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Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims
Clinical Radiology xxx (2015) 1e7
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims L. Shannon, T. Peachey, N. Skipper, E. Adiotomre, A. Chopra, B. Marappan, N. Kotnis* Department of Medical Imaging and Medical Physics, Sheffield Teaching Hospitals, Sheffield, UK
art icl e i nformat ion Article history: Received 13 May 2015 Received in revised form 13 May 2015 Accepted 18 June 2015
AIM: To assess the accuracy of the trauma team leader’s clinical suspicion of injury in patients who have undergone whole-body computed tomography (WBCT) for suspected polytrauma, and to assess the frequency of unsuspected injuries and specific patterns of injury at WBCT. MATERIALS AND METHODS: Requests for patients who underwent WBCT for suspected polytrauma from April 2011 to March 2014 were reviewed and each body area that was clinically suspected to be injured was recorded. Body areas were divided into the following groups based on anatomical regions covered in each segment of the WBCT examination: head (including facial bones); neck (including cervical spine); chest (including thoracic spine); and abdomen/pelvis (including lumbar spine). The formal radiology report for each study was reviewed and injuries found at CT were grouped into the same body areas. For each patient, the number of clinically suspected injured areas was compared to the number of confirmed injured areas at WBCT. RESULTS: Five hundred and eighty-eight patients were included in the study. Thirty-two percent (186/588) had a normal scan. Ninety-three percent (546/588) had fewer injured body areas at WBCT than suspected. Four percent (27/588) had the equivalent number of injured areas at WBCT as suspected. Three percent (15/588) had more injured areas at WBCT than suspected. Fifty percent (263/527) with clinically suspected chest injuries were confirmed to have chest injuries at WBCT. This was lower for other areas: abdomen/pelvis 31% (165/535); head 29% (155/533); neck 13% (66/513). Four percent of (24/588) patients had unsuspected injuries found at WBCT. Seventy-five percent (18/24) of unsuspected injuries were considered as serious, where failure to treat would have the potential for significant morbidity. Most of these patients had severe injuries to other body areas that were correctly suspected. Of the 165 with abdominal/pelvic region injuries, there were associated injuries in the thoracic region in 62% (103/165) cases. Of the 278 thoracic injuries, there were abdominal/pelvic region injuries in 37% (103/278) and injuries to the neck in 19% (52/278) cases. Of the 158 head injuries, there were neck injuries in 22% (34/158) cases. CONCLUSION: Clinical suspicion of injury correlates poorly with findings at WBCT, with a high proportion of uninjured body areas. The number of unsuspected injuries found at WBCT was low, but the majority of these were serious injuries, possibly masked by distracting injury
* Guarantor and correspondent: N. Kotnis, Department of Medical Imaging and Medical Physics, Sheffield Teaching Hospitals, Sheffield, UK. Tel.: þ44 0114 2714339. E-mail address: [email protected] (N. Kotnis). http://dx.doi.org/10.1016/j.crad.2015.06.084 0009-9260/Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
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L. Shannon et al. / Clinical Radiology xxx (2015) 1e7
to other body areas. The use of a WBCT protocol is recommended for suspected polytrauma, but regular monitoring of WBCT findings and regular feedback of the results to emergency physicians is suggested to help inform their selection of patients for trauma WBCT. Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction Whole-body computed tomography (WBCT) is now a key step in the initial assessment of polytrauma patients in major trauma centres.1,2 Large studies have found that WBCT significantly reduces mortality in polytrauma victims and is associated with better outcomes than targeted CT examination.3e5 As a result, the role of WBCT as an essential screening tool in trauma victims with multiple injured body areas is now firmly established; however, predicting who, amongst the many trauma patients that arrive at the emergency department, will have multiple injured body areas is difficult. Studies have shown that mechanism alone and clinical examination in isolation, are both poor indicators to identify patients with multiple injuries.6,7 Physiological parameters (e.g., pulse and blood pressure) in isolation are a poor predictor of haemorrhagic injury, particularly in young patients with no pre-existing comorbidity who will often have a high physiological reserve.8 Prediction models using a combination of mechanism, physiological parameters, the presence of the trauma team and patient demographics have also not proved accurate.9 This has led some authors to conclude that the decision to choose WBCT should be left to the discretion of the attending emergency physician.9 Based on this rationale, the trauma team leader, who is usually an experienced emergency department physician, has the final decision on whether a patient undergoes WBCT, which confers one of the highest radiation dose examinations carried out in the radiology department. Given that the routine use of trauma WBCT has led to increased radiation doses in a population skewed towards younger age groups, the appropriate use of this high-dose examination clearly needs to be monitored.10 The primary aim of the present study was to assess the accuracy of the trauma team leader’s clinical suspicion of injury in patients who have undergone WBCT for suspected polytrauma. A secondary aim was to assess for the frequency of unsuspected injuries and for specific patterns of injury at WBCT.
Materials and methods The study was granted institutional review board approval from the Trust’s Clinical Effectiveness Department. CT requests forms for patients who underwent WBCT for suspected polytrauma from April 2011 to March 2014 were reviewed and each body area that was clinically suspected to be injured was recorded. Referral criteria for WBCT were based on guidelines for imaging the severely injured patient
published by the Royal College of Radiologists, but with adaptations made based on previous experience11 (Fig 1). The request card encourages the emergency physician to consider mechanism, clinical findings, and physiological parameters when making the decision to request for WBCT. Body areas were divided into the following groups based on anatomical regions covered in each segment of the WBCT examination: head (including facial bones); neck (including cervical spine); chest (including thoracic spine); abdomen/pelvis (including lumbar spine). The formal consultant-verified radiology report for each study was reviewed and injuries found at CT were grouped into the same body areas. For each patient, the number of clinically suspected injured areas was compared to the number of injured areas at WBCT. All examinations were performed using a 64-section VCT Phillips CT system (Milwaukee, WI, USA). The WBCT polytrauma protocol evolved during this period. An unenhanced CT examination of the head and cervical spine was initially followed by an arterial phase of the chest/abdomen/pelvis and a portal venous phase abdomen/pelvis for all patients with an additional delayed (100 seconds) abdomen/pelvis phase in the unstable patients; however, on review of the efficacy of this technique and radiation dose levels, the protocol was altered to follow a technique previously described in military trauma.12 A single phase of the chest, abdomen and pelvis was performed at 70 seconds from start of a dual bolus injection, with a more slowly delivered bolus allowing homogeneous organ enhancement and a later more rapidly infused bolus providing a simultaneous angiographic phase. A delayed scan was performed in the unstable patient.
Results Five hundred and ninety-five patients underwent WBCT for suspected polytrauma during the study period. Seven patients were found to have incomplete clinical details on the request cards and were thus excluded, leaving a study group of 588 patients. A summary of injuries identified at WBCT is highlighted in Table 1. 32% (186/588) patients had a normal scan. Thirtyfive percent (202/588) of patients had an injury to only one body area. Less than 2% (11/588) had injuries to all four body areas (Fig 2). Ninety-three percent (546/588) of patients had fewer injured body areas at WBCT than suspected. Four percent (27/588) had the equivalent number of injured areas at WBCT as suspected. Three percent (15/588) had more injured areas at WBCT than suspected. Fifty percent (263/527) of patients with clinically suspected chest
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
L. Shannon et al. / Clinical Radiology xxx (2015) 1e7
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Figure 1 Institutional polytrauma request form.
injuries were confirmed to have chest injuries at WBCT. These were lower for other areas: abdomen/pelvis 31% (165/535); head 29% (155/533); neck 13% (66/513; Table 2). Four percent (24/588) of patients had injuries at CT that were not clinically suspected (Table 2). Of these, nine had unsuspected cervical spine injuries; 15 had unsuspected injuries visible at CT through the thoracic region; four had unsuspected injuries at CT of the head; and three had an unsuspected injury at CT of the abdomen/pelvis. In 75% (18/ 24) patients, the unsuspected injuries were considered serious, where failure to treat would have the potential for
significant patient morbidity. Most of these patients had multiple, severe injuries to other body areas that were correctly suspected (Table 3). The distribution of age ranges for all patients in the study is demonstrated in Table 4 and Fig 3. The largest group was the 16e25 years, accounting for 22% (130/588) patients with the next largest being the 26e35 year group making up 15% (94/588) patients. Of the 186 patients in whom no injury was found at WBCT, 27% (50/186) were in the 16e25 year group and 19% (36/186) were in the 26e35 year group.
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
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L. Shannon et al. / Clinical Radiology xxx (2015) 1e7
Table 1 Summary of Injuries confirmed at whole-body computed tomography (WBCT). Injuries CT head Normal Abnormal Intracranial haemorrhage Contusion Skull vault fracture CT neck Normal Abnormal Fractures Other CT thorax Normal Abnormal Pneumothorax/haemothorax Lung contusion Pleural effusion Vessel injury Rib fractures Thoracic spine fractures CT abdomen/pelvis Normal Abnormal Solid-organ injury Active bleeding Free fluid Bowel injury/perforation Lumbar spine fractures Multiple pelvic fractures Single pelvic fractures
No.
%
430 158 85 45 52
73.1 26.9 14.5 7.7 8.8
512 76 62 14
87.1 12.9 10.5 2.4
310 278 110 99 27 8 163 85
52.7 47.3 18.7 16.8 4.6 1.4 27.7 14.5
420 168 37 17 13 11 55 30 30
71.4 28.6 6.3 2.9 2.2 1.9 9.4 5.1 5.1
Of the 165 patients with abdominal/pelvic region injuries, there were associated thoracic region injuries in 62% (103/165) cases. Of the 278 patients with thoracic injuries, there were abdominal/pelvic region injuries in 37% (103/ 278) and injuries to the neck in 19% (52/278) cases. Of the 158 patients with head injuries, neck injuries were present in 22% (34/158) cases.
Discussion Previous studies have concluded that WBCT reduces mortality in polytrauma victims when compared to
Figure 2 Number body areas injured per case at WBCT.
Table 2 Comparison of suspected injuries against confirmed injuries at whole-body computed tomography (WBCT) for each body area. Body area
Suspected injury by emergency physician
Total number of injuries found at WBCT
% of suspected injuries confirmed by WBCT
% of injuries found at WBCT that were unsuspected
Head Neck Thorax Abdomen/pelvis
533 513 527 535
158 76 278 165
29% 13% 50% 31%
2% 13% 5% 2%
(155) (66) (263) (164)
(3) (10) (15) (4)
selective CT.13e15 Other studies have demonstrated how WBCT reduces time to events in hospital when compared to selective CT16,17; however, a meta-analysis of the literature has suggested that the improved mortality rates in these studies may not be attributable to WBCT alone with other confounding factors, such as patient selection and variations in quality of care, that also potentially influence mortality.18 Furthermore, the authors concluded that there was insufficient evidence to be certain that selective scanning had a higher rate of “missed” injuries than WBCT.18 Clinical assessment as a predictor for injury at WBCT has been shown to be poor, even amongst experienced emergency physicians. In their study of 400 patients, Smith et al.7 asked emergency physicians to grade their clinical suspicion of injuries for different body regions. They found that bedside assessment was sensitive in excluding serious injury in patients with a “very low” suspicion of injury, but overall diagnostic accuracy was low.7 Just under one-third of patients in the present study had normal CT examinations with no injuries to any of the body areas. Despite this being a significant proportion of all patients examined, the present findings are similar to those previously published in the literature.2,19,20 In the present study, 93% of patients had fewer body areas injured than clinically suspected. Although this may not be entirely unexpected, the fact that less than 2% of patients had injuries to all four body areas and that the “no injuries” or “injury to one body area” groups were the largest, does suggest that there is an overtendency to clinically categorise patients as being polytrauma victims and investigate them with WBCT. WBCT should be reserved for patients with multi-region injury. Patient selection for the examination can be made based on indicators such as clinical evidence of multi-area injury, mechanism, and abnormal physiological parameters.9 There is a wide variation in opinion amongst authors regarding the indication for WBCT. In a study by Salim et al.21 of 592 trauma patients with no clinical evidence of injury, occult injuries that led to a change in clinical management were identified in 18.9% of patients at WBCT, leading the authors to conclude that liberal use of WBCT is indicated in patients with suspected blunt multi-system trauma. Several studies have demonstrated a benefit to introducing a mandatory WBCT protocol for suspected polytrauma.21e23 Reduction in the number of missed torso
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
L. Shannon et al. / Clinical Radiology xxx (2015) 1e7 Table 3 Summary of unsuspected injuries found in patients at whole body computed tomography (WBCT) along with injuries that were correctly suspected in those patients. Injury not suspected
Injuries correctly suspected
Bilateral lung contusions
T2-6#s, left superior pubic ramus # and haematoma.
Brain contusion, inferior pubic ramus #
Peg #.
C1, C3, C4 #s
T6, T9-11 #s, multiple transverse process #s, small pneumothorax, sternal # and haematoma.
C4 and C6#
None.
C4/5# dislocation
Sternal #, left pneumothorax, bilateral rib #s, T5#, T10-11#s.
C5-6 transverse process #s, clavicle #, rib #, T6-7#s
Facial #s.
C5-7#s
SDH, rib #.
C7# dislocation
Right clavicle #, T1#, T5-8 transverse process #s, lung contusion.
C7#
Clavicle #, small left pneumothorax.
C6/7 # dislocation, active deltoid haemorrhage
SDH, EDH, basal skull #, severe facial #, complex pelvic #.
Facial #, small pneumothorax and pneumomediastinum
None.
Facial #, small pneumothorax, right inferior pubic ramus #
None.
Clavicle #
None.
Lung contusion
SAH, cerebral contusion.
Occipital condyle #
Right tension pneumothorax, multiple rib #s, liver laceration, trace of free fluid pelvis.
Peg#, C6/7#
SAH, complex facial #, T4#, rib #s.
Clavicle #
None.
Pneumothorax, lung contusions, clavicle #, scapula #, L5#
SAH, diffuse axonal injury.
Rib #
Renal laceration.
Rib #s, right pubic bone #
None.
T4#, multiple rib #s
None.
T4-5#s with haematoma, rib #
C1-2#s.
T9#, lung contusion
None.
Tiny pneumothorax
Complex pelvic # with haematoma.
5
Table 4 Summary of number of injured and uninjured patients according to age range. Age group (years)
Total patients
Patients with injuries confirmed at WBCT
Patients with no injuries at WBCT
16e25 26e35 36e45 46e55 56e65 66e75 76e85 >85 Total
130 94 86 88 65 53 46 26 588
80 58 57 56 52 42 39 18 402
50 36 29 32 13 11 7 8 186
WBCT, whole-body computed tomography.
when compared to pre-protocol WBCT imaging.20 Asha et al.10 found that a mandatory WBCT protocol led to a significant increase in radiation exposure. Hsiao et al.9 concluded that a prediction model for using WBCT did not significantly alter clinical accuracy and advocated using a thorough clinical assessment by the emergency physician as the most appropriate method to decide on the indication for WBCT.9 In our centre a combination of factors is used to decide on the indication for WBCT, as it is known that any one factor in isolation has a poor specificity for severe injury.11,24 The presence of a significant mechanism of injury, clinical evidence or significant suspicion of injury to two or more body areas, and haemodynamic instability are all key indicators for WBCT (Fig 1). For all cases where the trauma team have been called, the emergency physician can request WBCT directly through the CT control room. In cases without trauma team activation, the request for WBCT must be discussed directly with a radiologist. Only 3% of patients in the present study had serious injuries at WBCT that were not suspected by the emergency physicians. Salim et al.21 reported 18.9% patients as having clinically occult injuries that would have significantly altered patient management in their similarly sized study; however, the two studies are not directly comparable as injuries were suspected based on clinical findings, physiological parameters, and mechanism in the present study,
#, fracture; SDH, subdural haemorrhage; SAH, subarachnoid haemorrhage; EDH, extradural haemorrhage.
injuries, detecting clinically significant injuries that would have been missed pre-protocol, and faster time to definitive diagnoses are some of the benefits reported as a result of mandatory WBCT trauma protocol21e23; however, introducing a mandatory WBCT protocol has been associated with increased numbers of negative examinations
Figure 3 Age ranges of patients who underwent WBCT for suspected polytrauma.
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
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L. Shannon et al. / Clinical Radiology xxx (2015) 1e7
whereas Salim et al. 21 used clinical findings alone. Four percent (24/588) of patients with unsuspected injuries represent a small proportion of those selected for WBCT. These injuries could have been missed with potential for very significant morbidity without a WBCT protocol, although this represents a relatively low yield given the number of patients that were examined. Interestingly, most of the patients with unsuspected injuries at WBCT had significant “distracting” injuries at other body locations, which may have masked the injury to the unsuspected areas. A WBCT protocol for trauma does expose patients to a high-dose radiation examination, many of whom are young. Nearly one-fifth of patients who underwent WBCT in this study were in the 16e25 years group. Over half of patients who had no injuries at WBCT were aged 35 years or less. Thirty-eight percent of patients (9/24) with unsuspected injuries were aged 35 years or under. Although it is generally accepted that active bleeding can be difficult to identify clinically in young patients due to their greater physiological reserve, none of the unsuspected injuries in the present study were related to active haemorrhage. The most common pattern of injury found in the present study was synchronous injury within the thorax and abdomen/pelvis. Sixty-two percent of patients with abdominal/pelvic injuries also had thoracic injuries. Thirtyseven percent of patients with thoracic injuries also had abdominal/pelvic injuries. This certainly suggests that the thorax should be scanned routinely in cases where significant trauma to the abdomen/pelvis alone is suspected and a strong case can be made for scanning the abdomen/ pelvis in suspected thoracic injury. Neck injuries were seen in nearly one-fifth of patients with head injuries. Given the potential significance of cervical spine injury, scanning the cervical spine is advocated in suspected traumatic head injury if the patient is unresponsive or difficult to assess clinically. The main limitation of the present study was the inability to analyse the initial findings that led the physician to suspect whether a body area was injured and how this compared to WBCT findings. The CT request card has both an area to describe clinical concern and a tick-box for each body location. Although some physicians stated why they were concerned about a body area, some only filled in the tick-box; thus, for some patients, there are no data to indicate whether the suspicion was based on clinical findings, mechanism, or a combination. Smith et al.7 used a ratings system for grading clinical suspicion of injury from “very low” to “very high”. This would have been an interesting area to explore further, but how much use this has in high-pressure clinical situations is unclear. The situations faced by emergency physicians can be extremely challenging. Patients are sometimes severely traumatised by the event and may be even unresponsive, which makes obtaining a history or performing a thorough clinical assessment very difficult. Resuscitation rooms can be chaotic and crowded places, sometimes making a detailed, uninterrupted clinical assessment difficult. Once the
suspicion of injury to a body area has occurred to an emergency physician, the likelihood is that many will feel obliged to investigate using CT regardless of the precise level of suspicion. In summary, clinical suspicion of injury correlates poorly with findings at WBCT, with a high proportion of examinations of uninjured body areas. The number of unsuspected injuries found at WBCT was low, but the majority of these were serious injuries, possibly masked by distracting injuries to other body areas. The use of a WBCT protocol is advocated for suspected polytrauma, and there do appear to be patterns of injury between certain body areas. Given the high radiation dose in a population skewed towards a younger age group, the financial costs and increased workload that is incurred with Trauma WBCT, we recommend regular monitoring of the findings and regular feedback of the results to emergency physicians to better inform their decisions when selecting patients for this examination.
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L. Shannon et al. / Clinical Radiology xxx (2015) 1e7 15. Kimura A, Tanaka N. Whole-body computed tomography is associated with decreased mortality in blunt trauma patients with moderate-tosevere consciousness disturbance: a multicenter, retrospective study. J Trauma Acute Care Surg 2013;75:202e6. 16. Wurmb TE, Fruhwald P, Hopfner W, et al. Whole-body multislice computed tomography as the first line diagnostic tool in patients with multiple injuries: the focus on time. J Trauma 2009;66:658e65. 17. Wurmb TE, Quaisser C, Balling H, et al. Whole-body multislice computed tomography (MSCT) improves trauma care in patients requiring surgery after multiple trauma. Emerg Med J 2011;28:300e4. 18. Surendran A, Mori A, Varma DK, et al. Systematic review of the benefits and harms of whole-body computed tomography in the early management of multitrauma patients: are we getting the whole picture? J Trauma Acute Care Surg 2014;76:1122e30. 19. Briggs RH, Rowbotham E, Johnstone AL, et al. Provisional reporting of polytrauma CT by on-call radiology registrars. Is it safe? Clin Radiol 2010;65:616e22.
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20. Smith CM, Woolrich-Burt L, Wellings R, et al. Major trauma CT scanning: the experience of a regional Trauma centre in the UK. Emerg Med J 2011;28:378e82. 21. Salim A, Sangthong B, Martin M, et al. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Arch Surg 2006;141:468e75. 22. Lawson CM, Daley BJ, Ormsby CB, et al. Missed injuries in the era of the trauma scan. J Trauma 2011;70:452e8. 23. Weninger P, Mauritz W, Fridrich P, 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;62:584e91. 24. Barraco RB, Chiu WC, Bard MR, , et alThe EAST Practice Management Guidelines Work Group. Practice management guidelines for the appropriate triage of the victim of trauma. Chicago: Eastern Association for the Surgery of Trauma; 2010.
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
Contents lists available at ScienceDirect
Clinical Radiology journal homepage: www.clinicalradiologyonline.net
Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims L. Shannon, T. Peachey, N. Skipper, E. Adiotomre, A. Chopra, B. Marappan, N. Kotnis* Department of Medical Imaging and Medical Physics, Sheffield Teaching Hospitals, Sheffield, UK
art icl e i nformat ion Article history: Received 13 May 2015 Received in revised form 13 May 2015 Accepted 18 June 2015
AIM: To assess the accuracy of the trauma team leader’s clinical suspicion of injury in patients who have undergone whole-body computed tomography (WBCT) for suspected polytrauma, and to assess the frequency of unsuspected injuries and specific patterns of injury at WBCT. MATERIALS AND METHODS: Requests for patients who underwent WBCT for suspected polytrauma from April 2011 to March 2014 were reviewed and each body area that was clinically suspected to be injured was recorded. Body areas were divided into the following groups based on anatomical regions covered in each segment of the WBCT examination: head (including facial bones); neck (including cervical spine); chest (including thoracic spine); and abdomen/pelvis (including lumbar spine). The formal radiology report for each study was reviewed and injuries found at CT were grouped into the same body areas. For each patient, the number of clinically suspected injured areas was compared to the number of confirmed injured areas at WBCT. RESULTS: Five hundred and eighty-eight patients were included in the study. Thirty-two percent (186/588) had a normal scan. Ninety-three percent (546/588) had fewer injured body areas at WBCT than suspected. Four percent (27/588) had the equivalent number of injured areas at WBCT as suspected. Three percent (15/588) had more injured areas at WBCT than suspected. Fifty percent (263/527) with clinically suspected chest injuries were confirmed to have chest injuries at WBCT. This was lower for other areas: abdomen/pelvis 31% (165/535); head 29% (155/533); neck 13% (66/513). Four percent of (24/588) patients had unsuspected injuries found at WBCT. Seventy-five percent (18/24) of unsuspected injuries were considered as serious, where failure to treat would have the potential for significant morbidity. Most of these patients had severe injuries to other body areas that were correctly suspected. Of the 165 with abdominal/pelvic region injuries, there were associated injuries in the thoracic region in 62% (103/165) cases. Of the 278 thoracic injuries, there were abdominal/pelvic region injuries in 37% (103/278) and injuries to the neck in 19% (52/278) cases. Of the 158 head injuries, there were neck injuries in 22% (34/158) cases. CONCLUSION: Clinical suspicion of injury correlates poorly with findings at WBCT, with a high proportion of uninjured body areas. The number of unsuspected injuries found at WBCT was low, but the majority of these were serious injuries, possibly masked by distracting injury
* Guarantor and correspondent: N. Kotnis, Department of Medical Imaging and Medical Physics, Sheffield Teaching Hospitals, Sheffield, UK. Tel.: þ44 0114 2714339. E-mail address: [email protected] (N. Kotnis). http://dx.doi.org/10.1016/j.crad.2015.06.084 0009-9260/Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
2
L. Shannon et al. / Clinical Radiology xxx (2015) 1e7
to other body areas. The use of a WBCT protocol is recommended for suspected polytrauma, but regular monitoring of WBCT findings and regular feedback of the results to emergency physicians is suggested to help inform their selection of patients for trauma WBCT. Ó 2015 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.
Introduction Whole-body computed tomography (WBCT) is now a key step in the initial assessment of polytrauma patients in major trauma centres.1,2 Large studies have found that WBCT significantly reduces mortality in polytrauma victims and is associated with better outcomes than targeted CT examination.3e5 As a result, the role of WBCT as an essential screening tool in trauma victims with multiple injured body areas is now firmly established; however, predicting who, amongst the many trauma patients that arrive at the emergency department, will have multiple injured body areas is difficult. Studies have shown that mechanism alone and clinical examination in isolation, are both poor indicators to identify patients with multiple injuries.6,7 Physiological parameters (e.g., pulse and blood pressure) in isolation are a poor predictor of haemorrhagic injury, particularly in young patients with no pre-existing comorbidity who will often have a high physiological reserve.8 Prediction models using a combination of mechanism, physiological parameters, the presence of the trauma team and patient demographics have also not proved accurate.9 This has led some authors to conclude that the decision to choose WBCT should be left to the discretion of the attending emergency physician.9 Based on this rationale, the trauma team leader, who is usually an experienced emergency department physician, has the final decision on whether a patient undergoes WBCT, which confers one of the highest radiation dose examinations carried out in the radiology department. Given that the routine use of trauma WBCT has led to increased radiation doses in a population skewed towards younger age groups, the appropriate use of this high-dose examination clearly needs to be monitored.10 The primary aim of the present study was to assess the accuracy of the trauma team leader’s clinical suspicion of injury in patients who have undergone WBCT for suspected polytrauma. A secondary aim was to assess for the frequency of unsuspected injuries and for specific patterns of injury at WBCT.
Materials and methods The study was granted institutional review board approval from the Trust’s Clinical Effectiveness Department. CT requests forms for patients who underwent WBCT for suspected polytrauma from April 2011 to March 2014 were reviewed and each body area that was clinically suspected to be injured was recorded. Referral criteria for WBCT were based on guidelines for imaging the severely injured patient
published by the Royal College of Radiologists, but with adaptations made based on previous experience11 (Fig 1). The request card encourages the emergency physician to consider mechanism, clinical findings, and physiological parameters when making the decision to request for WBCT. Body areas were divided into the following groups based on anatomical regions covered in each segment of the WBCT examination: head (including facial bones); neck (including cervical spine); chest (including thoracic spine); abdomen/pelvis (including lumbar spine). The formal consultant-verified radiology report for each study was reviewed and injuries found at CT were grouped into the same body areas. For each patient, the number of clinically suspected injured areas was compared to the number of injured areas at WBCT. All examinations were performed using a 64-section VCT Phillips CT system (Milwaukee, WI, USA). The WBCT polytrauma protocol evolved during this period. An unenhanced CT examination of the head and cervical spine was initially followed by an arterial phase of the chest/abdomen/pelvis and a portal venous phase abdomen/pelvis for all patients with an additional delayed (100 seconds) abdomen/pelvis phase in the unstable patients; however, on review of the efficacy of this technique and radiation dose levels, the protocol was altered to follow a technique previously described in military trauma.12 A single phase of the chest, abdomen and pelvis was performed at 70 seconds from start of a dual bolus injection, with a more slowly delivered bolus allowing homogeneous organ enhancement and a later more rapidly infused bolus providing a simultaneous angiographic phase. A delayed scan was performed in the unstable patient.
Results Five hundred and ninety-five patients underwent WBCT for suspected polytrauma during the study period. Seven patients were found to have incomplete clinical details on the request cards and were thus excluded, leaving a study group of 588 patients. A summary of injuries identified at WBCT is highlighted in Table 1. 32% (186/588) patients had a normal scan. Thirtyfive percent (202/588) of patients had an injury to only one body area. Less than 2% (11/588) had injuries to all four body areas (Fig 2). Ninety-three percent (546/588) of patients had fewer injured body areas at WBCT than suspected. Four percent (27/588) had the equivalent number of injured areas at WBCT as suspected. Three percent (15/588) had more injured areas at WBCT than suspected. Fifty percent (263/527) of patients with clinically suspected chest
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
L. Shannon et al. / Clinical Radiology xxx (2015) 1e7
3
Figure 1 Institutional polytrauma request form.
injuries were confirmed to have chest injuries at WBCT. These were lower for other areas: abdomen/pelvis 31% (165/535); head 29% (155/533); neck 13% (66/513; Table 2). Four percent (24/588) of patients had injuries at CT that were not clinically suspected (Table 2). Of these, nine had unsuspected cervical spine injuries; 15 had unsuspected injuries visible at CT through the thoracic region; four had unsuspected injuries at CT of the head; and three had an unsuspected injury at CT of the abdomen/pelvis. In 75% (18/ 24) patients, the unsuspected injuries were considered serious, where failure to treat would have the potential for
significant patient morbidity. Most of these patients had multiple, severe injuries to other body areas that were correctly suspected (Table 3). The distribution of age ranges for all patients in the study is demonstrated in Table 4 and Fig 3. The largest group was the 16e25 years, accounting for 22% (130/588) patients with the next largest being the 26e35 year group making up 15% (94/588) patients. Of the 186 patients in whom no injury was found at WBCT, 27% (50/186) were in the 16e25 year group and 19% (36/186) were in the 26e35 year group.
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
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L. Shannon et al. / Clinical Radiology xxx (2015) 1e7
Table 1 Summary of Injuries confirmed at whole-body computed tomography (WBCT). Injuries CT head Normal Abnormal Intracranial haemorrhage Contusion Skull vault fracture CT neck Normal Abnormal Fractures Other CT thorax Normal Abnormal Pneumothorax/haemothorax Lung contusion Pleural effusion Vessel injury Rib fractures Thoracic spine fractures CT abdomen/pelvis Normal Abnormal Solid-organ injury Active bleeding Free fluid Bowel injury/perforation Lumbar spine fractures Multiple pelvic fractures Single pelvic fractures
No.
%
430 158 85 45 52
73.1 26.9 14.5 7.7 8.8
512 76 62 14
87.1 12.9 10.5 2.4
310 278 110 99 27 8 163 85
52.7 47.3 18.7 16.8 4.6 1.4 27.7 14.5
420 168 37 17 13 11 55 30 30
71.4 28.6 6.3 2.9 2.2 1.9 9.4 5.1 5.1
Of the 165 patients with abdominal/pelvic region injuries, there were associated thoracic region injuries in 62% (103/165) cases. Of the 278 patients with thoracic injuries, there were abdominal/pelvic region injuries in 37% (103/ 278) and injuries to the neck in 19% (52/278) cases. Of the 158 patients with head injuries, neck injuries were present in 22% (34/158) cases.
Discussion Previous studies have concluded that WBCT reduces mortality in polytrauma victims when compared to
Figure 2 Number body areas injured per case at WBCT.
Table 2 Comparison of suspected injuries against confirmed injuries at whole-body computed tomography (WBCT) for each body area. Body area
Suspected injury by emergency physician
Total number of injuries found at WBCT
% of suspected injuries confirmed by WBCT
% of injuries found at WBCT that were unsuspected
Head Neck Thorax Abdomen/pelvis
533 513 527 535
158 76 278 165
29% 13% 50% 31%
2% 13% 5% 2%
(155) (66) (263) (164)
(3) (10) (15) (4)
selective CT.13e15 Other studies have demonstrated how WBCT reduces time to events in hospital when compared to selective CT16,17; however, a meta-analysis of the literature has suggested that the improved mortality rates in these studies may not be attributable to WBCT alone with other confounding factors, such as patient selection and variations in quality of care, that also potentially influence mortality.18 Furthermore, the authors concluded that there was insufficient evidence to be certain that selective scanning had a higher rate of “missed” injuries than WBCT.18 Clinical assessment as a predictor for injury at WBCT has been shown to be poor, even amongst experienced emergency physicians. In their study of 400 patients, Smith et al.7 asked emergency physicians to grade their clinical suspicion of injuries for different body regions. They found that bedside assessment was sensitive in excluding serious injury in patients with a “very low” suspicion of injury, but overall diagnostic accuracy was low.7 Just under one-third of patients in the present study had normal CT examinations with no injuries to any of the body areas. Despite this being a significant proportion of all patients examined, the present findings are similar to those previously published in the literature.2,19,20 In the present study, 93% of patients had fewer body areas injured than clinically suspected. Although this may not be entirely unexpected, the fact that less than 2% of patients had injuries to all four body areas and that the “no injuries” or “injury to one body area” groups were the largest, does suggest that there is an overtendency to clinically categorise patients as being polytrauma victims and investigate them with WBCT. WBCT should be reserved for patients with multi-region injury. Patient selection for the examination can be made based on indicators such as clinical evidence of multi-area injury, mechanism, and abnormal physiological parameters.9 There is a wide variation in opinion amongst authors regarding the indication for WBCT. In a study by Salim et al.21 of 592 trauma patients with no clinical evidence of injury, occult injuries that led to a change in clinical management were identified in 18.9% of patients at WBCT, leading the authors to conclude that liberal use of WBCT is indicated in patients with suspected blunt multi-system trauma. Several studies have demonstrated a benefit to introducing a mandatory WBCT protocol for suspected polytrauma.21e23 Reduction in the number of missed torso
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
L. Shannon et al. / Clinical Radiology xxx (2015) 1e7 Table 3 Summary of unsuspected injuries found in patients at whole body computed tomography (WBCT) along with injuries that were correctly suspected in those patients. Injury not suspected
Injuries correctly suspected
Bilateral lung contusions
T2-6#s, left superior pubic ramus # and haematoma.
Brain contusion, inferior pubic ramus #
Peg #.
C1, C3, C4 #s
T6, T9-11 #s, multiple transverse process #s, small pneumothorax, sternal # and haematoma.
C4 and C6#
None.
C4/5# dislocation
Sternal #, left pneumothorax, bilateral rib #s, T5#, T10-11#s.
C5-6 transverse process #s, clavicle #, rib #, T6-7#s
Facial #s.
C5-7#s
SDH, rib #.
C7# dislocation
Right clavicle #, T1#, T5-8 transverse process #s, lung contusion.
C7#
Clavicle #, small left pneumothorax.
C6/7 # dislocation, active deltoid haemorrhage
SDH, EDH, basal skull #, severe facial #, complex pelvic #.
Facial #, small pneumothorax and pneumomediastinum
None.
Facial #, small pneumothorax, right inferior pubic ramus #
None.
Clavicle #
None.
Lung contusion
SAH, cerebral contusion.
Occipital condyle #
Right tension pneumothorax, multiple rib #s, liver laceration, trace of free fluid pelvis.
Peg#, C6/7#
SAH, complex facial #, T4#, rib #s.
Clavicle #
None.
Pneumothorax, lung contusions, clavicle #, scapula #, L5#
SAH, diffuse axonal injury.
Rib #
Renal laceration.
Rib #s, right pubic bone #
None.
T4#, multiple rib #s
None.
T4-5#s with haematoma, rib #
C1-2#s.
T9#, lung contusion
None.
Tiny pneumothorax
Complex pelvic # with haematoma.
5
Table 4 Summary of number of injured and uninjured patients according to age range. Age group (years)
Total patients
Patients with injuries confirmed at WBCT
Patients with no injuries at WBCT
16e25 26e35 36e45 46e55 56e65 66e75 76e85 >85 Total
130 94 86 88 65 53 46 26 588
80 58 57 56 52 42 39 18 402
50 36 29 32 13 11 7 8 186
WBCT, whole-body computed tomography.
when compared to pre-protocol WBCT imaging.20 Asha et al.10 found that a mandatory WBCT protocol led to a significant increase in radiation exposure. Hsiao et al.9 concluded that a prediction model for using WBCT did not significantly alter clinical accuracy and advocated using a thorough clinical assessment by the emergency physician as the most appropriate method to decide on the indication for WBCT.9 In our centre a combination of factors is used to decide on the indication for WBCT, as it is known that any one factor in isolation has a poor specificity for severe injury.11,24 The presence of a significant mechanism of injury, clinical evidence or significant suspicion of injury to two or more body areas, and haemodynamic instability are all key indicators for WBCT (Fig 1). For all cases where the trauma team have been called, the emergency physician can request WBCT directly through the CT control room. In cases without trauma team activation, the request for WBCT must be discussed directly with a radiologist. Only 3% of patients in the present study had serious injuries at WBCT that were not suspected by the emergency physicians. Salim et al.21 reported 18.9% patients as having clinically occult injuries that would have significantly altered patient management in their similarly sized study; however, the two studies are not directly comparable as injuries were suspected based on clinical findings, physiological parameters, and mechanism in the present study,
#, fracture; SDH, subdural haemorrhage; SAH, subarachnoid haemorrhage; EDH, extradural haemorrhage.
injuries, detecting clinically significant injuries that would have been missed pre-protocol, and faster time to definitive diagnoses are some of the benefits reported as a result of mandatory WBCT trauma protocol21e23; however, introducing a mandatory WBCT protocol has been associated with increased numbers of negative examinations
Figure 3 Age ranges of patients who underwent WBCT for suspected polytrauma.
Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084
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L. Shannon et al. / Clinical Radiology xxx (2015) 1e7
whereas Salim et al. 21 used clinical findings alone. Four percent (24/588) of patients with unsuspected injuries represent a small proportion of those selected for WBCT. These injuries could have been missed with potential for very significant morbidity without a WBCT protocol, although this represents a relatively low yield given the number of patients that were examined. Interestingly, most of the patients with unsuspected injuries at WBCT had significant “distracting” injuries at other body locations, which may have masked the injury to the unsuspected areas. A WBCT protocol for trauma does expose patients to a high-dose radiation examination, many of whom are young. Nearly one-fifth of patients who underwent WBCT in this study were in the 16e25 years group. Over half of patients who had no injuries at WBCT were aged 35 years or less. Thirty-eight percent of patients (9/24) with unsuspected injuries were aged 35 years or under. Although it is generally accepted that active bleeding can be difficult to identify clinically in young patients due to their greater physiological reserve, none of the unsuspected injuries in the present study were related to active haemorrhage. The most common pattern of injury found in the present study was synchronous injury within the thorax and abdomen/pelvis. Sixty-two percent of patients with abdominal/pelvic injuries also had thoracic injuries. Thirtyseven percent of patients with thoracic injuries also had abdominal/pelvic injuries. This certainly suggests that the thorax should be scanned routinely in cases where significant trauma to the abdomen/pelvis alone is suspected and a strong case can be made for scanning the abdomen/ pelvis in suspected thoracic injury. Neck injuries were seen in nearly one-fifth of patients with head injuries. Given the potential significance of cervical spine injury, scanning the cervical spine is advocated in suspected traumatic head injury if the patient is unresponsive or difficult to assess clinically. The main limitation of the present study was the inability to analyse the initial findings that led the physician to suspect whether a body area was injured and how this compared to WBCT findings. The CT request card has both an area to describe clinical concern and a tick-box for each body location. Although some physicians stated why they were concerned about a body area, some only filled in the tick-box; thus, for some patients, there are no data to indicate whether the suspicion was based on clinical findings, mechanism, or a combination. Smith et al.7 used a ratings system for grading clinical suspicion of injury from “very low” to “very high”. This would have been an interesting area to explore further, but how much use this has in high-pressure clinical situations is unclear. The situations faced by emergency physicians can be extremely challenging. Patients are sometimes severely traumatised by the event and may be even unresponsive, which makes obtaining a history or performing a thorough clinical assessment very difficult. Resuscitation rooms can be chaotic and crowded places, sometimes making a detailed, uninterrupted clinical assessment difficult. Once the
suspicion of injury to a body area has occurred to an emergency physician, the likelihood is that many will feel obliged to investigate using CT regardless of the precise level of suspicion. In summary, clinical suspicion of injury correlates poorly with findings at WBCT, with a high proportion of examinations of uninjured body areas. The number of unsuspected injuries found at WBCT was low, but the majority of these were serious injuries, possibly masked by distracting injuries to other body areas. The use of a WBCT protocol is advocated for suspected polytrauma, and there do appear to be patterns of injury between certain body areas. Given the high radiation dose in a population skewed towards a younger age group, the financial costs and increased workload that is incurred with Trauma WBCT, we recommend regular monitoring of the findings and regular feedback of the results to emergency physicians to better inform their decisions when selecting patients for this examination.
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Please cite this article in press as: Shannon L, et al., Comparison of clinically suspected injuries with injuries detected at whole-body CT in suspected multi-trauma victims, Clinical Radiology (2015), http://dx.doi.org/10.1016/j.crad.2015.06.084