Clinical Perspective
m CT:
inical
Current controversies in emergency room
CT: could trauma total-body CT scanning
improve clinical outcome?
Ludo F Beenen,
Practice points
• Both pre- and in-hospital care for the trauma patient is organized worldwide according to
the principles of ATLS® (Advanced Trauma Life Support). It follows the central paradigm:
treat first that kills first.
• At the emergency department, standard radiological evaluation entails x-rays of the
chest and pelvis and focused assessment with sonography for trauma ultrasound, with
additional selective computed tomography (CT) scanning, if necessary.
• The rationale for early total-body CT (TBCT) scanning is to detect all important injuries and
begin treatment without missing injuries and losing time, thus reducing mortality.
• TBCT scanning can lead to early detection of life threatening injuries, but may expose
trauma patients to significant radiation. Only a few studies exist on cost–effectiveness and
unsuspected findings, therefore, these topics remain unclear.
• Pooled analysis of studies comparing TBCT with selective CT scanning show a trend, but no
significant difference, in mortality. However, TBCT results in improvement of emergency
department time and changes in treatment.
• For a more definite statement, firm clinical outcome data from randomized controlled
trials are needed, and are expected from the prospective REACT-2 trial in the coming years.
• To reduce time delays, a trauma patient should be scanned in the emergency department.
• For justification and optimization of CT scanning, and direct and complete interpretation
of the radiological findings, an emergency department radiologist should be present at
the trauma bay.
Accident & Emergency Radiology,
Department of Radiology, Academic
Medical Center, Amsterdam,
Meibergdreef 9, 1105 AZ Amsterdam,
The Netherlands
l.f.beenen@ amc.uva.nl
In trauma patients who have sustained multiple injuries, every second counts: time is
life. Immediate total-body computed tomography (TBCT) can give quick and complete
radiological diagnoses for these critically ill patients. Hence, direct scanning can result
in increased survival and a reduction in emergency department time. Several, mostly
retrospective studies, have shown the potential of TBCT scanning in trauma patients.
In these studies, TBCT appears to be associated with reduced evaluation times and
decreased mortality. On the other hand, concerns have risen concerning the amount
of radiation exposure in this overall relatively young population. Therefore, the need
for prospective studies has been stressed recently by several authors. If immediate
TBCT scanning is found to be the best imaging strategy in severely injured trauma
patients, it could replace conventional imaging with selective CT in this specific group.
Keywords: adults • computed tomography • emergency radiology • mortality • radiation
exposure • trauma • whole body scanning
Introduction
In recent years, the role of emergency radiology in trauma has become more and more
prominent [1,2] . Owing to the improvements
10.2217/CPR.14.59 © 2014 Future Medicine Ltd
in computed tomography (CT) technology, trauma CT scanning has changed from
what was once called a “donut of death”
for severely injured patients into an invalu-
Clin. Pract. (2014) 11(6), 591–603
part of
ISSN 2044-9038
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Clinical Perspective Beenen
able “circle of life”. But what is the role for radiology,
or more specifically emergency radiology, and total
body scanning in trauma? For this perspective paper,
all relevant publications on trauma and radiology/
CT were searched. Databases of PubMed, Embase,
Web of Science and Cochrane Library were screened
for papers published until December 2013, using
the terms “trauma” or “injury”, in combination with
“Total-Body CT (TBCT)” or “Whole Body CT” or
“Full Body CT”, or “panscan”. In addition, reference
lists of selected articles were evaluated for additional
references. In this way, the many different aspect of
TBCT scanning will be discussed. We will begin with
what happens to a trauma patient from the moment of
the accident, until after admission, when every minute
counts.
Where do the paramedics take the trauma
patient?
At the trauma scene, the paramedics will perform an
ATLS® (Advanced Trauma Life Support) based care
on the trauma patient, which will be described in more
detail later. The decision of the paramedics at the scene
is to “stay and play” or “scoop and run”. That is, will
they institute some care at the trauma scene, which
will cost time and where resources are limited. After
a short evaluation and stabilization, the patient will
be transported to a hospital, either by ambulance or
helicopter. However, should transport be to the nearest
hospital, even if that is not accustomed to trauma care,
without direct availability of all necessary specialists
and no dedicated intensive care unit (ICU)? Or should
they take more time and take the trauma patient to a
dedicated major trauma center [3] ?
Regionalization of trauma care has been a slow, but
steady process over recent years [4] . Concentration of
severely injured patients in trauma centers is associated
with better outcomes [5,6] . Regular contact to low frequency, highly complex problems is best handled by
a limited number of hospitals, thus increasing exposure and hence experience. TBCT scanning with its
specific demands will also be part of the standard
armamentarium. Thus, a settled trauma system with
better handling for complications will lead to reduced
mortality and morbidity [7] . A major trauma center has
proven to save lives when having >250 trauma patients
per year. For hemodynamically unstable patients delay
to interventional radiologic procedures independently
is associated with a twofold higher risk in mortality
[8] . Therefore, also interventional radiology should be
available on a 24/7 basis.
Although the sensitivity for pre-hospital triage is
high, in daily practice both overtriage and undertriage occurs [9] . Therefore, every emergency department
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(ED) should be prepared to receive severe trauma
patients, and have updated trauma protocols. When a
patient has been undertriaged and brought to a local
hospital without experience in total body trauma CT
scanning, the risk exists that this may not be performed
appropriately. As trauma is not a static but a dynamic
process, the admitted patient could deteriorate unexpectedly in hospital, and the severity of injuries could
be more serious than the physicians ordinarily see.
Of note, in cases of a mass casualty, every hospital is
obliged to contribute to its capabilities.
During transport the paramedics will evaluate the
clinical condition of the patient, specifically the vital
parameters, such as blood pressure, heart rate and
Glasgow Coma Score. It is paramount that this essential information is transmitted to the receiving hospital, so that they can prepare the whole trauma team
(surgery, emergency, anesthesia, radiology) and take
appropriate measures.
What happens after admission at the ED?
The patient will be handed over by the paramedics
to the trauma team. Worldwide trauma patient care
is organized according to the principles of ATLS, a
well-established method originating in 1976 for the
systematic care on trauma patients, both in the field as
well as in the hospital [10] . Due to this common ATLS
language, communication and collaboration of all
­professionals involved is facilitated.
The basic principles are to first adress the injuries
that are the most endangering, i.e. “treat first that
kills first”. Therefore, a stepwise approach is used,
performed in strict order. A systematic evaluation and
treatment is started according to the “ABCDE”:
• A: Airway
• B: Breathing
• C: Circulation
• D: Disability
• E: Exposure and Environment
Standard radiological evaluation mostly entails
x-rays of the chest and pelvis, and focused assessment
with sonography for trauma (FAST) ultrasound [11,12] .
Therefore, pneumothoraxes as well as injuries with large
blood loss (hematothorax, pelvic ring fracture) can be
recognized. In FAST, free intraperitoneal fluid (blood
in trauma) can be detected irrespective of the hemodynamic status of the patient, although sensitivity for
parenchymal injury is not as good [13] . Alternatively, a
LODOX-Statscan system can produce a complete radiographic display of the whole body of a trauma patient
future science group
Current controversies in emergency room CT: could trauma TBCT scanning improve clinical outcome? [14] . However, unlike CT, it cannot give information
about parenchymal organ injuries, therefore, it never
gained much popularity and nowadays is surpassed by
CT and TBCT.
In a second systematic survey of the patient from
head to toe, other injuries of the extremities are evaluated. According to the ATLS guidelines, CT can be
used as an adjunct to conventional radiology or physical examination to more clearly depict the location and
severity of injuries. It can also be valuable in excluding pathology and, as such, can have the patient safely
discharged from the ED. Therefore, not only for high
energy trauma but also for low energy trauma, patients
can benefit from the use of CT. Compared with conventional radiography and ultrasound, CT yields new and
additional findings in polytrauma [15] . These new findings primarily involve the head; additional findings are
found in the chest, pelvis and spine, and are potentially
life t­ hreatening in nature.
When a CT is performed, different set ups and protocols can be chosen, depending on indications, local
circumstances, logistics and preferences. As a member of
the multidisciplinary team, the radiologist must decide
which is the most adequate technique and protocol for
each situation after taking in consideration the technological resources available [16,17] .
How reliable is physical examination?
Can all injuries be evaluated with good accuracy and
consequently safely excluded, thus avoiding radiological exams? The answer is no. Physical examination in
patients with blunt abdominal trauma is useful but not
completely reliable [18] . This was recently confirmed in
a prospective study including 400 high-acuity patients
[19] . Although bedside examination by emergency physicians could adequately attribute a very low probability of
injury in the head, cervical spine, chest, abdomen/pelvis and thoracic/lumbar spine injuries, overall diagnostic accuracy was low. Therefore, in these patients, they
advised TBCT to prevent injuries being missed.
The severity of trauma is assessed using the Injury
Severity Score (ISS), ranging from 0–75, which correlates with mortality, morbidity and hospitalization time
after trauma. A major trauma (or polytrauma) is defined
as an ISS being greater than 15 [20] .
One major problem is that not all trauma patients are
cooperative, or in severe trauma cases are unconscious
or intubated, resulting in limited communication possibilities. As the context, such as mechanism of injury,
is important and unreliable when not verified, this also
hampers interpretation. The right context can sometimes put findings into another perspective; from unnoticed and irrelevant, to potentially life endangering. This
applies to both physical and radiological examinations.
future science group
Clinical Perspective
Why do we need CT & what is the rationale
for early CT?
Historically, the timing of trauma deaths has been
described using a trimodal mortality model (immediate deaths, early deaths and late deaths) [21,22] . Immediate deaths occur within minutes of the accident,
mostly at the scene or shortly after arrival in hospital,
due to non-survivable injuries and account for 50%
of all mortality. The second peak are the early deaths,
within hours of arrival in the hospital. Late deaths
occur days to weeks after the injury. As trauma systems mature and ICU care improves, a decline in late
deaths and hence a shift toward a bimodal distribution
has emerged.
Hence, the main focus for controlling mortality in
trauma lies in the prevention of early deaths. The first
24 h after trauma are the deadliest for trauma patients.
Primary and secondary CNS injuries are the leading
causes of death [23,24] . Next, almost a third of victims
die of hemorrhage. For hypotensive trauma patients
needing emergency laparotomy, mortality increases
1% for every 3 min in the ED [25] .
Therefore, the ratio for early CT lies in the early
detection of these life-threatening injuries and associated possibility of starting treatment early. CT for
trauma has a reported high accuracy for a wide variety
of injuries, low missed injury rate, it is quick, available
everywhere and can prevent unnecessary surgeries. Performing direct TBCT means surpassing conventional
radiography with its lower sensitivity and could spare
delay times up to 30 min. Detection of hematoma
logically targets on stop the bleeding (“C” problem),
but gathers no information on brain injury (“D” problem), therefore, only after correcting circulation is an
evaluation of the brain started, which could be too late
and the damage already irreversible. The most logical
approach is to instantly be informed on all potentially
life threatening injuries, to make the right treatment
decision and start this as soon as possible (Figure 1) .
Do we need to scan all? Do we need
selective CT or TBCT?
Compared with a trauma protocol with selective CT
after high-energy trauma, a routine CT of chest-abdomen-pelvis finds substantially more clinically relevant
diagnoses, even in patients with an unsuspicious clinical examination and normal radiography and FAST
[26,27] . This prospective TRACT cohort study from
May 2005 to November 2006 used a 16-slice multidetector CT (MDCT) scanner that was located in
a room adjacent to the trauma resuscitation room.
All patients underwent physical examination, FAST
and conventional radiography of the pelvis and lumbar spine, and subsequently routine CT of the abdo-
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Clinical Perspective Beenen
A
B
C
Figure 1. Total body CT of a young woman after fall from height and traumatic resuscitation setting (volume
rendering and coronal reconstructions in bone and soft tissue windows). Multiple injuries are diagnosed:
bilateral pneumothorax, pneumomediastinum and subcutaneous emphysema, multiple ribfractures, liver
laceration, hemoperitoneum, right hypogastric artery dissection, perineal injury, pelvic fractures, internal carotid
artery laceration, cervical, thoracic and lumbar spine fractures, and multiple fractures of arms and legs.
men, pelvis and lumbar spine. Before scanning, the
selective MDCT subgroup was defined on the basis
of all available clinical and radiological information.
Median ISS was 13. The study proved that in 20% of
465 patients, CT of the trunk could be safely omitted
when physical examination and standard conventional
radiological work-up including FAST was negative.
On the other hand, this selective CT protocol was
more expensive than scanning the patients directly.
Routine CT revealed additional traumatic injuries in
15% of the patients in the abdomen, in 2.4% in the
pelvis and in 8.2% in the lumbar spine, resulting in
treatment change in 6.4% and in the chest in 7%,
mostly because of additional findings of pulmonary
and mediastinal injury.
In a similar prospective single center observational
study between July 2007 and June 2008 a 16-slice
MDCT was used in the ED for 701 patients with blunt
trauma. Both a senior emergency physician and trauma
surgeon independently indicated which components
of TBCT they thought necessary [28] . The emergency
physicians more often choose to remove parts of TBCT
than the surgeons (35 vs 7% of scans). Of 992 scans
(35%) that one or both physicians indicated could be
omitted, 102 were abnormal and three of these abnormalities led to a predefined critical action. Of note,
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Clin. Pract. (2014) 11(6)
the median ISS of 5 was relatively low compared with
some other major trauma centers. In more severely
injured trauma patients, the number of critical missed
injuries could be even higher. Interestingly there was
disagreement between surgeons and emergency physicians with respect to the clinical significance of the
abnormalities on the 99 undesired scans that did not
lead to a critical action. Apparently fundamental differences exist on tolerability of diagnostic uncertainty
and on risk tolerances, as the accuracy of the scanning
itself was not debated.
In correlation with other ED imaging strategies, the
self-reported physician risk-taking behavior predicts
the use of imaging in ED patients for example with
abdominal pain, whereas malpractice fear and stress
due to uncertainty do not [29] . Furthermore, head
injury preferences for different decision approaches can
lead to significant differences in CT utilization [30] . It
clearly documents the trade-off between sensitivity
and specificity, and differences in the number needed
to scan to detect different outcomes (intracranial traumatic findings, clinically relevant findings or neurosurgical interventions). Therefore, selective scanning
can reduce the number of scans, but will miss some
injuries. However, no consensus exists what risk rate is
acceptable for missing the few critical ones.
future science group
Current controversies in emergency room CT: could trauma TBCT scanning improve clinical outcome? TBCT, whole-body CT, full body CT & panscan
The terms TBCT, whole-body CT, full body CT and
pan-scan all mean the same: scanning head/face, cervical spine and chest/abdomen/pelvis during one procedure. The technique to do so, however, is left unspecified, and unfortunately is only poorly documented in
the literature. Also few studies have evaluated the criteria and indications for TBCT [31,32] . When evaluating
this imaging approach, most important aspects to consider are effects on mortality, ED time management
and therapy changes. Several studies have described
these factors.
The largest study comparing TBCT with standard
evaluation appeared in The Lancet in 2009 [33] . In this
retrospective, multicenter study data of 4621 trauma
patients with an ISS >16 in the DGU German Trauma
database from 2002–2004 were analyzed. No specifications were set for scan protocols and equipment. Mean
age was 42 years, 73% were men and mean ISS was
29.7. Two different, validated trauma scoring systems
(trauma and ISS [TRISS] and revised injury severity
classification) were used to calculate the standardized
mortality ratio (actual/expected mortality) for two
groups: those that underwent TBCT (32%) versus
those that did not receive TBCT. In a logistic regression
model using sensitivity analyses, correction was made
for the year of treatment and level of trauma center. The
predicted mortality was equal to the actual mortality in
the non-TBCT group, but was lower than predicted for
the TBCT group (standardized mortality ratio based
on TRISS was 0.745 [95% CI: 0.633–0.859] and on
the revised injury severity classification score was 0.865
[0.774–0.956]). They concluded that TBCT significantly increased survival in both hemodynamically
stable and unstable trauma patients, and recommended
TBCT as a standard diagnostic method during the
early resuscitation phase for polytrauma patients. However, some criticism has been put forward concerning
the scanty discussion of the limitations of the database
and analyses [34–36] . The retrospective nature harbors
intrinsic potential confounders with unknown impact,
for example the decision to use TBCT or not.
In a follow-up retrospective multicenter study the
same DGU group evaluated 16,719 hemodynamically unstable patients who were in moderate, severe
or no shock (systolic blood pressure 90–110, <90 or
>110 mmHg) [37] . Overall mortality rate was 17.4%
for 9233 (55.2%) patients that underwent TBCT and
21.4% for 7486 patients without TBCT (p < 0.001).
They concluded that in hemodynamically unstable
trauma patients, TBCT seems to be safe, feasible and
justified if performed quickly within a well-structured
environment and by a well-organized trauma team.
future science group
Clinical Perspective
Apart from these two studies, several others compared TBCT with a more selective approach. Most
have been performed in the earlier years of this century,
and the CT scanners used were 4-, 16-, or 64-slice or
unspecified.
Weniger et al. retrospectively compared 185 patients
undergoing a pre-MDCT-protocol, admitted before
December 2002, with 185 patients undergoing a
16-slice MDCT protocol in 2003–2004 in patients
with an ISS >17 and at least one life threatening injury
of the head, chest or abdomen [38] . They concluded
that immediate MDCT in patients with blunt major
trauma lead to more accurate and faster diagnosis,
and reduction of early clinical time intervals. Also a
reduction in ventilation, ICU and days in hospital was
observed.
In another single center, prospective observational
study between July and December 2007, 284 blunt
trauma patients with an average ISS of 11 underwent
a TBCT [39] . Before CT acquisition, the need for each
scan was independently recorded by emergency medicine and trauma surgery. A total of 311 CT scans were
perceived to be unnecessary in 143 patients (27%),
mostly in the chest (n = 116) and abdomen/pelvis (n =
83) and to a lesser degree of the head (n = 62) and neck
(n = 50). Physicians were willing to omit 27% of scans,
consequently two injuries requiring immediate actions
were missed. Furthermore, in 17% of patients other
potentially important injuries would have been missed.
The multicenter PATRES (Pan-Scan for Trauma
Resuscitation) project covers research on different
aspects of TBCT in early trauma care. As part of this
project a single center retrospective study compared a
group of 536 patients not undergoing a pan-scan with
608 patients that because of a liberal TBCT policy
in the period 2002–2007 received a TBCT [40] . The
4-slice CT-scanner installed close to the trauma bay
was replaced by 64-slice MDCT in 2006. Overall mortality decreased from initially 23.3 to 7.9%
(p < 0.001). Both the availability and the actual use of
TBCT were associated with a lower mortality. As the
authors stated, the causal role of the scan itself must be
interpreted in the context of improved structural and
process quality.
A nationwide retrospective study of the Japan
Trauma Data Bank (2007–2010) analyzed 5208
patients with a diminished consciousness (Glasgow
Coma Scale 3–12) [41] . Patients that underwent TBCT
were compared with those that did not undergo
TBCT. For severity adjustment, the TRISS method
was used. Adjusted mortality was significantly lower
in the TBCT group, leading to the conclusion that
integration of TBCT into initial trauma management
may decrease mortality in blunt trauma patients with a
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Clinical Perspective Beenen
Glasgow Coma Scale score of 3 to 12.
In 2012 results of the FIRST study were published
[42] . In this prospective, multicenter cohort study 1696
out of 1950 (87%) consecutive severe blunt trauma
patients underwent total body CT. Recruitment was
between December 2004 and March 2007. No limitations on scanner type were given. The main outcome
was the vital status at 30 days or at ICU discharge if
discharge occurred within the first 30 days. Survival
significantly improved for TBCT patients related to
the TRISS predicted survival as compared with selective CT. Diagnostic TBCT was associated with a
­significant reduction in 30-day mortality.
Time requirements for resuscitation, diagnostic
work-up and transfer to definitive treatment were
analyzed in an observational study with retrospective
analysis after changing from the Trauma-Protocol in
2004 [43] . A mobile 16-slice ‘sliding gantry’ MDCT in
the trauma resuscitation suite was used and 82 patients
with suspected multiple trauma treated with the
MDCT-Trauma-Protocol in 2004 versus 79 patients
with the Conventional-Trauma-Protocol in 2002 were
analyzed. Patient care could be improved with the
TBCT approach as it shortened the time interval from
arrival in the ED to obtaining a final diagnosis and
management plan in trauma patients.
Does TBCT reduce mortality in severe
trauma patients?
To address this question and other benefits of TBCT,
three systematic reviews and meta-analyses have been
published, the most recent in 2013 [44] . Only studies
that directly compared TBCT with a conventional
approach with selective scanning were selected (most
of the abovementioned studies) [33,38,40,42,43] . Both
effects on mortality and time management were analyzed. This systematic review and meta-analysis could
provide Oxford grade level 2b evidence. Unfortunately, although indicative results of improved survival, most had a suboptimal design to definitively
prove that TBCT results in reduced mortality in blunt
high-energy trauma patients. All were non-randomized cohort studies and were prone to several sources
of bias (selection for non-randomized, performance
and detection to non blinding, attrition due to retrospective nature). Of note, traumatic brain injury is
known to be the single largest contributor to trauma
mortality [21,22] . Yet, no dedicated analysis on this
specific subgroup has been presented in these papers,
thereby limiting comparison and bias evaluation. In
the presented papers, baseline characteristics of different items on traumatic brain injury are displayed. In
some, a significant lower number of severe traumatic
brain injury was included in the TBCT group [33,40] .
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As a steady decline in trauma mortality is generally
seen worldwide, temporal comparisons can be major
confounders. The meta-analysis showed that in 8180
patients of five pooled studies, no significant difference
on mortality between groups was found (pooled OR:
0.68; 95% CI 0.43–1.09, p = 0.11). However, in 6073
patients in four studies, a TBCT resulted in improved
ED time intervals when compared with selective CT.
Owing to a significant reduction in the time spent
in the ED when patients underwent TBCT (pooled
effect size of weighted mean difference = -32.39 min;
95% CI: -51.78 to -13.00; p = 0.001), therapy in life
­threatening situations can be started sooner.
In an effort to display the whole picture, a recent
systematic review did not supply a meta-analysis, but
instead focused on the benefits (shorter time to diagnosis, treatment, stay, mortality, efficient diagnostics, fewer
missed injuries, potential lower total radiation exposure)
and harms (delayed time to immediate intervention,
increased radiation exposure) of TBCT [45] . Although
more benefits than harms were named, the authors
critically questioned whether the reported benefits in
mortality truly represents an improved survival due to
substantiated management changes, or whether this is
the result of hospital- or individual-level confounders.
To circumvent the weaknesses intrinsically associated with the used methodology in the reported studies, there is a need for high-quality studies and for
the best and most solid scientific proof. Therefore,
­randomized controlled trials are needed.
Prospective international multicenter
randomized clinical trial
The REACT-2 trial is an international, multicenter
randomized clinical trial that is evaluating the value of
immediate TBCT scanning during the primary survey
of severely injured trauma patients [46] . All participating trauma centers have a MDCT scanner located in
the trauma room or at the ED. Patients are randomized between direct TBCT scan (unenhanced head
and neck followed by repositioning of the arms with
contrast-enhanced imaging of chest-abdomen-pelvis)
versus ATLS-based conventional trauma imaging protocols with supplemental selective CT scanning. Inclusion started April 2011 and ended December 2013,
with follow-up of 1 year. The primary outcome is inhospital mortality and secondary outcomes are differences in mortality and morbidity during the first year,
several work-up time intervals at the ED, radiation
exposure, quality of life and cost–effectiveness.
What about radiation exposure?
When every minute counts, there is no time to think
about radiation exposure. It has to be done earlier, by
future science group
Current controversies in emergency room CT: could trauma TBCT scanning improve clinical outcome? setting up the right protocols by dedicated radiologists in good collaboration with specialized radiological technicians. All trauma team members should be
familiar with the protocols; protocols should be easily
accessible and clear to interpret.
If during trauma evaluation inappropriate use of CT
scanning has occurred, a correction of this procedure
should be undertaken by the responsible radiologist at
a later stage.
In general, trauma patients are relatively young,
mostly males between 20–50 years. In recent years, an
increasing number of publications on radiation exposure and trauma have appeared, not only for different
parts of the body, but also for total body scanning [47,48] .
Critics to a liberal use of scanning are emphasizing the
unnecessary radiation exposure without any impact on
mortality, missed injuries or length of stay [49] . After the introduction of a 64-slice TBCT protocol in 2007, an increasing number of trauma patients
received a radiation dose >20 mSv, regardless of age or
injury severity [50] . In another study from 2006, cumulative effective dose was 14.6 mSv per trauma patient
[51] . CT scans accounted for only 21% of radiologic
studies but for 93% of the cumulative effective dose.
Patients with ISS >9 and longer length of stay had a
higher cumulative effective dose rate.
Radiation during admission as well as during the
complete hospital period has been studied. Although
TBCT can increase the CT-induced trauma room
radiation dose compared with selective CT scanning,
the total overall effective dose during hospital admission was not significantly different before and after the
introduction of a dedicated TBCT protocol (20 vs 24
mSv, p = 0.509) [52] .
As trauma patients are exposed to significant radiation doses from diagnostic imaging, resulting in a small
but measurable cancer risk, unnecessary CT scans
should be avoided [53] . Diagnostic benefit always needs
to be weighed against risk of the cumulative radiation
dose [54] . The risk of mortality from trauma was calculated to be six times higher than the estimated risk
of radiation-induced cancer mortality in intermediate
level trauma patients [55] . As mortality is greatest in
older trauma patients, a more liberal attitude toward
CT-scanning in these patients could be of advantage.
Efforts to reduce radiation exposure to trauma patients
should certainly focus on young patients with minor
injuries, for example, by standard usage of commonly
available techniques for dose reduction, such as automated exposure control. Iterative reconstructions are
considered a valuable quality improvement technique
in comparison to the commonly used filtered back projection. Depending on preferences one can choose for
either improving image quality for a constant radia-
future science group
Clinical Perspective
tion exposure or reduction of radiation exposure, while
maintaining the same image quality [56,57] . A major
downside of this technique, however, is the intrinsic
higher time consumption, which is unwanted in major
trauma patients.
In addition, some specific trauma related issues can
be mentioned. By limiting redundant imaging in overlap zones, TBCT reduces radiation exposure compared
with a segmented approach while covering the same
range [58] . Scanning with the arms alongside the body
can result in a 45% increased radiation exposure and
a decrease in image quality compared with scanning
patients with a cranial position of the arms [59] . Scanning with one arm cranial and one caudal (superman
configuration) results in in-between exposure and
image quality. Thus, effort should be made to position
the arms above the shoulder when possible.
Some bearing devices can increase radiation dose
and affect image quality. For the best balance therefore preferably aluminum and metal-free devices are
chosen. Nowadays, with new hardware, software and
individual placement algorithms, significant dose savings to a radiation level of 10 mSv can be reached [60] .
As with the newest high-end CT-scanners, in some
cases, radiation doses are approaching ranges of conventional radiography, which could potentially challenge that modality. There may even be a paradigm
shift, challenging the early ATLS resuscitation phase
by using CT as the primary screening tool.
Specific populations: children, pregnant
women, elderly & obese patients
Children are more sensitive to radiation compared
with adults, therefore, the younger the patient at the
time of exposure, the higher the radiation dose to the
organs [61] . Higher organ radiation doses are associated
with an increased risk for cancer in this population.
The majority of radiation exposure to pediatric trauma
patients is secondary to CT [62] . Scan protocols should
be adapted to specific age categories. In trauma, the
mean whole body effective dose is 17.4 mSv [63] . However, no survival benefit of TBCT in pediatric trauma
has been established. Therefore, the indiscriminate use
of CT in the evaluation of the pediatric trauma patient
is not warranted.
In a step-up imaging strategy for pediatric patients
with blunt abdominal trauma, decisions for observation or intervention depends on the vital parameters of
the patient in combination with the evaluation of free
fluid at FAST and the findings on CT (performed only
on indication) [64] . This step-up imaging strategy has a
high sensitivity and a high negative predictive value for
ruling out abdominal injury without missing clinically
relevant injuries.
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Clinical Perspective Beenen
Trauma is the leading cause of non-obstetric
maternal mortality and a significant cause of fetal
loss. Ultrasound can be a good screening alternative, however, even in pregnant women with severe
trauma, CT imaging is of importance but must be
used wisely. Of course the risks of radiation exposure
should be weighted individually against the benefits,
and most are small compared with the possible effects
of missed injuries. The pregnant trauma patient
requires imaging tests to diagnose maternal injuries
and diagnostic tests to evaluate the viability of her
pregnancy [65,66] .
Older patients have an increased mortality in
trauma, even without physiological derangement on
admission. Exposure to radiation is less of an issue in
this age group, so active diagnosis and treatment should
not be discouraged. By doing so, in older patients, significant survival rates can achieved [67] .
Obesity is an increasing problem in the modern
world. In these patients, higher rates of injuries to torso
and proximal upper extremities are found [68] , and
even more so in older patients. For these imaging challenges, specific adjustments must be made in diagnostic studies, including optimizing scanning parameters,
using antiscatter grids with tight collimation, iterative
reconstruction and artifact reduction techniques [69] .
Disadvantages of TBCT
Including the aforementioned radiation exposure,
there are other disadvantages to TBCT: economics/
cost–effectiveness and unsuspected findings/incidentalomas. Injuries can be missed because of image
overload, lack of context or over reliance on TBCT
findings [70] . Furthermore, injuries are not always
immediately apparent, as imaging is only a snapshot
in time. Therefore, correlation with clinical findings
by implementing tertiary and quarterly survey is fundamental, as well as studying imaging reports [71] or an
itemized structured reporting.
In 45% of trauma patients that underwent TBCT
scanning an incidental finding is found [72] . Of these,
7% are category I findings (potentially severe condition, further diagnostic work-up required), 24% category II findings (diagnostic work-up dependent on
patients’ symptoms) and 69% are category III incidental findings (findings of minor concern, no diagnostic
work-up required). Both additional radiologic imaging and further invasive work-up or treatment could,
therefore, be needed.
Costs
Scanning a complete body can theoretically cause an
increase in total costs. However, in a recent study,
changing to a liberal mechanism-driven scanning
598
Clin. Pract. (2014) 11(6)
protocol not only resulted in change of treatment in
74% of patients, including prevention of unnecessary
admission, but also saved £93,000 [73] . During a 1-year
observation period, 336 of 452 trauma patients (74%)
had a positive scan. However, due to the chosen set
up, it remains unclear if observation of the other 116
would have lead to additional imaging or not. If so,
this would have added to even higher costs.
Is more needed?
Just moving the patient in the scanner will not save
a life. There are some crucial elements that are often
overlooked, but are essential for good trauma care, and
even more so for TBCT. These are: place, technique
and interpretation of the scan.
Where should we scan the patient?
Should the patient go to a CT scan in the radiology
department, which is often on another floor? Do we
need a scanner in the ED, or is a remote scanner in the
radiology department fulfilling all demands?
There are some disadvantages to sending the trauma
patient to the radiological department. First, transport
itself harbors the danger of complications. For critical patients, intra-hospital transport is associated with
a higher risk for complications, such as pneumothorax, atelectasis or displacement of lines and tubes [74] .
In addition, they have to wait until a CT scanner is
available, costing even more critical minutes. When
the condition of the patient deteriorates during scanning, who can care for the patient or are there sufficient resuscitation possibilities available? This could be
especially dangerous if only radiological technicians
and ED nurses are present.
The prospective REACT-1 study compared the
impact of having a CT in the trauma room versus the
radiology department in 1124 patients in two Dutch
level-1 trauma hospitals [75] . In this randomized controlled trial there was a reduction in the number of
patient transfers and transports, and a significant
reduction in time to first CT imaging (13 min shorter,
p < 0.001) was recorded for the trauma room CT setting. Although not statistically significant, it also
favored a reduction in mortality and out-of-hospital
days.
Therefore, the best option is a CT scanner in the
ED or, even better, a CT scanner in the trauma bay
[76–78] . Choosing the optimal planning and distribution strategies depend on the number and location of
available CT scanners, along with number of trauma,
urgent and regular patients [79] . With a sliding gantry
solution (The Amsterdam Trauma Workflow concept
with one CT scanner servicing two rooms), one room
is always available for the highest emergency. A CT
future science group
Current controversies in emergency room CT: could trauma TBCT scanning improve clinical outcome? scanner located in the trauma room reduces the time
to acquire CT images, improves workflow and also
reduces the number of transport movements for the
trauma patient.
Who is interpreting the images?
The best person to interpret the scan is an emergency
radiologist, present in the ED as part of a trauma team
[80,81] . Remote interpretation by a radiologist harbors
the danger of the radiologist not knowing the context
for interpretation, in addition to not be able to directly
react to sudden changes in the patient’s condition.
Therefore, the radiologist should also be where the
patient is, whether that is the trauma bay or ED. There
they can be part of a multidisciplinary team and be
involved in the critical decision making by justifying
the chosen protocols as well as direct reporting of all
imaging.
Missed injuries in the initial ‘hot report’ can occur
in up to half of cases. Most of the time they are minor,
often musculoskeletal and associated with higher age
and ISS. To prevent these missed injuries in night
exams, a second ‘cold’ read by a dedicated radiologist
should be advised [71] .
Subspecialty radiologists know much about their
specific area, but this mostly concerns chronic pathology. Adjacent areas are usually referred to other subspecialties. For trauma the integral vision on the
whole patient with multimorbidity is often beyond
their experience. In polytrauma patients with involvement of many different organ systems, a fragmented
approach could result in numerous phonecalls to different subspecialties. When for example consecutively
a neuroradiologist for brain trauma, a musculoskeletal
specialist for the spine, a chest radiologist for chest and
aortic pathology, an abdominal radiologist for abdominal injuries and an interventional radiologist for angioembolization must be contacted, much time is wasted.
When every minute counts, the time wasted on phoning remote subspecialists, explaining the clinical context, and waiting for their answers and their interpretations could take too much time in an emergency,
which is detrimental to the patient. If an emergency
radiologist is present at the ED, they know the condition of the patient and how to put this into perspective,
which is beneficial, especially since the development
of interventional radiology affords therapeutic procedures alternative to surgery [82] . Fundamental trauma
analysis demands the personal involvement of a dedicated radiologist, so as to prevent time and effort being
wasted.
When every minute counts, a dedicated emergency
radiologist should be interpreting the images and be
present in the ED as part of the trauma team.
future science group
Clinical Perspective
How should we scan the patient?
As previously mentioned, only a few publications are
present on scan techniques and even fewer compare the
accuracy of different protocols [83] . If accuracy is different, the detection of significant injuries would also be
different and, thus, the impact on outcome. In trauma
various injuries can occur, each with its own prerequisites for imaging. A non-enhanced CT can be used for
diagnosing fractures. Contrast CT scanning in arterial phase is used to visualize vascular pathology, for
example aortic and craniocervical injuries and contrast
blushes indicating arterial extravasation. Portovenous
imaging is used to evaluate parenchymal injuries as
well as contrast extravasation development in time. To
evaluate urological lesions a (5–10 min) delayed series
is used. Hence, imaging in four phases has the advantage of not missing information in a specific phase, but
can result in a quadruple radiation exposure. A single
pass protocol has the advantage of reducing radiation
exposure as well as the image volume load. Scanning
the trunk in portovenous phase will cover most of the
needs, but at the cost of lower enhancement in arterial structures. On the other hand, Stengel et al. used
a single pass scanning technique from skull base to
symphysis and reported a good accuracy [84] . An interesting alternative is the split bolus technique that combines different contrast phases into one acquisition,
thereby diminishing radiation exposure with only
­limited increase of the amount of contrast medium [85] .
Overall, no consensus exists on trauma protocols
and every hospital has a variety of choices:
• Segmented, single pass, combined hybrid
• Arms/shoulders alongside the trunk or repositioning of the arms after brain CT
• Contrast: only torso, or including CTA of head and
neck, extremities?
• Bolus triggering or fixed delay
• Native, arterial, portovenous, 10 min delayed,
split-bolus
• One or multiple protocols
• Second/follow up CT.
Conclusion
In trauma, time = life. Immediate TBCT follows that
philosophy. Several, mostly retrospective, studies have
shown the potential of immediate TBCT scanning in
trauma patients for improved survival and ED time.
The need for prospective studies, however, has been
stressed recently by several authors. Firm clinical out-
www.futuremedicine.com
599
Clinical Perspective Beenen
come data are expected to emerge in the near future
as the international REACT-2 trial is set up to answer
the questions raised, studying not only at survival, but
also at quality of life, cost–effectiveness and radiation burden. If immediate TBCT scanning is found
to be the best imaging strategy in severely injured
trauma patients, it could replace conventional imaging
­supplemented with CT in this specific group.
at levels of conventional radiography and, therefore, no
longer a big issue. For the severely injured, CT scanning will move in forefront and become mainstay of
trauma care. Its use as a screening tool could change
the “ABCDE” to “AB CT”.
Financial & competing interests disclosure
Future perspective
In the next 5–10 years, TBCT scanning will be the
standard examination, particularly in patients with
severe trauma, but also in low risk patients. Processing and post-processing techniques will continuously
develop in such a way that radiation exposure will be
The author has no relevant affiliations or financial involvement
with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed
in the manuscript. This includes employment, consultancies,
honoraria, stock ownership or options, expert testimony,
grants or patents received or pending, or royalties.
No writing assistance was utilized in the production of this
manuscript.
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