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a
b
Fig. 18.7 (a) Stab wound to the left chest with evidence of diaphragm
injury adjacent to wound tract. (b) Coronal reconstruction of diaphragm
injury showing herniation of abdominal fat through defect
shown to be a useful screening tool for patients with transmediastinal gunshot wounds. High-resolution imaging can
be especially useful to evaluate for hemopericardium concerning for penetrating cardiac injury if formal echocardiography is not immediately available. It is important to
remember that traditional chest X-ray in this setting has signicant limitations and a normal chest X-ray does not
exclude signicant cardiac injury.
CT angiography is also extremely useful to evaluate for
major central vascular injury where it has virtually supplanted traditional angiography as a screening study. Further,
it is useful in the planning for operative and/or interventional
angiographic approach to complex injuries. In patients who
have injuries identied which require operative intervention,
chest CT has been shown to accurately locate the injury and
in some cases provide information leading to a change in the
operative approach best suited for the injuries identied
(Fig.18.7).
Chest CT is also extremely useful in the workup of more
minor chest injuries. It is far better than conventional chest
radiography at predicting the presence of signicant undrained hemothorax needing surgical evacuation and can also
be useful in quantifying the size of small pneumothoraces to
allow for safe observation. As a screening tool, chest CT can
be used to exclude signicant thoracic injury, reducing the
need for follow-up imaging and allowing for safe discharge
directly from the emergency department.
One area where newer-generation CT scans have become
more useful is the detection of diaphragm injuries. New multidetector CT scanners can now resolve the presence of diaphragm injuries with a sensitivity and specicity of 82–94%
and 88–95.9% with an overall accuracy of almost 96% and
negative predictive value of 93%. However, it is important to
remember that small diaphragm injuries can still be difcult
to detect with imaging alone and a high index of suspicion
remains important as signicant injuries can still be missed.
Other means of more denitive evaluation for patients with
thoracoabdominal penetrating injuries, such as diagnostic
laparoscopy, remain important adjuncts in the workup to
avoid missed injury.
Finally, the importance of postoperative imaging even after
emergent surgical intervention has been completed must be
considered. Surgical literature, in both the civilian and military
settings, recognizes that critical information regarding additional injuries can be obtained during postoperative imaging
after emergent surgical procedures. As emergent operative
intervention is often focused on immediate lift-threatening
injuries, assessment for other injuries outside of the immediate
surgical eld is vitally important to avoid missed injuries with
their associated morbidity and mortality.
All said, chest CT and CT angiography provide a rapid
means of triage and diagnosis of injuries in stable patients
with penetrating chest trauma. When used as a screening tool
to allow for rapid discharge of patients without signicant
injury and to identify those patients either with denitive evidence of injury or for whom further workup is needed, it can
provide a wealth of information. While some suggest that it
is overutilized, it has the ability to rapidly detect lifethreatening injuries and provides the information needed for
optimal treatment. Conversely, it also provides a means to
facilitate rapid discharge of patients without signicant
injury, freeing scarce resources for the treatment of patients
more in need.
18.3 Abdomen
When faced with the workup of a patient with penetrating
injuries to the abdomen, it is essential to consider all available information and resources available. A subset of these
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patients will present in extremis with hemodynamic instability or evidence of peritonitis. These patients clearly require
emergent operative intervention. However, in the stable
patient without evidence of peritonitis, many centers have
embraced a trail of nonoperative management in patients
injured with low-energy edged weapons and, more recently,
those with higher-energy injuries caused by gunshot wounds.
The rst consideration, of course, is determining the need for
any advanced imaging. Past evidence has demonstrated that
patients with abdominal stab wounds and conrmed peritoneal penetration by local wound exploration, physical exam,
when combined with a variety of diagnostic and imaging
modalities, allowed nonoperative management in about
80–90% of these patients. A variety of imaging modalities
including conventional radiography and ultrasound have
been examined specically to determine their usefulness in
evaluating patients with penetrating trauma. Overall, their
roles are likely limited due to their relatively low sensitivity
in determining the need for further intervention or
laparotomy.
In penetrating abdominal trauma with both low-energy
mechanisms (such as stab wounds) and higher-energy mechanisms (gunshot wounds), multiple institutions have evaluated the use of CT scan in the workup of patients without
obvious indication for immediate laparotomy. Initially, these
studies were aimed at the determination of peritoneal penetration with subsequent operative exploration if the peritoneum had been violated. Multiple studies have demonstrated
a high sensitivity, specicity, and negative predictive value
for CT imaging to determine peritoneal penetration. While
IV contrast was used in all studies, the use of triple contrast—intravenous (IV), oral, and rectal—did improve the
specicity. However, a recent review of single-contrast CT
imaging, using IV contrast alone, demonstrated a high sensitivity in predicting the need for laparotomy in penetrating
trauma, highest in patients with gunshot wounds.
When considering abdominal stab wounds, there is a
large amount of data supporting the increasing use of nonoperative management of stable patients. Local wound exploration has been long thought to be an important part of any
treatment algorithm. If it can be denitively determined that
peritoneal penetration has not occurred, the patient can often
be safely discharged directly from the emergency department. However, once peritoneal penetration has been established, the issue is somewhat less clear. Multiple protocols
have been suggested including serial abdominal exams,
imaging followed by serial abdominal exams, serial abdominal exams and laboratory analysis, and selective imaging.
However, many institutions use abdominal CT imaging as a
screening step to demonstrate the likely absence of injury
requiring immediate laparotomy. Multiple guidelines have
been established by trauma organizations including the
Eastern Association for the Surgery of Trauma and the
Western Trauma Association. Each of these recommends
advanced imaging, especially in the workup of patients
where clinical questions exist or the physical exam is
questionable.
Abdominal gunshot wounds represent an area of even
greater controversy. Given the increased energy involved, the
relative risk of signicant injury is somewhat higher than
with wounds involving edged weapons. However, a subset of
patients can clearly tolerate and even benet from nonoperative management. Evaluation of CT imaging in the evaluation of gunshot wound to the abdomen demonstrate a role for
determination of the tract of the missile and a high negative
predictive value in determination of the need for a laparotomy. By helping to determine trajectory, CT imaging has
been demonstrated to be useful in diagnosing signicant
solid organ or vascular injury. In another recent large series
looking specically at nonoperative management of abdominal gunshot wounds, the authors found that CT imaging was
useful in both reducing overall cost and unnecessary laparotomies. One important word of caution regarding this
approach—if higher-power rearms are involved, especially
modern military or large game hunting ries—the possibility
of blast effect and resulting hydrostatic pressure causing
intraperitoneal injury exists even with a tangential wound
and the absence of peritoneal penetration. While there are
sporadic reports in the literature of this occurring with other
lower-energy rearms, the vast majority involves highenergy ries. In the case of a tangential injury involving a
high-energy rearm, an additional period of observation may
be warranted. However, even with this potential risk, the
military units have reported the successful use of CT imaging in battleeld penetrating abdominal injury to help identify patients that can successfully undergo nonoperative
management.
One subset of patients with penetrating abdominal trauma
deserves a special mention—those with isolated solid organ
injury identied on abdominal imaging. Looking specically
at penetrating abdominal trauma, both retrospective and prospective data have demonstrated that in the hemodynamically stable patient without peritonitis in whom isolated
wounds to solid organs are identied by CT scan, most can
be safely managed nonoperatively with observation. An
added benet in nonoperative management was the rapid
identication via CT imaging of patients who would benet
from angiographic treatment of solid organ hemorrhage.
Additionally, nonoperative management led to an overall
decrease in the length of stay, even in the face of more serious injuries.
The issue of nonoperative management of penetrating
abdominal trauma had been addressed in multiple practice
management guidelines as discussed above. Most guidelines
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include some recommendation for abdominopelvic CT scan
be considered as a diagnostic tool to facilitate initial management decision. Subsequent to these guidelines, multiple
authors have published protocols for the nonoperative management of penetrating abdominal trauma. While most recommend the liberal use of CT imaging in this population,
several do point out that a deteriorating physical exam may
be the most important indicator for failure. Almost universally
these nonoperative management guidelines have been demonstrated to be safe, with a low rate of missed or delayed
diagnosis of injuries.
A patient presenting with hemodynamic instability or
peritonitis after penetrating injury clearly requires emergent
operative intervention. However, the increasing role for nonoperative management in the stable patient is just as clear. In
the stable patient, with an abdominal stab wound, nonoperative intervention is clearly an option, especially with a CT
scan that is suggestive of no injury. One possible exception is
a patient with a wound which places them at risk for a diaphragm injury; these patients would probably benet from
diagnostic laparoscopy to exclude this injury. However as
was mentioned previously, there is a growing role for CT
imaging in the diagnosis of diaphragm injury after penetrating thoracoabdominal trauma. This must be tempered with
the recognition that small injuries can be very difcult to
detect on imaging and other modalities such as diagnostic
laparoscopy may also be indicated. Gunshot wounds are
another matter. My personal bias is to have a low threshold
for operative intervention for abdominal gunshot wounds
given the tremendous energy transfer that can take place and
sometimes unpredictable missile path. However, in the completely stable patient with a benign abdominal exam, CT
imaging can prove to be an extremely useful adjunct if nonoperative management is being considered.
As with thoracic trauma, patients undergoing emergency
operative exploration for penetrating trauma with obvious
hemodynamic instability or peritonitis may benet from
postoperative imaging. If initial damage control surgical
techniques are employed, postoperative imaging can help
determine missile trajectory and aide in the diagnosis of
other injuries out of the immediate operative eld.
ities, such as diagnostic peritoneal lavage and laparoscopy,
offer limited usefulness due to the difculty with evaluation
of the retroperitoneum. Since the 1980s, CT scan, enhanced
by the administration of contrast to ensure opacication of
the colon and other retroperitoneal structures, has been demonstrated to be a safe, reliable, and effective method to rule
out signicant injuries due to back or ank stab wounds. The
use of the “triple-contrast CT” allows for rapid identication
of those patients with injury, as well as more rapid discharge
of those without and clinically signicant trauma (Figs.18.8
and 18.9).
Fig. 18.8 Stab wound to the left back without intraperitoneal or retroperitoneal penetration
18.4 Back andFlank
Penetrating injuries to the ank and back present an especially difcult diagnostic challenge. It has been clearly noted
that, overall, these mechanisms have a low risk for injury
requiring surgical intervention. However, due to the anatomic considerations involved including the retroperitoneal
location of many at-risk structures, the diagnosis of these
rare injuries may be signicantly delayed with subsequent
increase in morbidity and mortality. Other diagnostic modal-
Fig. 18.9 Gunshot wound to back with evidence of intraperitoneal
penetration. Patient found to have multiple enterotomies at laparotomy
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M. E. Hamill
While rearm injuries tend to leave a more obvious
wound tract, stab wounds with their lower energy are more
problematic. Given the challenge in fully delineating the
exact trajectory of the wound tract, the technique of CT tractography has been developed. Simply put—prior to the
imaging—the wound tracts are packed with gauze soaked in
a radiopaque solution. This allowed for more accurate determination of intraperitoneal or retroperitoneal penetration,
while virtually excluding penetration or signicant injury in
the majority of patients. While this technique is certainly not
universally accepted and employed, it might prove useful in
certain circumstances.
With penetrating gunshot wounds to the back and ank,
the same potential issue regarding high-energy rearms
exists as with tangential abdominal gunshot wounds. A clinician should have a high index of suspicion for occult injury
with bowel wall contusion and potential late presentation of
injury in cases where the rearm used is of an especially high
energy, such as a military or large caliber game rie. In these
cases, signicant injury can occur even with the absence of
direct bowel penetration, even with tangential missile paths.
With these injuries it is recommended that, at the very minimum, the patient be observed for up to 24 h and further
investigation be undertaken as dictated by the patient’s clinical status.
a
b
18.5 Extremities
When dealing with penetrating extremity trauma, the use of
CT and CT angiography can enhance the clinical picture in
the appropriately selected patient. Certainly, in a patient
with hard signs of vascular injury (including pulsatile bleeding, expanding hematoma, pulselessness, thrill/bruit) and
active hemorrhage, the primary intervention should be operative, with the use of on-table angiography as dictated by
the operative ndings. However, in the stable patient with
soft signs of vascular injury including decreased pulses or
ankle- brachial index (ABI), non-expanding hematoma, history of signicant bleeding, or concerning proximity of the
wound tract to major vascular structures, CT angiography
can be of benet both in conrming the injury and determining the character and location of the injury and potential
appropriateness of nonoperative and less invasive interventions such as stenting or angioembolization (Fig. 18.10).
Even in the setting of limb threatening ischemia, preoperative CT angiography can provide critical information regarding the exact location of the injury and help guide the
appropriate choice of intervention and operative exposure to
restore blood ow.
In the radiographic evaluation of extremities for vascular
injuries, conventional angiography was long considered the
gold standard. However, over the past several years with the
Fig. 18.10 (a) Gunshot wound to the left lower extremity. No evi-
dence of signicant bony or vascular injury. Treated with local wound
care. (b) CTA reconstruction of lower extremity vasculature demonstrating no evidence of vascular injury
development of multidetector CT scanners, CT angiography
has been shown by several authors to offer both a high sensitivity (95–100%) and specicity (87–100%) for the detection
of injuries, without the potential drawbacks of conventional
angiography such as access site thrombosis, groin hematoma, distal plaque embolization, or intimal dissection.
Given the quality obtained with the current imaging systems,
many consider CT angiography to have supplanted traditional angiography at the initial imaging modality of choice.
When the use of CT angiography was retrospectively evaluated at an urban US level 1 trauma center, Peng etal. found
that its use effectively ruled out injuries in 55% of studies
and was associated with zero false negatives or missed injuries as well as excellent correlation between CT angiography
results and operative ndings in patients who had injuries
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a
b
Fig. 18.11 (a) Gunshot wound to the left lower extremity with evi-
dence of contrast extravasation in the territory of supercial femoral
artery (SFA). Patient required vascular repair using vein graft. (b)
Vascular reconstruction demonstrating SFA injury with extravasation as
well as distal reconstitution of vessel
CT angiography represents a step forward in the workup
of stable patients with extremity injuries concerning for vascular injury without hard signs. While it only allows for diagnosis, it does so without many of the potential hazards
associated with conventional angiography. With its high sensitivity and specicity and low potential for complications
compared to conventional angiography, CT angiography
offers an excellent radiographic tool for the rapid diagnosis
of peripheral vascular injuries. Once the presence of CT
angiographic signs of arterial injury, including active extravasation, pseudoaneurysm formation, abrupt narrowing of a
vessel, loss or opacication of an arterial segment, or arteriovenous stula, has been conrmed, either operative intervention, interventional radiographic intervention, or appropriate
observation can be undertaken as dictated by the injury. It is
important to note that the ability to detect injury is potentially related to the resolving power of the scanner. Limited
resolution provided by older-generation multidetector CT
scanners can severely limit the usefulness of the imaging
obtained.
However—with the proliferation of new-generation scanners—CT angiography has virtually replaced traditional
angiography for the initial diagnosis of occult vascular injuries. Even in the military setting, where operative intervention had been the mainstay of therapy, there is increased
recognition that penetrating or blast injuries result in a signicant incidence of occult vascular injuries, and routine CT
angiography provides the ability to rapidly and safely diagnose these injuries, while limiting unnecessary operative
interventions. In fact, in a recent review of available imaging
modalities for vascular trauma, Patterson and colleagues
concluded in no uncertain terms that, in the absence of indication for immediate operative intervention, CT angiography
should be the rst imaging modality for all patients with suspected vascular trauma. However, it is important to consider
physical exam in the choice of imaging modalities. Some
suggest that routine extremity CT imaging is signicantly
overutilized and that orthopedic evaluation should be undertaken prior to all imaging decisions. Regardless, it is clear
the appropriate use of advanced imaging can play a signicant role in the workup of patients with potential for vascular
injury after penetrating trauma.
identied and subsequently underwent operative exploration. Multiple other reviews have demonstrated that CT angiography has a high sensitivity and specicity for injuries,
with a low false-negative rate. There is, however, a signicant concern with its use in penetrating trauma. Specically
with gunshot wounds, some authors have found that scatter
artifact from retained metal fragments can signicantly
degrade image quality, leading to studies that are noninterpretable in some cases (Fig.18.11).
18.6 Conclusion
The use of CT scanning in penetrating trauma has led to several important advances in the care that can be provided.
Given the rapid and accurate information that it provides, we
are now able to more accurately determine which patients
will benet from operative intervention. It has allowed the
expansion of selective nonoperative care for penetrating
wounds to a variety of regions. In addition, with high-
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resolution scanners and CT angiography, it allows for screening and diagnosis previously only available through more
invasive techniques. With it, we can be better at identifying
those patients with signicant injury and more rapidly commence appropriate treatment. At the same time, we are able to
more expeditiously exclude injury in a signicantly large
number of patients, leading to faster discharge and less use of
scarce resources. Selective use of advanced imaging in stable
patients with penetrating injuries, combined with an understanding of the principles of ballistics and, most importantly,
recognition of the limitations inherent in imaging, represents
a major step forward in the diagnosis and treatment of patients
with both blunt and penetrating trauma. While it is important
to remember that each of these modalities is associated with a
level of radiation exposure, in the vast majority of cases, this
risk is likely far outweighed by the risk of missing a signicant injury as well as the potential long-term complications
associated with negative operative exploration.
Important Points
• The place for a hemodynamically unstable patient after
penetrating trauma is the operating room, not the CT
scanner!
• In patients without hard signs of clinical injury, highresolution CT imaging has virtually replaced mandatory
neck exploration in the initially evaluation of penetrating
neck trauma.
• Chest CT and CTA provide a rapid method of diagnosing signicant intrathoracic injury after penetrating
trauma.
• The absence of signicant injury on CT chest can be used
to facilitate rapid discharge after penetrating thoracic
trauma.
• CT scanning is widely recommended in patients selected
to undergo nonoperative management of penetrating injuries to the abdomen.
• CT imaging, augmented by colonic contrast, is the
modality of choice in evaluating for injury to retroperitoneal structures in penetrating trauma to the back and
ank.
• High-energy penetrating mechanisms (e.g., military or
large game caliber hunting ries) can rarely lead to signicant intra-abdominal injury even with tangential
wounds that do not penetrate the peritoneal cavity.
Patients with these types of wounds may benet from an
additional period of observation to exclude injury and a
low threshold for surgical exploration.
• CTA has surpassed conventional angiography as the
modality of choice for the initial evaluation of suspected
vascular injury.
• Advanced imaging in the postoperative setting after emergent operation in penetrating injuries can be considered to
help exclude injuries outside of the operative eld.
• Again, the place for an unstable patient after penetrating
trauma is the operating room, not the CT scanner.
Suggested Reading
Head and Neck
Gonzales RP, Falimirski M, Holevar MR, etal. Penetrating zone II neck
injury: does dynamic computed tomographic scan contribute to the
diagnostic sensitivity or physical exam for surgically signicant
injury/a prospective blinded study. J Trauma Inj Infect Crit Care.
2003;54(1):61–5.
Gracias VH, Reilly PM, Philpott J, etal. Computed tomography in the
evaluation of penetrating neck trauma: a preliminary study. Arch
Surg. 2001;136(11):1231–5.
Munera F, Soto JA, Palacio D, et al. Diagnosis of arterial injuries
caused by penetrating trauma to the neck: comparison of helical CT angiography and conventional angiography. Radiology.
2000;216(2):356–62.
Inaba K, Branco BC, Menaker J, etal. Evaluation of multidetector com-
puted tomography for penetrating neck injury: a prospective multicenter study. J Trauma. 2012;72(3):576–84.
Tisherman SA, Bokhari F, Collier B, etal. Clinical practice guideline:
penetrating zone 2 neck trauma. J Trauma Inj Infect Crit Care.
2008;64(5):1392–405.
Sperry JL, Morore EE, Coimbra R, etal. Western trauma association
critical decisions in trauma: penetrating neck trauma. J Trauma
Acute Care Surg. 2013;75(6):936–40.
Shiroff AM, Gale SC, Martin ND, et al. Penetrating neck trauma: a
review of management strategies and discussion of the “no zone”
approach. Am Surg. 2013;79(1):23–9.
Ibraheem K, Khan M, Rhee P, et al. “No zone” approach in pen-
etrating neck trauma reduces unnecessary computed tomography angiography and negative explorations. J Surg Res.
2018;211(1):113–20.
Thoracic
Burack JH, Kandil E, Sawas A, et al. Triage and outcome of
patients with mediastinal penetrating trauma. Ann Thorac Surg.
2007;83(2):377–82.
Grossman MD, May AK, Schwab CW, et al. Determining anatomic
injury with computed tomography in selected torso gunshot wounds.
J Trauma Inj Infect Crit Care. 1998;45(3):446–56.
Gunn ML, Clark RT, Sadro CT, et al. Current concepts in imaging
evaluation of penetrating Transmediastinal injury. Radiographics.
2014;34:1824–41.
Co SJ, Yong-Hing CJ, Galea-Soler S, etal. Role of imaging in pen-
etrating and blunt traumatic injury to the heart. Radiographics.
2011;31:E101–15.
Magnotti LJ, Weinberg JA, Schroeppel TJ, etal. Initial chest CT obvi-
ates the need for repeat chest radiograph after penetrating thoracic
trauma. Am Surg. 2007;73(6):569–73.
18 Computed Tomography intheWorkup ofPatients withPenetrating Trauma
https://t.me/medicina_free
163
Eddine SBZ, Boyle KA, Dodgion CM, etal. Observing pneumotho-
races: the 35-millimeter rule is safe for both blunt and penetrating
chest trauma. J Trauma Acute Care Surg. 2019;86(4):557–64.
Velmahos GC, Demetriades D, Chan L, et al. Predicting the need
for thoracoscopic evacuation of residual traumatic hemothorax:
chest radiograph is insufcient. J Trauma Inj Infect Crit Care.
1999;46(1):65–70.
O’Connor JV, Scalea TM. Penetrating thoracic great vessel injury:
impact of admission hemodynamics and pre-operative imaging. J
Trauma Inj Infect Crit Care. 2010;68(4):834–7.
Augustin P, Guivarch E, Tran-Dinh A, etal. Usefulness of CT-scan in
the management of chest stab trauma: a prospective observational
study. Euro J Trauma Emergency Surg. 2020;46(6):1385–91.
Yucel M, Bas G, Kulali F, etal. Evaluation of diaphragm in penetrating
left thoracoabdominal stab injuries: the role of multislice computed
tomography. Inj Int J Care Inj. 2015;46:1734–7.
Nummela M, Thorisdottir S, Oladottir GL, Koskinen SK.Imaging of
penetrating thoracic trauma in a large Nordic trauma center. Acta
Radiologica Open. 2019;8(12):1–10.
Lichtenberger JP, Kim AM, Fisher D, et al. Imaging of Compat-
related thoracic trauma– review of penetrating trauma. Mil Med.
2018;183(3/4):e81–8.
Abdomen and Pelvis
Benjamin E, Demetriades D.Nonoperative management of penetrating
injuries to the abdomen. Curr Trauma Rep. 2015;1:102–6.
Como JJ, Bokhari F, Chiu W, et al. Practice management guideline
for selective nonoperative management of penetrating abdominal
trauma. J Trauma Inj Infect Crit Care. 2010;68(3):721–33.
Martin MJ, Brown CVR, Shatz DV, etal. Evaluation and management of
abdominal stab wounds: a Western trauma association critical decisions algorithm. J Trauma Acute Care Surg. 2018;85(5):1007–15.
Bif WL, Leppaniemi A. Management guidelines for penetrating
abdominal trauma. World J Surg. 2015;39:1373–80.
Morrison JJ, Clasper JC, Gibb I, et al. Management of penetrating
abdominal trauma in the conict environment: the role of computed
tomography scanning. World J Surg. 2011;35:27–33.
Velmahos GC, Demetriades D, Tourouzaz KG, et al. Selective non-
operative management in 1,856 patients with abdominal gunshot
wounds: should routine laparotomy still be the standard of care?
Ann Surg. 2001;234(3):395–403.
Navsaria PH, Nicol AJ, Edu S, etal. Selective nonoperative manage-
ment in 1106 patients with abdominal gunshot wounds. Ann Surg.
2015;261(4):760–4.
Demetriades D, Hadjizacharia P, Constantinou C, etal. Selective non-
operative management of penetrating abdominal solid organ injuries. Ann Surg. 2006;244(4):620–8.
Tien HC, van der Hurk TW, Dunlop MP, etal. Small bowel injury from
a tangential gunshot wound without peritoneal penetration: a case
report. J Trauma Inj Infect Crit Care. 2007;62(3):762–4.
Owers C, Garner J.Intra-abdominal injury from extra-peritoneal bal-
listic trauma. Inj Int J Care Inj. 2014;45:655–8.
Hasaniya N, Demetriades D, Stephens A, etal. Early morbidity and
mortality of non-therapeutic operations for penetrating trauma. Am
Surg. 1994;60(10):744–7.
Akkoca Nm Balis S, Yilmaz KB, etal. C-guided tractography is a safe
and complementary diagnostic tool in the management of penetrating abdominal trauma. Asian J Surgery. 2019;42:148–54.
Alexander LF, Hanna TN, LeGout JD, etal. Multidetector CT ndings
in the abdomen and pelvis after damage control surgery for acute
traumatic injuries. Radiographics. 39:1183–202.
Back and Flank
Phillips T, Sclafani SJA, Goldstein A, etal. Use of the contrast enhanced
CT enema in the management of penetrating trauma to the ank and
back. J Trauma Inj Infect Crit Care. 1986;26(7):593–601.
Meyer DM, Thal ER, Weigelt JA, etal. The role of abdominal CT in the
evaluation of stab wounds to the back. J Trauma Inj Infect Crit Care.
1989;29(9):1226–30.
Bansal V, Reid CM, Fortlage D, etal. Determining injuries from poste-
rior and ank stab wounds using computed tomography tractography. Am Surg. 2014;80(4):403–7.
Albrecht RM, Schermer CR, Demarest GB III, etal. Stab wounds to
the back/ank in hemodynamically stable patients: evaluation using
triple contrast computed tomography. Am Surg. 1999;65(7):683–8.
Kirton OC, Wint D, Thrasher B, et al. Stab wounds to the back and
ank in the hemodynamically stable patient: a decision algorithm
based on contrasted-enhanced computer tomography with colonic
opacication. Am J Surg. 1997;173(3):189–93.
Macleod J, Freiberger D, Lewis F, et al. What is the optimal obser-
vation time for a penetrating wound to the ank? Am Surg.
2007;73(1):25–31.
Extremities
Foster BR, Anderson SW, Soto JA. CT angiography of extremity
trauma. Tech Vasc Interv Radiol. 2006;9(4):156–66.
Miller-Thomas MM, West OC, Cohen AM.Diagnosing traumatic arte-
rial injury in extremities with CT angiography: pearls and pitfalls.
Radiographics. 2005;25(Suppl 1):S133–42.
Peng PD, Spain DA, Tataria M, etal. CT angiography effectively evalu-
ates extremity vascular trauma. Am Surg. 2008;74(2):103–7.
Ramirez RM, Cureton EL, Ereso AQ, etal. Single contrast computed
tomography for the triage of patients with penetrating torso trauma.
J Trauma Inj Infect Crit Care. 2009;67(3):583–8.
Soto JA, Munera F, Morales C, etal. Focal arterial injuries of the proxi-
mal extremities: helical CT angiography as the initial method of
diagnosis. Radiology. 2001;218(1):188–94.
Callan AK, Bauer JM, Mir HR.Over-utilization of computer tomog-
raphy angiography in extremity trauma. OTA. International.
2019;e030:1–5.
Watchorn J, Miles R, Moore N.The role of ct angiography in military
trauma. Clin Radiology. 2013;68:39–46.
Portable Ultrasound asanAdjunct
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inPenetrating Trauma
JimConnolly
19
As ultrasound (US) machines have become increasingly portable, cheap and robust, they have also become increasingly
available to non-radiologists, not just outside of the radiology department but also increasingly out of hospital. Pointof- care ultrasound (PoCUS) is considered to be a ‘visual
stethoscope’ and just like the stethoscope is used as an
adjunct to examination, rather than as a replacement for that
examination or radiological test. As the modality matures, it
is increasingly recognised that its value is in improving the
accuracy of physical examination. In this regard, its accuracies far exceed those of some more classical examination
techniques.
Even limited training can achieve highly focused views
and help decision-making in time-critical situations. Such
focused practice has been shown to have a steep learning
curve. Importantly, you should never consider point-of-care
ultrasound a replacement for examination, rather as a skill
that adds extra vital information to that assessment and
improves its accuracy. Critically in the context of modern
mature trauma systems, any new technology should only be
deployed when it will add to the encounter especially in
time-critical cases and not for procrastination (e.g. in penetrating thoracic trauma with recent loss of cardiac output,
ultrasound is more likely to mislead and delay your decision
to move to resuscitative thoracotomy).
19.1 Introduction
Ultrasound machines for point of care should be simple and
power up rapidly to make them ready to use within seconds.
For this reason, most modern machines can be dened down
to a small set of buttons, and most have a preset application
set (providing the best settings for any particular purpose)
that enable speed of use.
J. Connolly (*)
Emergency Department, Royal Victoria Inrmary,
Newcastle-upon-Tyne, UK
The machine should meet your specic needs. For example, if you work in an isolated area with intermittent power
supply, the machine needs to have a good battery life.
Robustness and portability are very important if you are
working in the prehospital arena.
19.1.1 How Should YouUse Point-of-Care
Ultrasound?
Point-of-care ultrasound may be of use in all aspects of managing penetrating injury:
• Dening the injury
• Assessing volume status
• Assisting interventions
• Managing patients in the initial and recovery phases of
their injury
19.1.2 Dening theInjury
Ultrasound can be useful not just in detecting and dening
injury but also in triaging which body cavity is injured.
In penetrating trauma, it may be used to detect haemothorax, pneumothorax, pericardial effusions and free abdominal
uid. It can pick up these life-threatening injuries in the primary survey phase much more accurately and rapidly than
physical examination alone and more rapidly than portable
X-ray. Increasingly, this concept has been honed in to that of
an ultrasound-enhanced primary survey.
It is however not so good at detecting which organ is
injured or in detecting retroperitoneal blood/injury, diagnoses which require CT.
Although of denite value, it should never delay critical
actions in life-threatening penetrating injury.
FAST scanning has come in for criticism for not being
accurate enough in the assessment of intra-abdominal bleeding. Key to an understanding of its accuracy above physical
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
E. Degiannis et al. (eds.), Penetrating Trauma, https://doi.org/10.1007/978-3-031-47006-6_19
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J. Connolly
examination or other tests is an appreciation of how we make
decisions in medicine. In this regard, often subconsciously,
we repeatedly use Bayesian principles.
This involves deciding what the pretest probability is and
then applying a test/question/investigation or physical sign
that either increases (positive likelihood—LR+ ratio) or
decreases (negative likelihood ratio LR−) the likelihood of
that condition being present. A positive likelihood of 10 is
considered a good test for ruling in, and a negative likelihood ratio of <0.1 is good for ruling out a condition (note
this does not make it ten times more or less likely but moves
the probability signicantly (about 45% more or less
likely)).
In this regard, it is worth considering the LRs for FAST
are considered in the order of LR+ 30, which means that if
free uid is seen, it is highly predictive of free uid being
present. However, the LR− is only 0.26, which means it is
not so accurate for ruling uid out.
So if we were starting with a 50/50 possibility of there
being bleeding, one can see in Fig.19.1 (Fagan nomogram)
Fig. 19.1 Showing a starting pre-test probability of 50/50. Likelihood
ratios for FAST plotted to show post-test probability—note LR− the
lower line still shows a negative FAST carries a chance of missing
bleeding
that seeing free uid means the chance of it being positive
after the test is high, whereas not seeing uid does not
exclude free uid.
This compares very well to other tests and examinations
(e.g. a low BP carries an approximate LR+ of 5.2, abdominal guarding an LR+ 3.7. No tenderness carries an
LR−0.61).
SCANNING SHOULD NEVER DELAY DEFINITIVE
MANAGEMENT.
19.1.3 Detecting Abdominal Blood (FAST
Scan)
The term focused assessment with sonography in trauma
(FAST) was initially coined by Grace Rozycki and her team
in Washington in the mid-1990s to describe a screening scan
for free uid.
It is normally the right hepato-renal pouch that becomes
positive rst, as this is the most dependent area in a recumbent patient, whatever the area of intra-abdominal injury. In
an upright patient, uid will gravitate to the pelvis. The minimum uid volume required for a FAST scan to become positive is considered to be in the order of a few hundred
millilitres. This is important to appreciate as this may lead to
a false-negative scan even with substantial intra-abdominal
injury, where the blood volume is depleted by bleeding from
other sources—put simply, you need blood to bleed! This
explains why FAST is a much better rule in than rule out test
as shown by its likelihood ratios.
YOU NEED BLOOD TO BLEED.
With limited training, you can quickly achieve sensitivities in the order of 85% for free uid, but this has been
shown to rise to nearly 100% in those with shock. In the
context of both penetrating and blunt trauma, particularly
gunshot wounds, it can usefully predict the need for exploration (coeliotomy) and has been shown to reduce the time
to theatre.
Standard views (Fig. 19.2) are obtained of the six Ps
(pericardial, perihepatic, perisplenic, pelvic and both pleurae). The probe positions are as shown in Fig. 19.2. The
probe has an indicator on it and when commencing a scan,
this should be uppermost—the indicator corresponds with
the dot on the screen which should be on the left of the screen
so that on the screen, the head is on the left and the feet on
the right to maintain a standard orientation. It is precisely
this standardisation of approach that will allow you to
achieve rapid competence in the technique.
All rotations of the probe in FAST should be anticlockwise from this starting position, such that the patient’s right
side comes to lie to the right of the screen. This again maintains a standard accepted orientation.
e
Diaphragm
19 Portable Ultrasound asanAdjunct inPenetrating Trauma
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a
Liver
Bladder
Spleen
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Kidney
Spleno-renal spac
Kidney
Fig. 19.2 Probe positions for FAST
Fluid is (mostly!!) black and will collect in one of the
areas as depicted in Fig.19.3a–c. However, fresh blood with
clot may appear grey and mislead the inexperienced user. It
is for this reason that using it in penetrating thoracic trauma
with loss of output is not recommended as it stands the risk
of misleading the team.
You should be aware of the pitfalls of a FAST scan. The
most important of these is the fact that you need blood to
bleed. A negative scan does not exclude injury. Remember in
all situations to trust your clinical judgement. Repeat regularly as this improves accuracy and detects evolving
bleeding.
CLOTTED BLOOD MAY APPEAR GREY.
The presence of signicant surgical emphysema can make
a view impossible (air is the enemy of ultrasound!). As you
learn this technique, be wary of false positives, particularly
Liver
RA RV
LA LV
Fig. 19.3 (a) Schematic drawings of scans. RV right ventricle, RA
right atrium, LV left ventricle, LA left ventricle. (b) Four normal scans.
(c) Four abnormal scans
Pericardium
interpreting the gall bladder and inferior vena cava (IVC) on
the right as free uid in the abdomen.
The best way to avoid this is to look for uid in predened
spaces—if you are not getting a view of both the liver and
kidney (as in Fig.19.3), then you can easily mistake the IVC
or gall bladder for free uid. If you are not seeing both the
kidney and liver, do not call it.
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