Do clinical guidelines for whole body computerised tomography in trauma improve diagnostic accuracy and reduce unnecessary investigations? A systematic review and narrative synthesis

Abstract

Introduction: Whole body computerised tomography has become a standard of care for the investigation of major trauma patients. However, its use varies widely, and current clinical guidelines are not universally accepted. We undertook a systematic review of the literature to determine whether clinical guidelines for whole body computerised tomography in trauma increase its diagnostic accuracy. Materials and methods: A systematic review of Medline, Cinhal and the Cochrane database, supplemented by a manual search of relevant papers was undertaken, with narrative synthesis. Studies comparing clinical guidelines to physician gestalt for the use of whole body computerised tomography in adult trauma were included. Results: A total of 887 papers were identified from the electronic databases, and 1 from manual searches. Of these, seven papers fulfilled the inclusion criteria. Two papers compared clinical guidelines with routine practice: one found increased diagnostic accuracy while the other did not. Two papers investigated the performance of established clinical guidelines and demonstrated moderate sensitivity and low specificity. Two papers compared different components of established triage tools in trauma. One paper devised a de novo clinical decision rule, and demonstrated good diagnostic accuracy with the tool. The outcome criteria used to define a 'positive' scan varied widely, making direct comparisons between studies impossible. Conclusions: Current clinical guidelines for whole body computerised tomography in trauma may increase the sensitivity of the investigation, but the evidence to support this is limited. There is a need to standardise the definition of a 'clinically significant' finding on CT to allow better comparison of diagnostic studies.

Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

“…Male and female patients of all ages with suspected blunt multiple trauma presenting to the emergency department and assigned to WBCT according to red flag criteria of the national evidence- and consensus-based best practice guideline for managing patients with severe injuries (Box) were eligible to participate in the study . Indication for WBCT matched international recommendations as summarized in recent systematic reviews . Patients were approached, informed about the study, and asked for consent to participate as soon as allowed by their physical and mental condition.…”

“…21 Indication for WBCT matched international recommendations as summarized in recent systematic reviews. [22][23][24][25][26] Patients were approached, informed about the study, and asked for consent to participate as soon as allowed by their physical and mental condition. Relatives, legal representatives, and patients were informed by physicians or professional clinical trial staff.…”

Clinical guided computer tomography decisions are advocated in potentially severely injured trauma patients: a one-year audit in a level 1 trauma Centre with long pre-hospital times

“…The alternative to immediate SWBCT as a screening for injuries would be a clinical decision tool providing evidence based selection criteria for CT examination strategy decision. Hare et al [70] reviewed the literature to clarify whether such tools improve diagnostic accuracy of whole body CT, and concluded that the evidence to support this is limited. All identified studies were retrospective analyses of predictors for CT findings [32,34,65,71].…”