The Utility of Additional Imaging in Trauma Consults with Mild to Moderate Injury

Abstract

Limiting CT imaging in the ED has gained interest recently. After initial trauma workup for consultations in the ED, additional CT imaging is frequently ordered. We assessed the benefits of this additional imaging. Our hypothesis was that additional imaging in lower acuity trauma consults results in the diagnosis of new significant injuries with a change in treatment plan and increased Injury Severity Score (ISS). The registry at our Level I trauma center was queried from November 2015 to November 2016 for trauma consults initially evaluated by ED physicians. Patients with mild to moderate injuries were included. Injury findings before and after additional imaging were determined by chart review and pre- and postimaging ISS were calculated. Blinded trauma surgeons assessed the findings for clinical significance and changes in treatment. Four hundred and twenty-one patients were evaluated, 41 were excluded. One hundred and forty patients (37%) underwent additional CT imaging. Forty-seven patients (34%) had additional injuries found, with 16 (12%) increasing their ISS (mean 0.54, SD 1.66). Ninety-three per cent of cases resulted in at least one physician finding the new injuries clinically significant; however, agreement was low (κ = 0.095). For 70 per cent, at least one physician felt the findings warranted a change in treatment plan (κ = 0.405). Additional imaging in ED trauma consults resulted in the identification of new injuries in 1/3 of our patient sample. This suggests that current efforts to limit the use of CT imaging in trauma patients may result in significant injuries going undiscovered and undertreated. Further research is needed to determine the risk of attempts to limit imaging.

Should Radiation Exposure be an Issue of Concern in Children With Multiple Trauma?

“…However, in a retrospective adult study at a Level 1 trauma center, of the clinical decisions making process to expose adults to radiation versus no change in clinical management, showed 34% of injuries were missed and this would have changed their management had they been known at the time. 30 Which would support the proposition that if in doubt imaging should be undertaken. Clinical scoring systems could be used to address this tradeoff between clinical evaluations with and without exposure to radiation.…”

“…Thus, any type of such analysis needs to be treated with caution. However, in a retrospective adult study at a Level 1 trauma center, of the clinical decisions making process to expose adults to radiation versus no change in clinical management, showed 34% of injuries were missed and this would have changed their management had they been known at the time 30 . Which would support the proposition that if in doubt about the diagnosis imaging should be undertaken.…”

Different Perceptions Exist Between Health Care Providers and the General Population Regarding the Importance of Findings on Additional Imaging for Trauma Consults

“…The previous study 9 weighed on the existing body of knowledge regarding the benefits 10,20 and disadvantages 11,12 of obtaining additional imaging for mild to moderately injured patients. This study investigated scenarios based on patients from that prior work.…”

“…7,8 This study is intended to be a follow-up investigation of our previous findings, which explored the benefit of additional imaging in patients for which the trauma service was consulted after initial workup in the emergency department (ED). 9 That work explored additional injuries which were identified by follow-up computed tomography (CT) imaging for mild to moderately-injured patients following trauma consultation, as significant controversy exists regarding extensive radiologic imaging for these patients. [10][11][12] New injuries were discovered in approximately a third of those who underwent additional imaging.…”