Improving Outcomes in the Patient with Polytrauma: A Review of the Role of Whole-Body Computed Tomography

https://doi.org/10.1016/j.rcl.2015.02.006Get rights and content

Section snippets

Key points

  • Whole-body computed tomography (WBCT) has become a widely used technique for the workup of the patient with blunt polytrauma.

  • Current evidence suggests that WBCT is associated with improved or no change in patient survival and reduces the emergency department (ED) length of stay (LOS).

  • However, randomized studies, at least one of which is underway, are needed to determine for certain whether early WBCT improves survival, to clarify which patients benefit the most and to model the costs of this

Definition of whole-body computed tomography in trauma

The techniques used for WBCT (otherwise known as pan-scan or total-body CT) in trauma vary tremendously, but generally, WBCT is considered to include CT of the head, neck, chest, abdomen, and pelvis during a single visit to the CT scanner. Less commonly, CT has been used to refer specifically to thoracoabdominal CT for trauma. Usually, a WBCT scan comprises a CT of the head without intravenous contrast, CT of the cervical spine (acquired before, or following, intravenous contrast), and CT of

Indications for whole-body computed tomography in trauma

There is no consensus in the literature and no validated clinical prediction rule that defines clear criteria for WBCT following trauma or to define patients in whom WBCT can be safely omitted. In the published studies to date, a range of indications have been applied to select patients with trauma for WBCT rather than selective CT. Broadly, indications for WBCT have included the mechanism of injury, injury location or pattern, initial vital signs, or a combination of these.17

Impact of whole-body computed tomography on patient mortality

A recent Cochrane systematic review attempted to assess the effects of routine thoracoabdominal CT compared with selective CT on mortality in patients with high-energy blunt trauma.20 This systematic review noted the absence of any randomized controlled trials meeting their inclusion criteria and concluded that “while the diagnostic value of WBCT seems clear, its benefits on mortality cannot be established.”

Several prospective observational studies and retrospective cohort studies have been

Arm Positioning and Imaging Quality

There is no consensus regarding the best WBCT technique. Varying approaches categorized into 2 broad groups, multipass and single pass, have been described.

A multipass CT acquisition technique generally involves separate helical CT phases of different body regions. Typically, this approach involves noncontrast CT of the head and cervical spine, with the upper extremities resting beside the patient’s torso. Following acquisition of the cervical spine, the upper extremities are raised beside the

Incidental findings

Incidental radiologic findings are findings totally unrelated to the referring clinician’s reason for obtaining the study, for which the term incidentaloma has been coined.71 As the frequency and scope of medical imaging obtained on patients in the ED has increased, so too has the detection of unrelated but potentially clinically significant incidental findings. Some of the most common examples include small nodules in the lungs and adrenal gland. Several of these demonstrate imaging features

Summary

WBCT has become a widely used technique for the workup of the patient with blunt polytrauma. Evidence suggests that WBCT is associated with improved or no change in patient survival and reduces the ED LOS. However, randomized studies, at least one of which is underway, are needed to determine for certain whether early WBCT improves survival, to clarify which patients benefit the most, and to model the costs of this technique compared with traditional workup. Advancements in modern MDCT

First page preview

First page preview
Click to open first page preview

References (77)

  • P. Naulet et al.

    Evaluation of the value of abdominopelvic acquisition without contrast injection when performing a whole body CT scan in a patient who may have multiple trauma

    Diagn Interv Imaging

    (2013)
  • H. Marmery et al.

    Correlation of multidetector CT findings with splenic arteriography and surgery: prospective study in 392 patients

    J Am Coll Surg

    (2008)
  • M.L. Gunn

    Imaging of aortic and branch vessel trauma

    Radiol Clin North Am

    (2012)
  • G. Yaniv et al.

    Revised protocol for whole-body CT for multi-trauma patients applying triphasic injection followed by a single-pass scan on a 64-MDCT

    Clin Radiol

    (2013)
  • L. Berlin

    The incidentaloma: a medicolegal dilemma

    Radiol Clin North Am

    (2011)
  • A.P. Ekeh et al.

    The prevalence of incidental findings on abdominal computed tomography scans of trauma patients

    J Emerg Med

    (2010)
  • W.A. Messersmith et al.

    The prevalence and implications of incidental findings on ED abdominal CT scans

    Am J Emerg Med

    (2001)
  • H. Eskandary et al.

    Incidental findings in brain computed tomography scans of 3000 head trauma patients

    Surg Neurol

    (2005)
  • World Health Organization. Injuries and violence: the facts. 2010. Available at:...
  • Heron M. Deaths: leading causes for 2010. National vital statistics reports, vol. 62. no. 6. Hyattsville (MD): National...
  • Centers for Disease Control and Prevention. All injuries. 2013. Available at:...
  • Centers for Disease Control and Prevention. Accidents or unintentional injuries. Accidents or unintentional injuries....
  • E.J. MacKenzie et al.

    A national evaluation of the effect of trauma-center care on mortality

    N Engl J Med

    (2006)
  • B. Haas et al.

    The mortality benefit of direct trauma center transport in a regional trauma system: a population-based analysis

    J Trauma Acute Care Surg

    (2012)
  • R. Pfeifer et al.

    Missed injuries in trauma patients: a literature review

    Patient Saf Surg

    (2008)
  • A. Salim et al.

    Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study

    Arch Surg

    (2006)
  • D. Stengel et al.

    Accuracy of single-pass whole-body computed tomography for detection of injuries in patients with major blunt trauma

    CMAJ

    (2012)
  • J. Deunk et al.

    Routine versus selective multidetector-row computed tomography (MDCT) in blunt trauma patients: level of agreement on the influence of additional findings on management

    J Trauma

    (2009)
  • S. Huber-Wagner et al.

    Whole-body CT in haemodynamically unstable severely injured patients–a retrospective, multicentre study

    PLoS One

    (2013)
  • S. Asha et al.

    Comparison of radiation exposure of trauma patients from diagnostic radiology procedures before and after the introduction of a panscan protocol

    Emerg Med Australas

    (2012)
  • R. Van Vugt et al.

    Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients

    Cochrane Database Syst Rev

    (2013)
  • R. van Vugt et al.

    Effects on mortality, treatment, and time management as a result of routine use of total body computed tomography in blunt high-energy trauma patients

    J Trauma Acute Care Surg

    (2012)
  • N.Z. Millo et al.

    Appropriateness of CT of the chest, abdomen, and pelvis in motorized blunt force trauma patients without signs of significant injury

    Am J Roentgenol

    (2011)
  • I. Cowan et al.

    Selective versus mandatory whole-body computed tomography scanning in the multiply injured patient

    Emerg Med Australas

    (2012)
  • M. Hutter et al.

    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)
  • R. van Vugt et al.

    An evidence based blunt trauma protocol

    Emerg Med J

    (2013)
  • D.A. Healy et al.

    Systematic review and meta-analysis of routine total body CT compared with selective CT in trauma patients

    Emerg Med J

    (2014)
  • P. Weninger et al.

    Emergency room management of patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified by an urban trauma center

    J Trauma

    (2007)
  • Cited by (25)

    • Utilization of torso computed tomography for the evaluation of ground level falls: More imaging does not equal better care

      2023, Injury
      Citation Excerpt :

      Another study with n=152 patients undergoing WBCT found that WBCT led to a significant change in management for only 3 (2%) of GLF patients, with 1 change involving the chest and 2 changes involving the cervical spine [16]. Previous studies have suggested that more conservative use of CT imaging may be beneficial for patients presenting with GLF [1,14–20]. This is especially pertinent for torso imaging, as patients who are found down very rarely have intra-abdominal injury and thus most likely will not benefit from abdominal CT imaging [21].

    • Variability in CT imaging of blunt trauma among ED physicians, surgical residents, and trauma surgeons

      2017, Journal of Surgical Research
      Citation Excerpt :

      After the initial assessment and resuscitation is completed and the patient is stabilized, diagnostic imaging is performed to identify injuries that are not evident clinically. Computed tomography (CT) imaging is used routinely as a screening and diagnostic tool to identify injuries in trauma patients.9–11 However, there has been some debate as to whether or not the benefit outweighs the risk and higher cost.

    • R-SCAN: Whole-Body Blunt Trauma CT Imaging

      2017, Journal of the American College of Radiology
    • Introduction of a pan-scan protocol for blunt trauma activations: what are the consequences?

      2017, American Journal of Emergency Medicine
      Citation Excerpt :

      Several European registry-based studies have identified and confirmed a decrease in mortality at centers where a PS is used. However, there are several concerns with the designs of these studies [2,3]. In addition, there has been increasing concern on whether or not the benefits outweigh the risks [4,5].

    • Cambridge Polytrauma Pathway: Are we making appropriately guided decisions?

      2016, Injury
      Citation Excerpt :

      In major blood loss, low fibrinogen has been shown to indicate developing acute coagulopathy of trauma [26]. Early trauma computed tomography (CT) imaging has been fundamental to advances in trauma management, improving survival even in haemodynamically unstable patients [27–32]. NHS England standard contract for Major trauma Centres states a maximum time to CT of 60 min and ideal time of less than 30 min [33].

    View all citing articles on Scopus
    View full text