Alexander L Eastman1, Vijay Muraliraj, Jason L Sperry, Joseph P Minei. 1. The Division of Burns, Trauma and Critical Care, Department of Surgery, The University of Texas Southwestern Medical Center, Dallas, Texas, USA. alexander.eastman@utsouthwestern.edu
Abstract
BACKGROUND: Advances in computed tomography capabilities have enabled trauma surgeons to screen for and diagnose the severity of blunt cervical vascular injury (BCVI) using computed tomographic angiography (CTA) alone. We hypothesized that the use of CTA-alone screening and diagnostic methods would reduce the time interval from admission to diagnosis and, hence, also reduce the stroke rates associated with these injuries. METHODS: All patients admitted to a level I trauma center after December 1999 at risk for BCVI were screened. Until March 2005, patients were screened with cervical catheter angiography (CA). Subsequently, a CTA-alone screening/diagnostic program was initiated simultaneously with standardized interdisciplinary treatment guidelines for BCVI. Data for controls were subsequently obtained by reviewing trauma registry records. RESULTS: Of 3012 trauma service admissions from April 2005 to July 2006, 26 patients were found to have BCVI diagnosed by CTA alone. A standardized, injury grade-based set of treatment guidelines were then initiated immediately based on CTA findings. Time to diagnosis and stroke rate in these patients were then compared with 79 patients found to have BCVI from December 1999 to March 2005 during CA-based screening. There were no differences in sex, mean age, Injury Severity Score, head/neck Abbreviated Injury Scale, or arrival Glasgow Coma Scale between the CA and CTA groups. With CA-based screening, the mean +/- SD time from trauma center admission to diagnosis was 31.2 +/- 41.1 hours. After transition to CTA screening in March 2005, this time was reduced to 2.65 +/- 3.3 hours (p < 0.001). During the era of CA-based screening, the overall stroke rate for BCVI at our institution was 15.2% (n = 12 of 79). After the initiation of CTA-based screening, the stroke rate was reduced to 3.8% (n = 1 of 26, p = 0.046). CONCLUSIONS: The initiation of a CTA-based screening and diagnostic program, along with interdisciplinary standardized treatment guidelines, reduced the time to diagnosis of BCVI 12-fold and the institutional stroke rate due to BCVI fourfold. This may be due to earlier diagnosis and initiation of definitive therapy.
BACKGROUND: Advances in computed tomography capabilities have enabled trauma surgeons to screen for and diagnose the severity of blunt cervical vascular injury (BCVI) using computed tomographic angiography (CTA) alone. We hypothesized that the use of CTA-alone screening and diagnostic methods would reduce the time interval from admission to diagnosis and, hence, also reduce the stroke rates associated with these injuries. METHODS: All patients admitted to a level I trauma center after December 1999 at risk for BCVI were screened. Until March 2005, patients were screened with cervical catheter angiography (CA). Subsequently, a CTA-alone screening/diagnostic program was initiated simultaneously with standardized interdisciplinary treatment guidelines for BCVI. Data for controls were subsequently obtained by reviewing trauma registry records. RESULTS: Of 3012 trauma service admissions from April 2005 to July 2006, 26 patients were found to have BCVI diagnosed by CTA alone. A standardized, injury grade-based set of treatment guidelines were then initiated immediately based on CTA findings. Time to diagnosis and stroke rate in these patients were then compared with 79 patients found to have BCVI from December 1999 to March 2005 during CA-based screening. There were no differences in sex, mean age, Injury Severity Score, head/neck Abbreviated Injury Scale, or arrival Glasgow Coma Scale between the CA and CTA groups. With CA-based screening, the mean +/- SD time from trauma center admission to diagnosis was 31.2 +/- 41.1 hours. After transition to CTA screening in March 2005, this time was reduced to 2.65 +/- 3.3 hours (p < 0.001). During the era of CA-based screening, the overall stroke rate for BCVI at our institution was 15.2% (n = 12 of 79). After the initiation of CTA-based screening, the stroke rate was reduced to 3.8% (n = 1 of 26, p = 0.046). CONCLUSIONS: The initiation of a CTA-based screening and diagnostic program, along with interdisciplinary standardized treatment guidelines, reduced the time to diagnosis of BCVI 12-fold and the institutional stroke rate due to BCVI fourfold. This may be due to earlier diagnosis and initiation of definitive therapy.
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