Structured approach with primary and secondary survey for major trauma care: an overview of reviews (original) (raw)
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Emergency radiology, 2024
Trauma is a significant cause of mortality and morbidity. It is crucial to diagnose trauma patients quickly to provide effective treatment interventions in such conditions. Whole-body computed tomography (WBCT)/pan-scan is an imaging technique that enables a faster and more efficient diagnosis for polytrauma patients. The purpose of this systematic review and metaanalysis is to evaluate the efficacy of WBCT in diagnosing injuries in polytrauma patients. We will also assess its impact on the mortality rate and length of hospital stay among trauma centers between patients who underwent WBCT and those who did not (non-WBCT). Twenty-seven studies meeting our inclusion criteria were selected among PubMed, Scopus, Web of Science, and Google Scholar. The criteria were centered on the significance of WBCT/pan-scan application in trauma patients. Stata version 15 was used to perform statistical analysis on the data. The authors have also used I 2 statistics to evaluate heterogeneity. Egger and Begg's tests were performed to rule out any publication bias. Total of twenty-seven studies including 68,838 trauma patients with a mean age of 45.0 ± 24.7 years were selected. Motor vehicle collisions were the most common cause of blunt injuries (80.0%). Head, neck, and face injuries were diagnosed in 44% (95% CI, 0.28-0.60; I 2 = 99.8%), 6% (95% CI, 0.02-0.09; I 2 = 97.2%), and 9% (95% CI, 0.05-0.13; I 2 = 97.1%), respectively. Chest injuries were diagnosed by WBCT in 39% (95% CI, 0.28-0.51; I 2 = 99.8%), abdominal injuries in 23% (95% CI, 0.03-0.43; I 2 = 99.9%) of cases, spinal injuries 19% (95% CI, 0.11-0.27; I 2 = 99.4%), extremity injuries 33% (95% CI, 0.23-0.43; I 2 = 99.2%), and pelvic injuries 11% (95% CI, 0.04-0.18; I 2 = 97.4%). A mortality odd ratio of 0.94 (95% CI, 0.83-1.06; I 2 = 40.1%) was calculated while comparing WBCT and non-WBCT groups. This systematic review and meta-analysis provide insight into the possible safety, efficacy, and efficiency of WBCT/pan-scan as a diagnostic tool for trauma patients with serious injuries, regardless of their hemodynamic status. In patients with serious injuries from trauma, whether or not there are indicators of hemodynamic instability, our recommended approach is to, wherever possible, perform a WBCT without stopping the hemostatic resuscitation. By using this technology, the optimal surgical strategy for these patients can be decided upon without causing any delays in their final care or greatly raising their radiation dose.
Injury, 2017
Traumatic injury is the third leading cause of death overall. To optimize the outcomes in these patients, hospitals employ whole-body computed tomography (WBCT) imaging due to the high diagnostic yield and potential to identify missed injuries. However, this delays time-critical interventions. Currently, there is an absence of any high-level evidence to support or refute either view. We present a meta-analysis of the available literature to elucidate the efficacy of WBCT in improving the outcomes of trauma, specifically the mortality rate. A systematic review of studies comparing WBCT and selective CT imaging in secondary survey was conducted, using MEDLINE, EMBASE, the Cochrane Review and Scopus databases. The articles were evaluated for intervention using WBCT to reduce mortality rate, followed by subgroup analysis for other secondary measures, using Review Manager 5.3 software. Eleven studies of 32,207 patients were included. There were lower overall (OR=0.79; 95% CI 0.74,0.83, p...
Lancet (London, England), 2016
Published work suggests a survival benefit for patients with trauma who undergo total-body CT scanning during the initial trauma assessment; however, level 1 evidence is absent. We aimed to assess the effect of total-body CT scanning compared with the standard work-up on in-hospital mortality in patients with trauma. We undertook an international, multicentre, randomised controlled trial at four hospitals in the Netherlands and one in Switzerland. Patients aged 18 years or older with trauma with compromised vital parameters, clinical suspicion of life-threatening injuries, or severe injury were randomly assigned (1:1) by ALEA randomisation to immediate total-body CT scanning or to a standard work-up with conventional imaging supplemented with selective CT scanning. Neither doctors nor patients were masked to treatment allocation. The primary endpoint was in-hospital mortality, analysed in the intention-to-treat population and in subgroups of patients with polytrauma and those with t...
BMC Emergency Medicine, 2012
Background: Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients. Methods/design: The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, nonpregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness.
Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine
Background The International Commission on Radiological Protection’s (ICRP) justification principles state that an examination is justified if the potential benefit outweighs the risk for radiation harm. Computer tomography (CT) contributes 50% of the radiation dose from medical imaging, and in trauma patients, the use of standardized whole body CT (SWBCT) increases. Guidelines are lacking, and reviews conclude conflictingly regarding the benefit. We aimed to study the degree of adherence to ICRP’s level three justification, the individual dose limitation principle, in our institution. Methods This is a retrospective clinical audit. We included all 144 patients admitted with trauma team activation to our regional Level 1 trauma centre in 2015. Injuries were categorized according to the Abbreviated Injury Scale (AIS) codes. Time variables, vital parameters and interventions were registered. We categorized patients into trauma admission SWBCT, selective CT or no CT examination strateg...
Panamerican Journal of Trauma, Critical Care & Emergency Surgery, 2015
Background There is an important increase in the use of whole body computed tomography (WBCT) around the world although its benefits are still controversial. We hypothesized that the use of a WBCT protocol in the major trauma patients based on mechanism of injury alone would reduce the number of injuries that would have been missed if CT was only done based on clinical findings. Study design A prospective observational study with the inclusion of 144 patients with major blunt trauma during 5 months at our academic center. Data were collected from all patients including: epidemiology, clinical status on scene and at the emergency department, time of the scan (including patient handling), clinical findings during initial assessment and WBCT scan findings, dividing exams in with or without findings (normal). Looking for findings that would go unnoticed if CT was done based on clinical findings. Glasgow coma scale (GCS) 15 and GCS <15 were compared and data are presented as absolute ...
Emergency medicine journal : EMJ, 2017
Whole-body CT (WBCT) use in patients with trauma in England and Wales is not well documented. WBCT in trauma can reduce time to definitive care, thereby increasing survival. However, its use varies significantly worldwide. We performed a retrospective observational study of Trauma Audit and Research Network (TARN) data from 2012 to 2014. The proportion of adult patients receiving WBCT during initial resuscitation at major trauma centres (MTCs) and trauma units/non-designated hospitals (TUs/NDHs) was compared. A model was developed that included factors associated with WBCT use, and centre effects within the model were explored to determine variation in usage beyond that expected from the model. Of the 115 664 study participants, 16.5% had WBCT. WBCT was performed five times more frequently in MTCs than in TUs/NDHs (31% vs 6.6%). In the multivariate model, increased injury severity, low GCS, shock, comorbidities and triage category increased the chances of having a WBCT, but there wa...
BMJ open, 2018
Quality improvement (QI) is mandatory in trauma centres but there is no prescription for doing successful QI. Considerable variation in implementation strategies and inconsistent use of evidence-based protocols therefore exist across centres. The quality of reporting on these strategies may limit the transferability of successful initiatives across centres. This systematic review will assess the quality of reporting on guideline, protocol or algorithm implementation within a trauma centre in terms of the Revised Standards for Quality Improvement Reporting Excellence (SQUIRE 2.0). We will search for English language articles published after 2010 in EMBASE, MEDLINE, CINAHL electronic databases and the Cochrane Central Register of Controlled Trials. The database search will be supplemented by searching trial registries and grey literature online. Included studies will evaluate the effectiveness of guideline implementation in terms of change in clinical practice or improvement in patien...
European Journal of Emergency Medicine, 2012
We sought to identify the impact of whole-body computed tomography (WBCT) on working and suspected diagnoses in Emergency Department (ED) trauma patients and to determine the rate of WBCT scans with no detectable traumatic injuries. We performed a retrospective database analysis of all trauma patients who underwent WBCT in 2009, comparing pretest suspicion of specific injury to WBCT findings, looking for the rates of unexpected findings and the absence of traumatic injury in WBCT studies. Our results showed that of the 179 patients who underwent WBCT, no traumatic injury reported in 17 patients while 162 patients demonstrated pathology (47 confirming previously suspected or diagnosed injury and 115 with previously unexpected injury). Overall, WBCT results differed from clinical findings in 130 (72.6%) patients, a statistically significant difference (P < 0.0001). In conclusion, WBCT identifies previously unexpected injuries in almost 66% of ED trauma patients, supporting its continued use in the initial assessment of trauma patients.