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ORIGINAL ARTICLE
Year : 2021  |  Volume : 24  |  Issue : 5  |  Page : 667-673

Trauma patients and whole-body computerized tomography imaging: Location of CT-Scan and factors affecting mortality


1 Department of Emergency Medicine, Eskisehir Osmangazi University, College of Medicine and Health Sciences, Eskisehir, Turkey
2 Department of Emergency Medicine, Eskisehir Osmangazi University, College of Medicine and Health Sciences, Eskisehir, Turkey; Department of Internal Medicine, Emergency Medicine Section, Al Ain, United Arab Emirates
3 Department of Surgery, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates

Date of Submission05-Apr-2020
Date of Acceptance17-Aug-2020
Date of Web Publication20-May-2021

Correspondence Address:
Dr. A A Cevik
Department of Internal Medicine, Emergency Medicine Section, United Arab Emirates University, College of Medicine and Health Sciences, Al Ain, 17666

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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njcp.njcp_317_20

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   Abstract 


Objective: We aimed to study the factors affecting the mortality of trauma patients who underwent whole-body computerized tomography (CT) on Emergency department (ED) time frames in a developing emergency care system. Materials and Methods: This is a retrospective analysis of adult patients who received WBCT from August to November for two consecutive years (2014 and 2015). Non-parametric statistical methods were used to compare the patients who died and survived. The Backward logistic regression model was used to define factors significantly affecting mortality. Results: During 2014, 200 patients out of 827 (24.1%) received WBCT. During 2015, 263 patients out of 951 (27.6%) received WBCT. Four hundred sixteen patients were entered into the analysis. The overall mortality was 3.4% (7% in 2014 and 1% in 2015, P = 0.002). Significant factors found in backward logistic regression model defining factors affecting mortality were ISS (p < 0.0001), Glasgow Coma Scale (GCS) (p = 0.001). CT location (outside the ED in 2014, inside the ED in 2015) showed a very strong trend for affecting mortality (p = 0.054). Patients who had WBCT in the ED had lower ISS (p < 0.0001). CT imaging in the ED decreased ED to CT time 15.5 minutes (p < 0.0001), but admission time was 75.5 minutes longer. Conclusions: ISS and GCS were the main factors predicting mortality in patients who received WBCT. Patients received more WBCT imaging and physicians showed a tendency to order WBCT for less severe patients when the CT located in the ED. CT location did not show a significant effect on mortality, but on some operational time frames.

Keywords: Coma scale, injury severity, tomography, trauma


How to cite this article:
Kaya F B, Cevik A A, Ozkan B, Koksal A, Ozakin E, Abu-Zidan F M. Trauma patients and whole-body computerized tomography imaging: Location of CT-Scan and factors affecting mortality. Niger J Clin Pract 2021;24:667-73

How to cite this URL:
Kaya F B, Cevik A A, Ozkan B, Koksal A, Ozakin E, Abu-Zidan F M. Trauma patients and whole-body computerized tomography imaging: Location of CT-Scan and factors affecting mortality. Niger J Clin Pract [serial online] 2021 [cited 2022 Dec 3];24:667-73. Available from: https://www.njcponline.com/text.asp?2021/24/5/667/316463




   Introduction Top


Whole-body computerized tomography (WBCT) for trauma consists of the non-contrast head and cervical spine scans, and contrast-enhanced thorax, abdomen, and pelvis scans.[1] WBCT protocol reduces the mortality compared with conventional imaging strategies.[2],[3],[4],[5]

The effects of CT scan machine technology and location on trauma care in the emergency department (ED) have been studied.[6],[7],[8] Both technical improvements and closer location improve trauma care by increasing accessibility to the CT. There are few studies in the literature studying the effect of the CT scan machine location on mortality of trauma patients. Previous studies supported the proximity between CT and trauma bays.[9],[10] However, CT scan machines have been located outside the trauma resuscitation area in the majority of emergency departments.[11],[12]

Critical decision making in the management of trauma depends on the resources and the environment. Accordingly, factors affecting outcomes may differ between facilities in developing systems. We aimed to study the factors affecting the mortality of trauma patients who underwent WBCT and investigate the effect of CT location on ED time frames in a developing emergency care system.


   Materials and Methods Top


Study design and setting

This is a retrospective analysis of patients treated from August to November for two consecutive years (2014 and 2015) in the Department of Emergency Medicine (ED) of Eskisehir Osmangazi University Medical Center. The 1200 beds hospital is a tertiary care center that provides continuous emergency service for all trauma patients. The center hosts all residency programs for medical and surgical specialties. ED treats 115,000 patients and 1600 multiple trauma patients a year. This study was reviewed and approved by The Research Ethics Committee of the College of Medicine of Eskisehir Osmangazi University (Reference No: 2016-21).

Study population

All consecutive trauma patients, who were older than 18 years and received WBCT from August to November (highest acuity of trauma in our setting) for two consecutive years (2014 and 2015) were included regardless of the severity of the injury. The patients who were pregnant, left against medical advice or directly transferred from the ED to other facilities were excluded.

Patient management process

All trauma patients were initially evaluated and managed by certified Emergency Physicians (EPs) and senior (3rd–4th year) emergency medicine residents. There was no formal trauma team establishment in the center. Specific surgical departments evaluated patients who needed specialized trauma care as judged by EPs. The ED team is responsible for providing continuous care during the ED stay of the patients. The admission/operation decisions were made by relevant surgical departments. However, admission decisions of ambiguous patients were made by faculty members of the Emergency Medicine (EM) residency program and it has been defined by national legislation.[13]

During 2014, WBCT was performed at the radiology department which was located one level above and 292 meters away from the ED necessitating the use of an elevator. During 2015 WBCT was done at the ED radiology unit which was 45 meters away from the ED trauma/resuscitation room and on the same floor. Because there were no established guidelines for WBCT during the study period, the decision for WBCT was made by the EPs depending on the mechanism of injury, and the primary and secondary trauma survey of the patients. The WBCT results, which read and reported by senior radiology residents and radiology faculty consultant, were extracted from the hospital information system. The management of patients was implemented according to advanced trauma life support guidelines.

Data collection

Data were extracted from the hospital information system and the patients' files in the hospital archives during study months. Patients' demography, presentation time, comorbidities, Glasgow coma scale (GCS), systolic blood pressure, heart rate, injury severity score (ISS), mechanism of injury, injury to ED presentation time, ED presentation to WBCT time, ED presentation to ward or intensive care unit (ICU) admission time and CT to ward or ICU admission time, traumatic pathologies in WBCT, and 30-days mortality were collected. All extracted data were entered into a specifically designed protocol and then entered into an excel sheet by two senior residents and then coded. A faculty member of the residency program controlled the data accuracy for each case.

Statistical analysis

Non-parametric statistical methods were used to compare the patients who died and survived. Fisher's exact test and Mann–Whitney U test were used to compare categorical, continuous, or ordinal data as appropriate. Univariate analysis was used to define significant factors affecting mortality. Factors having a loose P value of less than 0.1 were then entered into a backward logistic regression model to define factors affecting mortality. Receiving operating characteristic curve (ROC) was used to define the best cut off point predicting mortality. PASW Statistics 24, SPSS Inc., USA was used to analyze the data. A P value of less than 0.05 was accepted to be significant.


   Results Top


A total of 34,081 adult patients were treated in the ED during the study period, 1,778 of which were adult trauma patients. In 2014, 200 patients out of 827 (24.1%) and in 2015, 263 patients out of 951 (27.6%) received WBCT. Forty-seven patients (38 in 2014, and 9 in 2015), who were pregnant, left against medical advice, had inadequate data in the hospital information system or were directly transferred to other facilities, were excluded. Totally, 416 patients were analyzed [Figure 1]. 280 (67.3%) patients were males. Motor vehicle collisions were responsible for 61.5% of injury (256 out of 416). The mean (SD) age of the patients was 43.9 (18.9) years. A total of 100 patients were severely injured (ISS > 15). Median (range) GCS and ISS were 15 (3 – 15) and 6 (3 – 66), respectively. The majority of the patients (317 out of 416) presented between 8 a.m. and midnight (76.2%). 216 (51.9%) patients were admitted to the hospital, 123 (56.9%) were operated. The overall mortality was 3.4% (14 out of 416). The mortality rate was 7% (11 out of 162) in 2014 and 1% (3 out of 254) in 2015. We found the difference statistically significant (p = 0.002).
Figure 1: A flow-chart showing the study population

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Significant factors affecting mortality in the univariate analysis [Table 1] were low systolic blood pressure (p = 0.01), increased heart rate (p = 0.034), low GCS (p < 0.0001), increased ISS (p < 0.0001), CT location (p = 0.003), positive findings on CT (p < 0.0001), WBCT to admission time (p < 0.0001), and ED to admission time (p < 0.0001).
Table 1: Univariate analysis comparing variables of patients who died and those who survived in the study population

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The backward logistic regression model defining factors affecting mortality was significant (Nagelkerke R2: 0.672, P < 0.0001) [Table 2]. The significant factors in the model were ISS (p < 0.0001) and GCS (p = 0.001). Eleven out of 14 deaths (78.6%) were in the first year (2014). A one-point increase in the ISS increased the odds of death by 11% and one-point decrease in GCS increased the odds of death by 31% [Table 2]. The areas under the curve (AUC) for ISS and GCS for predicting mortality were 92.8% and 83.3%, respectively [Figure 2] and [Figure 3]. ISS of 15.5 was the best cut off point for predicting mortality having a sensitivity of 92.9% and specificity of 78.4%. GCS of 13.5 was the best cut off point for predicting mortality having sensitivity of 95.6%% and specificity of 71.4%. CT location showed a strong trend for affecting mortality (p = 0.054).
Table 2: Backward logistic regression model defining significant factors affecting mortality

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Figure 2: Receiver Operating Characteristic curve (ROC) defining the best cut off point of GCS that predicts mortality (AUC 83.3%)

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Figure 3: Receiver Operating Characteristic curve (ROC) defining the best cut off point of ISS that predicts mortality (AUC 92.8%)

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[Table 3] shows the variables of patients according to CT location. When the CT machine was located in the ED, the median (IQR) ED to CT time was 32 (16.5) minutes compared to 47.5 (21.5) when it was located in the radiology department (p < 0.001). The median ISS of patients who received WBCT in the ED were lower than the median ISS of those who received WBCT in the radiology department (9 and 18, respectively; P < 0.0001). When CT located in the ED, the number of severely injured (ISS > 15) patients who received WBCT were significantly less compared to when CT located in the radiology department (n: 25 (25%) and n: 75 (75%), respectively; Fisher's exact test, P < 0.001).
Table 3: Variables of patients according to CT location

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   Dıscussıon Top


Our study showed that ISS and GCS were the main factors predicting mortality in patients who received WBCT. When the CT machine was located in the ED, EPs ordered more WBCT imaging and they also ordered more WBCT imaging to less severe patients. Although we could not find significance, CT location showed a strong trend for affecting mortality.

ISS and GCS are the most important factors predicting trauma mortality in different settings.[14],[15],[16],[17] Similarly, ISS and GCS were the most significant factors predicting mortality in our study. A one-point increase in the ISS increased the odds of death by 11% (cut off 15.5) and a one-point decrease in GCS increased the odds of death by 31% (cut off 13.5).

Major trauma is usually defined as having an ISS of more than 15.[18] However, there are multiple cut-off levels ranging from 8 to 20 in describing severe trauma.[18],[19],[20] Our cut-off level in this study was 15.5 which goes with international data. Sending hemodynamically unstable patients to the radiology department away from the ED is inappropriate in many settings. In contrast, diagnostic WBCT has been found useful in reducing mortality in severely injured patients.[21] Our study revealed that the ED team sent patients who had low systolic blood pressure (SBP) to CT imaging. We also found that SBP was not a significant factor affecting mortality according to the backward logistic regression. SBP is traditionally used to define the hemodynamic instability. The median SBPs were 120 and 100 for survivors and nonsurvivors, respectively, in our study. These results may show that the universally accepted 90 mmHg cut-off level may not be appropriate. Similar to our results, a cut-off of 110 mmHg for young ages and 140 mmHg for the elderly has a significant relation to mortality in trauma patients.[22],[23] Huber-Wagner et al. studied the effect of WBCT imaging on reducing mortality in severely unstable (SBP <90 mmHg), moderately unstable (SBP 90-110 mmHg) and normotensive patients (SBP >110 mmHg).[24] As a result, WBCT is described as an independent predictor for survival in hypotensive patients.

There is an increasing trend towards CT usage in the emergency departments over the years.[25] Today, CT is one of the major components of trauma care because of its diagnostic accuracy and availability.[26] Recent systematic review and meta-analyses showed that using WBCT imaging significantly reduces the time spent in the ED and decreases mortality.[4],[27],[28] The location of the CT scan, which varies among different ED settings, is another important factor affecting clinical outcome.[11],[12] Locating the CT scan in the ED provides better compliance with the trauma golden hour strategy.[26] Fung Kon Jin et al. showed that the completion of diagnostic workup required an extra 26 minutes when the CT imaging is done in the radiology unit compared with the ED.[29] Our study supports this finding. Similar to our results, Saltzherr et al. found that an extra 13 minutes difference is needed to perform CT imaging outside the ED.[9] Although Fung Kon Jin did not find a difference in using WBCT when it was located in the ED,[29] we found that WBCT increased when it was located in the ED. One of the surprising findings was the ISS of patients. The patients who received WBCT imaging had lower median ISS when the CT located in the ED than when it located in the RD (9 and 18, respectively). This result may show the tendency of our physicians to use WBCT imaging in less severe cases when they have a CT option inside the ED. In addition to the increased workload of ED CT unit and staff, this may create unnecessary radiation exposure for patients who might not need a whole-body CT scan.[30] On the other hand, WBCT use is recommended if there is a reasonable probability of occult injury.[31] This suggestion does not curtail the use of WBCT and guide the physicians to use the WBCT efficiently. Physiologic, anatomic, and mechanic descriptions of potential major trauma[32] may lower the physician's threshold to order WBCT to address clinically hidden injuries, especially when the CT is easily available.

Weninger et al. reported that the WBCT imaging can shorten the total ED time by 34 minutes.[33] This is an important gain in the era of ED crowding. However, our results showed that patients were admitted 75.5 minutes late when the WBCT completed in the ED. This might also be related to patients' severity. The patients who received WBCT in the ED had a lower ISS median score. Therefore, those patients might have been observed in the ED for longer periods and potentially discharged from the ED after observation.

Limitations

This is a single-center study which does not cover all trauma patients from all over the city. We also restricted our time frame to four months in two consecutive years when the number of trauma patients presenting the ED reached its peak. These two conditions were decisive in determining the sample size of our study and consequently affected the results. Besides, ED trauma management may have improved during the nine months gap between two cohorts which may have affected the outcome. However, we used non-parametric tests to increase the strength of our analysis and found significance in some variables, even in a comparably small sample size.

The mortality rate is also low in our study, thus the results obtained by the logistic regression model might be affected. Nevertheless, the R squared of the model was high 0.67 indicating that our model explained 67% of the variance of the data.


   Conclusions Top


Our study has shown that ISS and GCS were the main factors predicting mortality in patients who received WBCT. This finding was not surprising, as the ISS and GCS are well known prognostic factors for trauma. Patients received more WBCT imaging and physicians showed a tendency to order WBCT in less severe patients when the CT located in the ED. CT location did not show a significant effect on mortality, but it provided faster investigation time. ED presentation to admission time was not improved.

Ethical approval

This study was reviewed and approved by The Research Ethics Committee of the College of Medicine of Eskisehir Osmangazi University (Reference No: 2016-21).

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Figures

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    Tables

  [Table 1], [Table 2], [Table 3]



 

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