A Multicenter, Randomized Study of Early Assessment by CT Scanning in Severely Injured Trauma Patients (REACT-2)

February 4, 2018 updated by: J.C. Goslings, Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)

Randomized Study of Early Assessment by CT Scanning in Trauma Patients

Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made 'total body' CT scanning (TBCT) technically feasible and its usage is currently becoming common practice in several trauma centers.

However, literature provides limited evidence whether immediate 'total body' CT scanning leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate TBCT scanning in trauma patients.

The investigators hypothesize that immediate 'total body' CT scanning during the primary survey of severely injured trauma patients has positive effects on patient outcome compared with standard conventional ATLS based radiological imaging supplemented with selective CT scanning.

Study Overview

Status

Completed

Conditions

Intervention / Treatment

Detailed Description

Injuries are the cause of 5.8 million deaths annually which accounts for almost 10% of global mortality. Among adults aged 15-59 years the proportion of injuries as cause of death is even higher, ranging from 22% to 29% [1].

Specialized trauma centers all over the world provide initial trauma care and diagnostic work-up of trauma patients. This work-up is standardized and frequently based on the Advanced Trauma Life Support (ATLS) guidelines which include a fast and priority-based physical examination as well as screening radiographs supplemented with selective Computed Tomography scanning (CT). ATLS guidelines advise to routinely perform X-rays of thorax and pelvis and Focused Assessment with Sonography for Trauma (FAST) in trauma patients. Whether or not to perform CT scanning following conventional imaging is defined less clearly in the ATLS guidelines and depends upon national guidelines and local protocols.

In recent years CT scanning has become faster, more detailed and more available in the acute trauma care setting. CT shows high accuracy for a wide range of injuries which is reflected by a low missed diagnosis rate. Hence, the conventional radiological work-up according to the ATLS may not be the optimal choice of primary diagnostics anymore. Furthermore, severely injured patients frequently require secondary CT scanning of many parts of the body after conventional imaging. Modern multidetector CT scanners (MDCT) can perform imaging of the head, cervical spine, chest, abdomen and pelvis in a single examination ('total body' CT scanning). The past few years this 'total body' imaging concept gained popularity as a possible alternative to the conventional imaging strategy. With the use of immediate 'total body' CT (TBCT) scanning in trauma patients, rapid and detailed information of organ and tissue injury becomes available and a well-founded plan for further therapy can be made.

In the past, CT scanners were located in the radiology department, frequently even on another floor than the emergency department (ED) were the trauma patient is admitted. The past assumption that TBCT in severely injured trauma patients is too time consuming may no longer be held, since an increasing number of trauma centers have a CT scanner available at the ED or even in the trauma room itself. Several studies evaluated time intervals associated with TBCT usage in severely injured patients. Although these studies are incomparable with respect to design, CT scanners used, diagnostic work-up protocols and trauma populations, the main conclusion is clear. TBCT scanning in trauma patients is not as time consuming as was once expected and may even be time saving compared to conventional imaging protocols supplemented with selective CT.

More and more trauma centers encourage and are implementing immediate TBCT scanning in the diagnostic phase of primary trauma care. Since the burden of TBCT in terms of costs and radiation dose is at least controversial, the advantage of performing immediate TBCT should be proven in high quality studies resulting in high level evidence in order to make its implementation justifiable.

In order to assess the value of immediate TBCT scanning in severely injured trauma patients, the Academic Medical Center (AMC) in Amsterdam, the Netherlands, has initiated an international multicenter randomized clinical trial. Severely injured patients, who are thought to benefit the most from a 'total body' imaging concept, will be included.

Study Type

Interventional

Enrollment (Actual)

1083

Phase

  • Not Applicable

Contacts and Locations

This section provides the contact details for those conducting the study, and information on where this study is being conducted.

Study Locations

  • Netherlands
      • Amsterdam, Netherlands, 1105AZ
        • Academic Medical Center (AMC)
      • Groningen, Netherlands, 9700 RB
        • University Medical Center Groningen
      • Nijmegen, Netherlands, 6525 GA
        • University Medical Centre Nijmegen
      • Rotterdam, Netherlands, 3015 CE
        • Erasmus Medical Center
  • Switzerland
      • Basel, Switzerland, CH - 4031
        • University Hospital Basel

Participation Criteria

Researchers look for people who fit a certain description, called eligibility criteria. Some examples of these criteria are a person's general health condition or prior treatments.

Eligibility Criteria

Ages Eligible for Study

18 years and older (Adult, Older Adult)

Accepts Healthy Volunteers

No

Genders Eligible for Study

All

Description

Inclusion Criteria:

Trauma patient with presence of one of the following criteria:

At least one of the following parameters at hospital arrival:

  1. Respiratory rate ≥30/min or ≤10/min
  2. Pulse ≥120/min;
  3. Systolic blood pressure ≤100 mmHg
  4. Estimated external blood loss ≥500 ml
  5. Glasgow Coma Score ≤13
  6. Abnormal pupillary light reflex.

Or clinical suspicion of one of the following diagnoses:

  1. Fractures from at least two long bones
  2. Multiple rib fractures, flail chest or open chest
  3. Severe abdominal injury
  4. Pelvic fracture
  5. Unstable vertebral fractures or signs of spinal cord injury.

Or one of the following injury mechanisms:

  1. Fall from height (≥ 10 feet)
  2. Ejection from the vehicle
  3. Death occupant in same vehicle
  4. Severely injured patient in same vehicle
  5. Wedged or trapped chest / abdomen.

Exclusion Criteria:

  1. Age <18 years (if known)
  2. Known pregnancy
  3. Patients referred from other hospitals
  4. Clearly low-energy trauma with blunt injury mechanism
  5. Penetrating injury in 1 body region (except gun shot wounds) as the clearly isolated injury
  6. Any patient who is judged to be too unstable to undergo a CT scan and requires (cardiopulmonary) resuscitation or immediate operation because death is imminent.

Study Plan

This section provides details of the study plan, including how the study is designed and what the study is measuring.

How is the study designed?

Design Details

  • Primary Purpose: Diagnostic
  • Allocation: Randomized
  • Interventional Model: Parallel Assignment
  • Masking: None (Open Label)

Arms and Interventions

Participant Group / Arm
Intervention / Treatment
Other: Conventional imaging
The control group will be evaluated with X-rays, ultrasonography and selective CT scanning.
Other: Conventional imaging and selective CT scanning.

The control group will be evaluated according to a conventional trauma protocol with X-rays (of the chest and pelvis), ultrasonography (Focused Assessment with Sonography for Trauma (FAST)) and selective CT scanning.

Indications for the selective CT scanning are pre-defined and based on the combined local protocols of the participating centers.

Other Names:
  • CT
  • X-rays
  • FAST
  • Conventional radiography
  • Computed Tomography
Other: Immediate total body CT
The intervention group will receive a 'total body' CT scan from head to pelvis. Conventional radiography and FAST will be completely omitted.
Other: Total body Computed Tomography.

The CT protocol for the intervention group consists of a two-step whole-body acquisition (from vertex to pubic symphysis) starting with Head and Neck Non Enhanced CT (NECT) with arms alongside the body.

The preferred technique for the second complementary scan is a split-bolus intravenous contrast directly after repositioning of the arms alongside the head, and this second scan covers thorax, abdomen and pelvis. Participating centers however are free to choose their own technique as long as intravenous contrast is given for the chest and abdominal part of the TBCT.

Other Names:
  • Whole body CT
  • Pan CT
  • Full body CT
  • TBCT
  • WBCT

What is the study measuring?

Primary Outcome Measures

Outcome Measure
Measure Description
Time Frame
In-hospital mortality.
Time Frame: From date of randomization until the date of death from any cause, while being an inpatient, assessed up to 1 year.
Mortality during hospital admission.
From date of randomization until the date of death from any cause, while being an inpatient, assessed up to 1 year.

Secondary Outcome Measures

Outcome Measure
Measure Description
Time Frame
Overall mortality
Time Frame: 24-hour, 30-day and 1-year mortality.
Mortality in general during specific time frames.
24-hour, 30-day and 1-year mortality.
Several clinical relevant time intervals.
Time Frame: From date and time of randomization to date and time of immediate intervention or ICU arrival, with an expected duration of 1-3 hours.
  • time of arrival;
  • time to CT;
  • scanning time;
  • time to diagnosis;
  • time in the trauma room;
  • time to intervention.
From date and time of randomization to date and time of immediate intervention or ICU arrival, with an expected duration of 1-3 hours.
Radiation exposure
Time Frame: Until six months posttrauma.
Radiation dose in miliSievert.
Until six months posttrauma.
Quality of life
Time Frame: Six and twelve months posttrauma.
As recorded by completing the EuroQol-6D.
Six and twelve months posttrauma.
Morbidity
Time Frame: Up to six months posttrauma.
  • complications and total number of (re-)interventions and re-admissions;
  • transfusion requirements;
  • length of ICU stay;
  • number of ventilation days.
Up to six months posttrauma.
General health
Time Frame: Six and twelve months posttrauma.
As recorded by completing the HUI-3.
Six and twelve months posttrauma.
Cost-effectiveness analyses.
Time Frame: Until six months posttrauma.

Cost-effectiveness analyses will be performed with the costs per patient alive and costs per patient alive without serious morbidity as outcome measures.

Additionally, a cost-utility analysis will be done with the cost per QALY as outcome measure. Incremental cost-effectiveness ratios will be calculated, expressing the extra costs per (i) extra patients alive, (ii) extra patients alive and without serious morbidity, and (iii) additional QALY.
Until six months posttrauma.

Collaborators and Investigators

This is where you will find people and organizations involved with this study.

Sponsor

Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)

Collaborators

University Medical Center Groningen
Erasmus Medical Center
University Hospital, Basel, Switzerland
University Medical Center Nijmegen

Investigators

  • Principal Investigator: J Carel Goslings, PhD, Academisch Medisch Centrum - Universiteit van Amsterdam (AMC-UvA)

Publications and helpful links

The person responsible for entering information about the study voluntarily provides these publications. These may be about anything related to the study.

General Publications

Study record dates

These dates track the progress of study record and summary results submissions to ClinicalTrials.gov. Study records and reported results are reviewed by the National Library of Medicine (NLM) to make sure they meet specific quality control standards before being posted on the public website.

Study Major Dates

Study Start

April 1, 2011

Primary Completion (Actual)

July 1, 2014

Study Completion (Actual)

December 1, 2014

Study Registration Dates

First Submitted

January 20, 2012

First Submitted That Met QC Criteria

January 30, 2012

First Posted (Estimate)

February 1, 2012

Study Record Updates

Last Update Posted (Actual)

February 6, 2018

Last Update Submitted That Met QC Criteria

February 4, 2018

Last Verified

February 1, 2018

More Information

Terms related to this study

Keywords

Additional Relevant MeSH Terms

Other Study ID Numbers

  • 1711020323
  • NTR2607 (Registry Identifier: The Netherlands National Trial Register)

This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.

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