1. Michael D McGonigal MD Regions Hospital

2. Objectives Discuss new developments in FAST exam of the torso Review the diagnosis of abdominal and pelvic vascular injury with imaging techniques Examine the link between mortality and number of abdominal operations performed at trauma centers

3. FAST And Penetrating Trauma FAST was originally developed for diagnosis in blunt trauma – Sens: 46-85% – Spec: 52-89% – NPV: 60-98% – Accuracy: 98-90%

4. FAST And Penetrating Trauma Traditionally used in penetrating trauma, just for practice The question: – Is FAST able to rule out peritoneal or cardiac injury from penetrating trauma?

5. FAST And Penetrating Trauma Studies selected for meta-analysis – 148 studies identified Selection criteria – Age > 12 – Hemodynamically stable – Had confirmatory test Only 8 left for review!

6. FAST And Penetrating Trauma Only four of the 8 papers were useful Results – Specificity >94% – PPV > 75 – Likelihood ratio >8

7. FAST And Penetrating Trauma A hemodynamically stable patient with penetrating torso trauma and a positive FAST should undergo exploratory laparotomy

8. FAST And Penetrating Trauma A hemodynamically stable patient with penetrating torso trauma and a positive FAST should undergo exploratory laparotomy Patients with a negative FAST are stable enough to undergo further diagnostic studies

9. CT In Abdominal and Pelvic Vascular Injury CT offers a non-invasive technique for providing high quality images in torso trauma – New technology = delayed imaging Vascular injury presents in two different ways – End organ anomaly – Vascular abnormality Calling it a “blush” is no longer enough!

10. CT In Abdominal and Pelvic Vascular Injury End organ anomaly - hypoenhancement

11. CT In Abdominal and Pelvic Vascular Injury Vascular abnormality – Persistent hyperattenuation

12. CT In Abdominal and Pelvic Vascular Injury Vascular abnormality – Expanding hyperattenu- ation

13. CT In Abdominal and Pelvic Vascular Injury Vascular abnormality – Expanding hyperattenu- ation

14. CT In Abdominal and Pelvic Vascular Injury Vascular abnormality – Vessel irregularity

15. CT In Abdominal and Pelvic Vascular Injury Vascular abnormality – Vessel irregularity

16. CT In Abdominal and Pelvic Vascular Injury So what is a contrast blush anyway? – Contrast extravasation

17. CT In Abdominal and Pelvic Vascular Injury So what is a contrast blush anyway? – Contrast extravasation – Pseudoaneurysm

18. CT In Abdominal and Pelvic Vascular Injury So what is a contrast blush anyway? – Contrast extravasation – Pseudoaneurysm Contrast washes away

19. CT In Abdominal and Pelvic Vascular Injury So what is a contrast blush anyway? – Contrast extravasation – Pseudoaneurysm What’s the difference?

20. CT In Abdominal and Pelvic Vascular Injury So what is a contrast blush anyway? – Contrast extravasation – Pseudoaneurysm What’s the difference? – Both are bad!

21. CT In Abdominal and Pelvic Vascular Injury So what is a contrast blush anyway? – Contrast extravasation – Pseudoaneurysm What’s the difference? – Both are bad! – Pseudoaneurysm

22. CT In Abdominal and Pelvic Vascular Injury So what is a contrast blush anyway? – Contrast extravasation – Pseudoaneurysm What’s the difference? – Both are bad! – Pseudoaneurysm – Extravasation

23. CT In Abdominal and Pelvic Vascular Injury Bottom Line – If you diagnose a pseudoaneurysm, obtain a surgical consult and consider IR soon – If you see extravasation, order blood first, consult surgery and prepare patient for IR ASAP

24. Mortality and Operations Started with – Development of trauma centers

25. Mortality and Operations Started with – Development of trauma centers Moved to – Development of trauma systems

26. Mortality and Trauma Operations Started with – Development of trauma centers Moved to – Development of trauma systems Found that – Trauma center care decreased mortality Don’t know about – How care is delivered at trauma centers

27. Mortality and Trauma Operations Your patient is bleeding to death until proven otherwise Trauma centers are good at operative management of bleeding

28. Mortality and Trauma Operations Your patient is bleeding to death until proven otherwise Trauma centers are good at operative management of bleeding Trauma centers that operate a lot to stop bleeding have lower mortality

29. Mortality and Trauma Operations ACS TQIP project allows calculation of observed to expected mortality rates 1.Calculate O/E mortality rates 2.Calculate procedure rates for specific operations 3.Examine the association between numbers 1 and 2

30. Mortality and Trauma Operations Study population of 135,666 patients obtained from the NTDB – Level I or II centers – No DOA – No minor injuries – Complete data record

31. Mortality and Trauma Operations

33. How can this be? – More reliance on nonop management, less experience with operative control – No good guidelines as to when patients should go to OR – More severely injured in the first place

34. Mortality and Trauma Operations Implications – Quality problem has been identified – Now need to identify causes and solutions – Are similar outcomes associated with other operative procedures???

35. Video, Slides, Biblio www.regionstraumapro.com regionstrauma

36. Bibliography What is the utility of focused assessment with sonography in trauma (FAST) exam in penetrating torso trauma? – Injury, in press, 2010. – Department of Emergency Medicine, Downstate Medical Center, Brooklyn, NY.

37. Bibliography CT of blunt abdominal and pelvic vascular injury – Emerg Radiology 17:21-29, 2010 – Dept of Radiology, Boston University Medical Center

38. Bibliography More operations, more deaths? Relationship between operative intervention and risk- adjusted mortality at trauma centers. – J Trauma 69(1):70-77, 2010 – Multiple sites