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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 25
| Issue : 4 | Page : 496-501 |
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Whole-body CT indications in emergency medicine trauma patients
E Ozcete, I Uz, B Arslan, S Yalcinli, YA Altunci
Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir, Turkey
| Date of Submission | 09-Aug-2021 |
| Date of Acceptance | 16-Dec-2021 |
| Date of Web Publication | 19-Apr-2022 |
Correspondence Address:
Dr. E Ozcete
Department of Emergency Medicine, Ege University Faculty of Medicine, Izmir
Turkey
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/njcp.njcp_1727_21
 Abstract | | |
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.
Keywords: Emergency department, trauma, whole-body CT
How to cite this article:
Ozcete E, Uz I, Arslan B, Yalcinli S, Altunci Y A. Whole-body CT indications in emergency medicine trauma patients. Niger J Clin Pract 2022;25:496-501 |
How to cite this URL:
Ozcete E, Uz I, Arslan B, Yalcinli S, Altunci Y A. Whole-body CT indications in emergency medicine trauma patients. Niger J Clin Pract [serial online] 2022 [cited 2022 May 22];25:496-501. Available from: https://www.njcponline.com/text.asp?2022/25/4/496/343456 |
| Introduction | |  |
For the management of multi-trauma patients in the emergency department, detection of mortal injuries and treatment than in secondary care diagnosis and management of additional injuries have precedence. This approach summarizes Advanced Trauma Life Support (ATLS) protocol.[1] However ATLS pointed detailed physical examination and base radiological images, devolution in computerized tomography technology started daily practice change throughout early whole-body imaging.
Whole-body computerized tomography (CT) has already been used in multiple trauma patients since 1997.[2] Whole-body CT scan designed as early diagnosis of traumatic injuries and prevention of unnoticeable injuries. Also by courtesy of multi-slice CT, the scanning period ends in a brief period.[3] This quicknesses tailored Whole-body CT thinkable in unstable patients.[4] The advantages of whole-body CT on standard diagnoses approaches are leading definitive diagnoses and management plans in a short time.[5]
Whole-body CT is helpful if used appropriately in the management of trauma patients. But comparatively, in the young patient group, they were exposed to ionization radiation in high doses like 20 mSv.[6],[7] Using whole-body CT in trauma patients still controversial, there is no consensus on its indications.[8] Usually, physiological parameters and serious injury suspicion guide clinical decision-making.[9],[10] It is considered that we still need selection criteria with a high level of evidence.[11] Also, it shows a wide variety according to cut-off levels in vital parameters.
We aim to clarify indications and cut-off levels in vital parameters in trauma patients who undergo Whole-body CT to prevent unnecessary or negative scans.
| Subjects and Methods | | |
The study was conducted in an emergency department, which is a high-level trauma center retrospectively. After the XXX Ethics committee's approval (Approval number: 21-1.1T/66). Patients were admitted to our emergency department with trauma between 01.09.2019 and 30.09.2020. Patients above 18 years old with a whole-body CT scan (head, cervical, contrast-enhanced thorax, and abdominal CT) included. Patients with penetrant trauma, gunshot injury, and missing data were excluded from the study.
Patients' demographical data, initial vital parameters, trauma mechanism, shock index (systolic blood pressure (SBP)/pulse), Focused Assessment with Sonography for Trauma (FAST) findings, Glasgow Coma Scale (GCS), and outcome (hospitalization, discharge, etc.) evaluated.
Whole-body CT reports are evaluated according to five categories; cranial-facial, vertebra, thorax, abdomen, pelvis-bone. All injuries were noted for a single patient for each area. Patients are divided into groups by the number of injured areas. Patients were grouped as 'multi-trauma' with two affected trauma zones and 'serious multi-trauma' with three affected trauma zones.
Continuous data with a normal distribution are presented as means with standard deviation and non-normally distributed data are presented as medians with interquartile ranges. Categorical variables were examined with frequency tables, and descriptive statistics were calculated for continuous variables. Independent sample t-tests and Mann-Whitney U tests were used, respectively, to compare parametric and non-parametric continuous data. Pearson Chi-square test was used to examine categorical data in terms of groups. The significance level was taken as P < 0.05 in all hypothesis tests. Odds ratios of each parameter at a 95% confidence interval (CI) were calculated for each variable. Logistic regression analysis was used to determine Whole-body CT indications. IBM SPSS Version 25.0 statistical package program was used for statistical analysis.
| Results | | |
A total of 781 trauma patients who underwent whole-body CT were identified. Forty-three patients were under 18 years old, and 10 were penetrant injuries, nine were gunshot injury and two were had insufficient data. Finally, 717 patients included analysis. The mean age of patients was 43 ± 19 and 74.8% of patients were male.
The period of CT scan median value was 36 minutes (23-66). The median value of the shock index was 0.67 (0.59-0.76), and for GCS, it was 15 (15-15). Patients admitted to the emergency department by ambulance with a rate of 84.8%. Patients discharged from the emergency department with a rate of 65.4%. The in-hospital mortality rate was 1.5% (n = 11) and two of them were in the emergency department. The most affected zone was the thorax with (28.2%) and the least affected zone was the pelvis (8.5%) [Table 1]. | Table 1: Evaluation of Whole-body CT results according to five separate body regions
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After the re-examination of Whole-body CT, 46.3% were detected normally. Rates of injured zones were 53.7% at least one zone, 23.3% at least two zones, and 7.4% at least three zones respectively [Table 2]. | Table 2: Predictive value of Whole-body CT criteria in patients with injuries in at least two regions
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Scientific variables with three zones of injury were SBP ≤100, SBP ≤90 mm Hg, Pulse ≥100, or ≥110 or ≥120/min, shock index ≥0.9, GCS <15, or ≤13, or ≤9, and FAST positivity. Trauma mechanisms were not meaningful on three zones of injury [Table 3]. | Table 3: Predictive value of Whole-body CT criteria in patients with injuries in at least three regions
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Prediction criteria of Whole-body CT for the patients with two or three zones of injury were SBP ≤100 mm Hg, GCS <15, and presence of free fluid in the FAST according to regression analysis [Table 4]. | Table 4: Predictive value of Whole-body CT criteria in patients with injuries in at least two or three Regions
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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 [Table 5]. | Table 5: Whole-body CT Prediction values in patients with at least one of the three independent variables*
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| Discussion | | |
In the emergency department, it is a race against time to give the Whole-body CT decision and to identify vital injuries. For this reason, parameters are needed to detect patients groups who benefit from Whole-body CT. In our study, we find GCS <15, SBP ≤100 mm Hg, and free fluid in FAST as independent parameters for the indication of Whole-body CT scan.
GCS has already used for the Whole-body CT scan decision. Physical examination findings in patients with consciousness impairment are unreliable. It was suggested that for the patients with unreliable physical examination findings, a routine CT scan finds out unsuspected findings of up to 38% and changes treatment management between 19-26% rates.[12],[13]
The decision for Whole-body CT, the threshold value in GCS differs. Some studies recommended GCS ≤13 or ≤9 may be useful for this decision.[14],[15] However in our study GCS ≤13 or ≤9 were an effective predictor for two and three zones injury, according to regression analyze. GCS <15 was an independent determinant for serious injury. So we think that GCS <15 is a valid indicator for the Whole-body CT scan decision. Whole-body CT scan is useful for patients who have unstable hemodynamic risk. Vital signs like SBP <100 or 90 mm Hg are the recommended parameters for making the Whole-body CT scan decision.[14],[15] Although both value is effective in the decision of Whole-body CT, we determined that SBP ≤ 100 mm Hg is an independent variable.
The routine FAST examination is a suggested standard method in trauma management.[1] The application of point of care ultrasound has significantly impacted the evaluation and treatment of patients. Ultrasound has considerable advantages, including its bedside availability, ease of use, and reproducibility. Furthermore, it is non-invasive, employs no radiation or contrast agents, and is inexpensive.[16]
Trauma mechanisms, were not significant in whole body CT decision. Making Whole-body CT decisions based on the high-risk trauma mechanism without affecting vital parameters may cause unnecessary CT scans.
The use of Whole-body CT in trauma patients in the emergency department is gradually increasing.[17],[18] Radiation exposures will be a big problem in the future. In studies, the rate of unnecessary CT ranged from 14% to 47%, and in our study was 46%.[9],[19],[20],[21] Reducing the unnecessary use of CT is the smartest approach to do in this regard. Whole-body CT is beneficial in blunt trauma patients with impaired vital signs.[22] We suggest the use of SBP ≤100 mm Hg and GCS <15 as vital signs in deciding on Whole-body CT. With the addition of free fluid presence in FAST to these findings, the Whole-body CT decision can be made in terms of serious injury patients. With at least one of the three independent variables, a satisfactory rate of specificity (84%) can help to make a quick decision for a serious injury.
| Limitations | | |
This study was a retrospective and single-center study. It focused only one special trauma center so may less applicable for non-trauma centers. Our knowledge about the mechanism of trauma is limited, and it is not stated how high the patients fall, the speed of the vehicle in traffic accidents, or whether there is death at the scene. Besides, there is no evaluation such as injury severity score.
| Conclusion | | |
It is appropriate to use GCS <15 and SBP ≤ 100 mm Hg as the cut-off value of vital parameters in making Whole-body CT decisions in trauma patients. Also, free fluid detection in FAST can be used for Whole-body CT decision.
Consent to participate
Written informed consent wasn't obtained from each patient included in the study. Because these study is retrospective.
Ethical approval
This study has approval from Ege University Ethics Committee (approval number: 21-1.1T/66).
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | American College of Surgeons, editor. Advanced Trauma Life Support Student Course Manual. 9 th ed. American College of Surgeons; 2012.  |
| 2. | Low R, Duber C, Schweden F, Lehmann L, Blum J, Thelen M. Whole body spiral CT in primary diagnosis of patients with multiple trauma in emergency situations. RoFo 1997;166:382–8. |
| 3. | Davis JW, Hoyt DB, Mackersie RC, McArdle MS. Complications in evaluating abdominal trauma: Diagnostic peritoneal lavage versus computerized axial tomography. J Trauma 1990;30:1506–9. |
| 4. | Ptak T, Rhea J, Novelline R. Experience with a continuous, single-pass wholebody multidetector CT protocol for trauma: The three-minute multiple trauma CT scan. Emerg Radiol 2001;8:250–6. |
| 5. | Huber-Wagner S, Biberthaler P, Haberle S, Wierer M, Dobritz M, Rummeny E, et al. Whole-body CT in haemodynamically unstable severely injured patients – A retrospective, multicentre study. PLoS One 2013;8:e68880. doi: 10.1371/journal.pone. 0068880. |
| 6. | Brenner DJ, Elliston CD. Estimated radiation risks potentially associated with full-body CT screening 1. Radiology 2004;232:735–8. |
| 7. | Wedegartner U, Lorenzen M, Nagel HD, Weber C, Adam G. Diagnostic imaging in polytrauma: Comparison of radiation exposure from whole-body MSCT and conventional radiography with organ-specific CT. RoFo 2004;176:1039–44. |
| 8. | Treskes K, Saltzherr TP, Luitse JS, Beenen LF, Goslings JC. Indications for total-body computed tomography in blunt trauma patients: A systematic review. Eur J Trauma Emerg Surg 2017;43:35-42. |
| 9. | Wurmb TE, Fru¨hwald P, Hopfner W, Roewer N, Brederlau J. Whole-body multislice computed tomography as the primary and sole diagnostic tool in patients with blunt trauma: Searching for its appropriate indication. Am J Emerg Med 2007;25:1057–62. |
| 10. | Sloan R. A retrospective review of influences on clinicians to order whole body CT scans in trauma and its effectiveness in this regard. Scand J Trauma Resusc Emerg Med 2013;21(Suppl 1):S16. |
| 11. | Hunt P, Smith C, Oliver A. Early computed tomography scanning in multisystem trauma: The evidence. Trauma 2012;14:287–300. |
| 12. | Self ML, Blake AM, 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;186:609–13. |
| 13. | Salim A, Sangthong B, MartinM, Brown C, Plurad D, Demetriades D. Whole body imaging in bluntmultisystem trauma patients without obvious signs of injury: Results of a prospective study. Arch Surg 2006;141:468–73. |
| 14. | 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? Emerg Med Australas 2013;25:182–91. |
| 15. | Treskes K, Saltzherr TP, Edwards MJR, Beuker BJA, Van Lieshout EMM, Hohmann J, et al. Refining the criteria for immediate total-body CT after severe trauma. Eur Radiol 2020;30:2955-63. |
| 16. | Bloom BA, Gibbons RC. Focused Assessment with Sonography for Trauma. 2021. In: StatPearls. Treasure Island (FL): StatPearls Publishing; 2021. |
| 17. | TraumaRegister DGU(®). 20 years of trauma documentation in Germany--actual trends and developments. Injury 2014;45(Suppl 3):S14-9. |
| 18. | Hutter M, Woltmann A, Hierholzer C, Gärtner C, Bühren V, Stengel D. Association between a single-pass whole-body computed tomography policy and survival after blunt major trauma: A retrospective cohort study. Scand J Trauma Resusc Emerg Med 2011;19:73. |
| 19. | Smith CM, Woolrich-Burt L, Wellings R, Costa ML. Major trauma CT scanning: the experience of a regional trauma centre in the UK. Emerg Med J. 2011;28:378-82. doi: 10.1136/emj.2009.076414. Epub 2010 Jun 1. PMID: 20515906. |
| 20. | Sampson M, Colquhoun K, Hennessy N. Computed tomography whole body imaging in multi-trauma: 7 years experience. Clin Radiol 2006;61:365–9. |
| 21. | Beak P, Gabbott B, Williamson M, Hing CB. Four years of experience as a major trauma centre results in no improvement in patient selection for whole-body CT scans following blunt trauma. Eur J Orthop Surg Traumatol 2020;30:473-7. |
| 22. | Tsutsumi Y, Fukuma S, Tsuchiya A, Yamamoto Y, Fukuhara S. Whole-body computed tomography during ınitial management and mortality among adult severe blunt trauma patients: A nationwide cohort study. World J Surg 2018;42:3939-46. |
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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