients should go to OR • More severely injured in the first place

34. Mortality and Trauma Operations • Implications • Quality problem has been identified • Now need to identify causes and solutions • Are similar outcomes associated with other operative procedures???

35. Video, Slides, Biblio • www.regionstraumapro.com • regionstrauma

36. Bibliography • What is the utility of focused assessment with sonography in trauma (FAST) exam in penetrating torso trauma? • Injury, in press, 2010. • Department of Emergency Medicine, Downstate Medical Center, Brooklyn, NY.

37. Bibliography • CT of blunt abdominal and pelvic vascular injury • Emerg Radiology 17:21-29, 2010 • Dept of Radiology, Boston University Medical Center

38. Bibliography • More operations, more deaths? Relationship between operative intervention and risk-adjusted mortality at trauma centers. • J Trauma 69(1):70-77, 2010 • Multiple sites