Key points
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If indicated, whole-body-CT (WBCT) saves lives in severely injured patients.
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However, WBCT radiation dose risk versus benefit depends on severity of injury.
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Two WBCT protocols should be established (A: time/precision optimised, B: dose reduced).
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Protocol A should be used for clinically unstable patients/life-threatening conditions.
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For all other patients, protocol B should be selected.
Background
Methods
Key issues
Literature research
Inclusion/exclusion criteria for literature selection
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It is published as a guideline, i.e. using the word ‘guideline’ in the title
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The guideline is described as being current or no updated version is available
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Allowed study types: meta-analyses, systematic reviews, randomised controlled trials, cohort studies, case–control studies, cross-sectional studies, before—after studies
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Outcome: p-value < 0.05 and/or confidence interval (CI) > 95%
Classification, rating, and evidence level of studies
Grade of recommendation (GoR)
Good clinical practice points (GPP)
Consensus development at the conferences
Key question: Which patients can be classed as polytrauma (and should therefore receive a whole-body computed tomography)? | ||||
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No | Statement(s) | Consensus (positive votes on the statement, strength) | Grade (recommendation type, level) | Consensus (positive votes on the grade, strength) |
1.1 | The assessment should be undertaken by the medical team in the Emergency Trauma Room** with regard to a potential life threatening situation and continuously reassessed with special regard to: Abnormalties of vital signs Injury mechanism Multiple body regions injuries and injury location Cofactors such as age, comorbidity, anticoagulant medication, pregnancy | 100% strong | GPP A | 100% strong |
Comments: ESER does not assign a GoR because no evidence-based clear prospective definition was found in the literature. As a comment, ESER wants to recommend that the decision whether a patient is classed as polytrauma or not, should be taken by the trauma team leader in charge (a named person for each shift or patient). The trauma team leader has to decide in consultation with the rest of the trauma team, mainly the leading team members of Trauma Surgery, Anesthesiology and Radiology |
Key question: Where should the CT-scanner be located with regard to a short service time and the lowest possible mortality rate of polytrauma patients? | ||||
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No | Statement(s) | Cons | Grade | Cons |
2.1.1 | The computer tomograph ought to be located in or directly next to the Emergency Trauma Room | 71% weak | GoR B | 100% strong |
2.1.2 | If this is not possible, the distance should not exceed 50 m | 100% strong | GoR A | 100% strong |
2.1.3 | The transportation route to further therapy (Interventional Radiology, Operating Room, Intensive Care/Therapy Unit, and in rare cases Coronary Unit) ought to be short | 86% normal | GoR B | 100% strong |
Comments: A dual-room/ sliding gantry-CT may be considered in case of localisation in the Emergency Trauma Room |
Key question: Which computer tomography technology is needed for a polytrauma service? | ||||
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No | Statement(s) | Cons | Grade | Cons |
2.2.1 | Trauma Centres of the highest level of medical care should be equipped with a Multi-detector CT (MDCT) offering at least 64 simultaneous slices | 100% strong | GoR A | 86% normal |
2.2.2 | As isotropic scanning offers the advantages of high quality MPR (multiplanar reformations), a CT scanner ought to be preferred with at least 16 detector rows | 86% normal | GPP B | 86% normal |
2.2.3 | The computer tomographs ought to be equipped with current techniques for the reduction of radiation exposure, but this should not delay image reconstructions | 100% strong | GoR B | 86% normal |
2.2.4 | Dual-Energy/ Spectral imaging/ substraction imaging scanner may be considered | 86% normal | GPP 0 | 71% weak |
2.2.5 | Trauma centres of the highest level of medical care should be technically equipped to a standard that will allow a perfusion CT of the brain | 100% strong | GPP A | 100% strong |
2.2.6 | Trauma centres of the highest level of medical care should be technically equipped to a standard that will allow a cardiac CT, if needed | 14% none | - | - |
Comments: As the technological development was fast in the last decade (the interval for literature inclusion), literature included reports on four row CT-scanners for polytrauma service. The consensus conference states them as obsolete |
Key question: Which work organization is recommended for polytrauma management with regard to workstation, data processing, image display and communication? | ||||
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No | Statement(s) | Cons | Grade | Cons |
2.3.1 | Depending on the individual framework conditions, each facility should enable the fastest possible initial image evaluation | 100% strong | GoR A | 100% strong |
2.3.2 | For this initial evaluation, an optimised workstation connected directly to the CT control console ought to be used | 86% normal | GoR B | 100% strong |
2.3.3 | These initial images should not exceed a maximum slice thickness of 5 mm | 100% strong | GoR A | 100% strong |
2.3.4 | Depending on the individual framework conditions, each institution should define a suitable infrastructure for the immediate oral as well as the further written exchange of information | 100% strong | GoR A | 100% strong |
2.3.5 | The transmission of findings may be considered to be supported with a selection of relevant images | 86% normal | GoR 0 | 86% normal |
2.3.6 | There should be a way between hospitals to exchange CT images safely and timely | 100% strong | GoR A | 100% strong |
Comments: Mobile devices may be useful in distributing relevant information |
Key question: What does suitable quality management entail for the radiological care of polytrauma patients? | ||||
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No | Statement(s) | Cons | Grade | Cons |
2.4.1 | Every radiological facility should establish targeted, individual quality management for the treatment of polytrauma | 100% strong | GPP A | 100% strong |
2.4.2 | Such quality management ought to define, monitor and continuously improve defined meaningful indicators | 100% strong | GPP B | 100% strong |
2.4.3 | Such a quality management ought to be integrated into and coordinated with a radiological as well as a clinical overall quality management | 86% normal | GPP B | 86% normal |
Literature: No literature search was conducted | ||||
Comments: Quality management has long been established in industry and is increasingly proving itself in medical applications. Quality management is desirable, but so far little suitable reliable information is available. More precise recommendation on quality management should be the subject of future research and also of radiological or clinical consensus conferences. As a first choice useful parameters may be: time-to CT-service; time of CT-service; time-to therapy; total dose; image quality; errors in first, second and third readings; number and frequency of morbidity and mortality conferences |
Key question: What significance does the eFAST examination have in the Emergency Trauma Room treatment of polytrauma patients? | ||||
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No | Statement(s) | Cons | Grade | Cons |
3.1 | eFAST should be used as part of the Primary Survey | 100% strong | GoR A | 100% strong |
3.2 | eFAST should be implemented simultaneously with other measures, i.e. without additional expenditure of time for the overall care. If this is not possible, eFAST should not delay CT | 100% strong | GoR A | 100% strong |
Comments: eFAST ought to be a screening for diagnostic findings requiring immediate treatment. With this meaning eFAST is a filter to (maybe temporarily) exclude (very few) patients from CT-scanning because of reasons where the time effort of CT is expected to lead to higher mortality. Such findings in unstable patients may be tension pneumothorax, pericardial tamponade, massive bleeding in the pleural or peritoneal spaces |
Key question: What is the significance of conventional X-rays and under what conditions are conventional X-rays preferred to computer tomography in the Emergency Trauma Room treatment of polytrauma patients? | ||||
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No | Statement(s) | Cons | Grade | Cons |
4.1 | For the clarification of polytrauma, CT should be preferred to X-ray | 100% strong | GoR A | 100% strong |
4.2 | In addition to an eFAST, conventional X-ray should also be immediately available | 100% strong | GoR A | 100% strong |
Comments: None |
Key question: How does head- or feet-first positioning affect a polytrauma – WBCT scan? | ||||
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No | Statement(s) | Cons | Grade | Cons |
5.1.1 | If it is logistically possible, the patient ought to be positioned on the examination table with her/his feet in front of the gantry | 86% normal | GPP B | 86% normal |
5.1.2 | Otherwise, the scan ought to be done head first | 100% strong | GPP B | 86% normal |
Literature: detected = 328, excluded = 323, full-text: rated = 5, excluded = 5, included = 0 | ||||
Comments: Although without any evidence, the advantages of feet-first positioning appear to be clear in terms of reduced radiation exposure of personnel, reduced artifacts due to cable routing, reduced cable routing problems, easier accessibility to the head |
Key question: How do different arm positions of patients with polytrauma impact computed tomography scans with respect to radiation exposure, image quality and scan duration? | ||||
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No | Statement(s) | Cons | Grade | Cons |
5.2.1 | Depending on the patient or their clinical condition, the arms should be positioned down (time-optimised) or up (dose-optimised) | 86% normal | GoR A | 100% strong |
5.2.2 | For a time-optimised protocol (e.g. in haemodynamically unstable patients), arms ought to be crossed over the trunk in such a way that the hardening artifacts are distributed to best effect over the z-axis (time-optimised procedure equals quick) | 100% strong | GoR B | 100% strong |
5.2.3 | For a dose-optimised protocol (prerequisite: haemodynamically stable patients), arms for the CT scan of the trunk ought to be positioned above the head unless there is evidence of a significant injury to the corresponding local shoulder region (dose-optimised procedure equals lower radiation) | 86% normal | GoR B | 100% strong |
Comments: The positioning of the arms above the head costs time as well as coming with further drawbacks, however it does reduce the dose for the trunk. The positioning with crossed forearms over the abdomen distributes the hardening artifacts over the abdomen, is very fast and risk-free, easy to fix and favours the outflow of the given intravenous contrast media. In addition, the entire upper limb, which is often injured, is often imaged in this way |
Key question: What diagnostic value does the scout of a whole-body CT scan have in the case of a polytrauma patient and how should it be prepared? | ||||
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No | Statement(s) | Cons | Grade | Cons |
6.1.1 | The scout(s) ought to represent the entire body | 100% strong | GoR B | 100% strong |
6.1.2 | For a dose-optimised protocol, separate topograms should be prepared for the cranial CT (at least lateral projection) and the rest of the body (at least anterior—posterior projection). If the arms are raised, this should be done before the body topogram is prepared | 100% strong | GPP A | 86% normal |
Comments: The CT scout does not only hold information of important findings, it also is the basis to calculate the dose modulation during the CT scan. For protocols with elevated arms, a dose reduction only affects cases where the arms were raised before the CT scout was performed |
Results
Is an unenhanced cranial scan preferred to a cranial scan with contrast medium as first imaging option in the whole-body tomography scan of the polytrauma patient? | |||||
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No | Statement(s) | Cons | Grade | Cons | |
6.2.1 | The full body tomography scan of the polytrauma patient should begin with an unenhanced cranial CT scan | 100% strong | GoR A | 100% strong | |
6.2.2 | Depending on the findings and symptoms, an additional cranial CTA (computed tomography angiography) may be considered as useful | 86% normal | GoR 0 | 86% normal | |
Comments: Virtual unenhanced CT imaging with Dual Energy techniques should undergo more scientific evaluation. Maybe this method will allow single enhanced cranial CT scanning with sufficient detection rates of intracranial bleedings by virtual unenhanced imaging. If so, this may have the potential for both speeding up service and reducing the dose |
How should the head/neck region in the standard whole-body tomography protocol be performed in a polytrauma patient with regard to contrast agent administration and image calculation? | ||||
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No | Statement(s) | Cons | Grade | Cons |
6.3.1 | With a protocol that is not dose-optimised, the neck region should be included in the whole body tomography scan with intravenous contrast medium in such a way that the neck arteries and brain base arteries are well opacified | 100% strong | GoR A | 100% strong |
6.3.2 | If only a bony injury is suspected in the cervical spine, the scan may be considered without the administration of contrast medium within the framework of a dose-optimised protocol | 71% weak | GoR 0 | 71% weak |
6.3.3 | For dose reasons, the cranial scan ought not to be extended to the cervical spine | 86% normal | GPP B | 86% normal |
6.3.4 | Axial image reconstruction should be performed in thin slices with both a soft tissue and a bone kernel | 100% strong | GoR A | 100% strong |
6.3.5 | Image reformation should take place at all three orthogonal standard planes | 100% strong | GoR A | 86% normal |
6.3.6 | The neck may be considered as part of the body scan as long as a second image reconstruction with a Field-of-View adapted to the neck is performed | 100% strong | GoR 0 | 100% strong |
Comments: None |
Key question: What is the optimal phase for contrast enhanced emergency polytrauma imaging? | ||||
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No | Statement(s) | Cons | Grade | Cons |
6.4.1 | The choice of the injection protocol should be individually adapted to the patient and their clinical condition, in particular with regard to dose aspects and required diagnostic significance | 86% normal | GPP A | 86% normal |
6.4.2 | An unenhanced phase may be considered to be performed in case of question of blood components outside a vascular lumen | 57% weak | GoR 0 | 57% weak |
6.4.3 | For a given indication, it may be considered to calculate an unenhanced phase using the dual-energy technique | 100% strong | GoR 0 | 100% strong |
6.4.4 | Purely unenhanced CT imaging should not be performed on the trunk of the body | 100% strong | GoR A | 86% normal |
6.4.5 | A split bolus protocol ought to be part of a dose-optimised protocol | 71% weak | GPP B | 57% weak |
6.4.6 | Where a split bolus protocol identifies questionable relevant findings, the region in question ought to be supplemented with an additional appropriate further phase | 100% strong | GPP B | 100% strong |
6.4.7 | For a protocol with a focus on highest diagnostic precision, at least the upper abdomen should be depicted in both the arterial and venous phases | 86% normal | GoR A | 100% strong |
6.4.8 | For image findings suspicious of active bleeding, at least two temporally separated contrast phases ought to be present to estimate the activity | 100% strong | GoR B | 86% normal |
Comments: The section deals with intravenous contrast media. Mainly for time reasons oral or rectal filling is inappropriate / obsolete |
Key question: What do the WBCT protocol parameters manifest itself in case of a polytrauma patient regarding the application of contrast medium? | ||||
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No | Statement(s) | Cons | Grade | Cons |
6.5.1 | For a split bolus, the larger component ought to be used for the first injection (portal-venous phase part) | 100% strong | GoR B | 100% strong |
6.5.2 | A saline flush should be used at the end of each contrast medium injection | 100% strong | GoR A | 100% strong |
6.5.3 | Each facility ought to maintain multiple standard injection protocols and consider individual patient characteristics for injection | 86% normal | GPP B | 86% normal |
6.5.4 | Each institution should critically and regularly check the resulting image quality, inspect the protocols regarding this and a possible reduction of the contrast medium quantity | 100% strong | GPP A | 86% normal |
Comments: The contrast medium injection protocols are quite inconsistent. The Sections 6.4 and 6.5 overlap and should be merged in upcoming guideline updates |
Key question: What are the indications for extended imaging of the urinary tract? | ||||
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No | Statement(s) | Cons | Grade | Cons |
7.1.1 | The indications should be taken in conjunction with the guideline from the European Society of Urogenital Radiology (ESUR) | 100% strong | GPP A | 86% normal |
7.1.2 | A urographic phase should not delay other immediately necessary life-sustaining therapy | 100% strong | GPP A | 100% strong |
7.1.3 | If necessary, a urographic phase may be considered up to a few hours after the initial CT without further injection of contrast media | 100% strong | GPP 0 | 100% strong |
7.1.4 | If in situ, a bladder catheter should be clamped first before performing the urographic phase | 100% strong | GPP A | 100% strong |
7.1.5 | In case of unclear findings of the bladder and urethra, an additional retrograde filling may be considered | 100% strong | GoR 0 | 100% strong |
Comments: None |
Discussion and conclusions
Key question: Under which conditions should the standard WBCT protocol of the polytrauma patient be adapted with regard to CT-angiography of the extremities, aorta or intestinal/mesenteric? | ||||
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No | Statement(s) | Cons | Grade | Cons |
7.2.1 | CTA of the extremities ought not to be a standard part of the whole body CT polytrauma protocols | 100% strong | GPP B | 100% strong |
7.2.2 | In the case of an extension of the whole body CT scan, identified prior to the examination, the guidelines of the respective radiological -subspeciality societies should be taken into account, e.g. cardiovascular, abdominal | 100% strong | GPP A | 86% normal |
Comments: None |
Key question: What is the procedure for the assessment and evaluation of the whole body tomography scan in the case of a polytrauma patient to be as quick and accurate as possible? | ||||
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No | Statement(s) | Cons | Grade | Cons |
8.1 | The entire initial WBCT should be evaluated three times (primary, secondary, tertiary) for a very high level of diagnostic safety | 100% strong | GoR A | 100% strong |
8.2 | In total, reading should be carried out by at least two different radiologists, at least one of whom should be board certified. In each case, the assessment should be based on the ABCDE scheme | 100% strong | GPP A | 100% strong |
8.3 | Scout assessment: The scout should be interpreted immediately in order to triage the patient and/or adapt the scan protocols as required | 57% weak | GPP A | 57% weak |
8.4 | Primary assessment: As soon as the first CT series are available they should be evaluated immediately with the focus on acutely relevant findings (ABCDE scheme) | 100% strong | GPP A | 86% normal |
8.5 | Primary documentation and communication: should happen immediately verbally and be handled adequately according to the institutional setting and should be documented | 100% strong | GPP A | 86% normal |
8.6 | Secondary assessment: should also be carried out as quickly as possible, but at least within one hour after the primary assessment and based on the final images. Any relevant changes to the primary assessment should be communicated immediately and be documented | 100% strong | GPP A | 100% strong |
8.7 | Tertiary assessment: Should take place within 24 h at latest. In case of relevant changes in findings, these should also be communicated immediately and any changes in findings should be documented. In cases where the second report was authorised by a Board certified Radiologist, this should be done as an addendum | 100% strong | GPP A | 100% strong |
Comments: Reading polytrauma CT three times may seem time-consuming. The consensus group interpreted the first reading as the reading of the very first images (e.g. 1 mm axial slices in soft tissue kernel with MPR views from these data as provided automatically with first, often oral report. This includes reading of the scout but is not limited to the scout). The second reading means the reading of the final reconstructed images as stored in PACS (picture archiving and communication system) with written report. In most cases, the first and second reading will be performed by the same radiologist. Finally, the third reading should be done by a different radiologist. For CT scans during regular working hours this may be the reading performed by an attending radiologist (maybe in parallel with the second reading together with the radiologist who did the first reading). For CT scans during on call periods, the third reading may be performed in the morning of the next day. This may be the Radiologist on the next routine in-hours shift or next on-call Radiologist. As some European countries offer Emergency Radiology as a certified radiological subspecialty and some do not, ESER offers a European Diploma in Emergency Radiology as an international qualification. Although desirable, ESER does not mandate such a formal national or international Emergency Radiology qualification. Instead, ESER emphasises that in each case at least the second or the third reading has to be performed by a board certified radiologist with fundamental experience in Emergency Radiology |
Key question: In which cases should interventional radiology be consulted? | ||||
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No | Statement(s) | Cons | Grade | Cons |
9.1 | The indications should be taken in conjunction with the guideline from the relevant radiological subspecialty societies CIRSE (Cardiovascular and Interventional Radiological Society of Europe) and ESNR (European Society of Neuroradiology) | 100% strong | GPP A | 75% weak |
9.2 | Interventional (neuro-) radiology should be available 24/7 for consultation and treatment within a locally agreed timely manner | 100% strong | GPP A | 100% strong |
Literature: None | ||||
Comments: None |
Key question: Is one standard CT protocol sufficient? | ||||
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No | Statement(s) | Cons | Grade | Cons |
10.1 | Within the framework of radiological polytrauma management, at least two different WBCT protocols should be maintained as institutional standards. One should be optimised with regard to radiation dose yielding high diagnostic validity but prioritising lower radiation burden (Dose Protocol). The other one is a compromise, prioritising rapid diagnosis and very high diagnostic validity over the potential risks of increased radiation burden (Time/Precision Protocol) | 100% strong | GPP A | 100% strong |
10.2 | The Time/Precision Protocol should be preferred for polytrauma patients with life-threatening injuries or haemodynamically unstable conditions | 88% normal | GPP A | 100% strong |
10.3 | The Dose Protocol should be preferred for polytrauma patients provided they do not have obvious life-threatening injuries or are haemodynamically unstable | 100% strong | GPP A | 100% strong |
Literature: No literature search was conducted | ||||
Comments: It has been proven that the maintenance of a protocol standard for whole-body CT after polytrauma increases the probability of survival [149]. As a possible consequence of this fact, the experts at the conference observed an increase in Emergency Trauma Room admissions who subsequently receive a WBCT. In parallel, the ESER experts share the impression that the number of patients with minor injuries who undergo WBCT has also increased. The consensus group concluded that a single standard protocol can rarely do justice to this varied situation. A more refined but nevertheless simple differentiation would be desirable with regard to the essential influencing parameters: Injury severity, patient condition, patient age including the probability of relevant comorbidities and/or medication, dose aspects especially with regard to patient age. The other previous recommendations remain unaffected |
Limitations
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Only one person was involved in suggesting key issues (S.W.)
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Literature search was limited to two persons (S.W., J.H.)
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Literature preparation (exclusion, inclusion, grading) was also limited to S.W., J.H.
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The preparation of the consensus conference(s) including suggested statements and respective grading of them was limited to S.W., J.H.
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Literature inclusion was limited to free full access via the Ludwig-Maximilians University of Munich, Germany. However, this quote was about 95 percent in mean and always above 90 percent.
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German was the only non-English language that could be included in the literature search (because S.W. and J.H. were able to understand and translate it for the consensus conference members).
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The guideline does not cover special topics like paediatric patients or interventional radiology; these are an aspiration for future editions