Content uploaded by Johan G. Blickman
Author content
All content in this area was uploaded by Johan G. Blickman
Content may be subject to copyright.
REVIEW ARTICLE
Advanced Trauma Life Support®. ABCDE from a radiological
point of view
Digna R. Kool & Johan G. Blickman
Received: 3 April 2007 / Revised: 8 May 2007 /Accepted: 19 May 2007 / Published online: 12 June 2007
#
Am Soc Emergency Radiol 2007
Abstract Accidents are the primary cause of death in
patients aged 45 years or younger. In many countries,
Advanced Trauma Life Support® (ATLS®) is the founda-
tion on which trauma care is based. We will summarize the
principles and the radiological aspects of the ATLS®, and
we will discuss discrepancies with day to day practice and
the radiological literature. Beca use the ATLS® is neither
thorough no r u p-to-date concerning several parts of
radiology in trauma, it should not be adopted without
serious attention to defining the indications and limitations
pertaining to diagnostic imaging.
Keywords Trauma
.
Diagnostic imaging
.
Radiology
.
Thorax
.
Abdomen
.
Spine
Abbreviations
ATLS® Advanced Trauma Life Support®
FAST focused abdominal sonography in trauma
A airway
B breathing
C circulation
D disability
E environment and exposure
CT computed tomography
Introduction
In many countries, trauma care is based on Advanced
Trauma Life Support® (ATLS®) [1]. Althoug h the ATLS®
manual and course are neither evidence based nor up-to-
date concerning several parts of radiology in trauma,
surgeons use the ATLS® recommendations, if present,
routinely to support indications for diagnostic imaging. In
addition, surgeons refer to th e ATLS® unjustly with
indications for imaging that are not supported by the
ATLS® at all. Radiologists must be aware of this to
intervene appropriately when sub-optimal imaging indica-
tions are presented. In this respect, knowing the content and
the language of the ATLS can be helpful.
The objective of this review is to familiarize radiologist
with the ATLS®. For this purpose, the rationale and
indications of diagnostic imaging is assessed where it
pertains to the ATLS® protocol. Instances of disagreement
with the evidence in the literature and daily practice are
highlighted [1].
Purpose of ATLS®
Accidents are the primary cause of death in patients aged
45 years or younger. In The Netherland s, 22 out of 100,000
people die each year because of accidental injury. For every
one patient who dies, there are three survivors with serious
disabilities [1, 2].
The purpose of adequate trauma care is to decrease this
morbidity and mortality, which is expected to be achieved by
fast, systematic, and effective assessment and treatment of the
injured patient. Contrary to the ATLS guidelines, we think that
imaging should play a prominent role in this process.
Emerg Radiol (2007) 14:135–141
DOI 10.1007/s10140-007-0633-x
D. R. Kool (*)
:
J. G. Blickman
Department of Diagnostic Imaging,
University Medical Centre Nijmegen,
Geert Groote plein 10, route 667,
P.O. Box 9101, 6500 HB Nijmegen, The Netherlands
e-mail: d.kool@rad.umcn.nl
History of ATLS®
In 1976, an airplane with an orthopedic surgeon, his wife
and children crashed in a corn field in Nebraska. The wife
died. The surgeon and three of his four children were
seriously injured. Although they survived, he considered
the standard of care in the local hospital insufficient and
decided to develop a system to improve the care for trauma
victims, and thus, ATLS® was born.
Since the first ATLS® course in 1978, the concept has
matured, has been disseminated around the world and has
become the standard of emergency care in trauma patients
in 46 countries [1].
The ATLS® concept is also used in the pre-hospital
phase of trauma patient care and has been adopte d for non-
trauma medical emergencies and implemented in resuscita-
tion protocols around the world.
Originally, ATLS® was designed for emergency situa-
tions where only one doctor and one nurse are present.
Nowadays, ATLS® is also accepted as the standard of care
for the first (golden) hour in level-1 trauma centers. The
priorities of emergency trauma care according to the
ATLS® principles are independent of the number of people
caring for the patient.
ATLS® course
The ATLS® course is organized under license of the
American College of Surgeons. Before the course, the
students peruse the course manual. During a 2-day course,
16 students, mostly residents in surgery and anesthesiology,
are trained by eight instructors. These instructors now
number more than 100 in the Dutch ATLS® secti on, mostly
surgeons and anesthesiologists but also two radiologists.
During the course, all emergency measures are taught
and reviewed. By means of observing, practicing, and
repeating the ATLS® concepts, the object of the course is
that the students are capable to perform the necessary
measures independently with the correct priorities.
The course concludes with a written and practical
examination, which has a pass rate of 80–90%.
During the course, attention is also g iven to the
multidisciplinary character of trauma care and the organi-
zation and logistics of traumacareinhospitalsand
surrounding area.
Radiology has a minor part in the course There are only
50 min to teach the systematic evaluation of chest radio-
graphs and another 50 min to teach in cervical spine
radiographs, with the objective for the student to be able to
identify life-threatening and potentially life-threatening
injuries on chest radiographs and identify fractures on the
radiographs of the spine. There is no lecture or skill set
concerning computed tomography (CT).
Essentials of ATLS®
ATLS® is a method to establish priorities in emergency
trauma care. There are three underlying premises. (1) Treat
the greatest threat to life first. (2) Indicated treatment must
be applied even when a definitive diagnosis is not yet
established. (3) A detailed hist ory is not necessary to begin
evaluation and treatment.
Therefore, the assessment of a trauma patient is divided in
a primary and a secondary survey. In the primary survey, life-
threatening injuries are diagnosed and treated simultaneously.
All other injuries are evaluated in the secondary survey.
Primary survey
In the primary survey, the mnemonic ABCDE is used to
remember the order of assessment with the purpose to treat
first that kills first (Table 1). Airway obstruction kills
quicker than difficulty of breathing caused by a pneumo-
thorax, and a patient dies faster from bleeding from a
splenic laceration then from a subdural hematoma.
Injuries are diagnosed and treated according to the ABCDE
sequence. Only when abnormalities belonging to a letter are
evaluated and treated as efficacious as possible can one
continue with the next letter. In case of deterioration of a
patient’s condition during assessment, one should return to
‘A.’ Imaging should not intervene with or postpone treatment.
A: Airway
The airway is the first priority in trauma care. All patients
get 100% oxygen through a non-rebreathing mask. The
airway is not compromised when the pati ent talks normally.
A hoarse voice or audible breathing is suspicious; facial
fractures and soft tissue injury of the neck can compromise
the airway, while patients in a coma are not capable of
Table 1 In the primary survey, the mnemonic ABCDE is used to
remember the order of assessment with the purpose to treat first that
kills first
The ABCDE
A Airway and C-spine stabilization
B Breathing
C Circulation
D Disability
E Environment and Exposure
136 Emerg Radiol (2007) 14:135–141
keeping their airway patent. Endotracheal intubation is the
most definite way to secure the airway.
In ‘A,’ the cervical spine needs to be immobilized. As
long as the cervical spine is not cleared by physical
examination, with or without diagnostic imaging, the spine
should remain stabilized.
For the evaluation of ‘A,’ no diagnostic ima ging is
necessary. Imaging of the cervical spine is just an adjunct to
the primary survey and not part of the ‘A,’ specifically
because, as long as the spine is immobilized, possible
spinal injury is stabilized and diagnostic imaging can be
postponed. W hen ‘A’ is secure, one can continue with ‘B.’
B: Breathing
Breathing is the second item to be evaluated in trauma care.
Tension pneumothorax, massive hemothorax, flail thorax
accompanied by pulmonary contusion, and an open pneu-
mothorax compromise breathing acutely and can be diag-
nosed with physical examination alone and should be treated
immediately. Most clinical problems in ‘B’ can be treated
with relatively simple measures as endotracheal intubation,
mechanical ventilatio n, ne edle thorac ocentesis, or tube
thoracostomy. The lack of a definitive diagnosis should
never delay an indicated treatment. To evaluate the efficiency
of breathing, a pulse oximeter can be applied.
Injuries, like a simple pneumothorax or hemothorax, rib
fractures, and pulmonary contusion, are often more difficult
to appreciate with physical examination. Because these
conditions have less effect on the clinical condition of the
patient, they can be identified in the secondary survey.
A chest radiograph is an adjunct to the primary survey
and can be helpful in evaluating breat hing difficulties and is
necessary to evaluate the position of tubes and lines. When
‘B’ is stabilized, one can continue with ‘C.’
C: Circulation
Circulation is the third priority in the primary survey.
Circulatory problems in trauma patients are usually caused
by hemorrhage. The first action should be to stop the
bleeding. Hemorrhage can be external from extremity and
facial injury or not visible from bleeding in chest, abdomen,
and pelvis. Instable pelvic fractures can be temporarily
stabilized with a pelvic band to decrease blood loss.
Blood pressure and heart rate are measured; two intrave-
nous lines are started, and blood is obtained for laboratory
investigation.
In the search for internal blood loss, imaging can be very
helpful. Radiological investigations such as a chest radio-
graph, when not already performed, ultrasound of the
abdomen (focussed abdominal sonography in trauma, FAST)
and a pelvic X-ray can suggest the localization of the bleeding.
A tension pneumothorax can be the cause of circulatory
distress but is usually diagnosed and treated in ‘B.’ When a
patient’s condition deteriorates, this diagnosis must be
reconsidered. Hemodynamic instability can, infrequently,
be caused by pericardial tamponade. Therefore, ultrasonog-
raphy of the pericardial sac is part of a FAST examination.
Other less frequently occurring causes of circulatory
problems in trauma patients are myocardial contusion and
loss of sympathetic tone caused by cervical and upper
thoracic spinal cord injuries.
When it is not possible to stabilize the patient in the
trauma suite, other intervention like operation or emboliza-
tion should be performed. The remainder of the primary
survey will be finished thereafter. When ‘C’ is stabilized,
one can continue with ‘D.’
D: Disability
Disability should be assessed as the fourth priority in the
primary survey, and this includes asse ssment of the
neurological status. The Glasgow coma score (GCS) is
used to evaluate the severity of head injury. This score is
arrived at by scoring eye opening, best motor response, and
best verbal response. Patients who open their eyes
spontaneously, obey commands, and are normally oriented
score a total of 15 points. The worst score is 3 points. A
decreased GCS can be caused by a focal brain injury, such
as an epidural hematoma, a subdural hematoma, or a
cerebral contusion, and by diffuse brain injuries ranging
from a mild contusion to diffuse axonal injury. To prevent
secondary injury to the brain, optimal oxygenation and
circulation are importan t. Also, impaired consciousness can
be caused or aggrava ted by hypoxia or hypotension for
which ABC stabilization is essential.
If a cranial CT is indicated, it should be done in the
secondary survey.
E: Environment and exposure
Environment and exposure represent hypothermia, burns,
and possible exposure to chemical and radioactive sub-
stances and should be evaluated and treated as the fifth
priority in the primary survey.
At the end of the primary survey, before continuing with
the secondary survey, the ABCDEs should be re-evaluated
and confirmed.
Secondary survey
During the secondary survey, the patient is examined from
head to toe, and appropriate additional radiographs of the
thoracic and lumbar spine and the extremities are performed
Emerg Radiol (2007) 14:135–141 137
when indicated. CT scans, when indicated, are also done in
the secondary survey.
If, during the secondary survey, the patient’s condition
deteriorates, the primary survey should be repeated begin-
ning with ‘A.’
The rigid spine board should be removed as early as
possible because it is a serious risk for decubitus ulcer
formation. Removing the hard backboard should not be
delayed for the lone purpose of obtaining definitive spine
radiographs.
Diagnostic imaging
Radiographs of the chest, pelvis, C-spin e, and FAST are
adjuncts to the primary survey.
Imaging is considered helpful but should be used
judiciously and should not interrupt or delay the resus cita-
tion process. When appropriate, radiography may be
postponed until the secondary survey.
CT, contrast studies, and radio graphs of the thoracic
spine, lumbar spine, and extremities are also adjunc ts to the
secondary survey.
Imaging is most useful and efficient if consulting with a
radiologist becomes routine [3, 4]. We extrapolate this
advice to the trauma setting and endorse consultation with
clinicians strongly; however, consulting a radio logist is not
mentioned once in the ATLS® manual!
Contrary to (ever-increasing) daily practice, CT plays a
minor role in the ATLS®. With the increasing use of CT in
the evaluation of trauma patients, radiation exposure should
be a major issue in the field of emergency radiology. CT
scanners using an automatic exposure control techniqu e can
help to reduce radiation dose [5, 6].
Blunt trauma
Thorax
A chest radiograph must be obtained to document the
position of tubes and lines and to evaluate for pneumotho-
rax o r hemothorax and mediastinal abnormalities. When not
obtained in the primary survey, it should be done in the
secondary survey. From the ATLS® manual, it is not clear if
a chest radiograph should be performed in every patient [1].
However, this is in accordance with the literature. At
present, no clinical decision rule is available concerning the
indication for chest radiography in trauma patients.
A CT of the chest is considered an accurate screening
method for traumatic aortic injury. If a contrast enhanced
helical CT is negative for mediastinal hemorrhage and aortic
injury, no additional diagnostic imaging is necessary [1].
If a CT is positive, the ATLS® manual states that the
trauma surgeon is in the best position to determine which, if
any other, diagnostic imaging is warranted. The possibility
to construct multiplanar reconstructions (MPRs), maximum
intensity projections (MIPs), volumetric, and v irtual angio-
scopic three-dimensional views from MDCT data, making
diagnostic angiography superfluous, is not stated [7]. The
same post-processing tools can be used to differentiate
between traumatic aortic injury and norm al variants [7].
Neither consulting with a radiologist nor endovascular
treatment of traumatic aortic injury are mentioned in the
ATLS® manual.
Although it is recognized that the severity of pulmonary
contusions does not correlate very well with the chest
radiograph, a CT for the evaluation of pulmonary contusion
is not mentioned. The superiority of CT in the detection of
pneumothoraces and evaluation of the position of chest
tubes is not stated [8, 9].
Abdomen
FAST is used in hemodynamic abnormal patients as a rapid,
non-invasive, bedside, repeat able method to document fluid
in the pericardial sac, hepato-renal fossa, spleno-rena l fossa ,
and pelvis or pouch of Douglas. When FAST is available, it
replaces diagnostic peritoneal lavage (DPL) [10]. FAST is a
good performing screening tool in evaluating hypotensive
trauma patients to differentiate those patients who do need
urgent laparo tomy from those who do not [11].
An abdominal CT is the most sensitive and specific
investigation for the diagnosis of visceral and vascular
injury; however, according to the ATLS®, an abdominal CT
can only be performed in hemodynamically normal patients
because a CT is considered time consuming. This is no
longer true with the helical CT available today. The rate-
limiting step has become the movement of the patient to the
CT suite and on and off the CT table [12].
According to the ATLS® manual, an upper GI contrast
study is the imaging method of choice in suspected
diaphragm rupture. CT is not mentioned as an option. On
the contrary, it is stated that CT misses diaphragmatic
injuries. Although CT is not 1 00% sensitive, neither are GI
contrast studies. A comparative study is not available.
MDCT has the advantage that it is much easier and quicker
to perform in trauma patients [1, 13]. Although no consensus
of opinion exists, coronal, and sagittal multiplanar recon-
structions (MPRs) might improve the accuracy of MDCT
for the diagnosis of blunt traumatic diaphragm rupture
[14, 15].
A final omission, and contrary to daily practice in many
hospitals, is that interventional radiology is not mentioned
as an adjunct to non-operative management in patients with
abdominal visceral injury [16, 17 ].
138 Emerg Radiol (2007) 14:135–141
Pelvis
It is recommended that a pelvic radiograph shoul d be
performed when the mechanism of injury or the physical
examination indicates the possibility of a pelvic fracture.
Evaluation of the pelvis on an abdominal CT is not
mentioned [18]. Compared to conventional radiography,
CT has a higher sensitivity and specificity for the diagnosis
of pelvic fractures, and MPRs can be used to delineate the
full extend of the fracture [19, 20].
In a hemodynamically abnormal patient with a pelvic
fracture and no indication for intra-abdominal hemorrhage
on FAST or DPL, angiography with embolization is advised
preceding surgical pelvic fixation.
In patients with an unstable pelvic fracture, inability to
void, blood at the meatus, a scrotal hematoma, perineal
ecchymoses, or a high-riding prostate, there is a suspicion of
a urethral tear, and in these patients, a retrograde urethrogram
should be performed before insertin g a urinary catheter [1].
To exclude an intraperitoneal or extraperitoneal bladder
rupture in patients with hematuria, a conventional or a CT
cystogram can be performed [1, 21].
Cervical spine
Cervical spine radiographs are not indicated in patients who
are awake, alert, sober, neurologically normal, have no neck
pain or midline tenderness, can voluntary move their neck
from side to side, and flex and extend without pain. In all
other patients, a lateral, AP, and open-mouth odontoid view
should be obtained. Although it is not mentioned in the
ATLS® manual, this seems to be a combination of the
Canadian C-spine rules and the Nexus criteria but the cri-
terion ‘painful distracted injury’ has disappeared between
the sixth and the seventh edition of the ATLS manual [1,
22–24]. Possi bly, this was done because the definition of
painful distracting injury is difficult, but if omitted, this
reduces the sensitivity of the clinical decision rule [25].
On the lateral view of the cervical spine film, the base of
the skull to the first thoracic vertebra must be assessed. If
not all seven cervical vertebrae are visualized, a swimmers
view must be obtained and is considered sufficient and safe
[1]. Supine oblique v iews and, contrary to ava ilable
literature, performing a CT scan of this area is not
mentioned [26–28]. Further, of all suspicious areas and all
not adequat ely visualized areas, an axial CT with 3-mm
intervals should be obtained. In the cervical spine section,
multidetector CT as sessment with corona l and sagittal
MPRs is not mentioned at all [1].
Performing a CT of the cervical spine without a
preceding conventional radiograph as the screening method
of choice is not mentioned. The recent ACR appropriate-
ness criteria suggest otherwise [29].
To detect occult instability in patients without an altered
level of consciousness, or those who complain of neck pain,
flexion-extension radiographs of the C-spine may be
obtained [1]. As flexion-extension radiographs are often
non-diagnostic and necessitate movement of the spine that
is potentially dangerous, at least, performing a CT first to
exclude osseous injury or a magnetic resonance imaging
(MRI) for the detection of ligamentous injury should be
recommended today [27, 29, 30].
MRI is recommended in patients with neurological
deficits to detect an epidural hematoma or a traumatic
herniated disc. Contrary to the ACR appropriateness
criteria, the ATLS states that, when a MRI is not available,
CT myelography may be used [1, 29].
Angiography or CT angiography for the evaluation of
injury to the carotid or vertebral artery is not mentioned [1].
Head
Again, according to the protocol, a cranial CT should be
considered in all head-injured patients with a focal neuro-
logic deficit of which the cause can be localized in the brain,
a Glasgow coma scale less than 15, amnesia, loss of
consciousness of more than 5 min, or severe headaches.
This is insufficient to detect all clinical relevant brain injury.
There is no reference to evidence-based clinical decision
rules such as the Canadian head CT rule, the New Orleans
head CT rule or the CHIP prediction rule [1, 31–34].
Thoracic and lumbar spine
The indications for diagnostic imaging are the same as for
the cervical spine. AP and lateral radiographs should be
performed with additional CT of suspicious areas [1].
It is not mentioned that the thoracic and lumbar spine
can be reliably evaluated on a CT of thorax and abdomen.
When a CT of thorax and abdomen has already, or will be,
performed, conventional radiography does not have any
additional value especially when MPRs of the spine are
obtained [35].
Penetrating trauma
Chest
Pneumothorax and hemothorax can be diagnosed with a
chest radiograph. Even in patients with a normal chest
radiograph, a CT is advocated for the evaluation of heart,
pericardium, and great vessels in patients with a suspicion
of mediastinum transversing injury. For the heart and
pericardial sac, a CT can be replaced by ultrasound, and
for the major vessels, an angiography can be performed.
For the evaluation of oesophageal injury, esophagography
Emerg Radiol (2007) 14:135–141 139
using a water-soluble contrast agent and complementary
esophagoscopy should be performed. The trachea and
bronchial tree can be evaluated by bronchoscopy.
Patients with penetrating injury of the lower chest below
the transnipple line anterior and the inferior tip of the
scapula posterior are considered to have abdominal trauma
as well until proven otherwise [1].
Abdomen
A hemodynamically abnormal patient with a penetrating
abdominal wound does not need diagnostic imaging but
should undergo laparotomy immediately.
In a hemodynamically normal patient, an upright chest
radiograph can document intraperitoneal air and is useful to
exclude hemothorax or pneumothorax. An abdominal radio-
graph (supine, upright, or lateral decubitus) may be useful in
hemodynamically normal patients to detect extra-luminal air
in the retroperitoneum or free air under the diaphragm.
In all patients with penetrating abdominal injury, an
emergency laparotomy is a reasonable option, especially in
patients with gunshot wounds. In initially asymptomatic
patients with a lower chest wound or injuries to the back or
flank, the ATLS® considers double or triple contrast CT,
DPL, and serial physical examination less invasive diag-
nostic options, equivalent to each other [1].
For asymptomatic patients with anterior abdominal stab
wounds, DPL, laparoscopy, and serial physical examination
are mentioned as diagnostic options. However, alth ough
there is a significant body of evidence that this may not be
optimal, CT is not ment ioned as a diagnostic option in these
patients [36].
Conclusion
ATLS® is a well-tried systematic approach for the assess-
ment of trauma patients. In multidisciplinary trauma care, it
is beneficial and, maybe, even mandatory for effective
communication that all members of the trauma team,
including the radiologist, speak the same ATLS® language.
Although imaging should not intervene with or postpone
treatment, a chest radiograph, pelvic radiograph, and FAST
can direct treatment decisions and should be performed in
the primary survey when indicated. Imaging of the cervical
spine is also an adjunct to the primary survey but can be
postponed as long as the spine is immobilized. All other
imaging should be done in the secondary survey.
Unfortunately, according to the ATLS®, CT plays a minor
role in the evaluation of trauma victims. In the ATLS®, chest
CT is only mentioned for the diagnosis of traumatic aortic
injury but, in our experience, chest CT is valuable for the
evaluation of pulmonary contusions and hemothorax and
pneumothorax. Nowadays, abdominal CT is less time
consuming than the ATLS® states and can be used to evaluate
the extent of the abdominal injury in patients in whom no
immediate laparotomy is indicated to evaluate the possibilities
for non-operative management with or without endovascular
embolization. The indications for head CT according to the
ATLS® are insufficient to diagnose all patients with signifi-
cant head injury. CT of the cervical spine can be used as a
primary investigating tool and not only as an adjunct to
conventional radiography. When a CT of the chest and
abdomen is indicated, the thoracic and lumbar spine, as well
as the pelvis, can be evaluated on the axial CT images
combined with coronal and sagittal multiplanar reconstruc-
tions, and in these cases, conventional radiography of the
spine and pelvis do not have any additional diagnostic value.
Because the ATLS® is neither thorough nor up-to-date
concerning several parts of radiology in trauma, it should
not be adopted without questions to define indications for
diagnostic imaging. Consultation between clinicians and
radiologists can improve the efficiency and quality of
diagnostic imaging in trauma patients.
References
1. American College of Surgeons Committee on Trauma (2004)
Advanced trauma life support program for doctors, 7th edn.
American College of Surgeons, Chicago
2. World Health Organization (2007) Detailed data files of WHO
mortality database, 2003. WHO, The Netherlands. http://www.
who.int/whosis/database/mort/table1.cfm. Cited May 10, 2007
3. Khor asani R, Silverman SG, Meyer JE, Gibson M, Weissman BN,
Seltzer SE (1994) Design and implementation of a new radiology
consultation service in a teaching hospital. AJR Am J Roentgenol
163(2):457–459 (August)
4. Baker SR (1982) The operation of a radiology consultation service
in an acute care hospital. JAMA 248(17):2152–2154 (November 5)
5. McCollough CH, Bruesewitz MR, Kofler JM Jr (2006) CT dose
reduction and dose management tools: overview of available
options. Radiographics 26(2):503–512 (March)
6. Kalra MK, Rizzo SM, Novelline RA (2005) Reducing radiation
dose in emergency computed tomography with automatic expo-
sure control techniques. Emerg Radiol 11(5):267–274 (July)
7. Mirvis SE (2006) Thoracic vascular injury. Radiol Clin North Am
44(2):181–197, vii (March)
8. Ball CG, Kirkpatrick AW, Fox DL, Laupland KB, Louis LJ,
Andrews GD, Dunlop MP, Kortbeek JB, Nicolaou S (2006) Are
occult pneumothoraces truly occult or simply missed? J Trauma
60(2):294–298 (February)
9. Lim KE, Tai SC, Chan CY, Hsu YY, Hsu WC, Lin BC, Lee KT
(2005) Diagnosis of malpositioned chest tubes after emergency
tube thoracostomy: is computed tomography more accurate than
chest radiograph? Clin Imaging 29(6):401–405 (November)
10. McKenney M, Lentz K, Nunez D, Sosa JL, Sleeman D, Axelrad
A, Martin L, Kirton O, Oldham C (1994) Can ultrasound replace
diagnostic peritoneal lavage in the assessment of blunt trauma?
J Trauma 37(3):439–441 (September)
11. Farahmand N, Sirlin CB, Brown MA, Shragg GP, Fortlage D,
Hoyt DB, Casola G (2005) Hypotensive patients with blunt
140 Emerg Radiol (2007) 14:135–141
abdominal trauma: performance of screening US. Radiology 235
(2):436–443 (May)
12. Ptak T, Rhea JT, Noveline RA (2001) Experience with a
continuous, single–pass whole-body multidetector CT protocol
for trauma: the three-minute multiple trauma CT scan. Emerg
Radiol 8:250–256
13. Killeen KL, Shanmuganathan K, Mirvis SE (2002) Imaging of
traumatic diaphragmatic injuries. Semin Ultrasound CT MR 23
(2):184–192 (April)
14. Sliker CW (2006) Imaging of diaphragm injuries. Radiol Clin
North Am 44(2):199–211, vii (March)
15. Larici AR, Gotway MB, Litt HI, Reddy GP, Webb WR, Gotway
CA, Dawn SK, Marder SR, Storto ML (2002) Helical CT with
sagittal and coronal reconstructions: accuracy for detection of
diaphragmatic injury. AJR Am J Roentgenol 179(2):451–457
(August)
16. Pryor JP, Braslow B, Reilly PM, Gullamondegi O, Hedrick JH,
Schwab CW (2005) The evolving role of interventional radiology
in trauma care. J Trauma 59(1):102–104 (July)
17. Dondelinger RF, Trotteur G, Ghaye B, Szapiro D (2002)
Traumatic injuries: radiological hemostatic intervention at admis-
sion. Eur Radiol 12(5):979–993 (May)
18. Stewart BG, Rhea JT, Sheridan RL, Noveline RA (2002) Is the
screening portable pelvis film clinically useful in multiple trauma
patients who will be examined by abdominopelvic CT? Experi-
ence with 397 patients. Emerg Radiol 9:266–271
19. Lesc hka S, Alkadhi H, Boehm T, Marincek B, Wildermuth S
(2005) Coronal ultra-thick multiplanar CT reconstructions
(MPR) of the pelvis in the multiple trauma patient: a n alternative
for the initial conventional radiograph. Rofo 177(10):1405–1411
(October)
20. Wedegartner U, Gatzka C, Rueger JM, Adam G (2003) Multislice
CT (MSCT) in the detection and classification of pelvic and
acetabular fractures. Rofo 175(1):105–111 (January)
21. Corriere JN Jr, Sandler CM (2006) Diagnosis and management of
bladder injuries. Urol Clin North Am 33(1):67–71, vi (February)
22. American College of Surgeons Committee on trauma (1997)
Advan ced trauma life support for doctors, instructor course
manual, 6th edn. American College of Surgeons, Chicago
23. Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De
Maio VJ, Laupacis A, Schull M, McKnight RD, Verbeek R,
Brison R, Cass D, Dreyer J, Eisenhauer MA, Greenberg GH,
MacPhail I, Morrison L, Reardon M, Worthington J (2001) The
Canadian C-spine rule for radiography in alert and stable trauma
patients. JAMA 286(15):1841–1848 (October 17)
24. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI,
National Emergency X-Radiography Utilization Study Group
(2000) Validity of a set of clinical criteria to rule out injury to
the cervical spine in patients with blunt trauma. N Engl J Med 343
(2):94–99 (July 13)
25. Panacek EA, Mower WR, Holmes JF, Hoffman JR (2001) Test
performance of the individual NEXUS low-risk clinical screening
criteria for cervical spine injury. Ann Emerg Med 38(1):22–25
(July)
26. Contractor N, Thomas M (2002) Towards evidence based
emergency medicine: best BETs from Manchester Royal
Infirmary. Swimmers view or supine oblique views to visualise
the cervicothoracic junction. Emerg Med J 19(6):550–551
(November)
27. Hadley MN, Walters BC, Grabb PA, Oyesiku NM, Przybylski GJ,
Resnick DK, Ryken TC (2002) Radiographic assessment of the
cervical spine in symptomatic trauma patients. Neurosurgery 50(3
Suppl):S36–S43 (March)
28. Morris CG, Mullan B (2004) Clearing the cervical spine after
polytrauma: implementing unified management for unconscious
victims in the intensive care unit. Anaesthesia 59(8):755 –761
(August)
29. American College of Radiology (2007) ACR appropriateness
criteria, suspected cervical spine trauma. http://www.acr.org/s_acr/
bin.asp?CID=1206&DID=11775&DOC=FILE.PDF. Cited M ay
10, 2007
30. Beattie LK, Choi J (2006) Acute spinal injuries: assessment and
management. Emerg Med Pract 8(5):1–28
31. Smits M, Dippel DW, de Haan GG, Dekker HM, Vos PE, Kool
DR, Nederkoorn PJ, Hofman PA, Twijnstra A, Tanghe HL,
Hunink MG (2005) External validation of the Canadian CT head
rule and the New Orleans criteria for CT scanning in patients with
minor head injury. JAMA 294(12):1519–1525 (September 28)
32. Haydel MJ, Preston CA, Mills TJ, Luber S, Blaudeau E, DeBlieux
PM (2000) Indications for computed tomography in patients with
minor head injury. N Engl J Med 343(2):100–105 (July 13)
33. Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H,
Laupacis A, McKnight RD, Verbeek R, Brison R, Cass D,
Eisenhauer ME, Greenberg G, Worthington J (2001) The
Canadian CT head rule for patients with minor head injury.
Lancet 357(9266):1391–1396 (May 5)
34. Smits M, Dippel DW, Steyerberg EW, de Haan GG, Dekker HM,
Vos PE, Kool DR, Nederkoorn PJ, Hofman PA, Twijnstra A,
Tanghe HL, Hunink MG (2007) Predicting intracranial traumatic
findings on computed tomography in patients with minor head
injury: the CHIP prediction rule. Ann Intern Med 146(6):397–405
(March 20)
35. Inaba K, Munera F, McKenney M, Schulman C, de MM, Rivas L,
Pearce A, Cohn S (2006) Visceral torso computed tomography for
clearance of the thoracolumbar spine in trauma: a review of the
literature. J Trauma 60(4):915–920 (April)
36. Shanmuganathan K, Mirvis SE, Chiu WC, Killeen KL, Hogan GJ,
Scalea TM (2004) Penetrating torso trauma: triple-contrast helical
CT in peritoneal violation and organ injury—a prospective study
in 200 patients. Radiology 231(3):775–784 (June)
Emerg Radiol (2007) 14:135–141 141
