Four years of experience as a major trauma centre results in no improvement in patient selection for whole-body CT scans following blunt trauma

Whole-body CT indications in emergency medicine trauma patients

Background

Whole-body computerized tomography (CT) scan designed as early diagnosis of traumatic injuries and prevention of unnoticeable injuries. Using Whole-body CT in trauma patients still controversial, there is no consensus on indications.

Aims

The aim of this study is to clarify indications and cut-off levels in vital parameters in trauma patients who undergo Whole-body CT to prevent unnecessary or negative scans.

Patients and Methods

We evaluated patients with trauma who applied our emergency service between 01.09.2019 and 30.09.2020. Patients above 18 years old with Whole-body CT scan included. Whole-body CT reports were evaluated according to five categories; cranial-face, vertebra, thorax, abdomen, pelvis-bone.

Results

The review of whole-body CT reports, 46.3% detected normally. But, 53.7% of patients had injuries at least one zone, 23.3% at least two zones, and 7.4% at least three zones respectively. Prediction criteria of Whole-body CT for the patients with two or three zones injury, systolic blood pressure (SBP) ≤100 mm Hg, Glasgow coma scale (GCS) <15, and free fluid in Focused Assessment with Sonography for Trauma (FAST) were independent variables in regression analysis. When patients had at least one of three variables, the negative predictive value of whole-body CT was 96% for three zones and 91% for two zones.

Conclusion

The cut-off values of GCS <15 and SBP ≤100 mm Hg were useful vital parameters in making whole-body CT decisions in trauma patients in the emergency service. Also, free fluid detection in FAST can be used for whole-body CT decisions.

Current Standards for and Clinical Impact of Emergency Radiology in Major Trauma

In industrialized countries, high energy trauma represents the leading cause of death and disability among people under 35 years of age. The two leading causes of mortality are neurological injuries and bleeding. Clinical evaluation is often unreliable in determining if, when and where injuries should be treated. Traditionally, surgery was the mainstay for assessment of injuries but advances in imaging techniques, particularly in computed tomography (CT), have contributed in progressively changing the classic clinical paradigm for major traumas, better defining the indications for surgery. Actually, the vast majority of traumas are now treated nonoperatively with a significant reduction in morbidity and mortality compared to the past. In this sense, another crucial point is the advent of interventional radiology (IR) in the treatment of vascular injuries after blunt trauma. IR enables the most effective nonoperative treatment of all vascular injuries. Indications for IR depend on the CT evidence of vascular injuries and, therefore, a robust CT protocol and the radiologist's expertise are crucial. Emergency and IR radiologists form an integral part of the trauma team and are crucial for tailored management of traumatic injuries.

The association of hand and wrist injuries with other injuries in multiple trauma patients. A retrospective study in a UK Major Trauma Centre

BACKGROUND

Approximately 20,000 major trauma cases occur in England every year. However, the association with concomitant upper limb injuries is unknown. This study aims to determine the incidence, injury pattern and association of hand and wrist injuries with other body injuries and the Injury Severity Score (ISS) in multiply injured trauma patients.

METHODS

Single centre retrospective study was performed at a level-one UK Major Trauma Centre (MTC). Trauma Audit and Research Network (TARN) eligible multiply injured trauma patients that were admitted to the hospital between January 2014 and December 2018 were analysed. TARN is the national trauma registry. Eligible patients were: a trauma patient of any age who was admitted for 72 h or more, or was admitted to intensive care, or died at the hospital, was transferred into the hospital for specialist care, was transferred to another hospital for specialist care or for an intensive care bed and whose isolated injuries met a set of criteria. Data extracted included: age, gender, mode of arrival, location of injuries including: hand and/or wrist and mechanism of injury. We performed a logistic regression analysis to assess the association between hand/wrist injury to ISS score of 15 points or above/below and to the presentation of other injuries.

RESULTS

107 patients were analysed. Hand and wrist injuries were the second most common injury (26.2%), after thoracic injuries. Distal radial injuries were found in 5.6%, carpal/carpometacarpal in 6.5%, concurrent distal radius and carpometacarpal in 0.9%, phalangeal injuries in 4.7%, tendon injuries in 0.9% and concurrent hand and wrist injuries in 7.5% cases. There was a significant association between hand or wrist injuries and lower limb injuries (Odds Ratio (OR): 3.84; 95% confidence intervals (CI): 1.09 to 13.50; p = 0.04) and pelvic injuries (OR: 4.78; 95% CI: 1.31 to 17.44; p = 0.02). There was no statistical association between hand and wrist injuries and ISS score (OR: 0.80; 95% CI: 0.11 to 5.79; p = 0.82).

CONCLUSIONS

Hand and wrist injuries are prevalent in trauma patients admitted to MTCs. They should not be under-estimated but routinely screened for in multiply injured patients particularly those with a pelvic or lower limb injury.

Negative Whole-Body Computed Tomography Scans in Polytrauma Patients: A Retrospective Cohort Study

Background

Whole-body computed tomography (WBCT) has been a mainstay and an integral part of the evaluation of polytrauma patients in trauma centers and emergency departments (ED) for a comprehensive evaluation of the extent of injuries. However, routine use of WBCT remains controversial since it exposes patients to radiation and exponentially increases financial expense. The primary objective was to determine the rate of negative WBCT in polytrauma patients.

Patients and Methods

A retrospective cohort study was conducted at an academic hospital in the Kingdom of Saudi Arabia, which is a dedicated trauma center with a mean of 237,392 ED visits and 10,714 trauma per year. The study included all adult (≥18 years) polytrauma patients who presented to our ED, requiring trauma team activation, and underwent WBCT as part of their evaluation from January 2016 to May 2017. We excluded pediatric patients, patients transferred from another facility, and pregnant patients. The primary endpoint was to measure the rate of negative WBCT in polytraumatized patients.

Results

A total of 186 patients were included with a mean age of 28.8 ± 12.9 years. The rate of negative WBCT scans was 20.4%. The positive scans were subclassified based on the number of anatomical body regions that were affected radiologically. One body region was affected in 47 patients (31.8%), two body regions were affected in 50 patients (33.8%), and ≥3 body regions were affected in 51 patients (34.3%). In a subset analysis, we identified that oxygen saturation <94% and GCS ≤8 were associated with positive CT scans.

Conclusion

Our study revealed a slightly higher rate of utilization of WBCT in the management of trauma patients compared to studies with similar practice. We believe that in the correct setting with incorporating high index of suspicion, a physical examination with attention to vital signs and mental status, performing E-FAST, and dedicated X-Rays is a way to potentially reduce the use of WBCT in polytrauma patients.