Gary H. Danton

Autopsies are the gold standard for determining traumatic deaths causes, but rates have been decreasing. Postmortem computed tomography is an alternative; however, its utility and feasibility in patients who have undergone interventions is unknown. In addition, questions remain about artifacts caused by surgical interventions and postmortem putrefaction. We hypothesized that postmortem computed tomography is a rapid, reliable, and practical alternative to trauma autopsy, even in patients who underwent invasive interventions. All postmortem computed tomography scans at our trauma center from March 2023 to April 2024 were retrospectively reviewed and divided into those who received invasive interventions, defined as thoracostomy, thoracotomy, or laparotomy, and those who did not. Injury severity score pre- and postpostmortem computed tomography was compared between groups. postmortem computed tomography scans were reviewed to investigate missed injuries and the presence of ectopic air. In total, 54 patients received postmortem computed tomography, with a mean age of 42 ± 18 years. Most were male (78%) with blunt injury (82%). The median time from death to postmortem computed tomography was 126 minutes. Among the 25 patients (46%) who underwent invasive interventions, Injury Severity Score increased from 10 to 48 after postmortem computed tomography (P < .001). In the no-intervention group, Injury Severity Score increased similarly after postmortem computed tomography (3 vs 50, P < .001). Hepatic gas was seen in 70% and intracardiac air in 56% of patients. Time from death to postmortem computed tomography was similar in patients with and without hepatic gas and intracardiac air (P > .05). Postmortem computed tomography increases Injury Severity Score in patients who received invasive interventions and can identify injuries that may be missed on autopsy, such as ectopic air, making it a rapid and reliable alternative to autopsy. [Display omitted]

Use of whole-body CT scan (WBCT) is widespread in the evaluation of traumatically injured patients and may be associated with improved survival. WBCT protocols include the use of IV contrast unless there is a contraindication. This study tests the hypothesis that using plain WBCT scan during the global contrast shortage would result in greater need for repeat contrast-enhanced CT, but would not impact mortality, missed injuries, or rates of acute kidney injury (AKI).
All trauma encounters at an academic level-I trauma center between March 1, 2022 and June 24, 2022, excluding burns and prehospital cardiac arrests, were reviewed. Imaging practices and outcomes before and during contrast shortage (beginning May 3, 2022) were compared.
The study population included 1,109 consecutive patients (72% male), with 890 (80%) blunt and 219 (20%) penetrating traumas. Overall, 53% of patients underwent WBCT and contrast was administered to 73%. The overall rate of AKI was 6% and the rate of renal replacement therapy (RRT) was 1%. Contrast usage in WBCT was 99% before and 40% during the shortage (p < 0.001). There was no difference in the rate of repeat CT scans, missed injuries, AKI, RRT, or mortality.
Trauma imaging practices at our center changed during the global contrast shortage; the use of contrast decreased despite the frequency of trauma WBCT scans remaining the same. The rates of AKI and RRT did not change, suggesting that WBCT with contrast is insufficient to cause AKI. The missed injury rate was equivalent. Our data suggest similar outcomes can be achieved with selective IV contrast use during WBCT.

Ventilator associated pneumonia (VAP) is defined by the American College of Surgeons Trauma Quality Improvement Program (ACS TQIP) using laboratory findings, pathophysiologic signs/symptoms, and imaging criteria. However, many critically ill trauma patients meet the non-specific laboratory and sign/symptom thresholds for VAP, so the TQIP designation of VAP depends heavily upon imaging evidence. We hypothesized that physician opinions widely vary regarding chest radiograph findings significant for VAP.
The TQIP Spring 2021 Benchmark Report (BR) was used to identify 14 patients with VAP at an academic Level 1 Trauma Center. Critically ill trauma patients (n = 7) who spent at least four days intubated and met TQIP's laboratory and sign/symptom thresholds for VAP but did not appear as VAPs on the BR comprised the control group. For each deidentified patient, four successive chest radiographic images were compiled and arranged chronologically. Cases and controls were randomly arranged in digital format. Blinded physicians (n = 27) were asked to identify patients with VAP based solely on imaging evidence.
Radiographic evidence of VAP was highly subjective (Krippendorff α = 0.134). Among physicians of the same job description, inter-rater reliability remained low (α = 0.137 for trauma attending physicians; α = 0.141 for trauma fellows; α = 0.271 for radiologists). When majority judgment was compared to the TQIP BR, there was disagreement between the two tests (Cohen κ = 
0.071; sensitivity, 64.3%; specificity, 28.6%).
Current definitions of VAP rely on subjective imaging interpretation and ignore the reality that there are numerous explanations for opacities on CXR. The inconsistency of physicians' imaging interpretation and protean physiologic findings for VAP in trauma patients should preclude the current definition of VAP from being used as a quality improvement metric in TQIP.

We present a case report of the successful use of thoracic epidural analgesia for the surgical resection of a large recurrent desmoid tumor and forequarter amputation in an adolescent male. Spinal anesthesia has been reported for intra-operative management of desmoid tumor resection, however, there are no reported cases of thoracic epidural analgesia for this tumor. Thoracic epidural should be used with caution in this patient population due to risk of de novo tumor creation but can be useful adjuvant to multi-modal analgesia to decrease post-operative opioid requirement.

Penetrating abdominal trauma comprises a wide variety of injuries that will manifest themselves at imaging depending on the distinct mechanism of injury. The use of computed tomography (CT) for hemodynamically stable victims of penetrating torso trauma continues to increase in clinical practice allowing more patients to undergo initial selective non-surgical management. High diagnostic accuracy in this setting helps patients avoid unnecessary surgical intervention and ultimately reduce morbidity, mortality and associated medical costs. This review will present the evidence and the controversies surrounding the imaging of patients with penetrating abdominopelvic injuries. Available protocols, current MDCT technique controversies, organ-specific injuries, and key MDCT findings requiring intervention in patients with penetrating abdominal and pelvic trauma are presented. In the hemodynamically stable patient, the radiologist will play a key role in the triage of these patients to operative or nonoperative management.

Diaphragmatic Injuries (DIs) remain a challenging diagnosis with potential catastrophic delayed complications. A high degree of suspicion in every case of severe blunt thoracoabdominal trauma or penetrating thoracoabdominal injury is essential. This review will present the evidence and controversies on this topic providing a practical tutorial for radiologists hoping to improve their interpretive accuracy for both blunt and penetrating DIs. The imaging signs of diaphragmatic injuries will be explained with emphasis on multidetector CT. Diagnostic pitfalls, available protocols and other issues will be presented.

Blunt chest trauma, a frequent component of trauma admissions, is the second leading cause of death in motor-vehicle accidents. Additionally, it may be associated with significant morbidity in those who survive. Radiography, ultrasonography, and computed tomography (CT) have a widespread role in evaluating blunt chest trauma, importantly aiding in the diagnosis and management of injury. Herein, we discuss the most common salient injuries, imaging protocol considerations and imaging findings associated with acute blunt chest trauma.

Gastric duplication cysts are an extremely rare anomaly with few reported cases in association with accessory pancreatic tissue. Diagnosis can be challenging given a presentation of recurrent pancreatitis and resemblance to pancreatic pseudocysts. We report the case of a 6-year old boy with multiple episodes of pancreatitis who was discovered to have an accessory pancreatic lobe connected to a gastric duplication cyst, successfully treated with surgical excision.

Pregnancy increases the risk for thromboembolic disease. CT pulmonary angiogram (CTPA) is widely used for the diagnosis of pulmonary embolus (PE); however, a significant number of scans are suboptimal or non-diagnostic in pregnant patients. This phenomenon is attributed to physiology during the gravid state. The aim of this study is to examine whether all stages of pregnancy are similarly at risk for suboptimal scans.Pregnant patients who had CTPA scans between February 2008 and November 2014 were included. The attenuation in the major pulmonary arteries was compared among patients and controls. An attenuation of 200 Hounsfield units (HU) was used as a cutoff between adequate and suboptimal studies. Statistical analysis compared attenuation means and number of arteries with adequate versus suboptimal attenuation.Forty patients were included in the study. Nine were at or below 13 weeks of pregnancy and 31 between week 14 and term. A control group of 14 non-pregnant women of similar age were also included. All arteries showed a significantly higher attenuation in early pregnancy and in the control group compared to later in pregnancy, p < 0.05. Fewer suboptimal opacified arteries were found in early pregnancy (11.1%) and controls (5.7%) compared to later in pregnancy (33.3%), p < 0.01.Patients in early pregnancy are more likely to have a technically successful CTPA scan compared to later in pregnancy and show similar opacification to non-pregnant women. This suggests a possible paradigm shift from the current approach to suspected PE in pregnant patients.

Patients with lung cancer present to the emergency department (ED) in a variety of ways. Symptoms are often nonspecific and can lead to a delay in diagnosis. Here, a lung cancer mimicked two illnesses, adding to the diagnostic complexity. This case highlights diagnostic pitfalls as well as advantages and limitations of imaging utilized in the emergency setting. We report a case of an occult lung cancer occluding a pulmonary vein, which at first mimicked pneumonia and later a pulmonary embolism (PE) and arterial lung infarction. The patient presented to the ED with cough and a lung opacity on chest radiograph that was treated with antibiotics. However, recurrent visits to the ED with similar complaints were further investigated with computed tomography angiogram (CTA). At first the scan was considered positive for PE. Further inspection revealed that the CTA findings were not typical for PE, but rather a slow flow state likely caused by an occult mass occluding a pulmonary vein with venous infarction. Biopsy revealed a lung adenocarcinoma. In addition to the case presentation, the typical signs of PE on CTA with correlating images and diagnostic pitfalls are discussed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: This case report raises two themes that can be of interest to emergency physicians. The first is that lung cancer has many guises. Here it mimicked two distinctly different diseases, pneumonia and PE. The second is that, although CTA is highly sensitive and specific for diagnosing PE, it has limitations that may lead to false positive readings. When clinical signs and symptoms fail to correlate with the imaging diagnosis, alternative explanations should be sought.