Detailed information gain and therapeutic impact of whole body computed tomography supplementary to conventional radiological diagnostics in blunt trauma emergency treatment: a consecutive trauma centre evaluation

Christian Tibor Josef Magyar, Franziska Maeder, Michael Diepers, Felix Amsler, Thomas Gross, Christian Tibor Josef Magyar, Franziska Maeder, Michael Diepers, Felix Amsler, Thomas Gross

Abstract

Purpose: The indication of whole body computed tomography (WBCT) in the emergency treatment of trauma is still under debate. We were interested in the detailed information gain obtained from WBCT following standardized conventional imaging (CI).

Methods: Prospective study including all emergency trauma centre patients examined by CI (focused assessment of sonography in trauma, chest and pelvic X-ray) followed by WBCT from 2011 to 2017. Radiology reports were compared per patient for defined body regions for number and severity of injuries (Abbreviated Injury Scale, AIS; Injury Severity Score, ISS), incidental findings and treatment consequences (Wilcoxon signed rank test, Spearman rho, Chi-square).

Results: 1271 trauma patients (ISS 11.3) were included in this study. WBCT detected more injury findings than CI in the equivalent body regions (1.8 vs. 0.6; p < 0.001). In 44.4% of cases at least one finding was missed by CI alone. Compared to WBCT, injury severity of specified body regions was underestimated by CI on average by an AIS of 1.9 (p < 0.001). In 22.0% of cases injury severity increased by an AIS ≥ 2 following WBCT. In 16.8% of patients additional injury findings resulted in a change of treatment (number needed to profit, NNP = 6 patients): NNP decreased from 25 for patients with an ISS < 7 up to nearly 2 for patients with an ISS > 25 at final evaluation, thereby demonstrating a significant improvement in the NNP with increasing ISS (rho = 0.33, p < 0.001). Moreover, WBCT in 88.4% of patients identified ≥ 1 incidental finding (mean 3.4) vs. 28.9% by CI only (p < 0.001). Overall, WBCT had treatment consequences in 31.9% of cases (NNP = 3.1).

Conclusions: The application of WBCT in addition to CI in the emergency treatment of trauma had therapy consequences for almost every third patient. On the other hand, WBCT appeared not to be indicated (ISS < 8) in at least 2/5 of patients.

Keywords: Acute Care Surgery; Computed tomography; ER diagnostics; Imaging; Trauma; Whole body CT.

Conflict of interest statement

Christian Tibor Josef Magyar, Franziska Maeder, Michael Diepers, Felix Amsler and Thomas Gross declare that they have no conflicts of interest.

© 2020. The Author(s).

Figures

Fig. 1
Fig. 1
Study cohort flowchart

References

    1. American College of Surgeons (2012) Committee on Trauma. Advanced trauma life support : student course manual, 9th ed. American College of Surgeons, Chicago
    1. Sierink JC, Treskes K, Edwards MJR, Beuker BJA, den Hartog D, Hohmann J, et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet Elsevier Ltd. 2016;388:673–683. doi: 10.1016/S0140-6736(16)30932-1.
    1. Kinoshita T, Yamakawa K, Matsuda H, Yoshikawa Y, Wada D, Hamasaki T, et al. The survival benefit of a novel trauma workflow that includes immediate whole-body computed tomography, surgery, and interventional radiology, all in one trauma resuscitation room. Ann Surg. 2019;1:370. doi: 10.1097/SLA.0000000000002527.
    1. Hsiao KH, Dinh MM, Mcnamara KP, Bein KJ, Roncal S, Saade C, et al. Whole-body computed tomography in the initial assessment of trauma patients: is there optimal criteria for patient selection? EMA Emerg Med Australas. 2013;25:182–191. doi: 10.1111/1742-6723.12041.
    1. Palm HG, Kulla M, Wettberg M, Lefering R, Friemert B, Lang P. Changes in trauma management following the implementation of the whole-body computed tomography: a retrospective multi-centre study based on the trauma registry of the German Trauma Society (TraumaRegister DGU®) Berlin: Springer; 2017. pp. 1–8.
    1. Chidambaram S, Goh EL, Khan MA. A meta-analysis of the efficacy of whole-body computed tomography imaging in the management of trauma and injury. Injury. 2017;48:1784–1793. doi: 10.1016/j.injury.2017.06.003.
    1. Brenner DJ, Elliston CD. Estimated radiation risks potentially associated with full-body CT screening. Radiol US. 2004;232:735–738. doi: 10.1148/radiol.2323031095.
    1. Hinzpeter R, Boehm T, Boll D, Constantin C, Del Grande F, Fretz V, et al. Imaging algorithms and CT protocols in trauma patients: survey of Swiss emergency centers. Eur Radiol Germany Eur Radiol. 2017;27:1922–1928. doi: 10.1007/s00330-016-4574-1.
    1. Long B, April MD, Summers S, Koyfman A. Whole body CT versus selective radiological imaging strategy in trauma: an evidence-based clinical review. Am J Emerg Med. 2017;35:1356–1362. doi: 10.1016/j.ajem.2017.03.048.
    1. Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet. 2009;373:1455–1461. doi: 10.1016/S0140-6736(09)60232-4.
    1. Caputo ND, Stahmer C, Lim G, Shah K. Whole-body computed tomographic scanning leads to better survival as opposed to selective scanning in trauma patients: a systematic review and meta-analysis. J Trauma Acute Care Surg. 2014;77:534–539. doi: 10.1097/TA.0000000000000414.
    1. Yeguiayan J-M, Yap A, Freysz M, Garrigue D, Jacquot C, Martin C, et al. Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma for the FIRST Study Group. Crit Care. 2012;16:R101. doi: 10.1186/cc11375.
    1. Jiang L, Ma Y, Jiang S, Ye L, Zheng Z, Xu Y, et al. Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis. Scand J Trauma Resusc Emerg Med. 2014;22:1–11. doi: 10.1186/s13049-014-0054-2.
    1. Furugori S, Kato M, Abe T, Iwashita M, Morimura N. Treating patients in a trauma room equipped with computed tomography and patients’ mortality: a non-controlled comparison study. World J Emerg Surg. 2018;13:16. doi: 10.1186/s13017-018-0176-3.
    1. Eurin M, Haddad N, Zappa M, Lenoir T, Dauzac C, Vilgrain V, et al. Incidence and predictors of missed injuries in trauma patients in the initial hot report of whole-body CT scan. Injury. 2012;43:73–77. doi: 10.1016/j.injury.2011.05.019.
    1. Pfeifer R, Pape H-C. Missed injuries in trauma patients: a literature review. Patient Saf Surg. 2008;2:20. doi: 10.1186/1754-9493-2-20.
    1. Braken P, Amsler F, Gross T. Simple modification of trauma mechanism alarm criteria published for the TraumaNetwork DGU® may significantly improve overtriage—a cross sectional study. Scand J Trauma Resusc Emerg Med. 2018;26:32. doi: 10.1186/s13049-018-0498-x.
    1. Bouillon B, Flohé S, Kühne C, Lendemans S, Ruchholtz S, Siebert H. Whitebook Medical Care of the Severely Injured: recommendations on structure, organization, installations and equipment to promote quality, safety and reliability in the medical care of the severely injured in the Federal Republic of Germany. Stuttgart: Georg Thieme Verlag KG; 2012. pp. 1–64.
    1. Stengel D, Rademacher G, Ekkernkamp A, Güthoff C, Mutze S. Emergency ultrasound-based algorithms for diagnosing blunt abdominal trauma. Oxford: Wiley; 2015.
    1. Gennarelli T, Wodzin E. Association for the advancement of automotive medicine. The abbreviated injury scale 1990 Revision. Des Plaines: American Association for Automotive Medicine; 1990.
    1. Shannon L, Peachey T, Skipper N, Adiotomre E, Chopra A, Marappan B, et al. Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims. Clin Radiol. 2015;70:1205–1211. doi: 10.1016/j.crad.2015.06.084.
    1. Lang P, Kulla M, Kerwagen F, Lefering R, Friemert B, Palm HG. The role of whole-body computed tomography in the diagnosis of thoracic injuries in severely injured patients—a retrospective multi-centre study based on the trauma registry of the German trauma society (TraumaRegister DGU®) Scand J Trauma Resusc Emerg Med. 2017;25:1–11. doi: 10.1186/s13049-017-0427-4.
    1. Venugopal K, Kinghorn AF, Emordi CE, Atkinson PR, Kendall RJ. An evaluation of the use of whole-body computed tomography in trauma patients at a United Kingdom trauma centre. Eur J Emerg Med. 2012;19:193–195. doi: 10.1097/MEJ.0b013e32834ada14.
    1. Davies RM, Scrimshire AB, Sweetman L, Anderton MJ, Holt EM. A decision tool for whole-body CT in major trauma that safely reduces unnecessary scanning and associated radiation risks: an initial exploratory analysis. Injury. 2016;47:43–49. doi: 10.1016/j.injury.2015.08.036.
    1. Self ML, Blake A-M, Whitley M, Nadalo L, Dunn E. The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries. Am J Surg. 2003;186:609–613. doi: 10.1016/j.amjsurg.2003.08.003.
    1. Trupka AMD, Waydhas CMD, Hallfeldt KKJMD, Nast-Kolb DMD, Pfeifer KJMD, Schweiberer LM. Value of thoracic computed tomography in the first assessment of severely injured patients with blunt chest trauma: results of a prospective study. J Trauma Acute Care Surg. 1997;43:405–412. doi: 10.1097/00005373-199709000-00003.
    1. Soto JR, Zhou C, Hu D, Arazoza AC, Dunn E, Sladek P. Skip and save: utility of pelvic X-rays in the initial evaluation of blunt trauma patients. Am J Surg. 2015;210:1076–1081. doi: 10.1016/j.amjsurg.2015.07.011.
    1. Topp T, Lefering R, Lopez CL, Ruchholtz S, Ertel W, Kühne CA. Radiologic diagnostic procedures in severely injured patients—is only whole-body multislice computed tomography the answer? Int J Emerg Med. 2015;8:1–6. doi: 10.1186/s12245-015-0053-8.
    1. Sierink JC, Saltzherr TP, Russchen MJAM, de Castro SMM, Beenen LFM, Schep NWL, et al. Incidental findings on total-body CT scans in trauma patients. Injury. 2014;45:840–844. doi: 10.1016/j.injury.2013.10.009.
    1. Hoffstetter P, Herold T, Daneschnejad M, Zorger N, Jung E, Feuerbach S, et al. Nicht traumaassozierte Nebenbefunde bei Ganzkörpercomputertomografien im Rahmen der Polytraumadiagnostik. RöFo Fortschritte auf dem Gebiet der Röntgenstrahlen und der Bildgeb Verfahren. 2008;180:120–126. doi: 10.1055/s-2007-963594.
    1. Seah MKT, Murphy CG, McDonald S, Carrothers A. Incidental findings on whole-body trauma computed tomography: experience at a major trauma centre. Injury. 2016;47:691–694. doi: 10.1016/j.injury.2016.01.012.
    1. Treskes K, Bos SA, Beenen LFM, Sierink JC, Edwards MJR, Beuker BJA, et al. High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients; results of the REACT-2 trial. Eur Radiol. 2017;27:2451–2462. doi: 10.1007/s00330-016-4598-6.
    1. Munk M-D, Peitzman AB, Hostler DP, Wolfson AB. Frequency and follow-up of incidental findings on trauma computed tomography scans: experience at a level one trauma center. J Emerg Med. 2010;38:346–350. doi: 10.1016/j.jemermed.2008.01.021.
    1. Huisa BN, Stemer AB, Zivin JA. Atorvastatin in stroke: a review of SPARCL and subgroup analysis. Macclesfield: Dove; 2010. pp. 229–236.
    1. Deunk J, Dekker HM, Brink M, van Vugt R, Edwards MJ, van Vugt AB. The value of indicated computed tomography scan of the chest and abdomen in addition to the conventional radiologic work-up for blunt trauma patients. J Trauma US. 2007;63:757–763.
    1. Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury. Arch Surg. 2006;141:468. doi: 10.1001/archsurg.141.5.468.
    1. Zieleskiewicz L, Fresco R, Duclos G, Antonini F, Mathieu C, Medam S, et al. Integrating extended focused assessment with sonography for trauma (eFAST) in the initial assessment of severe trauma: impact on the management of 756 patients. Injury. 2018;49:1774–1780. doi: 10.1016/j.injury.2018.07.002.
    1. Gross T, Messmer P, Amsler F, Füglistaler-Montali I, Zürcher M, Hügli RW, et al. Impact of a multifunctional image-guided therapy suite on emergency multiple trauma care. Br J Surg. 2010;97:118–127. doi: 10.1002/bjs.6842.

Source: PubMed

Sponsorzy i współpracownicy

Warunki medyczne

Interwencje lekowe

3
Subskrybuj