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Appropriateness Criteria

Reference Study Type Patients/Events Study Objective(Purpose of Study) Study Results Study Quality
1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 1999-2020 on CDC WONDER Online Database, released in 2021. Data are from the Multiple Cause of Death Files, 1999-2020, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.  Available at: http://wonder.cdc.gov/ucd-icd10.html Review/Other-Dx N/A To discuss the data are from the Multiple Cause of Death Files. The Multiple Cause of Death database contains mortality and population counts for all U.S. counties. Data are based on death certificates for U.S. residents. Each death certificate contains a single underlying cause of death, up to twenty additional multiple causes, and demographic data. The number of deaths, crude death rates, age-adjusted death rates and 95% confidence intervals for death rates can be obtained by cause of death (4 digit ICD-10 codes, 113 selected causes of death, 130 selected causes of infant death, drug and alcohol related causes of death, injury intent and injury mechanism categories), place of residence (national, region, division, state, and county), age (single-year-of age, 5-year age groups, 10-year age groups and infant age groups), race (American Indian or Alaskan Native, Asian/Pacific Islander, Black or African American, White), Hispanic ethnicity, gender and year. Data are also available by urbanization categories for county of residence, place of death, month and week day of death, and whether an autopsy was performed. 4
2. Dreizin D, Munera F. Multidetector CT for Penetrating Torso Trauma: State of the Art. [Review]. Radiology. 277(2):338-55, 2015 Nov. Review/Other-Dx N/A To review the current state of multidetector CT as a triage tool for penetrating torso trauma and the primacy of trajectory evaluation in diagnosis, while emphasizing diagnostic challenges that have lingered despite tremendous technological advances since CT was first used in this setting 3 decades ago No results stated in the abstract 4
3. Naeem M, Hoegger MJ, Petraglia FW 3rd, et al. CT of Penetrating Abdominopelvic Trauma. Radiographics. 41(4):1064-1081, 2021 Jul-Aug. Review/Other-Dx N/A To discuss the CT of Penetrating Abdominopelvic Trauma No results stated in the abstract. 4
4. Breigeiron R, Breitenbach TC, Zanini LAG, Corso CO. Comparison between isolated serial clinical examination and computed tomography for stab wounds in the anterior abdominal wall. Rev. Col. Bras. Cir.. 44(6):596-602, 2017 Nov-Dec. Observational-Dx 66 patients To compare abdominal computer tomography (CT) with isolated serial clinical exam (SCE) in the management of anterior abdominal stab wounds. 66 patients were studied and 33 were included in each group, Of total, six were submitted to surgery, three of each group, In the SCE group, patients submitted to surgery in media waited 12 hours from arrival to diagnosis without any non-therapeutic surgeries, The remaining 30 patients of this group were discharged from hospital after 24 hours of observation, In the CT group, three patients showed alteration at CT and were submitted to laparotomy, one non-therapeutic, The others were discharged from hospital after 24 hours of observation, Abdominal computer tomography had a positive predictive value (PPV) of 67% and negative predictive value (NPV) of 100%, with 96% of accuracy, Isolated serial clinical exam showed PPV and NPV of 100% and 100% of accuracy. 2
5. Heller MT, Oto A, Allen BC, et al. ACR Appropriateness Criteria R Penetrating Trauma-Lower Abdomen and Pelvis. [Review]. Journal of the American College of Radiology. 16(11S):S392-S398, 2019 Nov. 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 penetrating trauma-lower abdomen and pelvis No results stated in abstract. 4
6. Baghdanian AH, Armetta AS, Baghdanian AA, LeBedis CA, Anderson SW, Soto JA. CT of Major Vascular Injury in Blunt Abdominopelvic Trauma. [Review]. Radiographics. 36(3):872-90, 2016 May-Jun. Review/Other-Dx N/A Identification of vascular injuries in the setting of blunt abdominal trauma can pose a diagnostic challenge, as detection is reliant on appropriate multidetector computed tomography (CT) scanning protocols and familiarity with the various imaging presentations of vessel injury. No results stated in abstract. 4
7. Kozar RA, Crandall M, Shanmuganathan K, et al. Organ injury scaling 2018 update: Spleen, liver, and kidney. J Trauma Acute Care Surg 2018;85:1119-22. Review/Other-Dx N/A To discuss the organ injury scaling 2018 update. No results stated in the abstract. 4
8. Hardee MJ, Lowrance W, Stevens MH, et al. Process improvement in trauma: compliance with recommended imaging evaluation in the diagnosis of high-grade renal injuries. The Journal of Trauma and Acute Care Surgery. 74(2):558-62, 2013 Feb. Observational-Dx 147 patients To evaluate compliance with this recommendation among adult Level I trauma centers in Utah. A total of 147 patients were identified with injuries of grade 3 or higher, but only 126 had available images for review at the time of the study. Of the 102 patients with a perinephric fluid collection or grade 4 to 5 injuries, delayed images were obtained in 74 (73%). In these patients, 14 (19%) had a collecting system injury. In the 28 patients without delayed images, 7 (25%) were later identified to have a collecting system injury. Of the 21 collecting system injuries, 7 (33%) had a delay in diagnosis because of lack of excretory images obtained on initial evaluation. 2
9. Paes FM, Durso AM, Pinto DS, Covello B, Katz DS, Munera F. Diagnostic performance of triple-contrast versus single-contrast multi-detector computed tomography for the evaluation of penetrating bowel injury. EMERG. RADIOL.. 29(3):519-529, 2022 Jun. Observational-Dx 997 patients To compare the diagnostic performance of triple-contrast (oral, rectal, and IV) against IV contrast-only CT, for the detection of bowel injury from penetrating abdominopelvic trauma, using surgical diagnosis as the reference standard. Bowel injury was present in 45 out of 143 patients (10 on triple-contrast group and 35 on IV contrast-only group). Specificity and accuracy were higher with triple-contrast CT (98% specific, 97-99% accurate) compared to IV contrast-only CT (66% specific, 78-79% accurate). Sensitivity was highest with IV contrast-only CT (91% sensitive) compared with triple-contrast CT (75% sensitive), although this difference was not statistically significant. Triple-contrast technique increased diagnostic accuracy for both radiologists regardless of mechanism of injury. 2
10. Saksobhavivat N, Shanmuganathan K, Boscak AR, et al. Diagnostic accuracy of triple-contrast multi-detector computed tomography for detection of penetrating gastrointestinal injury: a prospective study. Eur Radiol. 26(11):4107-4120, 2016 Nov. Observational-Dx 171 patients To determine the presence of a gastrointestinal injury and the need for surgery or observation. Of one hundred and seventy-one patients (72 gunshot wounds, 99 stab wounds; age range, 18-57 years; median age, 28 years) with penetrating torso trauma who underwent CT, 45 % were followed by an operation and 55 % by clinical follow up. Thirty-five patients had a gastrointestinal injury at surgery. The sensitivity, specificity, and accuracy of CT for diagnosing a gastrointestinal injury for all patients were each 91 %, and for predicting the need for surgery, they were 94 %, 93 %, 93 %, respectively. Among the 3 % of patients who failed observation, 1 % had a gastrointestinal injury. 2
11. Beattie G, Cohan CM, Tang A, Chen JY, Victorino GP. Observational management of penetrating occult pneumothoraces: Outcomes and risk factors for interval tube thoracostomy placement. J Trauma Acute Care Surg. 92(1):177-184, 2022 01 01. Observational-Dx 629 patients To (1) describe OPTX occurrence in penetrating chest injury, (2) determine the rate of interval TT placement in observational management and clinical outcomes compared with immediate TT placement, and (3) describe risk factors associated with failure of observational management. Of 629 penetrating pneumothorax patients, 103 (16%) presented with OPTX. Thirty-eight patients underwent immediate TT placement, and 65 were observed. Twelve observed patients (18%) needed interval TT placement. Regardless of initial management strategy, TT placement was associated with longer LOS and more chest radiographs. Chest injury complications and outcomes were similar. Factors associated with increased odds of interval TT placement included Chest Abbreviated Injury Scale score of =4 (adjusted odds ratio [aOR], 7.38 [95% confidence interval, 1.43-37.95), positive pressure ventilation (aOR, 7.74 [1.07-56.06]), concurrent hemothorax (aOR, 6.17 [1.08-35.24]), and retained bullet fragment (aOR, 11.62 [1.40-96.62]) (all p < 0.05). 2
12. Iacobellis F, Brillantino A, Di Serafino M, et al. Economic and clinical benefits of immediate total-body CT in the diagnostic approach to polytraumatized patients: a descriptive analysis through a literature review. [Review]. Radiologia Medica. 127(6):637-644, 2022 Jun.Radiol Med (Torino). 127(6):637-644, 2022 Jun. Review/Other-Dx N/A To report a descriptive analysis of the economic and clinical benefits of the adoption of immediate total-body CT in polytrauma patients through a literature review. No results stated in the abstract. 4
13. Netherton S, Milenkovic V, Taylor M, Davis PJ. Diagnostic accuracy of eFAST in the trauma patient: a systematic review and meta-analysis. CJEM Canadian Journal of Emergency Medical Care. 21(6):727-738, 2019 11. Review/Other-Dx 75 studies To search Medline and Embase from inception through October 2018, for diagnostic studies examining the sensitivity and specificity of the eFAST exam. Seventy-five studies representing 24,350 patients satisfied our selection criteria. Studies were published between 1989 and 2017. Pooled sensitivities and specificities were calculated for the detection of pneumothorax (69% and 99% respectively), pericardial effusion (91% and 94% respectively), and intra-abdominal free fluid (74% and 98% respectively). Sub-group analysis was completed for detection of intra-abdominal free fluid in hypotensive (sensitivity 74% and specificity 95%), adult normotensive (sensitivity 76% and specificity 98%) and pediatric patients (sensitivity 71% and specificity 95%). 4
14. Lucas B, Hempel D, Otto R, et al. Prehospital FAST reduces time to admission and operative treatment: a prospective, randomized, multicenter trial. Eur. j. trauma emerg. surg.. 48(4):2701-2708, 2022 Aug. Observational-Dx 296 patients To assess whether a pre-hospital FAST (p-FAST) influences pre-hospital strategy and the time to operative treatment. CEX-p-FAST showed a high sensitivity (94.7%) and specificity (97.6%) in detection of free fluid compared to CEX-only (80.0%, 84.4%). The median time to admission was reduced significantly by 13 min and to operative treatment by 15 min after CEX-p-FAST. We observed a cross-over rate of 30.8% of p-FAST (n = 36) to CEX-p-FAST during the CEX-only weeks. 2
15. Kondo Y, Ohbe H, Yasunaga H, Tanaka H. Initial focused assessment with sonography in trauma versus initial CT for patients with haemodynamically stable torso trauma. Emerg Med J. 37(1):19-24, 2020 Jan. Observational-Dx 9942 patients To compare in-hospital mortality and length of stay between patients undergoing initial FAST vs initial CT for haemodynamically stable torso trauma. There were 9942 patients; 8558 underwent initial FAST and 1384 underwent initial CT. Multivariable logistic regression showed no significant difference in in-hospital mortality between the initial FAST and initial CT groups (OR 1.37, 95% CI 0.94 to 1.99, p=0.10). Multivariable linear regression revealed that the initial FAST group had a significantly longer length of stay than the initial CT group (difference: 3.5 days; 95% CI 1.0 to 5.9, p<0.01). 2
16. Gamberini L, Tartaglione M, Giugni A, et al. The role of prehospital ultrasound in reducing time to definitive care in abdominal trauma patients with moderate to severe liver and spleen injuries. Injury. 53(5):1587-1595, 2022 May. Observational-Dx 199 patients To investigate if a positive prehospital FAST in abdominal trauma patients could have a role in reducing door-to-CT scan or door-to-operating room (OR) time. 199 patients were included in the final analysis. Of these, 44 had a prehospital FAST performed and in 27 of them, peritoneal free fluid was detected in the prehospital setting, while 128 out of 199 patients had a positive ED-FAST. Sensitivity was 62.9% (95% CI: 42.4%-80.6%) and specificity 100% (95% CI: 80.5% - 100%). Patients with a positive prehospital FAST reported a significantly lower door-to-CT or door-to-OR median time (46 vs 69 min, p < 0.001). Prehospital hypotension and Glasgow coma scale, first arterial blood lactate, ISS, age, positive prehospital and ED FAST were inserted in a stepwise selection for a multivariable Cox proportional regression hazards model. Only ISS and prehospital FAST resulted significantly associated with a reduction in the door-to-CT scan or door-to-operating theatre time in the multivariable model. 2
17. Cook MR, Holcomb JB, Rahbar MH, et al. An abdominal computed tomography may be safe in selected hypotensive trauma patients with positive Focused Assessment with Sonography in Trauma examination. Am J Surg. 209(5):834-40, 2015 May. Observational-Dx 92 patients To review the results of  patients in the Prospective Observational Multicenter Major Trauma Transfusion study with hypotension and a positive Focused Assessment with Sonography in Trauma (HF+) examination who underwent a CT (apCT+) were compared with those who did not. Of the 92 HF+ identified, 32 (35%) underwent apCT during initial evaluation and apCT was associated with decreased odds of an emergency operation (odds ratio .11, 95% confidence interval .001 to .116) and increased odds of angiographic intervention (odds ratio 14.3, 95% confidence interval 1.5 to 135). There was no significant difference in 30-day mortality or need for dialysis. 2
18. 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
19. 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
20. 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
21. Chiu WC, Shanmuganathan K, Mirvis SE, Scalea TM. Determining the need for laparotomy in penetrating torso trauma: a prospective study using triple-contrast enhanced abdominopelvic computed tomography. J Trauma. 51(5):860-8; discussion 868-9, 2001 Nov. Observational-Dx 75 patients To studied hemodynamically stable patients with penetrating injury to the torso (abdomen, pelvis, flank, back, or lower chest) without definite indication for laparotomy, admitted to our trauma center during the 1-year period from 7/99 through 6/00. There were 75 consecutive patients studied: mean age 30 years (range 15-85 years); 67 (89%) male; 41 (55%) gunshot wound, 32 (43%) stab wound, 2 (3%) shotgun wound; mean admission systolic blood pressure 141 mm Hg (range 95-194 mm Hg); 26 (35%) had positive CT and 49 (65%) had negative CT. In patients with positive CT, 18 (69%) had laparotomy: 15 therapeutic, 2 nontherapeutic, and 1 negative. Five patients had isolated hepatic injury and 2 had hepatic and diaphragm injury on CT and all were successfully managed without laparotomy. Of these seven patients, three had angioembolization and two had thoracoscopic diaphragm repair. In patients with negative CT, 47/49 (96%) had successful nonoperative management and 1 had negative laparotomy. The single CT-missed peritoneal violation had a left diaphragm injury at laparotomy. CT accurately predicted whether laparotomy was needed in 71/75 (95%) patients. 2
22. Fu CY, Liao CA, Liao CH, et al. Intra-abdominal injury is easily overlooked in the patients with concomitant unstable hemodynamics and pelvic fractures. Am J Emerg Med. 32(6):553-7, 2014 Jun. Observational-Dx 41 patients 2
23. Brown CV, Velmahos GC, Neville AL, et al. Hemodynamically "stable" patients with peritonitis after penetrating abdominal trauma: identifying those who are bleeding. Arch Surg. 140(8):767-72, 2005 Aug. Observational-Dx 139 patients 2
24. Baron BJ, Benabbas R, Kohler C, et al. Accuracy of Computed Tomography in Diagnosis of Intra-abdominal Injuries in Stable Patients With Anterior Abdominal Stab Wounds: A Systematic Review and Meta-analysis. Acad Emerg Med. 25(7):744-757, 2018 07. Review/Other-Dx 7 studies To evaluate the accuracy of computed tomography of abdomen and pelvis (CTAP) for diagnosis of intraabdominal injuries requiring therapeutic laparotomy (THER-LAP) in ED patients with AASW. Is a negative CT scan without a period of observation sufficient to safely discharge a hemodynamically stable, asymptomatic AASW patient? Seven studies were included encompassing 575 patients. The weighted prevalence of THER-LAP was 34.3% (95% confidence interval [CI] = 30.5%-38.2%). Studies had variable quality and the inclusion criteria were not uniform. The operating characteristics of CT scan were as follows: sensitivity = 50% to 100%, specificity = 39% to 97%, LR+ = 1.0 to 15.7, and LR- = 0.07 to 1.0. The high heterogeneity (I2 > 75%) of the operating characteristics of CT scan prevented pooling of the data and therefore the testing and treatment thresholds could not be estimated. 4
25. Ordoñez C, García C, Parra MW, et al. Implementation of a new Single-Pass Whole-Body Computed Tomography Protocol: Is it safe, effective and efficient in patients with severe trauma? 2020;51. Observational-Dx 263 patients 2
26. Ordonez CA, Herrera-Escobar JP, Parra MW, et al. Computed tomography in hemodynamically unstable severely injured blunt and penetrating trauma patients. The Journal of Trauma and Acute Care Surgery. 80(4):597-602; discussion 602-3, 2016 Apr. Observational-Dx 171 patients. To maintain aggressive resuscitation schemes in HU patients allows us to complete diagnostic imaging studies before rushing patients to the operating room (OR). We reviewed 171 patients. CT scans were performed in 80 HU patients (47%) immediately upon arrival (CT group); the remaining 91 patients (53%) went directly to the OR (63 laparotomies, 20 thoracotomies) and/or 8 (9%) to the angio suite (OA group). Of the CT group, 43 (54%) were managed nonoperatively, 37 (46%) underwent surgery (15 laparotomies, 3 thoracotomies), and 2 (5%) underwent angiography (CT OA subgroup). None of the mortalities in the CT group occurred in the CT suite or during their intrahospital transfers. 2
27. Watchorn J, Miles R, Moore N. The role of CT angiography in military trauma. Clin Radiol. 68(1):39-46, 2013 Jan. Review/Other-Dx 144 patients To review whole-body computed tomography (CT) angiography as an unmatched way of fully assessing battle-injured patients, and the prevalence of vascular, predominantly arterial, injuries identified. One hundred and forty-four patients underwent whole-body CT of which 17% had an occult vascular injury on CT. Twenty of these injuries (56%) were in the lower limbs, excluding extravasation at the site of amputation. Improvised explosive devices (IEDs) accounted for 71% (180 of 253) of battle injuries. The median time from admission to CT was 28 min. An additional 12% longer per patient is taken on average in a multiple casualty incident. Including contrast medium administration, whole-body angiography is completed in less than 2 min (mean 116 s). 4
28. Zaw AA, Stewart D, Murry JS, et al. CT Chest with IV Contrast Compared with CT Angiography after Blunt Trauma. American Surgeon. 82(1):41-5, 2016 Jan. Review/Other-Dx 281 patients To review of all blunt trauma patients who received a CTI or CTA during the initial evaluation at an urban Level I trauma center from January 1, 2010 to December 31, 2013. Two-hundred and eighty-one trauma patients met inclusion criteria. Most, 167/281 (59%) received CTI and 114/281 (41%) received CTA. There were no differences between cohorts in age, gender, initial heart rate, systolic blood pressure, and Glasgow Coma Scale in emergency department. Mortality rates were similar for CTI and CTA (4% vs 8%, P = 0.20). CTI identified an injury in 54 per cent compared with 46 per cent in CTA (P = 0.05). Overall, 2 per cent of patients had BAI with similar rates in CTI and CTA (2% vs 2%, P = 0.80). BAI was not missed using either CTI or CTA. Trauma patients studied with CTI had similar diagnostic findings as CTA. CTI may be preferable to CTA during the initial assessment for possible BAI because of a single contrast injection for whole body CT. 4
29. Nummela MT, Thorisdottir S, Oladottir GL, Koskinen SK. Imaging of penetrating thoracic trauma in a large Nordic trauma center. Acta Radiol Open. 8(12):2058460119895485, 2019 Dec. Review/Other-Dx 636 patients To evaluate incidence and imaging findings of penetrating chest trauma, gunshot wound (GSW) and stab wound (SW) injury spectrum, imaging protocols, and outcome in a large trauma center. Of 636 patients with penetrating injuries, 443 (69.7%) underwent imaging. Of these, 161 (36.3%) had penetrating thoracic injuries. Of 161 patients with penetrating chest trauma in imaging, 151 (93.8%) were men (mean age = 34.9 years) and 10 (6.2%) were women (mean age = 40.7 years). The majority of patients had SWs (138 SW vs. 15 GSW). Patients with GSWs were more severely injured (mean ISS 17.00 vs. 8.84 [P=0.0014] and ISS=16 in 53.3% vs. 16.7%) than SW patients. In CT, intrathoracic injuries were found in 49.4% (77/156) and active bleeding in 26.3% (41/156). Emergency surgery was performed in 6.2% (10/161) with postoperative CT imaging. Thirty-day mortality rate was 1.2% (2/161). 4
30. Ozimok CJ, Mellnick VM, Patlas MN. An international survey to assess use of oral and rectal contrast in CT protocols for penetrating torso trauma. EMERG. RADIOL.. 26(2):117-121, 2019 Apr. Review/Other-Dx 589 radiologist To survey radiologists from the American Society of Emergency Radiology membership database to determine consensus on CT protocols for penetrating trauma. We received 124 responses (21% response rate) with a majority from U.S. institutions (82%). Seventy-four percent of respondents indicated they do not routinely administer oral contrast in penetrating trauma, 68% do not administer rectal contrast, and 90% do not use commercially available software to assess penetrating injury trajectory. Results from U.S. and non-U.S. practices were comparable. The decision to administer intraluminal contrast is made by the referring physician at 52% of institutions. There is in-house attending level radiology coverage at 54% of institutions and when asked if trauma scans are reviewed before removing the patient from the table, 41% of respondents answered "No." 4
31. Naulet P, Wassel J, Gervaise A, Blum A. Evaluation of the value of abdominopelvic acquisition without contrast injection when performing a whole body CT scan in a patient who may have multiple trauma. Diagnostic and Interventional Imaging. 94(4):410-7, 2013 Apr. Observational-Dx 84 patients To evaluate the diagnostic value of non-contrast-enhanced abdominopelvic acquisition when performing a whole body CT scan in a patient who may have multiple trauma. This study did not reveal any significant difference, particularly concerning improvement in sensitivity, between interpretation of the acquisitions with contrast injection and interpretation of all the acquisitions with or without injection. Inter-observer agreement was substantial to almost perfect. Non-contrast-enhanced thoraco-abdominopelvic acquisition represented 20% to 25% of the effective dose for the entire examination. 4
32. Yang XY, Wei MT, Jin CW, Wang M, Wang ZQ. Unenhanced Computed Tomography to Visualize Hollow Viscera and/or Mesenteric Injury After Blunt Abdominal Trauma: A Single-Institution Experience. Medicine (Baltimore). 95(9):e2884, 2016 Mar. Observational-Dx 151 patients 2
33. Alexander LF, Hanna TN, LeGout JD, et al. Multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic Injuries. [Review]. Radiographics. 39(4):1183-1202, 2019 Jul-Aug. Review/Other-Dx N/A To discuss the multidetector CT Findings in the Abdomen and Pelvis after Damage Control Surgery for Acute Traumatic Injuries. No results stated in the abstract. 4
34. Manzano-Nunez R, Gomez A, Espitia D, et al. A meta-analysis of the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma. The Journal of Trauma and Acute Care Surgery. 90(2):388-395, 2021 02 01. Meta-analysis 556 patients (5 studies) To perform a systematic review (SR) and meta-analysis (MA) to determine the diagnostic accuracy of chest ultrasound (US) compared with a pericardial window (PW) for the diagnosis of occult penetrating cardiac injuries in hemodynamically stable patients with penetrating thoracic trauma. We included five studies in our SR and MA. These studies included a total of 556 trauma patients. The MA found that, compared with PW, the US was 79% sensitive and 92% specific for detecting occult penetrating cardiac injuries in hemodynamically stable patients. The presence of a concomitant left hemothorax was frequent in patients with false-negative results. Good
35. Gonzalez-Hadad A, Garcia AF, Serna JJ, Herrera MA, Morales M, Manzano-Nunez R. The Role of Ultrasound for Detecting Occult Penetrating Cardiac Wounds in Hemodynamically Stable Patients. World Journal of Surgery. 44(5):1673-1680, 2020 05. Observational-Dx 141 patient To report on a prospective single-center study to determine the diagnostic accuracy of chest ultrasound for the diagnosis of occult penetrating cardiac wounds in a low-resource hospital from a middle-income country. A total of 141 patients met the inclusion criteria. Our results showed that for diagnosing an occult cardiac injury, the sensitivity of the chest ultrasonography was 79.31%, and the specificity was 92.86%. Of the 110 patients with a normal or negative ultrasound, six had a positive pericardial window. All of these patients had left hemothoraces. None of them required further cardiac surgical interventions. 2
36. Abdellatif W, Vasan V, Kay FU, Kohli A, Abbara S, Brewington C. Know your way around acute unenhanced CT during global iodinated contrast crisis: a refresher to ED radiologists. Emerg Radiol 2022;29:1019-31. Review/Other-Dx N/A 4
37. Strumwasser A, Chong V, Chu E, Victorino GP. Thoracic computed tomography is an effective screening modality in patients with penetrating injuries to the chest. Injury. 47(9):2000-5, 2016 Sep. Observational-Dx 212 patients To hypothesize that thoracic CT effectively screens hemodynamically normal patients with penetrating thoracic trauma to surgery vs. expectant management (NOM). A total of 212 patients (mean injury severity score=24, Abbreviated Injury Score for Chest=3.9) met inclusion criteria. Of these, 84.3% underwent NOM, 9.1% necessitated abdominal exploration, 6.6% underwent exploration for retained hemothorax/empyema, 6.6% underwent immediate thoracic exploration for significant injuries on chest CT, and 1.0% underwent delayed thoracic exploration for missed injuries. Thoracic CT had a sensitivity of 82%, specificity of 99%, positive predictive value of 90%, a negative predictive value of 99%, and an accuracy of 99% in predicting surgery vs. NOM. 3
38. Gunn ML, Clark RT, Sadro CT, Linnau KF, Sandstrom CK. Current concepts in imaging evaluation of penetrating transmediastinal injury. [Review]. Radiographics. 34(7):1824-41, 2014 Nov-Dec. Review/Other-Dx N/A 4
39. Kim JS, Inaba K, de Leon LA, et al. Penetrating injury to the cardiac box. J Trauma Acute Care Surg 2020;89:482-87. Observational-Dx 330 patients To evaluate the relationship between penetrating trauma to the cardiac box and a clinically significant injury. During this 7-year period, 330 patients (92% male; median age, 28 years) sustained penetrating injuries isolated to the thorax: 138 (42%) within the cardiac box and 192 (58%) outside the cardiac box. By mechanism, 105 (76%) were stab wounds (SW) and 33 (24%) were gunshot wounds (GSW) inside the cardiac box, and 125 (65%) SW and 67 (35%) GSW outside the cardiac box. The overall rate of thoracotomy or sternotomy (35/138 [25.4%] vs. 15/192 [7.8%], p < 0.001) and the incidence of cardiac injury (18/138 [13%] vs. 5/192 [2.6%], p < 0.001) were significantly higher in patients with penetrating trauma within the cardiac box. This was, however, dependent on mechanism with SW demonstrating a higher incidence of cardiac injury (15/105 [14.3%] vs. 3/125 [2.4%], p = 0.001) and GSW showing no significant difference (3/33 [9.1%] vs. 2/67 [3%], p = 0.328]. There was no difference in overall mortality (9/138 [6.5%] vs. 6/192 [3.1%], p = 0.144). 2
40. Plurad DS, Bricker S, Van Natta TL, et al. Penetrating cardiac injury and the significance of chest computed tomography findings. Emergency Radiology. 20(4):279-84, 2013 Aug. Observational-Dx 333 patients To hypothesize that chest computed tomography (CCT) is potentially useful in evaluation. The records of all patients admitted to our center with wounds to the precordium or who sustained a hemothorax or pneumothorax after penetrating torso injuries over a 48-month period were reviewed. The potential diagnostic value of hemopericardium (HPC) and pneumopericardium (PPC) on CCT was examined. Most of the 333 patients were male [293 (88.0 %)] with a roughly equal distribution of gunshot [189 (56.8 %)] and stab [144 (43.2 %)] wounds. Mean age was 28.7 ± 12.6 years. Thirteen (3.9 %) patients had cardiac injuries that were operatively managed. Eleven (3.3 %) CCT studies demonstrated HPC and/or PPC. Ten of these patients had an injury with one false positive. Retained hemothorax and proximity findings on the three false negative CCT studies led to video-assisted thoracoscopic surgery or subxiphoid exploration with diagnosis of the injury. HPC and/or PPC on CCT had a sensitivity of 76.9 %, specificity of 99.7 %, positive predictive value of 90.9 %, and negative predictive value (NPV) of 99.1 % for cardiac injuries. However, including all findings that changed management, CCT had a sensitivity and NPV of 100 %. CCT is a potentially useful modality for the evaluation of cardiac injuries in high-risk stable patients. The presence of HPC and/or PPC on CCT after penetrating thoracic trauma is highly indicative of a significant cardiac injury. 2
41. Moussavi N, Talari H, Abedzadeh-Kalahroudi M, et al. Implementation of an algorithm for chest imaging in blunt trauma decreases use of CT-scan: Resource management in a middle-income country. Injury. 52(2):219-224, 2021 Feb.Injury. 52(2):219-224, 2021 Feb. Observational-Dx 165 patients 2
42. Cremonini C, Lewis MR, Jakob D, Benjamin ER, Chiarugi M, Demetriades D. Diagnosing penetrating diaphragmatic injuries: CT scan is valuable but not reliable. Injury. 53(1):116-121, 2022 Jan.Injury. 53(1):116-121, 2022 Jan. Observational-Dx 230 patients To evaluate the diagnostic ability of chest X-ray (CXR) and CT in patients with proven diaphragmatic injuries (DI). 230 patients were included, 62 (27%) of which had isolated pDI, while 168 (73%) had associated abdominal or chest trauma. Of the 221 patients with proven DI and preoperative CXR, the CXR showed hemo/pneumothorax in 99 (45%), elevated diaphragm in 51 (23%), and diaphragmatic hernia in 4 (1.8%). In 86 (39%) patients, the CXR was normal. In 126 patients with pDI and preoperative CT, imaging showed hemo/pneumothorax in 95 (75%), hemoperitoneum in 66 (52%), pneumoperitoneum in 35 (28%), definitive DI in 56 (44%), suspected DI in 26 (21%), and no abnormality in 3 (2%). Of the 57 patients with isolated pDI the CXR showed a hemo/pneumothorax in 24 (42%), elevated diaphragm in 14 (25%) and was normal in 24 (42%). 2
43. Berg RJ, Inaba K, Recinos G, et al. Prospective evaluation of early follow-up chest radiography after penetrating thoracic injury. World J Surg. 37(6):1286-90, 2013 Jun. Review/Other-Dx 88 patients To evaluate the ability of "early" repeat chest x-ray, at intervals approaching 1 h, to exclude clinically significant injury. One of the 88 patients with initially normal chest x-ray underwent tube thoracostomy at the discretion of the attending surgeon before any repeat imaging. Of the remaining patients, 4 of 87 (4.6 %) demonstrated radiographic abnormalities on "early" repeat imaging. Two patients had pneumothoraces, successfully managed without intervention; the remaining two demonstrated evidence of hemothorax, subsequently undergoing tube thoracostomy. Two more patients (2.3 %) developed pneumothoraces on "delayed" imaging, both successfully observed without intervention. 4
44. Sander A, Spence R, Ellsmere J, et al. Penetrating abdominal trauma in the era of selective conservatism: a prospective cohort study in a level 1 trauma center. Eur. j. trauma emerg. surg.. 48(2):881-889, 2022 Apr. Observational-Dx 805 patients To compare the presentation; management; and outcomes of patients with PAT managed operatively versus non-operatively. Over the 2-year study period, 805 patients with PAT were managed. There were 502 (62.4%); and 303 (37.6%) patients with gunshot (GSW) and stab wounds (SW), respectively. The majority were young men (94.7%), with a mean age of 28.3 years (95% CI 27.7-28.9) and median ISS of 13 (IQR 9-22). Successful non-operative management was achieved in 304 (37.7%) patients, and 501 (62.5%) were managed operatively. Of the operative cases, 477 (59.3%) underwent immediate laparotomy and 24 (3.0%) DOM. On univariate analysis, number; location; and mechanism of injuries were not associated with DOM. Rates of therapeutic laparotomy were achieved in 90.3% in the immediate, and 80.3% in the DOM cohorts. The mortality rate was 1.3, 11.3 and 0% in the in the NOM, immediate laparotomy and DOM subgroups, respectively. The rate of complications was no different in the immediate and DOM cohorts (p > 0.05). 2
45. Singh N, Hardcastle TC. Selective non operative management of gunshot wounds to the abdomen: a collective review. [Review]. Int Emerg Nurs. 23(1):22-31, 2015 Jan. Review/Other-Dx 37 studies (21330 patients) 4
46. Jawad H, Raptis C, Mintz A, Schuerer D, Mellnick V. Single-Contrast CT for Detecting Bowel Injuries in Penetrating Abdominopelvic Trauma. AJR Am J Roentgenol 2018;210:761-65. Observational-Dx 274 patients To conduct a retrospective review of electronic medical records at our institution to assess the accuracy of single-contrast CT for diagnosing bowel injuries in cases of penetrating abdominopelvic trauma. A total of 274 patients (median age, 27 years old) met our inclusion criteria; 77% had sustained gunshot wounds (GSWs). CT showed bowel injury in 173 cases; surgery revealed bowel injury in 162 cases. CT had 142 true-positive, 31 false-positive, 81 true-negative, and 20 false-negative cases, resulting in sensitivity of 88%, specificity of 72%, positive predictive value of 82%, and negative predictive value of 80% for detecting bowel injuries. CT had the highest sensitivity and specificity in patients with multiple GSWs (94% and 79%, respectively) and those with injuries to the stomach and rectum. 2
47. Munera F, Morales C, Soto JA, et al. Gunshot wounds of abdomen: evaluation of stable patients with triple-contrast helical CT. Radiology 2004;231:399-405. Observational-Dx 27 patients To assess helical computed tomography (CT) with contrast material administered intravenously, orally, and rectally (triple contrast helical CT)) in the prospective evaluation of stable patients with abdominal gunshot wounds in whom there is no clinical indication for immediate exploratory laparotomy. CT demonstrated abnormalities in 27 (57%) patients. Laparotomy was performed in 11 (23%) patients; 10 procedures were therapeutic and one was nontherapeutic. The remaining 20 patients had a negative CT scan. These patients were treated conservatively. One injury was missed at CT. For prediction of the need for laparotomy, sensitivity of CT was 96%; specificity, 95%; positive predictive value, 96%; negative predictive value, 95%; and accuracy, 96%. 2
48. Burack JH, Kandil E, Sawas A, et al. Triage and outcome of patients with mediastinal penetrating trauma. Ann Thorac Surg 2007;83:377-82; discussion 82. Observational-Dx 53 patients To conduct detailing an experience with echocardiography and contrast-enhanced helical computed tomographic angiographic (CTA) scans in the evaluation of stable patients with mediastinal penetrating trauma (MPT). Between 1997 and 2003, 207 patients had MPT. Seventy-two (35%) were unstable (45 gun shot wounds, 27 stab wounds) and 19 died in the emergency department. Fifty-three had emergent intervention and 32 survived. Work-up was done on 135 stable patients (65%) consisting of 46 gunshot wounds and 89 stab wounds, of which 5 had a positive TTE result and underwent a repair of a cardiac injury. CTA evaluation was normal in almost 80% of patients, who subsequently did not require further evaluation or treatment. In the stable patients, endoscopy or esophagography confirmed one tracheal injury and no esophageal injury. In the entire group, 10 patients (7%) had occult injury, and there were no deaths or missed injuries. 2
49. Hershkovitz Y, Shohat S, Kessel B, Schecter WP, Beicker A, Jeroukhimov I. Selective Management of Multiple Anterior Abdominal Stab Wounds: Is it Safe?. Isr Med Assoc J. 21(5):330-332, 2019 May. Observational-Dx 169 patients To evaluate whether multiple AASWs are associated with an increased risk of intra-abdominal injury requiring emergency surgery. The study included 169 patients. Of these, 143 patients had a single AASW and 26 had multiple AASWs. There were no differences between the groups regarding demographics, severity of injury, intra-abdominal penetration, specific organ injury, LOS, or LICU. There was no difference in the percentage of patients requiring laparotomy. The overall mortality was 2.36% (4/169). There was no significant difference in the mortality rate between the groups (P = 0.11). 2
50. Nguyen BM, Plurad D, Abrishami S, Neville A, Putnam B, Kim DY. Utility of Chest Computed Tomography after a "Normal" Chest Radiograph in Patients with Thoracic Stab Wounds. American Surgeon. 81(10):965-8, 2015 Oct. Review/Other-Dx 386 patients To determine the incidence of missed injuries detected on CCT after a negative chest radiograph (CXR) in patients with thoracic stab wounds. Of 386 patients with stab wounds to the chest, 154 (40%) underwent both CXR and CCT. One hundred and fifteen (75%) had a negative screening CXR. CCT identified injuries in 42 patients (37%) that were not seen on CXR. Pneumothorax and/or hemothorax occurred in 40 patients (35%), of which 14 patients underwent tube thoracostomy. Two patients had hemopericardium on CCT and both required operative intervention. Greater than one-third of patients with a normal screening CXR were found to have abnormalities on CCT. Future studies comparing repeat CXR to CCT are required to further define the optimal diagnostic strategy in patients with stab wounds to chest after normal screening CXR. 4
51. Augustin P, Guivarch E, Tran-Dinh A, Pellenc Q, Tanaka S, Montravers P. Usefulness of CT-scan in the management of chest stab trauma: a prospective observational study. European Journal of Trauma & Emergency Surgery. 46(6):1385-1391, 2020 Dec. Observational-Dx 153 patients To perform an efficient imaging strategy. Compared to chest X-ray, computed tomography (CT) scan has a higher sensitivity 153 patients were included. There were 92 patients with normal chest X-ray. 67 of them received a CT-scan. 34 (51%) patients had an abnormal CT-scan, including 19 (21%) patients with thoracic new findings, with 3 (4.5%) modification of management. There were 50 patients who had an abnormal chest X-ray. 31 of them received a CT-scan, and 31 (100%) had an abnormal CT-scan, including 19 thoracic new findings, with 11 (36%) modifications of management. The diagnostic performance of CT-scan for TDI was: sensitivity 50%; specificity 95%; NPV 72%; PPV 88%. 2
52. 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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