Elsevier

Clinical Radiology

Volume 61, Issue 4, April 2006, Pages 365-369
Clinical Radiology

Computed tomography whole body imaging in multi-trauma: 7 years experience

https://doi.org/10.1016/j.crad.2005.12.009Get rights and content

AIM

To assess the impact of the introduction of a computed tomography (CT) imaging protocol for multi-trauma patients on the workload, overall diagnostic yield, and effect on detection of cervical spine injury and pneumothorax.

METHOD

Between February 1997 and April 2004, all patients presenting acutely to the Emergency Department (ED) with haemodynamically stable trauma (Abbreviated Injury Scale 3 or more) involving more than two body systems were imaged with a comprehensive pre-set helical CT protocol (including non-contrast head, cervical spine: cranio-cervical and cervico-thoracic junctions; and oral and intravenous contrast-enhanced thoracic, abdomen and pelvis) after initial triage and a standard trauma series of radiographs (chest, lateral C-spine and pelvis).

Diagnosis of cervical spine fracture and pneumothorax was noted before and after the CT protocol was carried out and findings from all studies were recorded prospectively.

RESULTS

Over the 7-year period 296 multi-trauma CT studies were completed of which 41 (13.8%) were negative. Of the positive cases there were 127 (43%) head injuries; 25 cervical spine fractures (8%); 66 pelvic fractures (22%);48 thoracic or lumbar spine fractures (16%); 97 pneumothoraces (33%); 22 mediastinal injuries (7%) and 49 intra-abdominal injuries (17%) with 19 (6%) splenic tears/ruptures. Positive findings included many unsuspected injuries, including 19 cervical spine fractures which were not demonstrated on the standard lateral radiograph from the resuscitation room. Of the 97 CT detected pneumothoraces, 12 were bilateral, 52 already had a chest drain in situ and 36 were not detected on initial supine chest radiography in the resuscitation room. One undetected case had bilateral tension pneumothoraces that were promptly drained on the CT table. Only three patients did not complete their multi-trauma examination because of deterioration in clinical condition and these were all immediately returned to the resuscitation room.

CONCLUSION

Over the 7-year period in a large acute National Health Service (NHS) hospital trust currently averaging 85,000 ED attendances per year only 296 patients fulfilled the stated criteria for an immediate multi-trauma CT study. Although disruptive in the short-term, the overall impact on workload was small. A wide range of significant injuries were demonstrated rapidly, accurately and safely, including 19 cervical spine fractures and 26 pneumothoraces not detected on plain radiographs.

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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