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Diagnosis of Posttraumatic Pulmonary Embolism: Is Chest Computed Tomographic Angiography Acceptable?

Anderson, John T. MD; Jenq, Tina BA; Bain, Martin MD; Jacoby, Robert MD; Osnis, Robert MD; Gosselin, Robert C. MT; Owings, John T. MD

The Journal of Trauma: Injury, Infection, and Critical Care: March 2003 - Volume 54 - Issue 3 - p 472-477
doi: 10.1097/01.TA.0000047805.89700.C1

Background  Pulmonary angiography (PA-gram) has long been the accepted criterion standard for diagnosing pulmonary embolism (PE). Computed tomographic angiography has recently been advocated as an equivalent alternative to PA-gram. CT angiography is known to be insensitive for peripheral (segmental and subsegmental) emboli. We have previously found that a significant number of posttraumatic PEs occur early. We therefore hypothesized that because of the fragmentation of these early (soft) clots, posttraumatic PEs would be found disproportionately in the lung periphery.

Methods  Trauma patients with PE confirmed by PA-gram were identified from our trauma database and medical records. PA-grams and reports were re-reviewed and the location of all emboli was documented.

Results  We identified 45 patients, with an average age of 46 ± 19 years; two thirds of the patients were men and 82% had a blunt mechanism of injury. Patients had PE diagnosed between days 0 and 57. Overall, PE was confined to segmental or smaller vessels in 27 (60%) patients and to subsegmental vessels in 7 (16%) patients. Twelve patients (27%) had a PE within the first 4 days. Furthermore, 32 patients (71%) had unilateral clot and 22 patients (48.9%) had clot confined to one region.

Conclusion  PE frequently occurs soon after injury. The majority of PEs after trauma are found peripherally (in segmental or subsegmental vessels). Right/left pulmonary artery embolisms are likely to be found only later in a trauma patient’s course. Any diagnostic study used to diagnose pulmonary embolism in trauma patients must have sufficient resolution capacity to reliably detect segmental and subsegmental clot. A diagnostic modality such as CT scanning that is insensitive to peripheral embolisms may miss a significant number of posttraumatic PEs.

From the Departments of Surgery and Radiology, University of California, Davis Health System, Sacramento, California.

Submitted for publication October 13, 2002.

Accepted for publication October 28, 2002.

Presented at the 61st Annual Meeting of the American Association for the Surgery of Trauma, September 26–28, 2002, Orlando, Florida.

Address for reprints: John T. Anderson, MD, Department of Surgery, University of California, Davis Health System, 2315 Stockton Blvd., Room 6309, Sacramento, CA 95817.

© 2003 Lippincott Williams & Wilkins, Inc.