Trauma Team members typically wear a lead gown under their personal protective equipment so they don’t have to run out of the room when x-rays are taken. How often do you see people do this?
Is it really necessary? Or is it just a way to exercise your pecs and biceps? Tomorrow I’ll talk about how much radiation team members are really exposed to so you can decide if this is really necessary.
Contrast extravasation after major trauma can be very problematic. Extravasation into a solid organ (liver, spleen) generally requires a quick trip to interventional radiology or the operating room. Bleeding from the bowel mesentery assures an exploratory laparotomy. Gluteal vessel extravasation is best treated with angioembolization.
But what about extravasation from off the beaten path areas like the psoas muscle? This is an uncommon finding on trauma CT, so less is known about the usual clinical course. A group in Okayama Japan performed a 10-year retrospective review of data from their hospital. They reviewed hematoma size, associated injuries, and the relationship to treatment options.
Here are the factoids:
The right psoas has both contrast extravasation and a sizable hematoma
Bottom line: This study has many weaknesses, but does show that psoas extravasation occurs somewhat frequently, even at a low volume center. I always worry about studies that state something like “and xx patients required intervention.” Generally, this means that it was performed at the discretion of the clinician and no consistent rules were applied. And even though hematoma size was significantly correlated with angioembolization, it’s probably not worth the effort to have your radiologist calculate it. But it does illustrate one nearly universal trauma rule:
Patients with active extravasation on CT are bleeding to death until proven otherwise
Do not sit back and manage expectantly! The corollary to this rule is:
Contrast extravasation on CT always requires active measures to stop it
These active measures are typically angioembolization for difficult to reach areas in hemodynamically stable patients (gluteal artery for buttock, lumbar artery for psoas muscle, solid organs). Unstable patients absolutely require a trip to the OR for control. Superficial muscular bleeding frequently stops with good pressure dressings or positioning the patient so they lie on the affected area. Just don’t sit around and watch these patients bleed when you see extravasation on the CT.
Reference: Impact of contrast extravasation on computed tomography of thepsoas major muscle in patients with blunt torso trauma. J Trauma 86(2):268-273, 2019.
Every major trauma patient undergoes some type of radiographic imaging during their initial evaluation. On occasion, some incidental finding unrelated to trauma shows up unexpectedly. These incidentalomas add several additional layers of complexity to the evaluation process.
What does the finding mean? Is it important? How do I tell the patient? Their primary care provider? When? Many times, these findings have little clinical significance. But on occasion, they can be life changing, such as the incidental renal cell carcinoma.
The group at University of Tennessee – Knoxville reviewed one year of incidental findings in trauma evaluations at their Level I trauma center. They specifically looked at diagnoses with malignant potential, and how findings were disclosed to the patient.
Here are the factoids:
Here are some questions for the authors and presenter to consider in advance to help them prepare for audience questions:
This is a fascinating paper, and gives me some ideas for upcoming blog posts! I will definitely be in the audience for this presentation.
Reference: A novel use of the trauma registry: incidental findings in the trauma patient. EAST 2019, Quick Shot Paper #13.
And the variability is even greater when we throw a pediatric patient into the mix. Trauma professionals tend to be even more “generous” when ordering studies on children because they are afraid they might miss something. Unfortunately, this has the potential for overuse of imaging and exposure to unnecessary radiation.
Avery Nathens and a consortium of pediatric trauma centers used the Trauma Quality Improvement Database (TQIP) to review CT imaging practices on children age < 18 over a four year period. Only blunt trauma patients were studied, and the Abbreviated Injury Scale had to be at least 2 for a minimum of one organ system. Transfer patients were excluded because there is no data on imaging for the referring hospital in the TQIP database for them. Comparisons were made between practices at adult trauma centers treating children (ATC), mixed adult/pediatric centers (MTC) and pediatric only trauma centers (PCT).
Here are the factoids:
Bottom line: This is yet another reason to adopt a well-designed pediatric imaging guideline. Not only are adult centers using CT scanning much more that pediatric-only centers, but they are unnecessarily adding to the lifetime risk for cancer of our children!
As I always recommend, find a well-designed imaging guideline from an established pediatric center and “borrow” it. Sure, it may need a few minor tweaks to fit well with your hospital. That’s okay. Just get it done so your team can begin to order the initial imaging studies consistently and intelligently.
Reference: Computed tomography rates and estimated radiation-associated cancer risk among injured children treated at different trauma center types. Injury 2018, in press. https://doi.org/10.1016/j.injury.2018.09.036
This was a retrospective trauma registry review of 9 years worth of ground level falls. Patients were divided into young (18-54 years) and old (55+ years) groups. They were included in the study if they received a pan-scan.
Here are the factoids:
| Young (n=328) | Old (n=257) | |
| TBI | 35% | 40% |
| C-spine | 2% | 2% |
| Blunt Cereb-vasc inj * | 20% | 31% |
| Pneumothorax | 14% | 15% |
| Abdominal injury | 4% | 2% |
| Mortality * | 3% | 11% |
* = statistically significant
Bottom line: There is an ongoing argument, still, regarding pan-scan vs selective scanning. The pan-scanners argue that the increased risk (much of which is delayed or intangible) is worth the extra information. This study shows that the authors did not find much difference in injury diagnosis in young vs elderly patients, with the exception of blunt cerebrovascular injury.
Most elderly patients who fall sustain injuries to the head, spine (all of it), extremities and hips. The torso is largely spared, with the exception of ribs. In my opinion, chest CT is only for identification of aortic injury, which just can’t happen from falling over. Or even down stairs. And solid organ injury is also rare in this group.
Although the future risk from radiation in an elderly patient is probably low, the risk from the IV contrast needed to see the aorta or solid organs is significant in this group. And keep in mind the dangers of screening for a low probability diagnosis. You may find something that prompts invasive and potentially more dangerous investigations of something that may never have caused a problem!
I recommend selective scanning of the head and cervical spine (if not clinically clearable), and selective conventional imaging of any other suspicious areas. If additional detail of the thoracic and/or lumbar spine are needed, specific spine CT imaging should be used without contrast.
Related posts:
Reference: Pan-scanning for ground level falls in the elderly: really? ACS Surgical Forum, trauma abstracts, 2016.