Is Routine Spiral CT-Chest Justified in Evaluation of the Major Blunt Trauma Patients?

Routine versus selective chest and abdominopelvic CT-scan in conscious blunt trauma patients: a randomized controlled study

PURPOSE

CT-scan is increasingly used in blunt trauma, but the real impact on patient outcome is still unclear. This study was conducted to assess the effect of performing routine (versus selective) chest and abdominopelvic CT-scan on patient admission time and outcome in blunt trauma.

METHODS

Conscious and hemodynamically stable high-energy trauma patients were included (n = 140). Routine chest and abdominopelvic CT-scan was requested in addition to the conventional radiography and ultrasound for the intervention group and selective CT-scan according to clinical presentation was done for the control group. Patient admission times in the emergency room and surgery ward, complications, and performed surgical procedures were assessed. "Unsuspected injuries" defined as additional findings on CT-scan, which were not expected before CT-scan, were evaluated.

RESULTS

Admission time in the emergency ward and admission time in hospital were significantly shorter in the intervention group. Complications were similar in both groups. Abdominopelvic CT-scan in the intervention group revealed nine (7.8%) unsuspected injuries. All of these nine patients had also a positive clinical examination and injuries in other body regions. Chest CT-scan in the intervention group led to additional diagnoses in 17 patients (24.28%) leading to tube thoracostomy in 13 patients (18.57%).

CONCLUSION

Routine chest and abdominopelvic CT-scan in conscious blunt trauma patients decreases the hospitalization time, but has no impact on patient outcome and probably might lead to overtreatment of occult injuries. The option of using a selective approach should be further evaluated to decrease radiation exposure and facility overuse.

Towards evidence-based emergency medicine: best BETs from the Manchester Royal Infirmary. BET: Is CT thorax necessary to exclude significant injury in paediatric patients with blunt chest trauma?

A shortcut review was carried out to establish if CXR had sufficient sensitivity to rule out significant thoracic injury in haemodynamically stable, paediatric patients with a significant mechanism of trauma. No studies were found that directly answered the three-part question, but 13 studies were found which were considered relevant. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that important thoracic injuries may not be clinically apparent and that CT scans have a significantly higher sensitivity than CXR in detecting such injuries.

Routine Chest Computed Tomography and Patient Outcome in Blunt Trauma

Background:

Computerized Tomography (CT) scan is gaining more importance in the initial evaluation of patients with multiple trauma, but its effect on the outcome is still unclear. Until now, no prospective randomized trial has been performed to define the role of routine chest CT in patients with blunt trauma.

Objectives:

In view of the considerable radiation exposure and the high costs of CT scan, the aim of this study was to assess the effects of performing the routine chest CT on the outcome as well as complications in patients with blunt trauma.

Patients and Methods:

After approval by the ethics board committee, 100 hemodynamically stable patients with high-energy blunt trauma were randomly divided into two groups. For group one (control group), only chest X-ray was requested and further diagnostic work-up was performed by the decision of the trauma team. For group two, a chest X-ray was ordered followed by a chest CT, even if the chest X-ray was normal. Injury severity, total hospitalization time, Intensive Care Unit (ICU) admission time, duration of mechanical ventilation and complications were recorded. Data were evaluated using t-test, Man-Whitney and chi-squared test.

Results:

No significant differences were found regarding the demographic data such as age, injury severity and Glasgow Coma Scale (GCS). Thirty-eight percent additional findings were seen in chest CT in 26% of the patients of the group undergoing routine chest CT, leading to 8% change in management. The mean of in-hospital stay showed no significant difference in both groups with a P value of 0.098. In addition, the mean ICU stay and ventilation time revealed no significant differences (P values = 0.102 and 0.576, respectively). Mortality rate and complications were similar in both groups.

Conclusions:

Performing the routine chest CT in high-energy blunt trauma patients (with a mean injury severity of 9), although leading to the diagnosis of some occult injuries, has no impact on the outcome and does not decrease the in-hospital stay and ICU admission time. It seems that performing the routine chest CT in these patients may lead to overtreatment of nonsignificant injuries. The decision about performing routine CT scan in a trauma center should be made cautiously, considering the detriments and benefits.

Prehospital and Early Clinical Care of Infants, Children, and Teenagers Compared to an Adult Cohort : Analysis of 2,961 Children in Comparison to 21,435 Adult Patients from the Trauma Registry of DGU in a 15-Year Period

BACKGROUND

Although the incidence of pediatric patients in emergency services is as low as 5-10%, trauma remains one of the leading causes of death during childhood. Only a few reports exist about the quality of the initial treatment of pediatric trauma patients. Therefore, we tested the hypothesis of whether prehospital treatment and emergency management in pediatric trauma patients is similar to the treatment that is provided for adult patients.

MATERIALS AND METHODS

We performed a retrospective data analysis of the German Trauma Registry of the DGU from January 1993 to December 2007. Exclusion criteria were missing information about injury severity and/or age and patients older than 50 years. All pediatric patients were subdivided into five groups (infants 0-1 year, toddlers 2-5 years, children 6-9 years, pupils 10-13 years, teenagers 14-17 years) with regard to their age and were compared with the adult cohort (18-50 years). From 24,396 patients, 2,961 were below 18 years of age, thus, about 12% of the whole population of injured patients below the age of 50 years.

RESULTS

66.4% of infants sustained relevant head injuries (Abbreviated Injury Scale [AIS] ≥3), and this rate declined with increasing age. The mean Injury Severity Score (ISS) increased from 21.0 (±11.6) in the group of infants to 26.7 (±13.9) in the adult cohort. In all groups, the majority of patients were male. The injury pattern differed according to age, with predominant traumatic brain injury (TBI) in infants. During the preclinical treatment, infants were less often intubated and this was contrasted by a higher rate of cardiopulmonary resuscitation in this group (infants 16.2%, toddlers 6.8%, adults 3.1%). Diagnostic multislice computed tomography (CT) examination was less often performed in infants as compared to the other groups (infants 57.1%, toddlers 77.2%, adults 77.8%). Mortality and quality indicators such as timelines show no significant differences between children and adults.

CONCLUSION

We observed typical age-dependent differences regarding the injury pattern and severity and differences referring to the preclinical and initial treatment. With respect to the high rate of serious TBI in the infants and toddlers age groups, a more focused education and training of emergency physicians and paramedics should be considered.