michael d mcgonigal md regions hospital. objectives discuss new developments in fast exam of the...
TRANSCRIPT
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
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%
FAST And Penetrating Trauma
• Traditionally used in penetrating trauma, just for practice
• The question:– Is FAST able to rule
out peritoneal orcardiac injury frompenetrating trauma?
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!
FAST And Penetrating Trauma
• Only four of the 8 papers were useful
• Results– Specificity >94%– PPV > 75– Likelihood ratio >8
FAST And Penetrating Trauma
• A hemodynamically stable patient with penetrating torso trauma and a positive FAST should undergo exploratory laparotomy
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
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!
CT In Abdominal and Pelvic Vascular Injury
• So what is a contrast blush anyway?– Contrast extravasation
CT In Abdominal and Pelvic Vascular Injury
• So what is a contrast blush anyway?– Contrast extravasation– Pseudoaneurysm
CT In Abdominal and Pelvic Vascular Injury
• So what is a contrast blush anyway?– Contrast extravasation– Pseudoaneurysm• Contrast washes away
CT In Abdominal and Pelvic Vascular Injury
• So what is a contrast blush anyway?– Contrast extravasation– Pseudoaneurysm
• What’s the difference?
CT In Abdominal and Pelvic Vascular Injury
• So what is a contrast blush anyway?– Contrast extravasation– Pseudoaneurysm
• What’s the difference?– Both are bad!
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
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
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
Mortality and Operations
• Started with– Development of trauma
centers
• Moved to– Development of trauma
systems
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
Mortality and Trauma Operations
• Your patient is bleeding to death until proven otherwise
• Trauma centers are good at operative management of bleeding
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
Mortality and Trauma Operations
• ACS TQIP project allows calculation of observed to expected mortality rates
1. Calculate O/E mortality rates
2. Calculate procedure rates for specific operations
3. Examine the association betweennumbers 1 and 2
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
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
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???
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.
Bibliography
• CT of blunt abdominal and pelvic vascular injury– Emerg Radiology 17:21-29, 2010– Dept of Radiology, Boston University Medical
Center