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

LETTER TO THE EDITOR

Selective versus mandatorywhole-body computedtomography scanning in themultiply injured patientDear Editor,

There has been widespread uptake in developednations of the use of whole-body computed tomography(WBCT, also known as the ‘pan-scan’) in centres witheasy access to a CT scanner, for the assessment ofhaemodynamically stable, multiply injured patients.Studies concerning the use of CT in major traumapatients need to address the clinical impact of anyabnormal findings, in addition to simply describingtheir number. This is important in order to address thetrue risk–benefit balance of WBCT use.

Gupta et al. in California recently published a studythat prospectively tested whether it was possible toidentify components of the WBCT that could be omittedin select patients, without missing clinically importantinjuries.1 Gupta et al. gave detailed criteria for decidingif an injury was important, based upon a need for ‘criti-cal intervention’. They concluded that ‘selective scan-ning could reduce the number of scans, missing someinjuries but few crucial ones’ and that ‘the clinicalimportance of injuries missed on undesired scans wassubject to individual interpretation, which varied sub-stantially among authors’.1

The introduction in 2006 of WBCT at ChristchurchHospital, Christchurch, New Zealand (a regional aca-demic, general and tertiary centre) was studied prospec-tively to determine whether the use of WBCT detectedsignificant injuries that would have been missed usinga selective scanning approach based upon clinicaljudgment.

Adult patients were included if they were haemody-namically stable, and underwent WBCT scanning forblunt trauma. Most patients had three standard traumaseries radiographs before WBCT was requested;focused abdominal sonography in trauma was also uti-lized. The local guidance to trigger WBCT during thisperiod was clinical evidence of any injury to two ormore body areas, for example, a head-injured patientwith Glasgow Coma Scale score of 15 but with bruisingover the chest. The abdomen and pelvis were counted asone area. All scans were performed on a 64-slice GE

Lightspeed scanner (General Electric Medical Systems,Milwaukee, WI, USA).

Clinicians requesting a polytrauma scan were askedto prospectively record which body areas they thoughtwere injured and required scanning on a pre-designeddata collection form. This was the index test underevaluation. The reference standard for this study wasa clinically significant injury, which was defined as aninjury that necessitated either (i) a specific change inpatient management (beyond analgesia or ‘seeking aspecialist opinion’), or (ii) a change in primary special-ist team caring for the patient (e.g. orthopaedic to neu-rosurgery). The clinical notes of all patients werereviewed after an interval of at least 3 months toassess clinical outcome. All cases of clinically signifi-cant injury, or where there was doubt about this,were decided on by blinded panel consensus of threeinvestigators.

One hundred and thirty-seven patients undergoingWBCT had completed clinician impression forms.WBCT was thought not to be indicated in 64% (88/137)of patients, and occult injuries were discovered onWBCT in 20% (18/88) of these patients. These injurieswere panel adjudicated as clinically significant in only3.4% (3/88) patients. Clinical judgement that a WBCTwas not required thus had a negative predictive value of96.6% (90–99%) and a sensitivity of 94.1% (84–98%).All three cases involved a high-risk mechanism ofinjury, such as a pedestrian struck, a motorcyclist or animpact-side car passenger hit at speed by a truck(Table 1).

These findings from an Australasian centre aresimilar to those of Gupta et al. and suggest that selectivescanning might decrease WBCT use, while missing fewcritical injuries in patients without a high-risk mecha-nism of injury, although this remains a controversialarea. In our institution, trauma guidelines have sincebeen modified so that WBCT is not mandatory whentwo or more body areas are injured if: the mechanismis not high risk; the patient is not going to intensivecare; and there is clinician consensus towards selectivescanning.

Competing interests

None declared.

doi: 10.1111/j.1742-6723.2011.01528.x Emergency Medicine Australasia (2012) 24, 115–116

© 2012 The AuthorsEMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine

Reference

1. Gupta M, Schriger DL, Hiatt JR et al. Selective use of computedtomography compared with routine whole body imagingin patients with blunt trauma. Ann. Emerg. Med. 2011; 58:407–16.

Ian Cowan,1 Chris Cresswell,3 Henry Liu,1 Teck Siew,4

Michael Ardagh2 and Martin Than2

1Radiology Department, 2Emergency Department,

Christchurch Hospital, 3Emergency Department, Wanganui

Hospital, New Zealand; and 4Radiology Department,

Sir Charles Gairdner Hospital,

Perth, Australia

Table 1. Details of the three cases where a significant injury was not suspected clinically

Case one: 42-year-old man. Motorcyclist versus truck. Arrived in ED approximately 1.5 h after accident. In ED Glasgow Coma Scorewas 15, chest clinically normal, respiratory rate 16 /min. Patient had a fractured right femur, right fibula, left fourth and fifthmetacarpals and a right anterior cruciate ligament rupture. ED physician requested pan-scan, but noted on request form that thechest ‘did not need to be scanned’. WBCT found small right pneumothorax with fracture of first and second ribs on same side. Fivehours later, chest still clinically normal. The anaesthetist elected to place chest drains before anaesthetic for orthopaedic surgery.

Case two: 19-year-old man. Passenger in car struck on patient’s side of vehicle by truck travelling 100 km/h. Passenger behindpatient died on scene. Glasgow coma scale score was 15. Patient haemodynamically stable. Thoracic and lumbar spine tendernessonly. Clinician requested CT of head and entire spine. On WBCT possible small intimal tear in the aortic arch. Trans thoracicechocardiogram showed intimal flap 1 cm distal to Left subclavian artery, but a formal aortogram was reported as normal. Stentingwas attempted but iliac vessels too small. Managed in intensive care unit for 1 day. A further CT scan 2 days later showed a healingintimal tear. Discharged on day 5.

Case three: 68-year-old man. Cyclist versus truck at 70 km/h. Glasgow coma scale score 15. Tachycardic, and became hypotensiveafter morphine. Pericardial fluid on FAST scan. ED registrar requested a pan-scan but recorded that he thought only cervical spineand chest needed scanning. Surgical registrar agreed abdomen and pelvis were clinically normal. WBCT showed tracheal rupture anda pneumomediastinum with associated pericardial effusion; multiple rib and transverse process fractures on the left side; multiplelumbar vertebral transverse fractures without evidence of ureteric injury. Fractured left pubic rami. The transverse process andpelvic fractures were managed with touch weight bearing for 6 weeks.

FAST, focused abdominal sonography in trauma; WBCT, whole-body computed tomography.

Letter to the Editor

116 © 2012 The AuthorsEMA © 2012 Australasian College for Emergency Medicine and Australasian Society for Emergency Medicine