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Geriatric patients manifest pain and physical findings differently and are associated with higher mortality and complications. We hypothesized that physical exam (PE) is unreliable versus computed tomography (CT) for comprehensive injury identification in geriatric patients. Additionally, we quantified significant incidental radiologic findings. Our institution adopted a policy of Pan Scan (PS) CT for trauma activations of patients ≥65 years. PS included CT of head/neck and chest/abdomen/pelvis. PE and imaging findings were extracted from physician reports. 50 ​% of patients had clinically significant CT traumatic findings. Of these, 75 ​% had PE correlating to significant CT findings, while 25 ​% had significant PS findings not identifiable on PE (p ​< ​0.001). The NPV was 0.80 for the PE. 57.7 ​% had clinically significant incidental findings. Physical exam alone is not sensitive enough to detect all traumatic injuries in elderly patients. As an added benefit to PS, important incidental findings are identified. These data support use of PS in geriatric trauma to optimize care. •Physical exam alone is not reliable enough for injury detection in the elderly.•Pan Scan demonstrated superior sensitivity vs physical exam.•The NPV of physical exam in our cohort was 0.8.•Pan Scan can detect clinically important incidental findings.

Trauma is a significant cause of mortality and morbidity. It is crucial to diagnose trauma patients quickly to provide effective treatment interventions in such conditions. Whole-body computed tomography (WBCT)/pan-scan is an imaging technique that enables a faster and more efficient diagnosis for polytrauma patients. The purpose of this systematic review and meta-analysis is to evaluate the efficacy of WBCT in diagnosing injuries in polytrauma patients. We will also assess its impact on the mortality rate and length of hospital stay among trauma centers between patients who underwent WBCT and those who did not (non-WBCT). Twenty-seven studies meeting our inclusion criteria were selected among PubMed, Scopus, Web of Science, and Google Scholar. The criteria were centered on the significance of WBCT/pan-scan application in trauma patients. Stata version 15 was used to perform statistical analysis on the data. The authors have also used I2 statistics to evaluate heterogeneity. Egger and Begg’s tests were performed to rule out any publication bias. Total of twenty-seven studies including 68,838 trauma patients with a mean age of 45.0 ± 24.7 years were selected. Motor vehicle collisions were the most common cause of blunt injuries (80.0%). Head, neck, and face injuries were diagnosed in 44% (95% CI, 0.28–0.60; I2 = 99.8%), 6% (95% CI, 0.02–0.09; I2 = 97.2%), and 9% (95% CI, 0.05–0.13; I2 = 97.1%), respectively. Chest injuries were diagnosed by WBCT in 39% (95% CI, 0.28–0.51; I2 = 99.8%), abdominal injuries in 23% (95% CI, 0.03–0.43; I2 = 99.9%) of cases, spinal injuries 19% (95% CI, 0.11–0.27; I2 = 99.4%), extremity injuries 33% (95% CI, 0.23–0.43; I2 = 99.2%), and pelvic injuries 11% (95% CI, 0.04–0.18; I2 = 97.4%). A mortality odd ratio of 0.94 (95% CI, 0.83–1.06; I2 = 40.1%) was calculated while comparing WBCT and non-WBCT groups. This systematic review and meta-analysis provide insight into the possible safety, efficacy, and efficiency of WBCT/pan-scan as a diagnostic tool for trauma patients with serious injuries, regardless of their hemodynamic status. In patients with serious injuries from trauma, whether or not there are indicators of hemodynamic instability, our recommended approach is to, wherever possible, perform a WBCT without stopping the hemostatic resuscitation. By using this technology, the optimal surgical strategy for these patients can be decided upon without causing any delays in their final care or greatly raising their radiation dose.

Trauma patients often present with injuries requiring resuscitation and further evaluation. Many providers advocate for whole body computed tomography (WBCT) for rapid and comprehensive diagnosis of life-threatening injuries. Evaluate the literature concerning mortality effect, emergency department (ED) length of stay, radiation, and incidental findings associated with WBCT. Physicians have historically relied upon history and physical examination to diagnose life-threatening injuries in trauma. Diagnostic imaging modalities including radiographs, ultrasound, and computed tomography have demonstrated utility in injury detection. Many centers routinely utilize WBCT based on the premise this test will improve mortality. However, WBCT may increase radiation and incidental findings when used without considering pre-test probability of actionable traumatic injuries. Studies supporting WBCT are predominantly retrospective and incorporate trauma scoring systems, which have significant design weaknesses. The recent REACT-2 trial randomized trauma patients with high index of suspicion for actionable injuries to WBCT versus selective imaging and found no mortality difference. Additional prospective trials evaluating WBCT in specific trauma subgroups (e.g. polytrauma) are needed to evaluate benefit. In the interim, the available data suggests clinicians should adopt a selective imaging strategy driven by history and physical examination. While observational data suggests an association between WBCT and a benefit in mortality and ED length of stay, randomized controlled data suggests no mortality benefit to this diagnostic tool. The literature would benefit from confirmatory studies of the use of WBCT in trauma sub-groups to clarify its impact on mortality for patients with specific injury patterns.

IntroductionIncidental findings on comprehensive imaging in the adult trauma population occur at rates as high as 54.8%. We sought to determine the incidence of potentially malignant or pre-malignant incidental findings in a high-volume level 1 trauma center and to evaluate follow-up recommendations.MethodsThis was a retrospective review of all patients with incidental findings on imaging who were admitted to the trauma service at our level 1 trauma center between January 1st, 2014, and October 1st, 2019. A multi-disciplinary team characterized findings as potentially malignant or pre-malignant.ResultsThe study included 495 patients who had incidental findings, 410 of whom had potentially malignant or pre-malignant findings on imaging, resulting in a cumulative incidence of 6.6%. The mean age was 65 and 217 (52.9%) patients were male. The majority of “incidentalomas” were discovered on CT imaging (n=665, 98.1%); over half were solid (n=349, 51.5%), while 27.4% were cystic (n=186) in nature. The lungs (n=199, 29.4%), kidneys (n=154, 22.8%), liver (n=74, 10.9%), thyroid gland (n=58, 8.6%), and adrenal glands (n=53, 7.8%) harbored the most incidentalomas. Less than half of patients with incidental findings received specific follow-up recommendations on the radiologist’s report (n=150, 39%). Sixty-one percent of patients (n=250) had their incidentalomas detailed in the discharge paperwork.ConclusionThe results of our study suggest that potentially malignant or pre-malignant incidental findings are common among trauma patients. Specific follow-up recommendations were not presented in 61% of the radiology reports, highlighting the need to standardize medical record capture of an incidentaloma to ensure adequate and appropriate follow-up.

PurposeThe purpose of this study was to review and compare the image quality and radiation dose of split-bolus single-pass computed tomography(CT) in the assessment of trauma patients in comparison to standard multi-phase CT techniques.MethodsAn online electronic database was searched using the MESH terms “split-bolus,” “dual phase,” and “single pass.” Inclusion criteria required the research article to compare a split contrast bolus protocol in a single-pass scan in the assessment of trauma patients. Studies using split-bolus CT technique in non-traumatic injury assessment were excluded. Six articles met the inclusion criteria.ConclusionsParenchymal and vascular image qualities, as well as subjective image quality assessments, were equal or superior in comparison to non-split-bolus multi-phase trauma CT protocols. Split-bolus single-pass CT decreased radiation exposure in all studies. Further research is required to determine the superior split-bolus protocol and the specificity and sensitivity of detecting blunt cerebrovascular injury screening, splenic parenchymal vascular lesions, and characterization of pelvic vascular extravasation.

This study aimed to determine the incidence of intra-abdominal injuries in elderly patients after a ground-level fall. A 6-year retrospective review was conducted on patients 65 years of age or older involved in a fall from standing and evaluated at a level 1 trauma center. Each patient presented with a pelvic, thoracolumbar, and/or lower rib fracture. Data collection included demographics, injury characteristics, FAST exam results, CT imaging results, and hospitalization outcomes. A total of 324 patients met study inclusion criteria. The majority of patients were white (95.1%) females (65.4%) with an average age of 82.0 ± 7.3 years. Only 22 patients (6.8%) reported abdominal pain, although an abdominal CT was performed in 91 patients (28.1%). Only 1 patient (0.3%) was found to have an intra-abdominal injury when no abdominal pain was reported and the FAST exam was negative. This injury was not clinically significant enough to warrant surgical intervention. Elderly patients who suffer a ground-level fall do not benefit from PAN-SCAN, even when presenting with rib, thoracolumbar, and/or pelvic fractures. •Patients ≥65 with rib, thoracolumbar or pelvic fracture from ground level falls were studied.•Study purpose was to evaluate the incidence of significant intra-abdominal injury.•Only 6.8% reported pain, but 28.1% underwent PAN-SCAN imaging.•Intra-abdominal injury incidence without abdominal pain or positive FAST was 0.3%.•PAN-SCAN is unlikely to benefit elderly asymptomatic ground level fall patients.

Background In South Africa, doctors commonly treat patients suffering major trauma, often with multiple injuries, which necessitates the demand for a rapid diagnostic assessment. Whole body computed tomography (CT pan scan) allows for a rapid multisystem injury diagnosis. There is a scarcity of literature evaluating the extent of orthopaedic injuries in CT pan scan of polytrauma patients. The aim of the study was to evaluate the local epidemiology of orthopaedic injuries in polytrauma patients who underwent a CT pan scan. Methods A retrospective, observational analysis, based at an academic hospital, was done of polytrauma patients who underwent a CT pan scan during a two-year period. A database was compiled by accessing the picture archiving and communication system. Results A total of 296 polytrauma patients had a reported CT pan scan; 85% were male and 15% were female with a median age of 33 years. The most common mechanism of injury was motor vehicle accidents (33.1%). A total of 1 012 injuries were identified; 196 were spinal fractures (mostly cervical), 137 were pelvic/sacral fractures, and 101 were long bone fractures of the upper and lower limbs. The most frequent non-orthopaedic injury sustained was a chest injury. In a pedestrian-vehicle accident, the most common combination of injuries was a chest injury with an associated pelvic/sacral injury. Interpersonal and intentional injuries were significantly associated with a higher risk of thoracic spine fractures (relative risk [RR] 1.8, CI 1.1–2.9), whereas road traffic accidents were significantly associated with a higher risk of scapula/clavicula fractures (RR 2.0, CI 1.2–3.5) and a higher risk of tibia/fibula fractures (RR 3.5, CI 1.2–10.3). Conclusion The majority of polytrauma patients were young males involved in road traffic accidents. A patient involved in a road traffic accident is 3.5 times more likely to sustain a tibia/fibula fracture as opposed to any other fracture. One in four patients who sustained a chest injury had an associated cervical spine injury, and one in three patients had a pelvic/sacral injury, and similarly with head injuries. The findings of this study highlight injury patterns that should be anticipated in polytrauma patients. Level of evidence: Level 3

We describe the case of a 47‐year‐old man with severe pelvic trauma, in whom severe open pelvic fractures with blood vessel damage were treated by first performing fast and reliable hemostasis and then carrying out comprehensive hemicorporectomy. Based on our experience, hemicorporectomy might be the only treatment option in patients with severe pelvic injury when there are no reconstruction options. Background In severe pelvic fracture, keys of successful treatment are early hemostasis and timely definitive care. We present a case in which the patient was treated by fast and reliable hemostasis and subsequent comprehensive hemicorporectomy. Case Presentation We describe the case of a 47‐year‐old man with severe pelvic trauma. He received early intervention by the helicopter emergency medical service, which included rapid transarterial embolization as damage control interventional radiology in the hybrid emergency room, and hemicorporectomy as a multidisciplinary approach. This series of treatments saved his life and he was discharged home. Conclusion Hemicorporectomy could be the only treatment option in patients with severe pelvic injury when there are no reconstruction options. To the best of our knowledge, this is the first case of severe open pelvic fractures with blood vessel damage, successfully treated by initial hemostasis using the helicopter emergency medical service, hybrid emergency room system, and following hemicorporectomy as a definitive care.

Introduction Extensive research relying on Injury Severity Scores (ISS) reports a mortality benefit from routine non-selective thoracic CTs (an integral part of pan-computed tomography (pan-CT)s). Recent research suggests this mortality benefit may be artifact. We hypothesized that the use of pan-CTs inflates ISS categorization in patients, artificially affecting admission rates and apparent mortality benefit. Methods Eight hundred and eleven patients were identified with an ISS >15 with significant findings in the chest area. Patient charts were reviewed and scores were adjusted to exclude only occult injuries that did not affect treatment plan. Pearson chi-square tests and multivariable logistic regression were used to compare adjusted cases vs non-adjusted cases. Results After adjusting for inflation, 388 (47.8%) patients remained in the same ISS category, 378 (46.6%) were reclassified into 1 lower ISS category, and 45 (5.6%) patients were reclassified into 2 lower ISS categories. Patients reclassified by 1 category had a lower rate of mortality (P < 0.001), lower median total hospital LOS (P < .001), ICU days (P < .001), and ventilator days (P = 0.008), compared to those that remained in the same ISS category. Conclusion Injury Severity Score inflation artificially increases survival rate, perpetuating the increased use of pan-CTs. This artifact has been propagated by outdated mortality prediction calculation methods. Thus, prospective evaluations of algorithms for more selective CT scanning are warranted.