Digna R. Kool

Minor Head Injury: CT-based Strategies for Management—A Cost-effectiveness Analysis

PURPOSE To compare the cost-effectiveness of using selective computed tomographic (CT) strategies with that of performing CT in all patients with minor head injury (MHI). MATERIALS AND METHODS The internal review board approved the study; written informed consent was obtained from all interviewed patients. Five strategies were evaluated, with CT performed in all patients with MHI; selectively according to the New Orleans criteria (NOC), Canadian CT head rule (CCHR), or CT in head injury patients (CHIP) rule; or in no patients. A decision tree was used to analyze short-term costs and effectiveness, and a Markov model was used to analyze long-term costs and effectiveness. n-Way and probabilistic sensitivity analyses and value-of-information (VOI) analysis were performed. Data from the multicenter CHIP Study involving 3181 patients with MHI were used. Outcome measures were first-year and lifetime costs, quality-adjusted life-years, and incremental cost-effectiveness ratios. RESULTS Study results showed that performing CT selectively according to the CCHR or the CHIP rule could lead to substantial U.S. cost savings (

Arm Raising at Exposure-controlled Multidetector Trauma CT of Thoracoabdominal Region: Higher Image Quality, Lower Radiation Dose

120 million and

Predictors for the selection of patients for abdominal CT after blunt trauma: a proposal for a diagnostic algorithm.

71 million, respectively), and the CCHR was the most cost-effective at reference-case analysis. When the prediction rule had lower than 97% sensitivity for the identification of patients who required neurosurgery, performing CT in all patients was cost-effective. The CHIP rule was most likely to be cost-effective. At VOI analysis, the expected value of perfect information was

Outcome after Complicated Minor Head Injury

7 billion, mainly because of uncertainty about long-term functional outcomes. CONCLUSION Selecting patients with MHI for CT renders cost savings and may be cost-effective, provided the sensitivity for the identification of patients who require neurosurgery is extremely high. Uncertainty regarding long-term functional outcomes after MHI justifies the routine use of CT in all patients with these injuries.

Added Value of Routine Chest MDCT After Blunt Trauma: Evaluation of Additional Findings and Impact on Patient Management

PURPOSE To evaluate the effect of arm position on image quality and effective radiation dose in an automatic exposure-controlled (AEC) multidetector thoracoabdominal computed tomography (CT) protocol in trauma patients. MATERIALS AND METHODS This retrospective study of the data of 177 trauma patients (117 male; median age, 39 years) was approved by the institutional ethics board, with informed patient consent waived. Patients underwent scanning by using an AEC 16-detector thoracoabdominal CT protocol in which both arms were raised above the shoulder region (standard-position group, 132 patients), one arm was raised and the other was down (one-arm group, 27 patients), or both arms were down (two-arm group, 18 patients). Objective and subjective image quality was assessed. Individual effective radiation dose was calculated from the effective tube current-time product per exposed section. For this purpose, section location-dependent conversion factors were derived by using a CT dosimetry calculator. The effect of arm position on effective dose was quantified by using linear regression analysis with correction for patient volume and attenuation. RESULTS Compared with the image quality in the standard-position group, the image quality in the one- and two-arm groups was decreased but within acceptable diagnostic limits. The median corrected effective dose in the standard-position group was 18.6 mSv; the dose in the one-arm group was 18% (95% confidence interval: 11%, 25%) higher than this, and that in the two-arm group was 45% (95% confidence interval: 34%, 57%) higher. CONCLUSION Omitting arm raising results in lower but acceptable image quality and a substantially higher effective radiation dose. Hence, effort should be made to position the arms above the shoulder when scanning trauma patients. Clinical trial registration no. NCT00228111.

Routine Versus Selective Computed Tomography of the Abdomen, Pelvis, and Lumbar Spine in Blunt Trauma : A Prospective Evaluation

Objective:To select parameters that can predict which patients should receive abdominal computed tomography (CT) after high-energy blunt trauma. Summary Background Data:Abdominal CT accurately detects injuries of the abdomen, pelvis, and lumbar spine, but has important disadvantages. More evidence for an appropriate patient selection for CT is required. Methods:A prospective observational study was performed on consecutive adult high-energy blunt trauma patients. All patients received primary and secondary surveys according to the advanced trauma life support, sonography (focused assessment with sonography for trauma [FAST]), conventional radiography (CR) of the chest, pelvis, and spine and routine abdominal CT. Parameters from prehospital information, physical examination, laboratory investigations, FAST, and CR were prospectively recorded for all patients. Independent predictors for the presence of ≥1 injuries on abdominal CT were determined using a multivariate logistic regression analysis. Results:A total of 1040 patients were included, 309 had injuries on abdominal CT. Nine parameters were independent predictors for injuries on CT: abnormal CR of the pelvis (odds ratio [OR], 46.8), lumbar spine (OR, 16.2), and chest (OR, 2.37), abnormal FAST (OR, 26.7), abnormalities in physical examination of the abdomen/pelvis (OR, 2.41) or lumbar spine (OR 2.53), base excess <−3 (OR, 2.39), systolic blood pressure <90 mm Hg (OR, 3.81), and long bone fractures (OR, 1.61). The prediction model based on these predictors resulted in a R2 of 0.60, a sensitivity of 97%, and a specificity of 33%. A diagnostic algorithm was subsequently proposed, which could reduce CT usage with 22% as compared with a routine use. Conclusions:Based on parameters from physical examination, laboratory, FAST, and CR, we created a prediction model with a high sensitivity to select patients for abdominal CT after blunt trauma. A diagnostic algorithm was proposed.

Routine versus selective multidetector-row computed tomography (MDCT) in blunt trauma patients: level of agreement on the influence of additional findings on management.

BACKGROUND AND PURPOSE: Functional outcome in patients with minor head injury with neurocranial traumatic findings on CT is largely unknown. We hypothesized that certain CT findings may be predictive of poor functional outcome. Materials and METHODS: All patients from the CT in Head Injury Patients (CHIP) study with neurocranial traumatic CT findings were included. The CHIP study is a prospective, multicenter study of consecutive patients, ≥16 years of age, presenting within 24 hours of blunt head injury, with a Glasgow Coma Scale (GCS) score of 13–14 or a GCS score of 15 and a risk factor. Primary outcome was functional outcome according to the Glasgow Outcome Scale (GOS). Other outcome measures were the modified Rankin Scale (mRS), the Barthel Index (BI), and number and severity of postconcussive symptoms. The association between CT findings and outcome was assessed by using univariable and multivariable regression analysis. RESULTS: GOS was assessed in 237/312 patients (76%) at an average of 15 months after injury. There was full recovery in 150 patients (63%), moderate disability in 70 (30%), severe disability in 7 (3.0%), and death in 10 (4.2%). Outcome according to the mRS and BI was also favorable in most patients, but 82% of patients had postconcussive symptoms. Evidence of parenchymal damage was the only independent predictor of poor functional outcome (odds ratio = 1.89, P = .022). CONCLUSION: Patients with neurocranial complications after minor head injury generally make a good functional recovery, but postconcussive symptoms may persist. Evidence of parenchymal damage on CT was predictive of poor functional outcome.

Effects on mortality, treatment, and time management as a result of routine use of total body computed tomography in blunt high-energy trauma patients

OBJECTIVE The objective of our study was to evaluate the added value of a low-threshold routine thoracic MDCT algorithm compared with a selective MDCT algorithm in adult blunt trauma patients. SUBJECTS AND METHODS A prospective cohort study was conducted in 464 consecutive blunt trauma patients who met criteria indicative of severe blunt trauma (66% male; age range, 16-93 years; median injury severity score, 13). After clinical evaluation and conventional radiography of the chest and thoracic spine, all patients underwent routine thoracic MDCT with an IV contrast agent (routine MDCT algorithm). Within this routine MDCT group, a subgroup was prospectively defined with abnormal or inconclusive clinical or conventional radiography evaluation (selective MDCT group). Two investigators determined the type, extent, and clinical impact of additional injuries found on MDCT as compared to conventional radiography for both MDCT groups. RESULTS Of all 464 patients within the routine MDCT group, 164 patients underwent selective MDCT, which resulted in detection of additional diagnoses compared with conventional radiography in 97 (59%) patients. The routine MDCT algorithm detected additional diagnoses compared with conventional radiography in 201 of 464 patients (43%). Compared with the selective MDCT algorithm, this was an absolute increase of 104 of 464 (22%) extra patients, resulting in a change in patient management in 34 (7%; 95% CI, 5-9.7%), mostly because of additional findings of pulmonary and mediastinal injury. CONCLUSION Routine MDCT has relatively lower, though still substantial, added diagnostic value compared with selective MDCT of the chest.

A history of loss of consciousness or post-traumatic amnesia in minor head injury: "conditio sine qua non" or one of the risk factors?

BACKGROUND Discussion still remains whether computed tomography (CT) of the abdomen, pelvis, and lumbar spine should be performed routinely after blunt trauma with high energy impact or only in restricted situations. The purpose of this study was to evaluate the additional value of a routine CT algorithm as compared with a more restricted, selective CT algorithm. MATERIALS This prospective study consisted of 465 patients that met the inclusion criteria of our high-energy trauma protocol. All patients underwent physical examination, abdominal ultrasound (AUS), and conventional radiography (CR) of the pelvis and lumbar spine and subsequently routine CT of the abdomen, pelvis, and lumbar spine. Before CT, a subgroup of patients with abnormal physical examination or CR or AUS was prospectively defined as the selective CT group. Type and extent of injuries and impact on treatment were recorded for both the routine CT group and the selective CT subgroup. RESULTS Of all patients, 42 received selective CT of the abdomen, 71 of the pelvis, and 48 of the lumbar spine. Compared with the algorithm with selective CT, routine CT revealed additional traumatic injuries in 15% of the patients in the abdomen, in 2.4% in the pelvis and in 8.2% in the lumbar spine. This resulted in an overall change of treatment in 6.4% (95% confidence interval, 3.7-9.0) of the patients who would not have received CT in a selective CT algorithm. CONCLUSIONS Compared with an algorithm with selective CT, an algorithm with routine CT finds substantially more clinically relevant diagnoses, even in patients with unsuspicious clinical examination, normal CR, and normal AUS.

Predictors of abnormal chest CT after blunt trauma: a critical appraisal of the literature.

INTRODUCTION This study was performed to determine the agreement between and within surgeons concerning the influence on treatment plan of routine versus selective multidetector-row computed tomography (MDCT) findings in blunt trauma patients. PATIENTS For this study, 50 patients were randomly selected from a customized database that was originally used to compare a diagnostic algorithm with a selective use of MDCT with an algorithm with routine MDCT of the spine, chest, and abdomen within the same population. In all 50 patients, routine MDCT found additional diagnoses as compared with the selective MDCT algorithm. Of all patients, paper cases were created with detailed information on clinical parameters, findings by physical examination, and radiologic findings. The cases were independently presented to three different trauma surgeons. First, the surgeons were asked for their treatment plan based upon diagnoses found by physical examination, conventional radiography, and selective MDCT alone. Subsequently they were asked for their treatment plan with knowledge of the injuries additionally found by routine MDCT. This procedure was repeated after 3 months. The agreement between and within surgeons was determined for the change of patient management because of additional findings by routine MDCT. RESULTS The agreement on the influence of routine MDCT findings on patient management between surgeons was moderate ([kappa] = 0.46) in the first procedure and substantial in the second ([kappa] = 0.67). The agreement within surgeons ranged from moderate ([kappa] = 0.60) to excellent ([kappa] = 0.87). CONCLUSION All surgeons agreed that the traumatic injuries additionally found by routine MDCT, frequently resulted in a change of treatment plan. There was a moderate-to-excellent agreement between and within surgeons that these additional findings resulted in a change of treatment plan.