Here’s one from my old-timer collection of actual celluloid x-rays! If I give you the history, I will probably give away the diagnosis. So let’s see if you can do it without.
This xray is a classic for a specific trauma surgical injury. Give it your best shot! Here’s a hint to focus your attention: look at the thoracoabdomen, not the pelvis.
This image is especially appropriate for surgical residents / registrars.
Answer in the next post!
Blunt thoracic aortic injury (BTAI) is one of those high-acuity, low-occurrence events that trauma professionals cannot afford to miss. These injuries are a ticking time bomb that is just waiting to blow up your patient.
Diagnostic techniques have evolved over the years. Back in the old days (before CT angiography), we always performed a screening chest x-ray and used the “pager test.”
In those days, the x-rays were processed on celluloid and placed on a light box on the wall. We would place our pager against the film. If the aortic arch was wider than the length of the pager, the patient had a wide mediastinum, and we had to rule out BTAI. And in those days, contrast angiography was the only test available. This was a major production, and we did lots of them. Most were negative.
My, how we have advanced. We have now added contrast-enhanced CT (CECT) and transesophageal ultrasound (TEUS) to our armamentarium. The question now is, what is the best screening test?
A group of Italian clinicians performed a systematic review and meta-analysis of these modalities to determine which had the best diagnostic accuracy.
Here are the factoids:
| Modality | # studies | Sensitivity | Specificity | AUC (ROC) |
| Chest x-ray | 11 | .87 | .56 | .85 |
| Angiography | 16 | .97 | .99 | 1.00 |
| CECT | 34 | .98 | .97 | 1.00 |
| TEUS | 16 | .94 | .99 | .99 |
Bottom line: Basically, angiography, CECT, and TEUS were equivalent. Chest x-ray had poor sensitivity and specificity. So back in the day, we probably made a lot of errors.
When multiple tests have similar performance, the preferred test should be chosen based on availability, ease of use, and bonus information the study may provide. Hands down, the winner is contrast-enhanced chest CT. This is commonly performed in major trauma patients already and provides a wealth of diagnostic information. It is well-tolerated and relatively inexpensive.
The final answer, then, is contrast-enhanced CT. And I would add one little extra. As I’ve written about previously, our current criteria for identifying blunt carotid and vertebral injury (BCVI) miss about 25% of injuries. They are readily seen on CECT, though. It is relatively simple to modify the CECT chest protocol to capture the neck arteries with the same contrast dose. I strongly recommend updating your imaging protocol so that, whenever you obtain a CECT chest, the CECT neck is automatically added.
Reference: Defining the criterion standard for detecting blunt traumatic aortic injuries: A systematic review and meta-analysis of diagnostic test accuracy. J Trauma Acute Care Surg. 2025 Aug 1;99(2):279-288. doi: 10.1097/TA.0000000000004642. Epub 2025 May 20. PMID: 40390169.
Negative pressure dressings have been around for a long, long time. In the early days of damage control surgery, we used to fashion our own from surgical towels, cut-up pieces of plastic bowel bags, Jackson-Pratt drains, and sticky, clear dressings. Some enterprising companies that already made negative pressure wound dressings designed some excellent products for damage control based on this technology. They made damage control closures easy and fast. The literature suggested that they were a useful adjunct that controlled wound drainage and reduced infection rates.
But then the product creep began. In the early 2000’s, we started using these devices after the fascia was closed, but with the skin left open. These cases trended toward complex wounds like wound dehiscence. The literature continued to support this.
Finally, there was pressure from manufacturers for surgeons to apply the negative-pressure sponge to primarily closed surgical wounds. And of course, they showed that many studies supported the idea that this was helpful.
But was it? A phase 3, multicenter, randomized clinical trial was published last year that compared incisional negative-pressure wound therapy (iNPWT) with the “surgeon’s choice” standard dressing after an emergency laparotomy with primary skin closure. Adults from 34 hospitals in the UK and Australia were enrolled over a 2.5-year period. Patients were followed for 30 days to assess length of stay, wound-related readmissions, complications, pain, and quality of life.
Here are the factoids:
The authors concluded that for the average emergency laparotomy patient after trauma or acute care surgery, routine iNPWT over a primarily closed incision did not appear to reduce SSI or improve other short‑term outcomes compared with a good standard dressing.
Bottom line: This is a nicely done study that casts shade on the use of iNPWT for closed wounds in complex cases. It implies that these devices are of even less use in routine laparotomy wounds. How did we get here? Unfortunately, many of the earlier studies for this use case were clouded by industry support and bias. As one might imagine, it is very difficult for a research group to publish a negative study when they were heavily funded by one of the manufacturers.
Given the significant added cost and logistics of using iNPWT for closed laparotomy, it is hard to justify its blanket use in this population based on these data. Critically look at your own practice and decide if use of iNPWT in these cases makes sense for your hospital.
Reference: Negative Pressure Dressings to Prevent Surgical Site Infection After Emergency Laparotomy: The SUNRRISE Randomized Clinical Trial. JAMA. 2025 Mar 11;333(10):853-863. doi: 10.1001/jama.2024.24764. PMID: 39869330; PMCID: PMC11773404.
In my last post, I discussed a little-reviewed topic, strangulation. I recommended activating your trauma team only for patients who met the physiologic criteria for it.
But now, what about hangings? There are basically two types. The judicial hanging is something most of you will never see. This is a precisely executed technique that involves falling from a certain height while a professionally crafted noose arrests the fall. This results in a fairly predictable set of cervical spine/cord, airway, and vascular injuries. Death is rapid.
Suicidal hangings are far different. They involve some type of ligature around the neck, but rarely include a fall from any distance. This causes slow asphyxiation and death, sometimes. The literature dealing with near hangings is a potpourri of case reports, speculation, and very few actual studies. So once again, we are left with little guidance.
What type of workup should occur? Should the trauma team be called? A very busy Level I trauma center reviewed its registry for adult near-hangings over a 19-year period. Hanging was strictly defined as a ligature around the neck with only the body weight used for suspension. A total of 125 patients were analyzed and grouped into those with a normal GCS (15) and those with an abnormal GCS (<15).
Here are the factoids:
Bottom line: It is obvious that patients with normal GCS after attempted hanging are very different from those who are impaired. The authors developed an algorithm based on the initial GCS, which I agree with. Here is what I recommend:
Reference: A case for less workup in near hanging. J Trauma 81(5):925-930, 2016.
Trauma activation criteria generally fall into four broad categories: physiology, anatomy, mechanism of injury, and cofactors. Of these, the first two are the best predictors of patients who require assessment by the full trauma team. Many trauma centers employ mechanistic criteria, often to their chagrin. They typically end up with frequent team activations, and the patient usually ends up having only trivial injuries.
However, there are some mechanisms that just seem like they demand additional attention. Death of another occupant in the vehicle. Fall from a significant height. But what about a patient who has been strangled?
Unfortunately, the published literature gives us little guidance. This usually means that trauma centers will then just do what seems to “make sense.” And unfortunately, this frequently results in significant overtriage, with many patients going home from the emergency department.
Since there is little to no research to show us the way, I’d like to share my thoughts:
If physiologic and anatomic findings don’t trigger activation, then standard evaluation is warranted. Here are some things to think about:
Next post: Trauma Activation for Hanging: Yes or No?
Reference: Strangulation forensic examination: best practice for health care providers. Adv Emerg Nurs J 35(4):314-327, 2013.