Computed tomography whole body imaging in multi-trauma: 7 years experience
Introduction
In order to target treatment effectively it is necessary to assess the sites of multiple injuries accurately and rapidly. A clear history is rarely available and clinical findings have been shown to be equivocal or misleading in 20–50% of victims of blunt polytrauma.1 In the presence of head injury and decreased level of consciousness the reliability of physical examination in the detection of intra-abdominal injury falls to 16%.1, 2, 3, 4 Patients with trauma to two or more body parts (e.g., head and thorax, thorax and pelvis) are at increased risk of clinically occult injury.2 Indeed, it is not possible to exclude abdominal or pelvic organ injury on a clinical basis according to Advanced Trauma Life Support (ATLS) standards.5 Spinal, in particular cervical spinal, injury may lead to potentially devastating neurological damage and the detection of fractures is a source of much debate in the medical literature6, 7, 8 with a growing consensus that plain radiography alone is inadequate to exclude spinal injury in cases with a suspicious mechanism of injury.
Rapid clinical assessment, stabilization and early management should be instituted and haemodynamically unstable patients may require immediate surgical intervention. However, there is a group of patients who are stable after initial clinical triage that require urgent localization and evaluation of injuries. Traditional imaging strategies include plain radiographs of the chest (usually supine), pelvis and a lateral projection of the cervical spine as per ATLS guidelines,5 focused abdominal sonography, targeted computed tomography (CT) or a combination of these. However, these targeted strategies rely on the clinician asking the clinical question in the first place and upon the imaging demonstrating the abnormality adequately. The tendency for the detection of one radiographic injury to interfere with the detection of further injuries is well described and has been termed “satisfaction of search”.9 Injuries to the pelvis, spine and major joints are particularly likely to remain radiologically undetected in multiply injured patients10 and intra-abdominal damage may be missed in the presence of distracting injury.4
Several large series have documented the effectiveness of targeted CT in the management of haemodynamically stable patients with blunt thoracic or abdominal trauma.11, 12, 13, 14, 15 Studies examining the role of CT as an early screening tool in acute multisystem trauma have included relatively small numbers and have not been in the context of a general National Health Service (NHS) hospital. This article presents a prospective series of polytrauma victims brought in to the Emergency Department (ED) of a large acute NHS Trust who, following initial triage, underwent a standardised CT study (pre-contrast head and neck followed by post-contrast thorax, abdomen and pelvis) as part of a primary imaging assessment directly from the ED.
The CT protocol was designed to provide rapid and complete assessment of those areas most frequently affected in the polytrauma setting: head, cranio-cervical junction, cervico-thoracic junction, chest, abdomen and pelvis. The aim was to detect as many of the existing injuries as possible at presentation thus avoiding delay in diagnosis.
Section snippets
Method
Between February 1997 and April 2004, all haemodynamically stable patients presenting to the ED with major trauma involving two or more body regions, including head and neck, chest, abdomen and pelvis, spine and extremities of Abbreviated Injury Scale 2 or more (moderate, severe or critical)16 were imaged with the standard series of radiographs (chest, pelvis and lateral cervical spine) in the ED, followed by a pre-set CT study. All studies were performed on a General Electric CT HiSpeed
Results
Two hundred and ninety-six polytrauma CT studies were carried out between February 1997 and April 2004, averaging just over one per fortnight. These numbers do not include haemodynamically unstable patients, who were managed actively as per ATLS guidelines with imaging carried out as appropriate when the patient's condition allowed. Only three patients transferred to CT became too unstable to complete the examination. Table 1 lists the positive findings from the series. Only 41 out of the 296
Discussion
Urgent life-saving surgical intervention in unstable, traumatized patients should not be delayed by imaging. Patients should be assessed and managed along ATLS criteria: primary survey, resuscitation, secondary survey, including portable plain radiography of the lateral cervical spine, chest and pelvis in the ED. Necessary supportive treatments should be commenced before transfer from the ED.5
Once the patient's condition has been stabilized there is a need to rapidly and accurately delineate
Acknowledgements
The authors thank Dr Richard Blaquiere and Ms Kate Wallace for their support in the development of the protocol over many years.
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