Justification of whole-body CT in polytrauma patients, can clinical examination help selecting patients?

BACKGROUND

Whole-body computed tomography (WBCT) is used indiscriminately in trauma cases, just on the suspicion of them being polytrauma cases. A good clinical examination done pre-emptively could prevent the need for this investigation and its undesirous effects. We did this study with an overall aim to assess, if WBCT can be limited to subgroup of trauma patients without compromising clinical safety.

METHODS

Retrospective database analysis of 150 cases of polytrauma who underwent WBCT in 2017 was performed. We recorded age, gender, radiation dose and CT findings in all cases and calculated mean age, number of total patients and female patients less than 25 years of age, number of normal WBCT scans, mean radiation dose in the normal and total scans. We also compared pre-test clinical requests with whole-body CT findings, and categorised them in following seven categories: Category 1-Normal Scans; Category 2-Clinically expected Major Injuries; Category 3-Clinically expected Minor Injuries (low risk injuries with no risk of morbidity or mortality if remained undiagnosed), Category 4-Clinically expected CT findings with unexpected Minor (non-serious) injuries; Category 5-Clinically expected CT findings with unexpected Major (serious) injuries, Category 6-Unexpected Minor (non-serious) injuries; Category 7-Unexpected Major (serious) injuries. Categories 2 &3 of clinically expected major and minor injuries included patients with fewer injuries than expected. On the other hand, Category 4 & 5 consist of clinically expected findings with other unexpected injuries, including minor and major injuries respectively. Body injuries were reported in seven areas as per our institutional reporting protocol- Head (including face), Cervical Spine, Thoracolumbar Spine, Chest, Abdomen, Pelvis and Appendicular Skeleton (if asked for).

RESULTS

Overall, we found statistically significant correlation between clinical suspicion raised and WBCT findings with good clinical correlation noticed in 106 (70.66%) cases (including 61 cases of clinically suspected major injuries, 15 cases of clinically suspected minor injuries and 25 nearly normal scans with no obvious clinical concern). Isolated unexpected serious injury without any clinical suspicion was seen in only 1 case. Surprisingly, 25 scan requests were made due to high risk mechanism of injury with no obvious clinical concern and were found normal in 20 cases and showed very subtle injuries in 5. Notably, 30 cases of expected major and minor injuries showed highly accurate clinical findings with no injury other than the region of concern and in these cases, limited scan requests would have been sufficient. Mean radiation dose of the entire study group was 22.45 mSv and those to normal patients was 21.19 mSv.

CONCLUSIONS

This study re-emphasizes the significance of good clinical examination in the era of evidence based medicine, which would reduce the high number of unnecessary high dose WBCT (25 scans with no positive findings on clinical examination were nearly normal and in 30 cases limited CT would have been sufficient), thereby, decreasing radiation exposure and its potential side effects on polytrauma patients without affecting their survival.