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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. American College of Radiology. ACR Appropriateness Criteria®: Head Trauma. Available at: https://acsearch.acr.org/docs/69481/Narrative/. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for a specific clinical condition. No abstract available. 4
2. Beckmann NM, West OC, Nunez D, Jr., et al. ACR Appropriateness Criteria® Suspected Spine Trauma. J Am Coll Radiol 2019;16:S264-S85. Review/Other-Dx N/A Evidence-based guidelines to assist referring physicians and other providers in making the most appropriate imaging or treatment decision for suspected spine trauma. No results stated in abstract. 4
3. National Vital Statistics System, National Center for Health Statistics, CDC. 10 Leading Causes of Death by Age Group, United States.  Available at: https://www.cdc.gov/injury/wisqars/pdf/leading_causes_of_death_by_age_group_2015-a.pdf. Review/Other-Dx N/A To present 10 leading causes of death by age group in United States. No abstract available 4
4. Holmes JF, Wisner DH. Indications and performance of pelvic radiography in patients with blunt trauma. Am J Emerg Med. 30(7):1129-33, 2012 Sep. Observational-Dx 4737 patients To validate a set of clinical variables to identify patients with pelvic fractures and to determine the sensitivity of anteroposterior (AP) pelvic radiographs in patientswith pelvic fractures. We enrolled 4737 patients, including 289 (6.1%; 95% confidence interval [CI], 5.4%-6.8%) with pelvic fractures. Of the 289 patients, 256 (88.6%; 95% CI, 84.3%-92.0%) had at least one of the high-risk variables identified. Initial plain AP radiographs identified 234 (81.0%; 95% CI, 76.0%-85.3%) of 289 patients with pelvic fractures. The high-risk variables identified all 87 patients (100%; 95% CI, 96.6%-100%) undergoing surgery, whereas plain AP pelvic radiography identified a fracture in 83 patients (95.4%; 95% CI, 88.6%-98.7%) undergoing surgery. 2
5. Laselle BT, Byyny RL, Haukoos JS, et al. False-negative FAST examination: associations with injury characteristics and patient outcomes. Ann Emerg Med. 60(3):326-34.e3, 2012 Sep. Observational-Dx 332 patients To estimate associations between false-negative Focused assessment with sonography in trauma (FAST) results and patient characteristics, specific abdominalorgan injuries, and patient outcomes. During the study period, 332 patients met inclusion criteria. Median age was 32 years (interquartile range 23 to 45 years), 67% were male patients, the median Injury Severity Score was 27 (interquartile range 17 to 41), and 162 (49%) had a false-negative FAST result. Head injury was positively associated with false negative FAST result (odds ratio [OR] 4.9; 95% confidence interval [CI] 1.5 to 15.7), whereas severe abdominal injury was negatively associated (OR 0.3; 95% CI 0.1 to 0.5). Injuries to the spleen (OR 0.4; 95% CI 0.24 to 0.66), liver (OR 0.36; 95% CI 0.21 to 0.61), and abdominal vasculature (OR 0.17; 95% CI 0.07 to 0.38) were also negatively associated with false-negative FAST result. False-negative FAST result was not associated with mortality (OR 0.89; 95% CI 0.42 to 1.9), prolonged ICU length of stay (relative risk 0.88; 95% CI 0.69 to 1.12), or total hospital length of stay (relative risk 0.92; 95% CI 0.76 to 1.12). However, patients with false-negative FAST results were substantially less likely to require therapeutic laparotomy (OR 0.31; 95% CI 0.19 to 0.52). 2
6. Hajibandeh S, Hajibandeh S, Systematic review: effect of whole-body computed tomography on mortality in trauma patients. [Review]. Journal of Injury & Violence Research. 7(2):64-74, 2015 Jul. Review/Other-Dx 9 Studies To review studies investigating the effect of WBCT on mortality in trauma patients. Searching the keywords in Medline and PubMed resulted in 178 and 167 articles, respectively. Nine studies met the inclusion criteria and were reviewed. These included 8 retrospective and 1 prospective cohort studies. Mortality was measured as mortality rate or standardised mortality ratio (SMR) in the included studies. 4
7. Huber-Wagner S, Biberthaler P, Haberle S, et al. Whole-body CT in haemodynamically unstable severely injured patients--a retrospective, multicentre study. PLoS ONE. 8(7):e68880, 2013. Observational-Dx 4621 patients To assess whether whole-body CT during trauma-room treatment has an effect on the mortality of severely injured patients. 1494 (32%) of 4621 patients were given whole-body CT. Mean age was 42.6 years (SD 20.7), 3364 (73%) were men, and mean injury-severity score was 29.7 (13.0). SMR based on TRISS was 0.745 (95% CI 0.633-0.859) for patients given whole-body CT versus 1.023 (0.909-1.137) for those given non-whole-body CT (p<0.001). SMR based on the RISC score was 0.865 (0.774-0.956) for patients given whole-body CT versus 1.034 (0.959-1.109) for those given non-whole-body CT (p=0.017). The relative reduction in mortality based on TRISS was 25% (14-37) versus 13% (4-23) based on RISC score. Multivariate adjustment for hospital level, year of trauma, and potential centre effects confirmed that whole-body CT is an independent predictor for survival (p </= 0.002). The number needed to scan was 17 based on TRISS and 32 based on RISC calculation. 4
8. Raja AS, Mower WR, Nishijima DK, et al. Prevalence and Diagnostic Performance of Isolated and Combined NEXUS Chest CT Decision Criteria. Academic Emergency Medicine. 23(8):863-9, 2016 08. Observational-Dx 11,477 patients To determine screening performance of both individual and combined NEXUS Chest CT criteria as predictors of thoracic injury to inform chest CT imaging decisions in "non-low-risk" patients. Across the 11 study sites, rates of chest CT performance ranged from 15.5% to 77.2% (median = 43.6%). We found injuries in 1,493/5,169 patients (28.9%) who had chest CT; 269 patients (5.2%) had major clinical injury (e.g., pneumothorax requiring chest tube). With sensitivity of 73.7 (95% confidence interval [CI] = 68.1 to 78.6) and specificity of 83.9 (95% CI = 83.6 to 84.2) for major clinical injury, abnormal chest-x-ray (CXR) was the single most important screening criterion. When patients had only abnormal CXR, injury and major clinical injury prevalences were 60.7% (95% CI = 52.2% to 68.6%) and 12.9% (95% CI = 8.3% to 19.4%), respectively. Injury and major clinical injury prevalences when any other single criterion alone (other than abnormal CXR) was present were 16.8% (95% CI = 15.2% to 18.6%) and 1.1% (95% CI = 0.1% to 1.8%), respectively. Injury and major clinical injury prevalences among patients when two and three criteria (not abnormal CXR) were present were 25.5% (95% CI = 23.1% to 28.0%) and 3.2% (95% CI = 2.3% to 4.4%) and 34.9% (95% CI = 31.0% to 39.0%) and 2.7% (95% CI = 1.6% to 4.5%), respectively. 2
9. Akoglu H, Celik OF, Celik A, Ergelen R, Onur O, Denizbasi A. Diagnostic accuracy of the Extended Focused Abdominal Sonography for Trauma (E-FAST) performed by emergency physicians compared to CT. American Journal of Emergency Medicine. 36(6):1014-1017, 2018 Jun.Am J Emerg Med. 36(6):1014-1017, 2018 Jun. Observational-Dx 140 patients To compare the diagnostic accuracy of the E-FAST exam performed by EM residents with the results of CT scan as a gold standard. A total of 140 patients were recruited from eligible 144 patients. The final study population was 132 for abdominal and 130 for thorax examinations. In this study, AUC of E-FAST was 0.71 for abdominal free fluid, 0.87 for pneumothorax and 1.00 for pleural effusion. The sensitivity was 42.9% and specificity was 98.4%. The +LR for abdominal free fluid was 26.8 and -LR was 0.58. 2
10. Becker A, Lin G, McKenney MG, Marttos A, Schulman CI. Is the FAST exam reliable in severely injured patients?. Injury. 41(5):479-83, 2010 May. Observational-Dx 3181 patients To determine whether the FAST exam is reliable in severely injured patients. 3181 patients with blunt abdominal trauma included into the study were divided into the three groups according to the ISS. The mean ISS was 7.9+/-3.97, 19.6+/-2.48 and 41.3+/-11.95 in Groups 1, 2 and 3, respectively. The accuracy of ultrasound was 90.6% in the group of patients with the highest ISS (>or=25) compared with 97.5 and 97.1 for Groups 1 and 2 (p<0.001). Similarly, ultrasound had a significantly lower sensitivity, specificity, PPV and NPV for patients in Group 3 compared with the first two groups (p<0.001). There was a significantly lower sensitivity in Group 2 compared with Group 1 (p<0.001), but no differences in specificity, accuracy, PPV or NPV were demonstrated. 3
11. Abdulrahman Y, Musthafa S, Hakim SY, et al. Utility of extended FAST in blunt chest trauma: is it the time to be used in the ATLS algorithm?. World Journal of Surgery. 39(1):172-8, 2015 Jan. Observational-Dx 305 patients To investigate the utility of EFAST in blunt chest trauma (BCT) patients. A total of 305 BCT patients were included with median age of 34 (18-75). Chest CT was positive for pneumothorax in 75 (24.6 %) cases; of which 11 % had bilateral pneumothorax. Chest CT confirmed the diagnosis of pneumothorax in 43, 41, and 11 % of those who were initially diagnosed by EFAST, CE, and CXR, respectively. EFAST was positive in 42 hemithoraces and its sensitivity (43 %) was higher in comparison to CXR (11 %). Positive and negative PVs of EFAST were 76 and 92 %, respectively. The frequency of missed cases by CXR was higher in comparison to EFAST and CE. The lowest median score of missed pneumothorax was observed by EFAST. 2
12. Ballard RB, Rozycki GS, Newman PG, et al. An algorithm to reduce the incidence of false-negative FAST examinations in patients at high risk for occult injury. Focused Assessment for the Sonographic Examination of the Trauma patient. Journal of the American College of Surgeons. 189(2):145-50; discussion 150-1, 1999 Aug. Observational-Dx 102 patients To determine whether patients who are considered high-risk for occult injuries should undergo a CT scan of the abdomen when FAST is negative. One hundred two of 1,490 patients (6.8%) who had FAST examinations were entered into this study. Thirty-two patients (30.5%) had spine injuries, with only one false-negative ultrasound result. Seventy patients (68.6%) had pelvic fractures with 13 false-negative ultrasound results: 11 ring (9 from motor vehicle crashes, 2 from pedestrians struck), 1 acetabular, and 1 isolated pelvic fracture. Nine patients underwent nonoperative management for solid organ injuries, and 4 patients needed surgery. 4
13. Myint KS, French S, Williams-Johnson J, et al. Role of routine chest radiographs in the evaluation of patients with stable blunt chest trauma--a prospective analysis. West Indian Med J. 61(1):64-72, 2012 Jan. Observational-Dx 77 patients To assess the test performance characteristics of clinical judgement in the evaluation of stable blunt chest trauma patients compared with chest radiography (CXR) in the determination of significant intra-thoracic injury. During the six-month period, data were collected from 77 eligible stable blunt chest trauma patients (age over 16 years). Fifty-nine patients (76.6%) were male. Nine patients (11.7%) were radiologically confirmed to have significant blunt chest injuries including rib fractures, pneumothorax and an isolated case of pulmonary contusion. All nine (11.7%) patients had a positive (abnormal) radiograph for rib fractures. In addition, three (3.9%) of them also had both rib fracture and pneumothoraces and one (1.3%) had both a rib fracture and pulmonary contusion. Clinical judgement for the diagnosis of significant blunt chest injuries matched with the CXR finding with 95%confidence intervals (CIs): sensitivity 100% (95% CI 66.4, 100), specificity 32.4% (95% CI 21.5, 44.8), prevalence 11.7%, PPV 16.4% (95% CI 7.77, 28.8), NPV 100% (95% CI 84.6, 100), DLR+ 1.48 (95% CI 1.25, 1.74). 2
14. Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet. 373(9673):1455-61, 2009 Apr 25. Observational-Dx 4621 patients To compare the probability of survival in patients with blunt trauma who had whole-body CT during resuscitation with those who had not. 1494 (32%) of 4621 patients were given whole-body CT. Mean age was 42·6 years (SD 20·7), 3364 (73%) were men, and mean injury-severity score was 29·7 (13·0). SMR based on TRISS was 0·745 (95% CI 0·633–0·859) for patients given whole-body CT versus 1·023 (0·909–1·137) for those given non-whole-body CT (p<0·001). SMR based on the RISC score was 0·865 (0·774–0·956) for patients given whole-body CT versus 1·034 (0·959–1·109) for those given non-whole-body CT (p=0·017). The relative reduction in mortality based on TRISS was 25% (14–37) versus 13% (4–23) based on RISC score. Multivariate adjustment for hospital level, year of trauma, and potential centre effects confirmed that whole-body CT is an independent predictor for survival (p=0·002). The number needed to scanwas 17 based on TRISS and 32 based on RISC calculation. 3
15. Sierink JC, Saltzherr TP, Wirtz MR, Streekstra GJ, Beenen LF, Goslings JC. Radiation exposure before and after the introductionof a dedicated total-body CT protocolin multitrauma patients. EMERG. RADIOL.. 20(6):507-12, 2013 Dec. Observational-Dx 301 patients To assess the number of radiological investigations and their associated radiation exposure in multitrauma patients before and after the introduction of a total-body CT protocol as a primary diagnostic tool. In 2008, 20 % of severely injured patients underwent total-body CT scan, compared with 46 % of the patients in 2010. Trauma room radiation doses for conventional radiographs were significantly higher in 2008, while doses for CTscans were significantly lower. The total effective dose of trauma room radiological investigations was 16 milliSieverts (mSv) in 2008 vs. 24 mSv in 2010 (P=0.223). The overall effective dose during the total hospital admission was not significantly different between 2008 and 2010 (20 vs. 24 mSv, P=0.509). 3
16. Caputo ND, Stahmer C, Lim G, Shah K. Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: a systematic review and meta-analysis. [Review]. The Journal of Trauma and Acute Care Surgery. 77(4):534-9, 2014 Oct. Meta-analysis 465 publications To determine whether whole-body CT (WBCT), a protocol including a noncontrast scan of the brain and neck and a contrast-enhanced scan of thechest, abdomen, and pelvis, detects more clinically significant injuries as opposed to selective scanning as determined by mortality rates. Of the 465 publications identified, 7 were included, composing of 25,782 trauma patients who received CT scan following trauma. Of the patients, 52% (n = 13,477) received pan scan and 48% (n = 12,305) received selective scanning. Overall ISS was significantly higher for patients receiving WBCT versus those receiving selective scan (29.7 vs. 26.4, p < 0.001, respectively). Overall mortality rate was significantly lower for WBCT versus selective scanning (16.9; 95% confidence interval [CI], 16.3-17.6 vs. 20.3; 95% CI, 19.6-21.1, p < 0.0002, respectively). Pooled odds ratio for mortality rate was 0.75 (95% CI, 0.7-0.79), favoring WBCT. Good
17. Chidambaram S, Goh EL, Khan MA. A meta-analysis of the efficacy of whole-body computed tomography imaging in the management of trauma and injury. Injury. 48(8):1784-1793, 2017 Aug.Injury. 48(8):1784-1793, 2017 Aug. Meta-analysis 11 studies, 32207 patients To present a meta-analysis of the available literature to elucidate the efficacy of whole-body computed tomography (WBCT) in improving the outcomes of trauma, specifically the mortality rate. Eleven studies of 32,207 patients were included. There were lower overall (OR = 0.79; 95% CI 0.74,0.83, p<0.05) and 24 h mortality rates (OR = 0.72, 95% CI 0.66,0.79, p<0.05) in the WBCT cohort. Additionally, patients in the WBCT arm spent less time in the emergency room (MD=-14.81; 95% CI -17.02, -12.60, p<0.00001) and needing ventilation (MD=-2.01; 95% CI -2.41, -1.62, p<0.05) despite a higher baseline injury severity score Good
18. Sierink JC, Saltzherr TP, Beenen LF, et al. A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2). BMC emerg. med.. 12:4, 2012 Mar 30. Review/Other-Dx N/A To determine the value of immediate total-body CT scanning in trauma patients. No results stated in abstract. 4
19. Kelly J, Raptopoulos V, Davidoff A, Waite R, Norton P. The value of non-contrast-enhanced CT in blunt abdominal trauma. AJR Am J Roentgenol. 152(1):41-8, 1989 Jan. Observational-Dx 190 patients To assess prospectively whether the incorporation of a limited nonenhanced CT scanning sequence in patients with blunt abdominal trauma would provide information beyond that obtained with conventional scanning with IV contrast material. In 78, visceral injuries were confirmed at surgery or at follow-up CT. Of the patients with injuries, 14 (18%) had hyperdense hematomas on the noncontrast studies that became isodense after IV administration of contrast material. These hematomas generally were small and posed an immediate threat to life in only one patient (0.5% of all subjects). In 13% of patients with injury (5% of the total), the additional information did influence treatment planning (surgery in two and intensive conservative treatment in eight). Compared with conventional contrast scanning, the combined noncontrast-contrast technique increased the scanning time only by about 51/2 mm, but it improved the sensitivity and accuracy of CT in detecting visceral injuries from 74% and 84% to 92% and 91%, respectively (p <= .003 andp <= .04). 3
20. Mokrane FZ, Revel-Mouroz P, Saint Lebes B, Rousseau H. Traumatic injuries of the thoracic aorta: The role of imaging in diagnosis and treatment. [Review]. Diagnostic and Interventional Imaging. 96(7-8):693-706, 2015 Jul-Aug. Review/Other-Dx N/A To review how to detect traumatic injuries of thoracic aorta and to describe the imaging signs of serious damage. No results stated in abstract. 4
21. Caranci F, Cicala D, Cappabianca S, Briganti F, Brunese L, Fonio P. Orbital fractures: role of imaging. [Review]. Semin Ultrasound CT MR. 33(5):385-91, 2012 Oct. Review/Other-Dx N/A To determine the role of imaging. Computed tomography is considered the imaging modality of choice in this circumstance, as it is deemed to be the most accurate method in detecting fractures. The protocol is based on obtaining thin-section axial scans and multiplanar reformatted images, both are useful tools to guide treatment. Orbital fractures are not considered an ophthalmologic emergency unless there is visual impairment or globe injury. Surgical repair is indicated for patients who have persistent diplopia or cosmetic concerns (enophthalmos) and generaly is not performed until swelling subsides 7-10 days after injury 4
22. Hopper RA, Salemy S, Sze RW. Diagnosis of midface fractures with CT: what the surgeon needs to know. [Review] [9 refs]. Radiographics. 26(3):783-93, 2006 May-Jun. Review/Other-Dx N/A To describe the major fracture patterns of the midface buttresses and their surgical relevance. The goal is to aid radiologists in the description of complex midface fractures using terms directly relevant to the surgical triage and treatment of the injury. No results stated in abstract 4
23. Reuben AD, Watt-Smith SR, Dobson D, Golding SJ. A comparative study of evaluation of radiographs, CT and 3D reformatted CT in facial trauma: what is the role of 3D? Br J Radiol. 2005;78(927):198-201. Observational-Dx 23 patients (7 radiographs, 9 CT studies and 7 cases of 3D reconstruction), 17 trainee maxillofacial surgeons To examine the objective performance of trainee maxillofacial surgeons in their diagnostic evaluation of facial fractures on different imaging techniques, including 3D reformatted CT, and to determine the degree of correlation with their subjective views of the clinical value of each. Overall, surgeons showed more accurate diagnostic reading of radiographs and 3D reformatted images. This was in contrast to their subjective assessment of the clinical value of each modality, which showed a strong preference for 3D over all other techniques and for CT over radiographs. However the perceived benefit of axial CT images over radiographs was not reproduced on objective testing in this group; surgeons appear to perform less well in interpreting CT images than their subjective response to the modality would suggest. 3
24. Patterson BO, Holt PJ, Cleanthis M, et al. Imaging vascular trauma. [Review]. Br J Surg. 99(4):494-505, 2012 Apr. Review/Other-Dx 10 patients; 58 articles To define optimal first-line imaging in patients with suspected vascular injury in different anatomical regions. Of 1,511 titles identified, 58 articles were incorporated in the systematic review. Most described the use of CTA. The application of duplex US, MRI/angiography and transesophageal echocardiography was described, but significant drawbacks were highlighted for each. CTA displayed acceptable sensitivity and specificity for diagnosing vascular trauma in blunt and penetrating vascular injury within the neck and extremity, as well as for blunt aortic injury. 4
25. Lee CH, Haaland B, Earnest A, Tan CH. Use of positive oral contrast agents in abdominopelvic computed tomography for blunt abdominal injury: meta-analysis and systematic review. [Review]. Eur Radiol. 23(9):2513-21, 2013 Sep. Meta-analysis 36 studies To determine whether positive oral contrast agents improve accuracy of abdominopelvic CT compared with no, neutral or negative oral contrast agent. Thirty-two studies were divided into two groups. Group 1 comprised 15 studies comparing CT with positive and without oral contrast agents. Meta-analysis of five studies from group 1 provided no difference in sensitivity or specificity between CT with positive or without oral contrast agents. Group 2 comprised 17 studies comparing CT with positive and neutral or negative oral contrast agents. Systematic review of 12 studies from group 2 indicated that neutral or negativeoral contrasts were as effective as positive oral contrast agents for bowel visualisation. Inadequate
26. Uyeda JW, LeBedis CA, Penn DR, Soto JA, Anderson SW. Active hemorrhage and vascular injuries in splenic trauma: utility of the arterial phase in multidetector CT. Radiology. 270(1):99-106, 2014 Jan. Observational-Dx 147 patients To determine whether the addition of arterial phase computed tomography (CT) to the standard combination of portal venous and delayed phase imaging increases sensitivity in the diagnosis of active hemorrhage and/or contained vascular injuries in patients with splenic trauma. One hundred forty-seven patients met the inclusion criteria; 32 patients (22%) had active hemorrhage and 22 (15%) had several contained vascular injuries. In 13 ofthe 22 patients with contained injuries, the vascular lesion was visualized only at the arterial phase of image acquisition; the other nine contained vascular injuries were seen at all phases. Surgery or embolization was performed in 11 of the 22 patients with contained vascular injury. 2
27. Uyeda J, Anderson SW, Kertesz J, Rhea JT, Soto JA. Pelvic CT angiography in blunt trauma: imaging findings and protocol considerations. [corrected]. [Review] [23 refs][Erratum appears in Abdom Imaging. 2010 Jun;35(3):287]. Abdom Imaging. 35(3):280-6, 2010 Jun. Review/Other-Dx N/A To discuss the use of pelvic CTA in blunt pelvic trauma and its utility in detecting and characterizing vascular injury, including the differentiation of arterial from venous hemorrhage No results stated in abstract 4
28. Reeder SB. International Society for Magnetic Resonance in Medicine. The Role of MRI/MRA in Abdominal Trauma.  Available at: https://cds.ismrm.org/protected/09MProceedings/files/Tues%20C42_01%20Reeder.pdf. Review/Other-Dx N/A To review the role of MRI/MRA in abdominal trauma. No abstract available. 4
29. Rhea JT, Garza DH, Novelline RA. Controversies in emergency radiology. CT versus ultrasound in the evaluation of blunt abdominal trauma. [Review] [55 refs]. EMERG. RADIOL.. 10(6):289-95, 2004 Jul. Review/Other-Dx N/A To review the controversy in emergency radiology regarding ultrasonography (US) versus CT in blunt abdominal trauma No results stated in abstract 4
30. Gross JA, Lehnert BE, Linnau KF, Voelzke BB, Sandstrom CK. Imaging of Urinary System Trauma. [Review]. Radiologic Clinics of North America. 53(4):773-88, ix, 2015 Jul. Review/Other-Dx N/A To review the imaging of blunt urinary system trauma with specific references to penetrating trauma No results stated in abstract 4
31. Brewer ME, Wilmoth RJ, Enderson BL, Daley BJ. Prospective comparison of microscopic and gross hematuria as predictors of bladder injury in blunt trauma. Urology. 69(6):1086-9, 2007 Jun. Observational-Dx 8026 patients To prospectively demonstrate that bladder imaging is required for gross hematuria and unnecessary for microscopic hematuria. 1ST arm–214 patients had cystography for microscopic hematuria, and no bladder injuries were identified; 78 patients underwent cystography for gross hematuria, and 21 bladder injuries were identified. 2ND arm–308 patients presented with microscopic hematuria, none of whom underwent cystography, and 91 patients underwent cystography for gross hematuria, with 15 bladder injuries identified. Presence of gross hematuria demonstrated 100% sensitivity and 98.5% specificity as a screening test for bladder injury. No bladder injuries were missed. Study results reveal that the presence of gross hematuria warrants evaluation of the bladder. The presence of gross hematuria demonstrated improved sensitivity, specificity, PPV, NPV, and accuracy over the presence of microscopic hematuria in the detection of bladder injury. Using gross hematuria as an indication for bladder imaging will eliminate unnecessary imaging without compromising the quality of patient care. 3
32. Deck AJ, Shaves S, Talner L, Porter JR. Computerized tomography cystography for the diagnosis of traumatic bladder rupture. Journal of Urology. 164(1):43-6, 2000 Jul. Observational-Dx 316 patients Retrospective review to determine accuracy of CT cystography for diagnosis of bladder rupture. Surgical exploration was used as gold standard. 44 had diagnosis of bladder rupture; 42 had CT cystograms indicating bladder rupture. 28 had formal bladder exploration; 23 (82%) had operative findings that exactly matched the CT cystogram interpretation. CT cystography for bladder rupture: sensitivity 95%, specificity 100%, CT cystography for intraperitoneal rupture: sensitivity 78% specificity 99%. Recommends CT cystography over plain film cystography in patients having CT for other injuries associated with blunt trauma. 3
33. Deck AJ, Shaves S, Talner L, Porter JR. Current experience with computed tomographic cystography and blunt trauma. World J Surg. 2001; 25(12):1592-1596. Observational-Dx 316 patients Retrospective review to establish sensitivity and specificity of CT cystography for the diagnosis of bladder rupture in patients with blunt abdominal and pelvic trauma using operative findings as gold standard. 44 had an ultimate diagnosis of bladder rupture; 42 patients had CT cystograms indicating bladder rupture. 28 patients underwent formal bladder exploration; 23 (82%) had operative findings that exactly (i.e., presence and type of rupture) matched the CT cystogram interpretation.Sensitivity and specificity of CT cystography for detection of bladder rupture were 95% and 100%, respectively. Sensitivity and specificity for intraperitoneal rupture were 78% and 99% respectively.Recommends CT cystography over plain film cystography for patients undergoing CT evaluation for other blunt trauma-related injuries. 3
34. Chan DP, Abujudeh HH, Cushing GL, Jr., Novelline RA. CT cystography with multiplanar reformation for suspected bladder rupture: experience in 234 cases. AJR. 2006; 187(5):1296-1302. Observational-Dx 234 patients Retrospective review was performed to determine the accuracy of CT cystography and the role of multiplanar reformation in the diagnosis of bladder injury. From the total of 234 examinations, 216 (92.3%) were interpreted as negative and 18 examinations (7.7%) were interpreted as positive. On the 18 positive examinations, 11 were extraperitoneal bladder rupture, five were intraperitoneal bladder rupture, and two were combined intraperitoneal and extraperitoneal bladder rupture. Surgical bladder exploration and repair were performed in nine of the 18 cases. Seven (77.8%) of the nine cases had operative findings consistent with the CT cystogram findings. The overall sensitivity and specificity of CT cystography in diagnosing bladder rupture were each 100%. For extraperitoneal bladder rupture, the sensitivity and specificity were 92.8% and 100%, respectively. For intraperitoneal rupture, the sensitivity and specificity were 100% and 99%, respectively. CT cystography is accurate for diagnosing bladder rupture. Sagittal and coronal multiplanar reformations may be helpful in identifying most sites of bladder rupture. 3
35. Bigongiari LR, Zarnow H. Traumatic, inflammatory, neoplastic and miscellaneous lesions of the bladder. In: Medical radiology of the lower urinary tract. Lang EK ed. Berlin: Springer-Verlag. 1994:70-147. Review/Other-Dx N/A Book chapter. N/A 4
36. Cass AS.. Diagnostic studies in bladder rupture. Indications and techniques. [Review] [26 refs]. Urol Clin North Am. 16(2):267-73, 1989 May. Review/Other-Dx N/A Review indications and techniques in the diagnosis of bladder rupture. Retrograde cystogram with bladder filling of 400 ml of radiopaque dye followed by a washout film will diagnose intraperitoneal and extraperitoneal ruptures of the bladder. False-negative cystograms occur with penetrating injuries of the bladder when only 250 ml or less of contrast medium is used to fill the bladder. 4
37. Mee SL, McAninch JW, Federle MP. Computerized tomography in bladder rupture: diagnostic limitations. J Urol. 1987; 137(2):207-209. Review/Other-Dx 2 patients Prospective study to determine if CT is as accurate as retrograde cystography in the diagnosis of bladder rupture. CT showed no evidence of opacified urinary extravasation in one patient and only subtle evidence in the other. Cystography revealed gross intraperitoneal extravasation of opacified urine in both patients. Recommends retrograde cystography as test in suspected bladder rupture. 4
38. Pao DM, Ellis JH, Cohan RH, Korobkin M. Utility of routine trauma CT in the detection of bladder rupture. Acad Radiol. 2000; 7(5):317-324. Observational-Dx 54 patients Retrospective blinded review to determine the frequency with which CT fails to depict bladder rupture, the potential utility of delayed CT scans, and whether these findings might be useful in determining which patients may require subsequent cystography. Cystograms were used as the standard. Cystograms depicted bladder rupture in 10 patients. On CT scans, extravesical fluid was depicted in all three patients with intraperitoneal bladder rupture (although only a small amount of pelvic intraperitoneal fluid was present in two of these patients), in all seven patients with extraperitoneal bladder rupture, and in 32 of the 44 patients without bladder injury. Contrast material had been excreted into the bladder at the time of the initial or delayed CT in eight patients with bladder rupture; however, extravasation was identified in only four of the eight. In two of the four patients without extravasation, the bladder was distended at the time of CT. No bladder injuries were found in the 12 patients in whom pelvic fluid was not identified on CT scans. The absence of pelvic fluid on a trauma CT scan indicates that bladder rupture is unlikely. Even when a partially opacified bladder is passively distended, bladder injury may be present despite the absence of contrast material extravasation. 2
39. Shin SS, Jeong YY, Chung TW, et al. The sentinel clot sign: a useful CT finding for the evaluation of intraperitoneal bladder rupture following blunt trauma. Korean J Radiol. 2007; 8(6):492-497. Observational-Dx 74 consecutive trauma patients To evaluate the frequency and relevance of the "sentinel clot" sign on CT for patients with traumatic intraperitoneal bladder rupture in a retrospective study. 20 of the 74 patients had intraperitoneal bladder rupture. The sentinel clot sign was seen for 16 patients (80%) with intraperitoneal bladder rupture and for four patients (7%) without intraperitoneal bladder rupture (p < 0.001). Pelvic fracture was noted in five patients (25%) with intraperitoneal bladder rupture and in 39 patients (72%) without intraperitoneal bladder rupture (p < 0.001). Intraperitoneal free fluid was found in all patients (100%) with intraperitoneal bladder rupture, irrespective of an associated intraabdominal visceral injury, whereas 19 (35%) of the 54 patients without intraperitoneal bladder rupture had intraperitoneal free fluid (p < 0.001). Detection and localization of the sentinel clot sign abutting on the bladder dome may improve the accuracy of CT in the diagnosis of traumatic intraperitoneal bladder rupture, especially when the patients present with gross hematuria. 3
40. Hsieh CH, Chen RJ, Fang JF, et al. Diagnosis and management of bladder injury by trauma surgeons. American Journal of Surgery. 184(2):143-7, 2002 Aug. Observational-Dx 51 patients Retrospective review to analyze how bladder injuries have been managed as part of multiple traumas. 33 patients had abdominal CT, but only 20 were correctly diagnosed with accuracy of 60.6%. 24 patients had retrograde cystogram, with accuracy of 95.9% (23 of 24). Retrograde cystogram was performed in fewer than half of the patients (24 of 51), which means it is not feasible in many situations. 3
41. Farahmand N, Sirlin CB, Brown MA, et al. Hypotensive patients with blunt abdominal trauma: performance of screening US. Radiology. 2005;235(2):436-443. Observational-Dx 128 patients To determine retrospectively the accuracy of screening ultrasonography (US) in patients with hypotension (systolic blood pressure Sensitivity was 85% (44 of 52) for detection of any injuries, 97% (30 of 31) for surgical injuries (ie, injuries requiring surgery), and 100% (10 of 10) for fatal injuries. Specificity was 96% (73 of 76), 82% (80 of 97), and 69% (81 of 118), and accuracy was 91% (117 of 128), 86% (110 of 128), and 71% (91 of 128), for respective injury categories. One nonfatal surgical injury was missed in a high-risk patient. For each injury category, frequency of injury in patients with a fluid score of 2 or more was nine times that in patients with a score of 0 (P < .001 for all comparisons). Frequency of false-negative US findings in high-risk patients was eight times that in low-risk patients (P < .01). In patients who are hypotensive after blunt abdominal trauma and not hemodynamically stable enough to undergo diagnostic CT, negative US findings virtually exclude surgical injury, while positive US findings indicate surgical injury in 64% of cases. 3
42. McGahan JP, Rose J, Coates TL, Wisner DH, Newberry P. Use of ultrasonography in the patient with acute abdominal trauma. J Ultrasound Med. 1997;16(10):653-662; quiz 663-654. Observational-Dx 500 patients Prospective study to assess the ability of US to detect free-fluid and organ injury compared to CT and operative findings — not to clinical outcome. Sensitivity for fluid 63%, specificity 95%, accuracy 85%, PPV 86%, and NPV 85%. US fared better in cases of splenic laceration, permitting detection in 9/14 cases. The emergent US may be used to detect free fluid in the abdomen of the acutely traumatized patient. However, sonography is limited in detecting free fluid in the pelvis using the present technique and does not allow visualization of organ injury. 3
43. MacMahon R, Hosking D, Ramsey EW. Management of blunt injury to the lower urinary tract. Can J Surg. 1983; 26(5):415-418. Observational-Dx 33 patients Review cases of bladder rupture seen at a health centre over a 10 -year period to examine problems in the management of blunt injury to the lower urinary tract Cystography was performed in 24 of the 33 patients and indicated a ruptured urinary bladder in 23 instances. 23 patients underwent intravenous pyelography and in only 5(22%) was the diagnosis of a urinary bladder rupture made by this investigation. Cystography found to be reliable. 4
44. Bonavita JA, Pollack HM. Trauma of the adult bladder and urethra. Semin Roentgenol. 1983; 18(4):299-306. Review/Other-Dx N/A To review diagnosis of trauma of the adult bladder and urethra. Retrograde urethrography is the only safe and reliable method of diagnosing posterior urethral injury. 4
45. Carroll PR, McAninch JW. Major bladder trauma: the accuracy of cystography. J Urol. 1983; 130(5):887-888. Observational-Dx 51 patients To study accuracy of retrograde cystography in diagnosing traumatic bladder rupture. Extravasation was observed in 32 cases for which retrograde cystograms were available, including 3 (9%) in which additional infusion of contrast medium was required to demonstrate extravasation. Of the 32 cystograms 4 (13%) showed rupture on the drainage film only. If drainage radiographs and adequate distension of the bladder with contrast medium had been omitted, the rate of diagnostic accuracy of the cystogram would have been reduced to 79%. If attention is paid to adequate distension of the bladder with contrast material and to obtaining drainage films, diagnostic retrograde cystography for trauma should be almost totally accurate and delays or errors in diagnosis should be rare. 4
46. Werkman HA, Jansen C, Klein JP, Ten Duis HJ. Urinary tract injuries in multiply-injured patients: a rational guideline for the initial assessment. Injury. 22(6):471-4, 1991 Nov. Observational-Dx 866 patients (72 with urinary tract injuries) To evaluate the initial assessment of urinary tract injuries in multiply-injured patients. More than 35 RBC/high-power field in the sediment or macroscopic hematuria were found in patients with serious lesions of the urinary tract. All major injuries were demonstrated by the emergency intravenous urogram. US showed contusions of the kidney or bladder and rupture of the kidneys, but were not reliable in diagnosing ruptures of the bladder. 13 (8%) of 155 patients with a pelvic fracture had lower urinary tract injuries. All urethral lesions were detected with a retrograde urethrogram. Propose a rational guideline, which guarantees diagnostic accuracy of serious injuries of the urinary tract after blunt trauma, with little interference with the resuscitative and diagnostic procedures in severely injured patients. 4
47. Dane B, Baxter AB, Bernstein MP. Imaging Genitourinary Trauma. [Review]. Radiologic Clinics of North America. 55(2):321-335, 2017 Mar. Review/Other-Dx N/A To review radiologic imaging in genitourinary trauma No results stated in abstract 4
48. Langdorf MI, Medak AJ, Hendey GW, et al. Prevalence and Clinical Import of Thoracic Injury Identified by Chest Computed Tomography but Not Chest Radiography in Blunt Trauma: Multicenter Prospective Cohort Study. Ann Emerg Med. 66(6):589-600, 2015 Dec. Observational-Dx 5,912 patients To characterize the degree and pattern of improved sensitivity of chest CT over chest radiography for thoracic injuries and determined the clinical import by tracking subsequent management. Two thousand forty-eight patients (34.6%) had chest injury on chest radiography or chest CT, whereas 1,454 of these patients (71.0%, 24.6% of all patients) had occult injury. Of these, in 954 patients (46.6% of injured, 16.1% of total), chest CT found injuries not observed on immediately preceding chest radiography. In 500 more patients (24.4% of injured patients, 8.5% of all patients), chest radiography found some injury, but chest CT found occult injury. Chest radiography found all injuries in only 29.0% of injured patients. Two hundred and two patients with occult injury (of 1,454, 13.9%) had major interventions, 343 of 1,454 (23.6%) had minor interventions, and 909 (62.5%) had no intervention. Patients with occult injury included 514 with pulmonary contusions (of 682 total, 75.4% occult), 405 with pneumothorax (of 597 total, 67.8% occult), 184 with hemothorax (of 230 total, 80.0% occult), those with greater than 2 rib fractures (n¼672/1,120, 60.0% occult) or sternal fracture (n¼269/281, 95.7% occult),12 with great vessel injury (of 18 total, 66.7% occult), 5 with diaphragm injury (of 6, 83.3% occult), and 537 with multiple occult injuries. Interventions for patients with occult injury included mechanical ventilation for 31 of 514 patients with pulmonary contusion (6.0%), chest tube for 118of 405 patients with pneumothorax (29.1%), and 75 of 184 patients with hemothorax (40.8%). Inpatient pain control or observation greater than 24 hours was conducted for 183 of 672 patients with rib fractures (27.2%) and 79 of 269 with sternal fractures (29.4%). Three of 12 (25%) patients with occult great vessel injuries had surgery. Repeated imaging was conducted for 50.6% of patients with occult injury (88.1% chest radiography, 11.9% chest CT, 7.5% both). For patients with occult injury, 90.9% (1,321/1,454) were admitted, with 9.1% observed in the ED for median 6.9 hours. Forty-four percent of observed patients were then admitted (4.0% of patients with occult injury). 3
49. Rowan KR, Kirkpatrick AW, Liu D, Forkheim KE, Mayo JR, Nicolaou S. Traumatic pneumothorax detection with thoracic US: correlation with chest radiography and CT--initial experience. Radiology. 2002;225(1):210-214. Observational-Dx 27 patients To prospectively compare the accuracy of US with that of supine chest radiography in the detection of traumatic pneumothoraces, with CT as the reference standard 11 of 27 patients had pneumothorax at CT. All 11 of these pneumothoraces were detected at US, and four were seen at supine chest radiography. In the one false-positive US case, the patient was shown to have substantial bullous emphysema at CT. Sensitivity and NPV of US were 100% (11 of 11 and 15 of 15 patients, respectively), specificity was 94% (15 of 16 patients), and PPV was 92% (11 of 12 patients). Chest radiography had 36% (4 of 11 patients) sensitivity, 100% (16 of 16 patients) specificity, a 100% (four of four patients) PPV, and a 70% (16 of 23 patients) NPV. 2
50. Lopes JA, Frankel HL, Bokhari SJ, Bank M, Tandon M, Rabinovici R. The trauma bay chest radiograph in stable blunt-trauma patients: do we really need it? Am Surg. 2006;72(1):31-34. Observational-Dx 157 patients To evaluate the need for trauma bay chest radiographs (CXR) in stable blunt-trauma patients who are scheduled for chest computed tomography (CCT). Among 95 patients with a "normal" CXR, 38 patients (40%) were found on CCT to have traumatic injuries. Among 62 patients with an "abnormal" CXR, 18 (29%) were found to be normal on CCT. Of the remaining 44 patients, 34 had additional findings on CCT. In 32 patients, CCT led to changes in management. CCT was more sensitive in diagnosing thoracic injuries and led to significant changes in management. 3
51. Traub M, Stevenson M, McEvoy S, et al. The use of chest computed tomography versus chest X-ray in patients with major blunt trauma. Injury. 2007;38(1):43-47. Observational-Dx 141 patients To identify the clinical features associated with further diagnostic information obtained on a CT chest scan compared with a routine chest X-ray in patients sustaining blunt trauma to the chest. The CT chest scan is significantly more likely to provide further diagnostic information for the management of blunt trauma compared to a chest X-ray in patients with chest wall tenderness (OR = 6.73, 95% CI = 2.56, 17.70, p < 0.001), reduced airentry (OR = 4.48, 95% CI = 1.33, 15.02, p = 0.015) and/or abnormal respiratory effort (OR = 4.05, 95% CI = 1.28, 12.66, p = 0.017). CT scan was significantly more effective than routine chest X-ray in detecting lung contusions, pneumothoraces, mediastinal haematomas, as well as fractured ribs, scapulas, sternums and vertebrae. 3
52. Barrios C Jr, Pham J, Malinoski D, Dolich M, Lekawa M, Cinat M. Ability of a chest X-ray and an abdominal computed tomography scan to identify traumatic thoracic injury. Am J Surg. 200(6):741-4; discussion 744-5, 2010 Dec. Observational-Dx 200 patients To identify the utility of thoracic CT (TCT) in blunt trauma patients with a normal admission chest radiograph (CXR). 143 patients had a normal screening CXR; 36 of these patients (25%) had an abnormal TCT. TCT changed the management in only nine of these patients (6%): two required serial CXR for occult pneumothorax, four received additional imaging of the spine, and three were admitted to a monitored bed. 57 patients had an abnormal initial CXR. Of these, 41 (81%) had an abnormal TCT. TCT changed management in 21 (37%) of these patients: two aortic injuries identified, 12 aortic injuries excluded, two chest tubes placed, one patient taken to the Operating Room, and four patients required further diagnostic evaluation. TCT was significantly more likely to alter management in patients with an abnormal admission CXR (6% vs 37%, P < 0.001). 3
53. Vo NJ, Gash J, Browning J, Hutson RK. Pelvic imaging in the stable trauma patient: is the AP pelvic radiograph necessary when abdominopelvic CT shows no acute injury? Emerg Radiol 2004;10:246-9. Observational-Dx 509 patients To determine the utility of anteroposterior (AP) pelvic radiographs in stable trauma patients who will undergo or have undergone abdominopelvic CT as part of the initial trauma imaging evaluation Of these, 449 patients (88.2%) had no acute pelvic injury revealed by abdominopelvic CT. CT showed 163 acute injuries in 60patients. AP radiographs showed 132 acute injuries in 52 patients. No patients with a negative CT had an acute finding on the radiograph. There were eight false-negative pelvic radiographs (negative predictive value 98.25%). CT is highly accurate in excluding acute osseous pelvic injuries. 3
54. Richards JR, Ormsby EL, Romo MV, Gillen MA, McGahan JP. Blunt abdominal injury in the pregnant patient: detection with US. Radiology. 233(2):463-70, 2004 Nov. Observational-Dx 2319 examinations To determine the accuracy of ultrasonography (US) for the detection of blunt intraabdominal injury in pregnant patients and to compare differences betweenpregnant and nonpregnant patients of childbearing age. A total of 2319 US examinations for blunt trauma were performed in girls and women between the ages of 10 and 50 years. There were 328 pregnant patients, 23 of whom had intraabdominal injury. The mean age of the pregnant patients was 24.7 years +- 6.1 (standard deviation) (age range, 14–42 years). In pregnant patients, the sensitivity of US was 61% (14 of 23 patients), the specificity was 94.4% (288 of 305 patients), and the accuracy was 92.1% (302 of 328 patients). Pregnant patients were significantly more likely to have sustained injuries from assault (odds ratio: 2.6, P < .001). The most common pattern of free fluid accumulation detected at US in pregnant patients was that of fluid in the left and right upper quadrants and pelvis (n = 4, 29%); the second most common pattern was one of isolated pelvic fluid (n = 3, 21%). 3
55. Mirza FG, Devine PC, Gaddipati S. Trauma in pregnancy: a systematic approach. [Review]. Am J Perinatol. 27(7):579-86, 2010 Aug. Review/Other-Dx N/A To review the impact of trauma in pregnant women. No results stated in abstract 4
56. American College of Radiology. ACR–SPR Practice Parameter for the Safe and Optimal Performance of Fetal Magnetic Resonance Imaging (MRI). Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/mr-fetal.pdf Review/Other-Dx N/A To promote safe and optimal performance of fetal magnetic resonance imaging (MRI). No abstract available. 4
57. American College of Radiology. ACR-SPR Practice Parameter for Imaging Pregnant or Potentially Pregnant Patients with Ionizing Radiation. Available at: http://www.acr.org/~/media/ACR/Documents/PGTS/guidelines/Pregnant_Patients.pdf. Review/Other-Dx N/A To assist practitioners in providing appropriate radiologic care for pregnant or potentially pregnant adolescents and women by describing specific training, skills and techniques. No abstract available. 4
58. American College of Radiology. ACR-ACOG-AIUM-SMFM-SRU Practice Parameter for the Performance of Standard Diagnostic Obstetrical Ultrasound. Available at: https://www.acr.org/-/media/ACR/Files/Practice-Parameters/us-ob.pdf Review/Other-Dx N/A To promote the safe and effective use of diagnostic and therapeutic radiology by describing the key elements of standard ultrasound examinations in the first, second, and third trimesters of pregnancy. No abstract available. 4
59. American College of Radiology. Manual on Contrast Media. Available at: https://www.acr.org/Clinical-Resources/Contrast-Manual. Review/Other-Dx N/A To assist radiologists in recognizing and managing risks associated with the use of contrast media. No abstract available. 4
60. Expert Panel on MR Safety, Kanal E, Barkovich AJ, et al. ACR guidance document on MR safe practices: 2013. J Magn Reson Imaging. 37(3):501-30, 2013 Mar. Review/Other-Dx N/A To help guide MR practitioners regarding MR safety issues and provide a basis for them to develop and implement their own MR policies and practices. No abstract available. 4
61. American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://www.acr.org/-/media/ACR/Files/Appropriateness-Criteria/RadiationDoseAssessmentIntro.pdf. Review/Other-Dx N/A To provide evidence-based guidelines on exposure of patients to ionizing radiation. No abstract available. 4
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