Impact on survival of whole-body computed tomography before emergency bleeding control in patients with severe blunt trauma

Abstract

IntroductionWhole-body computed tomography (CT) has gained importance in the early diagnostic phase of trauma care. However, the diagnostic value of CT for seriously injured patients is not thoroughly clarified. This study assessed whether preoperative CT beneficially affected survival of patients with blunt trauma who required emergency bleeding control.MethodsThis retrospective study was conducted from January 2004 to December 2010 in two tertiary trauma centers in Japan. The primary inclusion criterion was patients with blunt trauma who required emergency bleeding control (surgery or transcatheter arterial embolization). CT before emergency bleeding control was performed at the attending physician's discretion based on individual patient condition (for example, hemodynamic stability or certain abnormalities in the primary survey). We assessed covariates associated with 28-day mortality with multivariate logistic regression analysis and evaluated standardized mortality ratio (SMR, ratio of observed to predicted mortality by Trauma and Injury Severity Score (TRISS) method) in two subgroups of patients who did or did not undergo CT.ResultsThe inclusion criterion was fulfilled by 152 patients with a median Injury Severity Score of 35.3. During the early resuscitation phase, 132 (87%) patients underwent CT and 20 (13%) did not. Severity of injury was significantly higher in the non-CT versus CT group patients. Observed mortality rate was significantly lower in the CT versus non-CT group (18% vs. 80%, P <0.001). Multivariate adjustment for the probability of survival (Ps) by TRISS method confirmed CT as an independent predictor for 28-day mortality (adjusted OR, 7.22; 95% CI, 1.76 to 29.60; P = 0.006). In the subgroup with less severe trauma (TRISS Ps ≥50%), SMR in the CT group was 0.63 (95% CI, 0.23 to 1.03; P = 0.066), indicating no significant difference between observed and predicted mortality in the CT group. In contrast, in the subgroup with more severe trauma (TRISS Ps <50%), SMR was 0.65 (95% CI, 0.41 to 0.90; P = 0.004) only in the CT group, whereas the difference between observed and predicted mortality was not significant in the non-CT group, suggesting a possible beneficial effect of CT on survival only in trauma patients at high risk of death.ConclusionCT performed before emergency bleeding control might be associated with improved survival, especially in severe trauma patients with TRISS Ps of <50%.

Comparison of whole-body computed tomography vs selective radiological imaging on outcomes in major trauma patients: a meta-analysis

“…Patients in the WBCT group had higher ISS than those in the control group in five studies [19]-[21],[40],[41]. On the contrary, in the study by Wada et al [23], patients in the NWBCT group had higher ISS than those in the WBCT group. In the study of Hutter et al [21], 831 patients were included after the introduction of a CT-scan policy.…”

“…Our results showed that the association between WBCT and lower mortality did not change and the pooled OR was 0.77 (95% CI: 0.63 to 0.94; P  = 0.009) with significant heterogeneity (I 2  = 69%). Similarly, a sensitivity analysis was performed after excluding the study by Wada et al [23], which revealed that WBCT was still significantly associated with lower mortality rate (OR, 0.72, 95% CI: 0.59 to 0.89; P  = 0.002) with significant heterogeneity (I 2  = 75%). Finally, a further sensitivity analysis was performed after simultaneously excluding these two studies.…”

Cumulative radiation dose due to diagnostic investigations in seriously injured trauma patients admitted to critical care

“…Data from retrospective studies suggest that full body trauma CT scanning is associated with a reduction in missed injuries and overall mortality. 3,4,20 The REACT-2 study is currently examining this premise by determining whether immediate total-body CT scanning during the primary survey in trauma patients compared with conventional imaging supplemented with CT scanning reduces mortality. 12 Until the results of this study are published, whole-body CT scanning is likely to continue which means that radiation dose reduction strategies in critical care patients will have to focus on imaging undertaken after discharge from the ED.…”

“…2 The use of whole-body CT scans (from occiput to sacrum) in the early resuscitation period of trauma patients, has been shown to increase the probability of survival in some retrospective studies 3,4 but evidence of definitive improvements in clinical outcomes is lacking at the present time. 5 Causal links between ionising radiation and carcinogenesis became apparent from the lifespan study of Japanese atomic bombs survivors, with the most recent Biological Effects of Ionising Radiation report attributing a 1% risk of carcinogenesis from exposure to 100 mSv of ionising radiation.…”

Objetivos y nuevas estrategias de resucitación en el paciente traumatizado grave

“…Por tanto, es esencial realizar un diagnóstico y detección precoz de dichas lesiones. A los métodos diagnósticos tradicionales, se han añadido otros, como la Focused Assessment Sonography in Trauma (ECO-FAST), la TAC helicoidal, la angiografía digital, etc., que facilitan, no solo la localización, sino la extensión y el alcance de las lesiones para una mejor aproximación quirúrgica 56 .…”