A decision tool for whole-body CT in major trauma that safely reduces unnecessary scanning and associated radiation risks: An initial exploratory analysis

Davies, Ronnie; Scrimshire, Ashley B; Sweetman, Lorna; Anderton, Michael J.; Holt, E. M.

doi:10.1016/j.injury.2015.08.036

Cited by 59 publications

(64 citation statements)

References 35 publications

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“…We found that information about a highenergy trauma mechanism increased the odds for being examined with a SWBCT. This is consistent with the recommendations suggested by Davis et al [65]. To our knowledge, proposed decision rules have not been validated in prospective observational studies or evaluated against alternative strategies, such as immediate SWBCT, in randomized trials.…”

Section: Discussionsupporting

confidence: 85%

“…To our knowledge, such studies have not been published. Active intervention chosen 0 (0) 0 (0.0) Demographics, injury pattern, use of emergency interventions and time from trauma admission to start of the first CT scan in our population mainly compares to previously published similar studies [62][63][64][65]. The median pre-hospital transportation time of nearly two hours is, however, long when compared to large urban area trauma populations, but comparable to the context in other rural populations in for example Canada [66].…”

Section: Discussionsupporting

confidence: 59%

“…Hare et al [70] reviewed the literature to clarify whether such tools improve diagnostic accuracy of whole body CT, and concluded that the evidence to support this is limited. All identified studies were retrospective analyses of predictors for CT findings [32,34,65,71]. Davis et al [65] recorded all findings from clinical examination, including superficial physical signs as bruising, tenderness and swelling.…”

Section: Discussionmentioning

confidence: 99%

“…All identified studies were retrospective analyses of predictors for CT findings [32,34,65,71]. Davis et al [65] recorded all findings from clinical examination, including superficial physical signs as bruising, tenderness and swelling. They suggested a decision rule based on physical signs, vital parameters and information about the mechanism of injury.…”

Section: Discussionmentioning

confidence: 99%

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Clinical guided computer tomography decisions are advocated in potentially severely injured trauma patients: a one-year audit in a level 1 trauma Centre with long pre-hospital times

Bågenholm

Dehli

Hermansen

et al. 2020

Scand J Trauma Resusc Emerg Med

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Background: The International Commission on Radiological Protection's (ICRP) justification principles state that an examination is justified if the potential benefit outweighs the risk for radiation harm. Computer tomography (CT) contributes 50% of the radiation dose from medical imaging, and in trauma patients, the use of standardized whole body CT (SWBCT) increases. Guidelines are lacking, and reviews conclude conflictingly regarding the benefit. We aimed to study the degree of adherence to ICRP's level three justification, the individual dose limitation principle, in our institution. Methods: This is a retrospective clinical audit. We included all 144 patients admitted with trauma team activation to our regional Level 1 trauma centre in 2015. Injuries were categorized according to the Abbreviated Injury Scale (AIS) codes. Time variables, vital parameters and interventions were registered. We categorized patients into trauma admission SWBCT, selective CT or no CT examination strategy groups. We used descriptive statistics and regression analysis of predictors for CT examination strategy. Results: The 144 patients (114 (79.2%) males) had a median age of 31 (range 0-91) years. 105 (72.9%) had at least one AIS ≥ 2 injury, 26 (18.1%) in more than two body regions. During trauma admission, at least one vital parameter was abnormal in 46 (32.4%) patients, and 73 (50.7%) underwent SWBCT, 43 (29.9%) selective CT and 28 (19.4%) no CT examination. No or only minor injuries were identified in 17 (23.3%) in the SWBCT group. Two (4.6%) in the selective group were examined with a complement CT, with no new injuries identified. A significantly (p < 0.001) lower proportion of children (61.5%) than adults (89.8%) underwent CT examination despite similar injury grades and use of interventions. In adjusted regression analysis, patients with a high-energy trauma mechanism had significantly (p = 0.028) increased odds (odds ratio = 4.390, 95% confidence interval 1.174-16.413) for undergoing a SWBCT.

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Section: Discussionsupporting

confidence: 85%

Section: Discussionsupporting

confidence: 59%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

See 2 more Smart Citations

Clinical guided computer tomography decisions are advocated in potentially severely injured trauma patients: a one-year audit in a level 1 trauma Centre with long pre-hospital times

Bågenholm

Dehli

Hermansen

et al. 2020

Scand J Trauma Resusc Emerg Med

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“…Trauma centers are increasingly using protocols that incorporate head-to-pelvis computed tomography (CT) (often referred to as pan-scan) for evaluation of adult patients with blunt trauma. [1][2][3][4] In previously reported analyses of large cohorts of adult patients with blunt trauma who received chest imaging in the NEXUS Chest studies, the management, morbidity, and mortality associated with…”

Section: Introductionmentioning

confidence: 99%

Pneumothorax and Hemothorax in the Era of Frequent Chest Computed Tomography for the Evaluation of Adult Patients With Blunt Trauma

Rodriguez

Canseco

Baumann

et al. 2019

Annals of Emergency Medicine

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Study objective: Although traditional teachings in regard to pneumothorax and hemothorax generally recommend chest tube placement and hospital admission, the increasing use of chest computed tomography (CT) in blunt trauma evaluation may detect more minor pneumothorax and hemothorax that might indicate a need to modify these traditional practices. We determine the incidence of pneumothorax and hemothorax observed on CT only and the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and describe the clinical implications of these injuries.Methods: This was a planned secondary analysis of 2 prospective, observational studies of adult patients with blunt trauma, NEXUS Chest , set in 10 Level I US trauma centers. Participants' inclusion criteria were older than 14 years, presentation to the emergency department (ED) within 6 hours of blunt trauma, and receipt of chest imaging (chest radiograph, chest CT, or both) during their ED evaluation. Exposure(s) (for observational studies) were that patients had trauma and chest imaging. Primary measures and outcomes included the incidence of pneumothorax and hemothorax observed on CT only versus on both chest radiograph and chest CT, the incidence of isolated pneumothorax and hemothorax (pneumothorax and hemothorax occurring without other thoracic injuries), and admission rates, hospital length of stay, mortality, and frequency of chest tube placement for these injuries.Results: Of 21,382 enrolled subjects, 1,064 (5%) had a pneumothorax and 384 (1.8%) had a hemothorax. Of the 8,661 patients who received both a chest radiograph and a chest CT, 910 (10.5%) had a pneumothorax, with 609 (67%) observed on CT only; 319 (3.7%) had a hemothorax, with 254 (80%) observed on CT only. Of 1,117 patients with pneumothorax, hemothorax, or both, 108 (10%) had isolated pneumothorax or hemothorax. Patients with pneumothorax observed on CT only had a lower chest tube placement rate (30% versus 65%; difference in proportions [D] -35%; 95% confidence interval [CI] -28% to 42%), admission rate (94% versus 99%; D 5%; 95% CI 3% to 8%), and median length of stay (5 versus 6 days; difference 1 day; 95% CI 0 to 2 days) but similar mortality compared with patients with pneumothorax observed on chest radiograph and CT. Patients with hemothorax observed on CT had only a lower chest tube placement rate (49% versus 68%; D -19%; 95% CI -31% to -5%) but similar admission rate, mortality, and median length of stay compared with patients with hemothorax observed on chest radiograph and CT. Compared with patients with other thoracic injury, those with isolated pneumothorax or hemothorax had a lower chest tube placement rate (20% versus 43%; D -22%; 95% CI -30% to -13%), median length of stay (4 versus 5 days; difference -1 day; 95% CI -3 to 1 days), and admission rate (44% versus 97%; D -53%; 95% CI -62% to -43%), with an admission rate comparable to that of patients without pneumothorax or hemothorax (49%).Conclusion: Under current imaging ...

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Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

et al. 2020

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Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure. OBJECTIVE To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure. DESIGN, SETTING, AND PARTICIPANTS This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019. INTERVENTIONS Standard-or low-dose WBCT. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy. RESULTS Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, −2.0% [95% CI, −7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001). CONCLUSIONS AND RELEVANCE Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.

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A decision tool for whole-body CT in major trauma that safely reduces unnecessary scanning and associated radiation risks: An initial exploratory analysis

Cited by 59 publications

References 35 publications

Clinical guided computer tomography decisions are advocated in potentially severely injured trauma patients: a one-year audit in a level 1 trauma Centre with long pre-hospital times

Clinical guided computer tomography decisions are advocated in potentially severely injured trauma patients: a one-year audit in a level 1 trauma Centre with long pre-hospital times

Pneumothorax and Hemothorax in the Era of Frequent Chest Computed Tomography for the Evaluation of Adult Patients With Blunt Trauma

Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

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