23 Imaging Triage for Ballistic Trauma

American Journal of Roentgenology, 1990

Radiologists can contribute substantially to the evaluation and treatment of the patient with a gunshot wound. Plain films, CT, angiography, and sometimes MR imaging are used to localize the missile, determine what path it followed in the body, assess missile and bone fragmentation, and identify missile emboli. If the peritoneal cavity was entered by a bullet, a laparotomy is required. Missiles subject to magnetic forces can complicate MR imaging. Certain locations of missile fragments predispose to lead poisoning or lead arthropathy. Angiography is useful for both diagnosis and treatment. Both angiographic hemostasis and percutaneous foreign body removal may be used. Gunshot wounding is an interaction between the penetrating projectile, the anatomy of the wounded subject, and the chance occurrences that determine the exact missile path. The mass and velocity of the projectile establish the upper limit of possible tissue damage. Whether this potential is realized, and where, depends on what tissue the missile encounters, whether the missile fragments or expands, and at what point along the missile path yaw occurs. (Yaw is the angle between the long axis of the bullet and its path of flight.) The radiologist can contribute substantially to the successful treatment of the patient with a gunshot wound. Important

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The Journal of Trauma: Injury, Infection, and Critical Care, 2002

Background: Little controversy surrounds the treatment of hemodynamically unstable patients with transmediastinal gunshot wounds (TMGSWs). These patients generally have cardiac or major vascular injuries and require immediate operation. In hemodynamically stable patients, debate surrounds the extent and order of the diagnostic evaluation. These patients can be uninjured, or can have occult vascular, esophageal, or tracheobronchial injuries. Evaluation has traditionally often included angiography, bronchoscopy, esophagoscopy, esophagography, and pericardial evaluation (i.e., pericardial window) for all hemodynamically stable patients with TMGSWs. Expansion of the use of computed tomographic (CT) scanning in penetrating injury led to a modification of our protocol. Currently, our TMGSW evaluation algorithm for stable patients consists of chest radiograph, focused abdominal sonography for trauma, and contrast-enhanced helical CT scan of the chest with directed further evaluation. The purpose of this study is to evaluate the efficiency of contrast-enhanced helical CT scan for evaluating potential mediastinal injuries and to determine whether patients can be simply observed or require further investigational studies. Methods: Medical records of hemodynamically stable patients admitted with TMGSWs over a 2-year period were reviewed for demographics, mechanism of injury, method of evaluation, operative interventions, injuries, length of stay, and complications. CT scans were considered positive if they contained a mediastinal hematoma or pneumomediastinum, or demonstrated proximity of the missile track to major mediastinal structures. Results: Twenty-two stable patients were studied. CT scans were positive in seven patients. Directed further diagnostic evaluation in those seven patients revealed two patients who required operative intervention. Sixty-eight percent of patients had negative CT scans and were observed in a monitored setting without further evaluation. There were no missed injuries. The hospital charges generated with the CT scan-based protocol are significantly less than with the standard evaluation. Conclusion: Contrast-enhanced helical CT scanning is a safe, efficient, and cost-effective diagnostic tool for evaluating hemodynamically stable patients with mediastinal gunshot wounds. Positive CT scan results direct the further evaluation of potentially injured structures. Patients with negative results can safely be observed in a monitored setting without further evaluation.

Seminars in Nuclear Medicine, 1983

Journal of the Royal Army Medical Corps, 2002

Radio-opaque markers in penetrating trauma are useful in both the clinical evaluation of the injuries and in the permanent record of the location of the wounds. The use of an unfolded paperclip taped over the wound as a marker is recommended as a valuable adjunct in the radiological evaluation of penetrating trauma.

Radiologic Clinics of North America, 2006

Chest pain is one of the most common presentations in emergency medicine. The initial evaluation should always consider life-threatening causes such as aortic dissection, pulmonary embolism, pneumothorax, pneumomediastinum, pericarditis, and esophageal perforation. Radiographic imaging is performed in tandem with the initial clinical assessment and stabilization of the patient. Radiologic findings are key to diagnosis and management of this entity.

Annals of Emergency Medicine, 2010

To derive a decision instrument (DI) that identifies patients who have virtually no risk of significant intrathoracic injury (SITI) visible on chest radiography and, therefore, no need for chest imaging. Methods: This is a prospective observational study. At three Level 1 trauma centers, physicians caring for blunt trauma patients aged Ͼ14 years were asked to record the presence or absence of 12 clinical criteria before viewing chest imaging results. SITI was defined as pneumothorax, hemothorax, aortic/great vessel injury, two or more rib fractures, ruptured diaphragm, sternal fracture, and pulmonary contusion on official radiograph readings. The (interrater reliability) and screening performance of individual criteria were determined. By using recursive partitioning, the most highly sensitive combination of criteria for SITI was derived. Results: Of the 2,628 subjects enrolled, 271 (10.3%) were diagnosed with a total of 462 SITIs, with rib fractures (73%), pneumothorax (38%), and pulmonary contusion (29%) as the most common injuries. Chest pain and chest wall tenderness had the highest sensitivity for SITI (65%). The DI of chest pain, distracting injury, chest wall tenderness, intoxication, age Ͼ60 years, rapid deceleration, and altered alertness/mental status had the following screening performance: sensitivity 99.3% (95% confidence interval [CI], 97.4 -99.8), specificity 14.0% (95% CI, 12.6 -15.4), negative predictive value 99.4% (95% CI, 97.8 -99.8), and positive predictive value 11.7% (95% CI, 10.5-13.1). All seven criteria in the DI met the predetermined cut off for acceptable (range, 0.51-0.81). Conclusions: We derived a DI consisting of seven clinical criteria that can identify SITI in blunt trauma patients with extremely high sensitivity. If validated, this instrument will allow for safe, selective chest imaging with potential resource savings.

Emergency Medicine Investigations, 2017

Background: According to Advanced Trauma Life Support, chest radiography must be performed during the initial evaluation of patients with trauma. We studied the CXR performed in the emergency room of Rajaie Hospital to determine its usefulness. Methods: In this prospective study, patients who referred with high-energy trauma from December 2013 until April 2014 were recruited. Their demographic characteristics, including age, gender, and cause of trauma were recorded. Meticulous medical history was taken from all patients and they were examined by emergency medicine specialist. Simple radiographic CXR was performed for selective patients and image findings and their mediastinal width were recorded. All statistical analysis was performed using SPSS software version 20.0 and P-value less than 0.05 was considered significant. Results: Of the total 790 patients assessed, 137 patients were female (17.3%) and 655 were male (82.7%). Mean age of patients was 35.13±17.01 (ranging from 12 to 91); Mean mediastinal width was 80.9±11.45 mm (range: 49.2-142.29). The most common causes of trauma included car-to-patient accident in 131 patients (16.5%), motor-to-car accident in 128 patients (16.2%), car turnover in 103 (13%), falling down in 93 (11.7%), and stab wound 88 (11.1%). The most common pathologic finding included rib fractures (42.7%), pneumothorax (11.6%), abnormal diaphragmatic findings (10.3%), and hemothorax (8.3%). Conclusion: The results of the current study, in accordance to previous studies, suggest rib fractures, pneumothorax, abnormal diaphragmatic findings, and hemothorax as the most frequent findings in CXR that need to be assessed meticulously. Moreover, the majority of patients were young males and the most frequent causes of trauma included car accidents, falling down, and stab wound. Therefore, paying attention to their diagnosis and treatment may increase the survival of this important group of patients.

Seminars in Interventional Radiology, 2010

Interventional radiologists are adopting an increasingly important role in the evaluation and management of the acutely injured patient. The interventional radiologist may be called upon to provide services while hemorrhage is active, the patient is hemodynamically compromised, and a comprehensive trauma assessment is incomplete. The initial diagnostic and management approach to the trauma patient is optimally organized through the principles of advanced trauma life support. A basic understanding of common injury patterns, immediate lifesaving interventions, and principles of resuscitation is of value to the interventional radiologist in his or her interactions with the trauma team and contribution to patient care.