Chih Yuan Fu

Evaluation of pelvic fracture stability and the need for angioembolization: pelvic instabilities on plain film have an increased probability of requiring angioembolization

BACKGROUND The use of pelvic x-rays (PXRs) as an early diagnostic adjunct in the evaluation of blunt trauma patients has become widely accepted, and computed tomographic (CT) scanning is now used universally in the assessment of abdominal and pelvic injuries. In this study, we have attempted to identify patients with pelvic fractures who might be at risk for vessel hemorrhage and determine if early angioembolization was required in these patients. MATERIAL AND METHODS We retrospectively reviewed patients who presented with pelvic fractures from June 2005 to August 2007. Both PXRs and CT scans were reviewed. Patients who presented with bleeding due to other associated injuries or who did not receive a CT scan were excluded. Patients with either initial hemodynamic instability or contrast extravasation on enhanced CT scan underwent angioembolization. Patient demographics, Injury Severity Score, the amount of blood transfused, and the relationship between the fracture pattern and angioembolization were analyzed. RESULTS A total of 54 patients were enrolled. A diagnosis of an unstable pelvic fracture on PXR was associated with a higher probability of angioembolization. Seven patients received incompatible diagnoses from the PXR and CT scan; these patients received larger amounts of transfused blood and demonstrated an increased need for angioembolization. CONCLUSIONS Although CT scan is more sensitive in the identification of acetabular or small pelvic fractures, PXR is sufficient for the early evaluation of pelvic fracture stability. Based on the current series, early angioembolization is suggested for patients with an initial diagnosis of an unstable pelvic fracture. In addition, patients receiving large amounts of transfused blood are more likely to require early angioembolization.

Angioembolization provides benefits in patients with concomitant unstable pelvic fracture and unstable hemodynamics

INTRODUCTION Pelvic fractures result in hemodynamic instability in 5% to 20% of patients, and the reported mortality rate is 18% to 40%. Previous studies have reported the application of angioembolization in pelvic fracture patients with a systolic blood pressure (SBP) less than 90 mm Hg, a fluid resuscitation requirement of more than 2000 mL, or a blood transfusion of more than 4 to 6 units within 24 hours. In the current study, we attempted to delineate the efficacy and outcome of angioembolization in unstable pelvic fracture patients with concomitant unstable hypotension status. METHODS We retrospectively reviewed the charts of patients with pelvic fractures between January 2005 and May 2010. We focused on unstable pelvic fracture patients with an SBP less than 90 mm Hg after fluid resuscitation who did not receive computed tomography scans. The demographics, injury severity score, abbreviated injury scale, and hemodynamic status after angioembolization were analyzed. RESULTS In total, 26 patients were enrolled. There were 16 patients receiving angioembolization directly without computed tomography scans and 12 patients receiving emergency laparotomy due to a finding of hemoperitoneum on sonography, followed by angioembolization. In both groups, the SBP improved significantly after angioembolization. The overall survival rate was 85.7%. CONCLUSIONS In patients with concomitant unstable hemodynamics and unstable pelvic fracture, angioembolization serves as an effective adjunct to hemostasis. Aggressive embolization should be performed even in patients without contrast extravasation in angiography.

Evaluation of need for angioembolization in blunt renal injury: discontinuity of Gerota's fascia has an increased probability of requiring angioembolization

BACKGROUND Angioembolization is an effective adjunct in the management of high-grade renal injuries not surgically treated. However, in some cases, the bleeding may stop spontaneously, without the need for embolization. The aim of this study was to define the characteristics of patients who need angioembolization for high-grade blunt renal injuries (BRIs). METHODS Patients with BRIs between January 2004 and May 2008 were retrospectively reviewed. Patients with contrast extravasation on computed tomographic scans who then underwent angiography were enrolled. Demographics, injury severity scores, abbreviated injury scale scores, amounts of blood transfused, and need for angioembolization were analyzed. RESULTS Twenty-six patients were enrolled. Patients with discontinuity of Gerotas fascia and pararenal hematoma expansion in BRIs required angioembolization at a higher rate. Furthermore, these patients displayed higher injury severity scores and abbreviated injury scale scores. Five patients experienced complications. CONCLUSIONS In patients with BRIs, discontinuity of Gerotas fascia and pararenal hematoma expansion seemed to be associated with the need for angioembolization. Early angioembolization should be considered in patients with severe associated trauma with BRIs.

Higher incidence of major complications after splenic embolization for blunt splenic injuries in elderly patients

BACKGROUND Nonoperative management (NOM) of blunt splenic injuries has been widely accepted, and the application of splenic artery embolization (SAE) has become an effective adjunct to NOM. However, complications do occur after SAE. In this study, we assess the factors leading to the major complications associated with SAE. MATERIALS AND METHODS Focusing on the major complications after SAE, we retrospectively studied patients who received SAE and were admitted to 2 major referral trauma centers under the same established algorithm for management of blunt splenic injuries. The demographics, angiographic findings, and factors for major complications after SAE were examined. Major complications were considered to be direct adverse effects arising from SAE that were potentially fatal or were capable of causing disability. RESULTS There were a total of 261 patients with blunt splenic injuries in this study. Of the 261 patients, 53 underwent SAE, 11 (21%) of whom were noted to have 12 major complications: 8 cases of postprocedural bleeding, 2 cases of total infarction, 1 case of splenic abscess, and 1 case of splenic atrophy. Patients older than 65 years were more susceptible to major complications after SAE. CONCLUSION Splenic artery embolization is considered an effective adjunct to NOM in patients with blunt splenic injuries. However, risks of major complications do exist, and being elderly is, in part, associated with a higher major complication incidence.

Diagnostic accuracy, biohazard safety, and cost effectiveness-the Lodox/Statscan provides a beneficial alternative for the primary evaluation of patients with multiple injuries.

BACKGROUND Lodox/Statscan is a new digital X-ray machine with a low dose of radiation exposure that provides rapid, whole-body scans. In the setting of acute trauma management, the importance of image study is well recognized. Here, we report the accuracy of diagnoses made using Lodox/Statscan in patients with multiple injuries. We analyze the cost effectiveness, biohazard safety, and detection rate for treatment using the Lodox/Statscan and evaluate whether it is a viable alternative to the conventional trauma X-ray. METHODS We retrospectively reviewed patients who received a Lodox/Statscan between November 2007 and January 2009. All patients who had received both a Lodox/Statscan and a computed tomographic (CT) scan were enrolled. The CT scan was used to make the final diagnosis. The detection rate for treatment, sensitivity, and specificity of the Lodox/Statscan in diagnosis was analyzed. RESULTS One hundred eighty-four patients were eligible for the study during the 15-month study period. The detection rates for treatment using the Lodox/Statscan for pneumothorax, pelvic fracture, cervical spine injury, and thoracic-lumbar spine injury were 95%, 96.0%, and 57.1%, and 100%, respectively. CONCLUSION In our series, the Lodox/Statscan provided similar quality images and conventional series to the CT scans. Although the Lodox/Statscan missed some injuries, most of the subsequent treatments were not changed. Overall, there were several advantages to using this system, including the short interval of study, low-radiation exposure, and low cost. The Lodox/Statscan could therefore be used as an alternative to the traditional trauma X-ray for evaluation of acute trauma patients.

Tomographic findings are not always predictive of failed nonoperative management in blunt hepatic injury.

BACKGROUND Nonoperative management (NOM) has become the standard treatment of blunt hepatic injury (BHI) for stable patients. Contrast extravasation (CE) on computed tomography (CT) scan had been reported as a sign that is associated with NOM failure. The goal of this study was to further investigate the risk factors of NOM failure in patients with CE on CT scan. METHODS From January 2005 to September 2009, patients with CE noted on a CT scan as a result of BHI were studied retrospectively. Physiological parameters, severity of injury, amount of transfusion, type of contrast extravasation, as well as treatment outcome were compared between patients with NOM failure and NOM success. RESULTS A total of 130 patients were enrolled. Injury severity scores, amount of blood transfusion before hemostatic procedure, and grade of liver injury were significantly higher in NOM failure than in NOM success patients. There was no statistical difference in the NOM success rate between patients with contrast leakage into the peritoneum and those with contrast confined in the hepatic parenchyma. CONCLUSIONS Higher injury severity score, more blood transfusion, and higher grade of liver injury are factors that correlate with NOM failure in patients with BHI. Contrast leakage into the peritoneum is not always a definite sign of NOM failure in BHI. Early and aggressive angioembolization is an effective adjunct of NOM in BHI patients, even with contrast leakage into peritoneum.

Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage

BACKGROUND With recent advances in radiologic diagnostic procedures, the use of diagnostic peritoneal lavage (DPL) has markedly declined. In this study, we reviewed data to reevaluate the role of DPL in the diagnosis of hollow organ perforation in patients with blunt abdominal trauma. METHODS Adult patients who had sustained blunt abdominal trauma and who were hemodynamically stable after initial resuscitation underwent an abdominal computed tomographic (CT) scan. Diagnostic peritoneal lavage was performed for patients who were indicated to receive nonoperative management and where hollow organ perforation could not be ruled out. RESULTS During a 60-month period, 64 patients who had received abdominal CT scanning underwent DPL. Nineteen patients were diagnosed as having a positive DPL based on cell count ratio of 1 or higher. There were 4 patients who sustained small bowel perforation. The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectively. No missed hollow organ perforations were detected. CONCLUSION For patients with blunt abdominal trauma and hemoperitoneum who plan to receive nonoperative management, DPL is still a useful tool to exclude hollow organ perforation that is undetected by CT.

Higher glucose on admission is associated with need for angioembolization in stable pelvic fracture

BACKGROUND Angioembolization is an effective adjunct to the management of retroperitoneal hemorrhage in pelvic fractures. Most patients with stable-type pelvic fracture are treated conservatively. However, in some stable pelvic fracture cases, patients should receive angioembolization for hemostasis upon incidental finding of contrast extravasation on computed tomography (CT). In this study, we attempted to define the characteristics of patients with stable pelvic fracture requiring angioembolization. METHODS We retrospectively reviewed the charts of patients with pelvic fractures between January 2005 and November 2009. We focused on stable pelvic fracture patients with contrast extravasation on CT who then received angioembolization. The demographics, Injury Severity Score (ISS), Abbreviated Injury Scale score, and the blood glucose levels on admission were analyzed. RESULTS In total, 334 patients were enrolled. Patients with higher blood glucose level on admission with stable pelvic fracture had a higher rate of angioembolization. Furthermore, these patients presented with a higher Abbreviated Injury Scale score and ISS. CONCLUSIONS In patients with stable pelvic fracture, higher blood glucose level on admission was associated with a higher likelihood of needing angioembolization. Blood glucose level should be checked during the initial survey of a pelvic fracture, and greater attention should be given to patients with higher blood glucose level or with an ISS of 25 or greater, even when the imaging study only reveals a stable pelvic fracture.

Lodox/Statscan provides rapid identification of bullets in multiple gunshot wounds.

Lodox/Statscan is a new digital radiograph machine with low-dose radiation exposure. It provides rapid and whole-body scans. In multiple gunshot trauma, the conventional radiograph or computed tomography scan might be time consuming, and the resuscitation might be paused temporarily. We applied the Lodox/Statscan to search bullets within a short period, and the resuscitation was nonstop during imaging study. As a result, it serves as a valuable adjunct in providing rapid identification of metal projectiles in multiple gunshot wounds.

Selective computed tomography and angioembolization provide benefits in the management of patients with concomitant unstable hemodynamics and negative sonography results

BackgroundThe FAST (focused assessment of sonography for trauma) examination can rapidly identify free fluid in the abdominal or thoracic cavity, which is indicative of hemorrhage requiring emergency surgery in multiple-trauma patients. In patients with negative FAST examination results, it is difficult to identify the site of the hemorrhage and to plan treatment accordingly. We attempted to delineate the role of selective computed tomography (CT) and transarterial angioembolization (TAE) in the management of such unstable patients.MethodsFrom January 2005 to April 2011 patients with concomitant unstable hemodynamics and negative FAST examination results were identified. Their demographic and time to start of embolization were recorded. The initial systolic blood pressure (SBP) in emergency department patients was compared with the SBP after TAE.ResultsA total of 33 patients were enrolled, and 85% required TAE. SBP improved significantly after TAE. There were 18 patients who received TAE without CT scan because the site of hemorrhage was obvious. Fifteen patients received a CT scan during the time required for angiography preparation. Ten of them received subsequent TAE based on the CT scan findings, and the treatment plan was changed in the other five patients. There was no significant difference between patients with or without a CT scan with respect to the time interval between arrival and starting embolization.ConclusionsTransarterial angioembolization is suggested in the management of patients with concomitant unstable hemodynamics and negative FAST examination results. During the time interval required for angiography preparation, a CT scan can be performed. This approach provides valuable information for further decision making without delaying definitive treatment.