PubMed Health⌕ Search

Biomedical subjects

James F Holmes

Publications and source records attributed to James F Holmes.

At least 19 recordsLinked to original sources
PubMed2006

Pediatric head trauma: changes in use of computed tomography in emergency departments in the United States over time.

STUDY OBJECTIVE: Head trauma is common in children. In the absence of evidence-based recommendations, variations exist in the initial emergency department (ED) evaluation and treatment of children with head trauma. We sought to describe the use of computed tomography (CT) over time in the treatment of children with acute closed head trauma in US EDs. METHODS: This was a cross-sectional analysis of data from the National Hospital Ambulatory Care Survey database from 1995 to 2003. We identified patients aged 0 to 18 years, with head trauma by chief complaint or discharge diagnosis. We collected the following data: chief complaint, patient demographics, patient disposition, discharge diagnosis, and use of CT. Frequency and characteristics of the use of CT scan for evaluation of children with head trauma. We used descriptive statistics with appropriate weighting to account for the survey methodology. We determined the frequency and the characteristics of the use of CT scans for evaluation of children with head trauma. We used descriptive statistics with appropriate weighting to account for the survey methodology. RESULTS: We identified 2,747 patient encounters, representing 10,536,717 pediatric head trauma visits during the 9-year period. The use of CT increased from 12.8% to 22.4% from 1995 to 2003, with a peak of 28.6% in 2000. CT was used more frequently in the older age groups: 13% (<1 year), 11% (1 to 4 years), 20% (5 to 9 years), and 32% (10 to 18 years). CT was also used more frequently in general EDs (22%) than in pediatric-specific EDs (13%). There were no differences in CT use between teaching and nonteaching facilities (21% in each). Overall, 6.4% of children were either admitted to the hospital or transferred, and this rate remained stable over time. CONCLUSION: The use of CT has increased substantially in the evaluation of children with head trauma from 1995 to 2003. Further study is needed to identify objective criteria for cranial CT in head-injured children and to evaluate the impact of increased CT use on patient outcomes.

Academic Medical Centers↗
PubMed2006

Ten-year experience with an emergency medicine resident research project requirement.

BACKGROUND: Controversy exists regarding the value and quality of required emergency medicine (EM) resident scholarly projects. OBJECTIVES: To describe the research designs and presentation rate at national scientific meetings and the publication rate of EM resident scholarly projects at a university-based residency program. METHODS: The authors reviewed the initial ten years (1993-2002) of resident scholarly projects from an EM residency program. Since the inception of the program, a formal research study has been required of all residents for residency graduation. Scholarly projects were reviewed and categorized by study design. Abstracts from the American Academy of Emergency Medicine (AAEM), American College of Emergency Physicians (ACEP), and Society for Academic Emergency Medicine (SAEM) annual meetings were searched to identify projects presented at any of these national meetings. A PubMed search for resident and faculty investigators was performed, and faculty and graduated residents were queried to identify all resident scholarly projects published in peer-reviewed journals. RESULTS: Eighty-seven residents produced 90 scholarly projects. Study designs were prospective data collection, 42 (47%); retrospective chart review, 38 (42%); survey, 5 (6%); animal, 4 (4%); and computer program development, 1 (1%). Of the 80 projects collecting patient data, 72 were conducted at a single center; 6, at two centers; and 2, at five centers each. Of the 42 prospective clinical studies, 27 (64%) were observational and 15 (36%) were interventional. Forty-six (51%) abstracts were presented at national meetings (SAEM, 20; ACEP, 19; AAEM, 3; and other, 4). Thirty-six (40%) of the projects have been published in peer-reviewed journals. Abstract presentation at national meetings (range, 13%-64% of projects per yr) and manuscript publication rates (range, 0-67% of projects per yr) were variable from year to year. CONCLUSIONS: Resident scholarly projects at one institution were equally likely to use a prospective or retrospective design, and most were conducted at a single center. More than half of the projects were presented at national research meetings, and more than a third were subsequently developed into manuscripts and published in peer-reviewed journals. When an original research study is required for satisfying the scholarly requirement for EM residency graduation, resident projects can contribute to the EM literature.

Abstracting and Indexing↗
PubMed2006

Performance of a decision rule to predict need for computed tomography among children with blunt head trauma.

OBJECTIVE: To assess the ability of the NEXUS II head trauma decision instrument to identify patients with clinically important intracranial injury (ICI) from among children with blunt head trauma. METHODS: An analysis was conducted of the pediatric cohort involved in the derivation set of National Emergency X-Radiography Utilization Study II (NEXUS II), a prospective, observational, multicenter study of all patients who had blunt head trauma and underwent cranial computed tomography (CT) imaging at 1 of 21 emergency departments. We determined the test performance characteristics of the 8-variable NEXUS II decision instrument, derived from the entire NEXUS II cohort, in the pediatric cohort (0-18 years of age), as well as in the very young children (<3 years). Clinically important ICI was defined as ICI that required neurosurgical intervention (craniotomy, intracranial pressure monitoring, or mechanical ventilation) or was likely to be associated with significant long-term neurologic impairment. RESULTS: NEXUS II enrolled 1666 children, 138 (8.3%) of whom had clinically important ICI. The decision instrument correctly identified 136 of the 138 cases and classified 230 as low risk. A total of 309 children were younger than 3 years, among whom 25 had ICI. The decision instrument identified all 25 cases of clinically important ICI in this subgroup. CONCLUSIONS: The decision instrument derived in the large NEXUS II cohort performed with similarly high sensitivity among the subgroup of children who were included in this study. Clinically important ICI were rare in children who did not exhibit at least 1 of the NEXUS II risk criteria.

Adolescent↗
PubMed2006

Epidemiology of blunt head injury victims undergoing ED cranial computed tomographic scanning.

STUDY OBJECTIVE: We sought to describe the epidemiology of emergency department (ED) patients with blunt head injury undergoing cranial computed tomography (CT) scanning for the evaluation of possible traumatic brain injury (TBI). METHODS: Prospective, multicenter, observational study of ED patients undergoing cranial CT after blunt head injury. Patient's date of birth, sex, and race/ethnicity were documented before CT scanning. Individual patients were considered to have "significant" TBI if the official radiographic interpretation at the end of all imaging studies associated with the trauma was consistent with any of a set of predefined diagnoses. The relative prevalence of TBI among various prespecified groups from those undergoing cranial CT scanning was also calculated. RESULTS: Of 13728 patients who were enrolled, 8988 (65%) were men and 1193 (8.7%) had a significant acute TBI. Demographic findings associated with increased risk of TBI, among patients selected for scanning, included the following: age below 10 years (relative risk [RR] = 1.44, 95% confidence interval [CI], 1.19-1.77); age above 65 years (RR = 1.59; 95% CI, 1.40-1.80), and male sex (RR = 1.27; 95% CI, 1.30-1.43). CONCLUSION: Among patients selected for cranial CT scanning after blunt head injury, men, patients younger than 10 years, and those older than 65 years have an increased likelihood of significant TBI.

Adolescent↗
PubMed2006

Utility of supine oblique radiographs in detecting cervical spine injury.

A retrospective case-control study was performed to determine if the addition of supine oblique radiographs to the routine cervical spine series results in the detection of patients with cervical spine injuries not identified with standard views alone. The cervical spine radiographs of 82 patients with known cervical spine injuries and 180 hospitalized patients without cervical spine injuries were collected. Radiographs of the two patient groups were randomly combined to form the study sample. The radiographs were reviewed independently by a board-certified radiologist and a board-certified emergency physician. During the first phase, each reviewer was provided with standard views of the cervical spine (lateral, anterior-posterior, open-mouth odontoid, and submental views). During the second phase, each reviewer was provided with the standard views and supine obliques. The reviewers were masked to all clinical information and previous radiologic interpretations. The results showed that in the first phase (standard views only), the two physicians had a sensitivity of 81% (95% confidence interval [CI] 74-87%) and a specificity of 93% (95% CI 90-96%). In the second phase (obliques included), the two physicians had a sensitivity of 76% (95% CI 69-83) and specificity of 90% (95% CI 87-93%). In a subset analysis of patients with posterior element (lamina, facet, and pedicle) fractures, the two physicians had a sensitivity of 88% (95% CI 78-95%) with standard radiographs and 86% (95% CI 76-94%) with the addition of oblique radiographs. In conclusion the addition of supine oblique radiographs to the standard trauma cervical spine series did not increase the readers' sensitivity for detecting patients with cervical spine injuries. Routinely including oblique radiographs in patients undergoing radiographic screening of the cervical spine is not warranted.

Case-Control Studies↗
PubMed2006

Prevalence and prognosis of traumatic intraventricular hemorrhage in patients with blunt head trauma.

BACKGROUND: Most studies of traumatic intraventricular hemorrhage (tIVH) contain fewer than 25 subjects and are retrospective in design, providing minimal information about the entity and its clinical significance. METHODS: We prospectively enrolled trauma patients from 18 centers in North America in the National Emergency X-Radiography Utilization Study (NEXUS) II if they received an emergent head computed tomography (CT) scan, as determined by the managing physician. Clinical data were collected at the time of enrollment and CT reports were compiled at least 1 month later. We calculated prevalence and demographics of tIVH from the 18 sites, while outcome data were gathered from medical records of patients with tIVH who were seen at any of six sites that participated in the follow-up portion of the study. We considered patients who underwent a neurosurgical intervention or who had a "poor outcome" (Glasgow Outcome Scale score of 1 to 3, death, persistent vegetative state, or severe disability) to have suffered a "combined outcome." RESULTS: Prevalence of tIVH among all trauma patients who received a head CT was 118 in 8,374, or 1.41%. Among tIVH patients, 70% had a "poor outcome" and 76% had a "combined outcome." A poor outcome appeared to be associated with an abnormal presenting Glasgow Coma Scale score and involvement of the third or fourth ventricle, whereas age appeared to be unrelated. Patients with tIVH and no major associated injury on CT tended to do well; only one patient with isolated tIVH had a poor outcome. CONCLUSIONS: Traumatic IVH is rare and is associated with poor outcomes that seem to be the consequence of associated injuries. Isolated tIVH patients who are clinically well appear to have a functional outcome; we were unable to identify a case of isolated tIVH, combined with a normal neurologic examination, resulting in a poor or combined outcome.

Adolescent↗
PubMed2006

Appearance of solid organ injury with contrast-enhanced sonography in blunt abdominal trauma: preliminary experience.

OBJECTIVE: The purpose of this study was to compare the detection rate of injury and characterize imaging findings of contrast-enhanced sonography and non-contrast-enhanced sonography in the setting of confirmed solid organ injury. SUBJECTS AND METHODS: This prospective study involved identifying hepatic, splenic, and renal injuries on contrast-enhanced CT. After injury identification, both non-contrast-enhanced sonography and contrast-enhanced sonography were performed to identify the possible injury and to analyze the appearance of the injury. The sonographic appearance of hepatic, splenic, and renal injuries was then analyzed, and the conspicuity of the injuries was graded on a scale from 0 (nonvisualization) to 3 (high visualization). RESULTS: Non-contrast-enhanced sonography revealed 11 (50%) of 22 injuries, whereas contrast-enhanced sonography depicted 20 (91%) of 22 injuries. The average grade for conspicuity of injuries was increased from 0.67 to 2.33 for spleen injuries and from 1.0 to 2.2 for liver injuries comparing non-contrast-enhanced with contrast-enhanced sonography, respectively, on a scale from 0, being nonvisualization, to 3, being high visualization. The splenic injuries appeared hypoechoic with occasional areas of normal enhancing splenic tissue within the laceration with contrast-enhanced sonography. Different patterns were observed in liver injuries including a central hypoechoic region. In some liver injuries there was a surrounding hyperechoic region. CONCLUSION: Contrast-enhanced sonography greatly enhances visualization of liver and spleen injuries compared with non-contrast-enhanced sonography. Solid organ injuries usually appeared hypoechoic on contrast-enhanced sonography, but often a hyperechoic region surrounding the injury also was identified with liver injuries.

Abdominal Injuries↗
PubMed2005

Do all patients with left costal margin injuries require radiographic evaluation for intraabdominal injury?

STUDY OBJECTIVE: We determine whether all patients with pain or tenderness to the left lower ribs after blunt traumatic injury require abdominal computed tomography (CT) scanning for the detection of splenic injury. METHODS: This was a prospective, observational cohort of all blunt-trauma patients who had pain or tenderness to the left lower ribs and presented to the emergency department (ED) of a Level I trauma center. Patients were enrolled if they had a Glasgow Coma Scale (GCS) score greater than 13 and pain or tenderness to the left lower ribs (ribs 7 to 12). Patients with pain or tenderness to the left lower ribs were considered to have pleuritic pain if the pain increased with inspiration or cough. All hemodynamically stable patients underwent abdominal CT scanning for detection of intraabdominal injuries. Data forms collecting information on the medical history and physical examination of all patients were completed before radiographic imaging. Patients with left lower rib pain or tenderness were considered to have "isolated" left lower rib injury if they were without all of the following: ED or out-of-hospital systolic blood pressure less than 90 mm Hg, abdominal or flank tenderness, pelvic or femur fractures, and gross hematuria. RESULTS: Eight hundred seventy-five patients had left lower rib pain or tenderness, 63 (7.2%; 95% confidence interval [CI] 5.6% to 9.1%) patients had splenic injuries, and 20 (2.3%; 95% CI 1.4% to 3.5%) patients had left renal injuries. Five hundred seventy-four patients had additional indications for abdominal imaging, leaving 301 patients with "isolated" left lower rib injury. Of the 301 patients, 9 (3.0%; 95% CI 1.4% to 5.6%) had splenic injuries. All 9 patients had a pleuritic component to their rib tenderness, and 3 (33%) patients underwent splenectomy. CONCLUSION: A small but important percentage of patients with pain or tenderness to the left lower ribs has splenic injuries. All patients with splenic injury had pleuritic pain.

Abdominal Injuries↗
PubMed2005

Altered mental status and ataxia secondary to acute Kava ingestion.

Kava has traditionally been used for a variety of purposes in the tropical islands of Polynesia but is becoming more frequently available in the United States health supplement market due to its calming effects in patients with anxiety. The side effect profile is poorly known but has recently gained the attention of the Food and Drug Administration (FDA). Although hepatitis and liver failure have been described with chronic ingestion, the effects of acute overdose are poorly described. We present a case of acute Kava overdose resulting in altered mental status and ataxia similar to that seen with ethanol intoxication.

Adult↗
PubMed2005

Distracting injuries in patients with vertebral injuries.

To describe the prevalence and types of distracting injuries associated with vertebral injuries at all levels of the spine in blunt trauma patients. A prospective cohort study was conducted at an urban Level I trauma center. All patients undergoing radiographic evaluation of the cervical, thoracic, or lumbar vertebrae after blunt trauma were enrolled. Patients had a data collection form completed by the treating physician before radiographic imaging and were evaluated for the following upon initial presentation: tenderness to the cervical, thoracic, or lumbar spine, distracting injuries, altered mental status, alcohol or drug intoxication, or neurological deficits. Patients with distracting injuries as the sole documented indication for vertebral radiographs were reviewed for the types of injuries present. A total of 4698 patients were enrolled in the study. There were 336 (7.2%) patients who had distracting injuries as the sole documented indication for obtaining radiographic studies of the vertebrae. Eight (2.4%, 95% CI 1.0-4.6%) of the 336 patients had 14 acute vertebral injuries including compression fractures (5), transverse process fractures (7), spinous process fracture (1), and cervical spine rotatory subluxation (1). There were 13 thoracolumbar injuries and one cervical spine injury. Distracting injuries in the eight patients with acute vertebral injuries included 13 bony fractures. Distracting injuries in those patients without vertebral injuries included bony fractures (333), lacerations (63), soft tissue contusions (62), head injuries (15), bony dislocations (12), abrasions (11), visceral injuries (8), dental injuries (5), burns (3), ligamentous injuries (3), amputation (1), and compartment syndrome (1). In conclusion, in patients with distracting injuries, bony fractures of any type were important for identifying patients with vertebral injuries. Other types of distracting injuries did not contribute to the sensitivity of the clinical screening criteria in the detection of patients with vertebral injuries.

Adolescent↗
PubMed2005

Is definitive abdominal evaluation required in blunt trauma victims undergoing urgent extra-abdominal surgery?

OBJECTIVES: To evaluate the utility of routine abdominal computed tomographic (CT) scanning for abdominal evaluation of blunt trauma patients before urgent extra-abdominal surgery. METHODS: In this observational cohort study, we prospectively enrolled all blunt trauma patients at least 8 years of age presenting to the emergency department of a Level 1 trauma center who were initially considered to require urgent extra-abdominal surgery within 24 hours of presentation. Patients were excluded if they had any of the following: 1) isolated extremity trauma, 2) signs or symptoms of intra-abdominal injury (including systolic blood pressure < 90 mm Hg; abdominal, flank, or costal margin tenderness; abdominal wall contusion or abrasion; pelvic fracture; and gross hematuria), or 3) unreliable findings on abdominal examination (Glasgow Coma Scale score < 14, paralysis, or mental retardation). Clinical data were documented on a data sheet before abdominal CT scanning. RESULTS: A total of 254 patients, with a mean (+/-SD) age of 32.3 (+/-16.1) years, were enrolled. A total of 201 patients ultimately underwent urgent extra-abdominal surgery for the following procedures: orthopedic, 182 (91%); facial, 17 (8%); laceration, 7 (3%); vascular, 6 (2%); neurosurgical, 3 (1%); urology, 2 (1%); and ophthalmology, 1 (0.4%). Three patients (1.2%; 95% confidence interval = 0.2% to 3.4%) were found to have intra-abdominal injuries. Two patients had splenic injuries that required only observation. One patient (0.4%; 95% confidence interval = 0% to 2.2%) underwent laparotomy. This patient sustained multiple injuries in a motorcycle crash, including splenic, kidney, and pancreatic injuries, and underwent a splenectomy. CONCLUSIONS: Abdominal CT scanning has a low yield in trauma patients whose sole indication for diagnostic abdominal evaluation is the need for general anesthesia for urgent extra-abdominal surgery. A small percentage of these patients, however, will have important intra-abdominal injuries such that further refinement of the recommendations for diagnostic study in this select population is needed.

Abdominal Injuries↗
PubMed2005

Performance of the pediatric glasgow coma scale in children with blunt head trauma.

OBJECTIVES: To compare the accuracy of a pediatric Glasgow Coma Scale (GCS) score in preverbal children with blunt head trauma with the standard GCS score in older children. METHODS: The authors prospectively enrolled children younger than 18 years with blunt head trauma. Patients were divided into cohorts of those 2 years and younger and those older than 2 years. The authors assigned a pediatric GCS score to the younger cohort and the standard GCS score to the older cohort. Outcomes were 1) traumatic brain injury (TBI) on computed tomography (CT) scan or 2) TBI in need of acute intervention. The authors created and compared receiver operating characteristic (ROC) curves between the age cohorts for the association of GCS scores and TBI. RESULTS: The authors enrolled 2,043 children, and 327 were 2 years and younger. Among these 327, 15 (7.7%; 95% confidence interval [CI] = 4.4% to 12.4%) of 194 who underwent imaging with CT had TBI visible and nine (2.8%; 95% CI = 1.3% to 5.2%) had TBI needing acute intervention. In children older than 2 years, 83 (7.7%; 95% CI = 6.2% to 9.5%) of the 1,077 who underwent imaging with CT had TBI visible and 96 (5.6%; 95% CI = 4.6% to 6.8%) had TBI needing acute intervention. For the pediatric GCS in children 2 years and younger, the area under the ROC curve was 0.72 (95% CI = 0.56 to 0.87) for TBI on CT scan and 0.97 (95% CI = 0.94 to 1.00) for TBI needing acute intervention. For the standard GCS in older children, the area under the ROC curve was 0.82 (95% CI = 0.76 to 0.87) for TBI on CT scan and 0.87 (95% CI = 0.83 to 0.92) for TBI needing acute intervention. CONCLUSIONS: This pediatric GCS for children 2 years and younger compares favorably with the standard GCS in the evaluation of children with blunt head trauma. The pediatric GCS is particularly accurate in evaluating preverbal children with blunt head trauma with regard to the need for acute intervention.

Adolescent↗
PubMed2005

Association between the "seat belt sign" and intra-abdominal injury in children with blunt torso trauma.

OBJECTIVES: To determine the association between an abdominal "seat belt sign" (SBS) and intra-abdominal injury (IAI) in children presenting to the emergency department (ED) after blunt trauma. METHODS: The authors performed a prospective, observational study of children at risk for IAI who presented to a Level 1 trauma center following a motor vehicle collision (MVC) during a two-year period. Physical examination findings were recorded prior to abdominal imaging or surgery. The SBS was defined as an area of erythema, ecchymoses, and/or abrasions across the patient's abdominal wall resulting from a seat belt restraint. Patients were divided into two cohorts based on the presence or absence of an SBS, then further subdivided based on abdominal tenderness or pain. The authors compared patients with and without SBS, and those with and without abdominal pain or tenderness for the presence of IAI. RESULTS: Three hundred ninety children, of whom 46 (12%, 95% CI = 9% to 15%) had an SBS, were enrolled. IAIs were more common in patients with, versus without, an SBS (14/46 vs. 36/344, relative risk 2.9; 95% CI = 1.7 to 5.0; p < 0.001). Patients with an SBS were more likely to have gastrointestinal injuries than those without an SBS (12/46 vs. 7/344, relative risk 12.8; 95% CI = 5.3 to 31; p = 0.001). Pancreatic injuries were also more common among patients with an SBS (3/46 vs. 1/344, relative risk 22; 95% CI = 2.4 to 211; p = 0.006). There was no difference in the prevalence of solid organ injuries between those with and without an SBS (4/46 vs. 34/344, relative risk 0.9, 95% CI = 0.3 to 2.4; p = 1.00). None of the six patients (0%, 95% CI = 0 to 39%) with an SBS, but without abdominal pain or tenderness, had IAIs. CONCLUSIONS: Patients with an SBS after an MVC are more likely to have IAIs than patients without an SBS, predominately due to a higher rate of gastrointestinal injuries. Patients with an SBS but without abdominal pain or tenderness appear to be at low risk for IAI.

Abdominal Injuries↗
PubMed2004

Performance of abdominal ultrasonography in blunt trauma patients with out-of-hospital or emergency department hypotension.

STUDY OBJECTIVES: We determine the test performance of abdominal ultrasonography for detecting hemoperitoneum in blunt trauma patients with out-of-hospital or emergency department (ED) hypotension. METHODS: We reviewed the medical records of all blunt trauma patients hospitalized at a Level I trauma center. Patients were included if they were older than 6 years and had out-of-hospital or ED hypotension (systolic blood pressure < or =90 mm Hg) and underwent ED ultrasonography. The initial interpretation of the abdominal ultrasonography was recorded, including the presence or absence of intraperitoneal fluid and the specific location of such fluid. Presence or absence of intra-abdominal injury was determined by abdominal computed tomography scan, laparotomy, or clinical follow-up. RESULTS: Four hundred forty-seven patients with a mean age of 36.0+/-17.5 years were enrolled. One hundred forty-eight (33%) patients had intra-abdominal injuries, and 116 (78%) of these patients had hemoperitoneum. Abdominal ultrasonography had the following test performance for detecting patients with intra-abdominal injury and hemoperitoneum: sensitivity 92/116 (79%; 95% confidence interval [CI] 71% to 86%), specificity 316/331 (95%; 95% CI 93% to 97%), positive predictive value 92/107 (86%; 95% CI 78% to 92%), and negative predictive value 316/340 (93%; 95% CI 90% to 95%). The positive likelihood ratio was 15.8, and the negative likelihood ratio was 0.22. One hundred five (91%) of the 116 patients with intra-abdominal injuries and hemoperitoneum underwent a therapeutic laparotomy. Abdominal ultrasonography demonstrated intraperitoneal fluid in 87 (sensitivity 83%; 95% CI 74% to 90%) of these 105 patients. CONCLUSION: Of patients with out-of-hospital or ED hypotension, abdominal ultrasonography identifies most patients with hemoperitoneum and intra-abdominal injuries. Hypotensive patients with negative abdominal ultrasonography results, however, must be further evaluated for sources of their hypotension, including additional abdominal evaluation, once they are hemodynamically stabilized.

Abdominal Injuries↗
PubMed2004

Defining "therapeutically inconsequential" head computed tomographic findings in patients with blunt head trauma.

STUDY OBJECTIVE: Many injuries detected by computed tomographic (CT) imaging of blunt head trauma patients are considered "therapeutically inconsequential." We estimate the prevalence of these findings and determine how frequently affected patients had "important neurosurgical outcomes," defined as either a directed intervention or a poor Glasgow Outcome Scale score. METHODS: We prospectively enrolled all blunt head trauma patients undergoing emergency head CT imaging at 18 centers participating in the National Emergency X-radiography Utilization Study II (NEXUS). From these cases, we identified all patients whose official CT reading met predefined criteria for "therapeutically inconsequential" injuries. We obtained detailed follow-up information on all such patients at 6 sites, including the need for neurosurgical intervention and Glasgow Outcome Scale scores. Among patients having "important neurosurgical outcomes," we assessed the frequency of 2 potential clinical identifiers: altered mental status and coagulopathy. RESULTS: "Therapeutically inconsequential" head CT findings were present in 155 of 8,374 subjects (1.85%; 95% confidence interval 1.57% to 2.16%). Sites participating in the follow-up study enrolled 81 of these patients, of whom 10 (12%) had "important neurosurgical outcomes." Follow-up information was available for 9 patients, all of whom had abnormal mental status at CT scanning. Coagulopathy was also present in 5 of 7 patients for whom coagulation status was known. CONCLUSION: "Therapeutically inconsequential" findings are identified in less than 2% of blunt head trauma patients who undergo CT scanning. A small proportion of these patients have an "important neurosurgical outcome," but it appears that such patients may be identified clinically by the presence of abnormal mental status or coagulopathy.

Adolescent↗
PubMed2004

Performance of helical computed tomography without oral contrast for the detection of gastrointestinal injuries.

STUDY OBJECTIVE: We describe the performance of helical abdominal computed tomography (CT) scan without oral contrast for the detection of blunt gastrointestinal injuries. METHODS: We retrospectively reviewed the records of a consecutive series of patients who underwent helical abdominal CT scanning for evaluation of blunt intra-abdominal injury and were admitted to a Level I trauma center from May 1996 to September 2001. Abdominal CT scans were performed with intravenous contrast but without oral contrast. Patients were considered to have gastrointestinal injuries if an injury was identified to the gastrointestinal tract from the duodenum to the sigmoid colon or associated mesentery and considered to have major gastrointestinal injuries if gastrointestinal perforation, active mesenteric hemorrhage, or mesenteric devascularization occurred. All gastrointestinal injuries were confirmed by laparotomy, autopsy, or additional imaging studies. RESULTS: Six thousand fifty-two patients underwent abdominal CT scan (mean age 35.5 +/- 21.1 years), and 106 (1.8%) patients had gastrointestinal injuries identified by laparotomy, autopsy, or additional (nonabdominal CT) imaging studies. Abdominal CT scan result was abnormal in 91 (86%; 95% confidence interval [CI] 78% to 92%) of the 106 patients with gastrointestinal injuries and revealed findings suggestive of gastrointestinal injury in 81 (76%; 95% CI 67% to 84%) patients. Abdominal CT scan demonstrated findings suggestive of gastrointestinal injury in 58 of 64 (91%; 95% CI 81% to 96%) patients with major gastrointestinal injuries. Two hundred thirty-eight (4.0%) patients had findings suspicious for gastrointestinal injuries on abdominal CT scan, but gastrointestinal injury was never confirmed. CONCLUSION: Helical abdominal CT scan without oral contrast identified nearly three fourths of patients with blunt gastrointestinal injuries who were selected for abdominal CT scanning. Sensitivity of this diagnostic test improves in the subset of patients with major gastrointestinal injuries.

Adolescent↗