Frederick A. Mann

Helical CT in the primary trauma evaluation of the cervical spine : an evidence-based approach

Abstract This review provides a summary of the cost-effectiveness, clinical utility, performance, and interpretation of screening helical cervical spine CT for trauma patients. Recent evidence supports the use of helical CT as a cost-effective method for screening the cervical spine in high-risk trauma patients. Screening cervical spine CT can be performed at the time of head CT to lower the cost of the evaluation, and when all short- and long-term costs are considered, CT may actually save money when compared with traditional radiographic screening. In addition to having higher sensitivity and specificity for cervical spine injury, CT screening also allows more rapid radiological clearance of the cervical spine than radiography. Patients who are involved in high-energy trauma, who sustain head injury, or who have neurological deficits are candidates for CT screening. Screening with CT may enhance detection of other potentially important injuries of the cervical region.

Wrist Terminology as Defined by the International Wrist Investigators' Workshop (IWIW)

ADAPTIVE CARPUS (FIGURE 1) Fig. 1: ADAPTIVE CARPUS-ADAPTIVE DISI: the distal articular surface of the radius is inclined 30° dorsally from an old impacted distal radius fracture. The lunate is tilted dorsally to account for dorsal inclination of the distal radius, while the capitate is in neutral position following the position of the metacarpals with the hand. Changes in the carpal alignment creates a capitolunate angle of approximately 30° and a scapholunate angle of 85°. The increased scapholunate angle creates a DISI (dorsal intercalated segmental instability) configuration. SYNONYM: none CLINICAL: NA RADIOLOGIC: a carpal malalignment usually identified by a dorsal or volar tilt of the lunate caused by an extracarpal osseous abnormality, usually a distal radial malunion without ligament tears COMMENTS: 1) every carpus must adjust in some way to alterations of the radius articular surface, the ulnar head position, and the shape or size of the carpal bones even if all of its ligaments are intact. Although these alterations of the osseous elements may disrupt the ligament anchorage, may be accompanied by ligament damage, or may secondarily develop ligament attenuation, they often begin as a normal carpus. 2) The carpus may be malaligned between the two rows or remain aligned within itself, while translating at the radiocarpal level to a new position (usually dorsal, sometimes volar, even ulnar or radial). 3) This definition refers to an extracarpal, not an intracarpal, problem. If the malalignment is due to an intracarpal problem, then the case falls into a CID, CIND, or CIC category and would not fit into the category of an adaptive carpus as described here. Any adaptive carpus, by definition, can be solved by an extracarpal intervention that does not require surgery on the carpus. However, with time an adaptive carpus may degenerate to a point that the intrinsic ligaments …

Evidence-based approach to using CT in spinal trauma

Computed tomography has revolutionized the diagnosis and treatment planning of the acutely injured spine. In the cervical spine, its appropriate use can improve outcome and save money. Although there are no clinical prediction rules validated outside of the cervical spine, these proven capabilities have been extrapolated to the thoracolumbar spine.

Computer-based videotape analysis of trauma resuscitations for quality assurance and clinical research.

PURPOSE To automate time (and motion) studies of major trauma resuscitations. TECHNIQUES We modified an existing time-motion study technique based on time-encoded videotaping for medical imaging workstation human factors analysis. Videotapes were recorded of the trauma room during normal clinical activity using an unobtrusive mounted camera. The videotapes are displayed through a customized interface using a Macintosh-based display system. Within this platform, the time-motion study module allows flexible task definition, multiple concordant task assignment, and various summary result presentations. We established an expert panel of two traumatologists, two emergency radiologists, and two time-motion study experts. The expert panel prospectively and uniquely defined important recognizable procedural and cognitive tasks and personnel (MD, RN, EMT, RT, etc.) involved in trauma resuscitation based on pilot recordings and collective experience. These task functions were used to define a menu in the time-motion analysis software. During retrospective videotape review, the beginning and ending times of each task performed were recorded by electronically highlighting each defined individual and task. The summary results can be displayed in list, tabular, or graphic form by individuals, personnel classifications, or tasks.

Cervical spine injury: accuracy of helical CT used as a screening technique

Objective: The study objective was to determine the sensitivity and specificity of a helical CT technique to screen for cervical spine injury in a high-risk trauma population. Materials and methods: The helical CT reports for a consecutive series of 601 high-risk adult blunt trauma victims were reviewed. Findings were confirmed using an independent reference standard, which consisted of additional cervical spine imaging (CT, MRI, or radiography), operative findings, autopsy results or clinical outcome. Results: Sensitivity and specificity of helical CT for injury were 77/81 (95 %; 95 % confidence limits: 90–100 %) and 484/520 (93 %; 95 % confidence limits 91–95 %) respectively. Four false negative cases were comprised of three missed ligamentous injuries and one missed fracture. False positive cases (n = 36) were mostly attributed to possible facet fracture (n = 6), possible ligamentous injury (n = 8) or technically inadequate scan (n = 6).The overall accuracy of the helical CT protocol for cervical spine injury in this population was 561/601 (93 %; 95 % confidence limits 91–95 %). Conclusion: Helical CT has high accuracy for cervical spine injury. We believe that helical CT should be the preferred imaging strategy in high-risk blunt trauma patients.

Communicating with the family: the risks of medical radiation to conceptuses in victims of major blunt-force torso trauma.

BACKGROUND Trauma surgeons must balance the risk and benefits of diagnostic radiographic procedures on potentially pregnant patients and should know the range and likelihood of effects that radiation might have on pregnancy. METHODS We present guidelines for assessing such radiation risks. Knowledge of a patients pregnancy status and an estimate of radiation dose to the conceptus (low, < 10 mGy [milligray]; intermediate, 10-250 mGy; high, > 250 mGy) allow provisional assessment of radiation-induced risks. RESULTS Dose estimates may be estimated at 2 mGy per exposure (radiographs), 5 mGy per slice (computed tomography), and 10 mGy per minute of fluoroscopy, when the conceptus is within the x-ray field. A formal radiation exposure assessment is appropriate when provisional estimates exceed 10 mGy. CONCLUSION A simple qualitative dose assessment can inform clinical decisions and guide appropriate triage to more formal quantitative assessment.

Computed Radiography Dose Data Mining and Surveillance as an Ongoing Quality Assurance Improvement Process

OBJECTIVE A data-mining program extracts computed radiography (CR) sensitivity-number (S-number) information from the PACS at our institution on a monthly basis as an ongoing quality assurance (QA) improvement project. These data are compared with the previous months data and departmental S-number goals. The results are presented at monthly QA meetings. The S-number trends are then used by technologists to modify radiographic technique charts to reach the departmental S-number target range goals. CONCLUSION This cyclic QA improvement process shows that mining PACS data can be useful in reducing patient radiation dose and interexamination dose variance.

Color and Pulsed Doppler Sonography for Arterial Bleeding Detection

Hemorrhage resulting from penetrating injuries in the extremities is the leading cause of preventable death in the modern battlefield. Development of methods for detection and localization of vascular bleeding is needed that could be applied emergently without special training outside the hospital setting. Our objective was to assess whether Doppler sonography can provide quantitative parameters that characterize the bleeding site in the extremities.

Cerebral infarct in head injury: relationship to child abuse☆

BACKGROUND To determine whether CT-detected cerebral infarct in young children is associated more often with abuse or unintentional head injury. METHODS Retrospective case-control study of injured children under age 6 who had abnormal initial head CT scans and who were admitted to the only Level I pediatric trauma center in Washington State for closed head injury (CHI) from January 1, 1992 to December 31, 1998. RESULTS Fifteen children developed cerebral infarct after CHI during the 7 year period. These cases were compared to 53 controls (those who did not develop infarct). After adjusting for the presence of SDH and for severity of injury, patients with infarcts were six times more likely to have been abused than patients without infarcts (OR 6.1; 95% CI, 1.02-36.0). CONCLUSIONS Cerebral infarct after CHI appears to result more frequently from abuse than unintentional injury in young children.

Variability in the practice of emergency radiology: a survey of the members of the American Society of Emergency Radiology

Objective: To assess the variation in practice for selected clinical scenarios among members of the American Society of Emergency Radiology. Methods: A survey was distributed to assess the standard imaging approach to nine common emergency radiology clinical scenarios. Institutional demographics were also assessed. The respondents institution was used as the primary unit of analysis. Results: A total of 140 institutions were included in the primary analysis. Major variation was identified in the imaging approach to all scenarios studied. Practice size and type did not explain the variation. However, significant differences (P < 0.006) were observed between practice in the United States and the remainder of the world. Conclusions: There is no consensus among the members of the American Society of Emergency Radiology as to the best imaging approach to nine common clinical problems. The identification of this variation may serve as the seed for future research and discussion.