Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma

In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist’s expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.

A practical biphasic contrast media injection protocol strongly enhances the aorta and pulmonary artery simultaneously using a single CT angiography scan

Background Enhancement profiles of the pulmonary artery (PA) and aorta differ when using computed tomography (CT) angiography. Our aim was to determine the optimal CT protocol for a one-time CT scan that assesses both blood vessels. Methods We prospectively enrolled 101 cases of CT angiography in patients with suspected pulmonary embolism or aortic dissection from our center between 2018 and 2020. We also retrospectively collected the data of 40 patients who underwent traditional two-time CT scans between 2015 and 2018. Patients were divided into four groups: test bolus (TB) I, TB II, bolus-tracking (BT) I, and BT II. The enhancement of the PA and aorta, and the radiation doses used in the four groups were collected. Those who underwent two-time scans were classified into the traditional PA or aorta scan groups. Data were compared between the BT and traditional groups. Results The aortic enhancement was highest in BT II (294.78 ± 64.48 HU) followed BT I (285.18 ± 64.99 HU), TB II (186.58 ± 57.53 HU), and TB I (173.62 ± 69.70 HU). The radiation dose used was lowest in BT I (11.85 ± 5.55 mSv) and BT II (9.07 ± 3.44 mSv) compared with that used in the traditional groups (20.07 ± 7.78 mSv) and accounted for half of the traditional group (45.17–59.02%). The aortic enhancement was also highest in BT II (294.78 ± 64.48 HU) followed by BT I (285.18 ± 64.99 HU) when compared with that in the traditional aorta scan group (234.95 ± 94.18 HU). Conclusion Our CT protocol with a BT technique allows for a lower radiation dose and better image quality of the PA and aorta than those obtained using traditional CT scans. Trial registration: NCT04832633, retrospectively registered in April 2021 to the clinical trial registry.

Effectiveness of SPECT/CT Imaging for Sentinel Node Biopsy Staging of Primary Cutaneous Melanoma and Patient Outcomes

Purpose Coregistered SPECT/CT can improve accuracy of sentinel node biopsy (SNB) for staging melanoma. This benefit has implications for pathology services and surgical practice with increased diagnostic and surgical workload. The purpose of this study was to investigate the effectiveness of SPECT/CT imaging. Methods SNB data were collected over a 10-year period. Preoperative SLN mapping was performed by using planar lymphoscintigraphy (LSG) for all patients (n = 1522) and after October 2015, patients underwent a second co-registered SPECT/CT scan (n = 559). The patients were stratified according to the imaging protocol. The number of nodes and nodal basins were assessed. The reasons for cancellation also were assessed. Results A total of 95% (1446/1522) of patients underwent a successful SNB procedure. Significantly more sentinel nodes were identified by the SPECT/CT protocol (3 vs. 2; p < 0.0001). More patients were cancelled in the SPECT/CT cohort (9.3% vs. 2.5%; p < 0.0001). Head & neck, lower limb, and AJCC IB primaries were significantly less likely to proceed to SNB. SPECT/CT identified significantly more positive SNBs (20.9% vs. 16.5%; p = 0.038). SPECT/CT imaging was associated with improved disease-free (hazard ratio [HR] = 0.74; 95% confidence interval [CI]: 0.54–1.0); p = 0.048) and disease-specific survival (HR = 0.48; 95% CI: 0.3–0.78; p = 0.003). Patients who did not proceed to SNB had a significantly increased nodal relapse rate (23.5% vs. 6.8%; HR = 3.4; 95% CI: 1.9–6.2; p < 0.0001) compared with those who underwent SNB. Conclusions This large cohort study confirms the increased accuracy of SPECT/CT for identifying SLN metastases, which would appear to have a significant therapeutic benefit, although an increased risk of cancellation of the SNB procedure on the day of surgery.

SP9.1.5 Compliance with the NELA pathway at a District General Hospital. Reducing time to theatre by limiting CT-associated delay - A prospective closed loop audit

Aim NELA recommends rapid request, conduct and reporting of CT to reduce the delay in time to theatre and thus ultimately improving patient outcomes. Our aim was to identify and reduce delays with regards to CT scanning and reporting. Methods Our Local Laparotomy Pathway standard recommends that CT scans be performed within one hour of being requested and reported within one hour of being performed. NELA data and electronic records were reviewed over a 3 month period (January 2020 to March 2020) - revealing that only 59% of pre-laparotomy CTs done (n = 17) complied with this standard. A dedicated “CT Emergency Laparotomy” protocol was introduced, which assigned the scan as top priority for both radiographers and radiologists. After making this change, data was prospectively collected to see if there was reduced time from CT request to report. Results Compliance with the pathway standard for the three month period from October 2020 to January 2021 increased to 81% (n = 21). Reasons for non-compliance included patient instability, awaiting renal profile; and COVID-related deep cleaning between patients. Out of hours, CT reporting was outsourced, which led to even quicker reporting – with multiple scans being both performed and reported within one hour of the request. Of the 16 patients that fit the criteria for urgent laparotomy, 87.5% (14 patients) were operated on within 6 hours of initial intention to operate. Conclusion Our re-audit showed that after the introduction of a dedicated laparotomy CT protocol, there was reduced time to CT report and ultimately reduced delay to Laparotomy.

Dynamic PEEP Study: A Non-Invasive Diagnostic Exam to Assess for Effective PEEP in Fragile Children With Severe BPD

ObjectiveTracheobronchomalacia (TBM) is common in neonates with bronchopulmonary dysplasia (BPD) and is associated with higher morbidity. This study evaluates the value of a CT protocol to assess the degree of TBM and gauge the adequacy of prescribed PEEP. Study DesignFour infants with severe BPD on invasive mechanical ventilation underwent a chest CT protocol, including limited reduced- dose expiratory scans with varying PEEP levels. ResultsBaseline PEEP was adjusted in all subjects after performing the Dynamic PEEP CT. In two infants, the PEEP was increased due to significant TBM, and in the other, two without signs of TBM PEEP was decreased. The clinical course improved in all patients after adjusting PEEP. ConclusionA "Dynamic PEEP" study is a highly reliable and non-invasive imaging modality for the evaluation of adequate ventilator settings in infants with severe BPD who are not optimal candidates for bronchoscopy.