Whole Body CT for Severe Trauma Might Not Offer Survival Advantage

Authors: Wurmb TE and Bernhard M., Lancet 2016 Jun 28;

There were no major outcome differences between patients randomized to immediate, whole-body computed tomography and those who underwent targeted imaging.

Retrospective studies in European cohorts have raised the possibility that immediate, whole-body computed tomography (CT) can decrease mortality for patients with severe trauma (NEJM JW Emerg Med May 2009 and Lancet 2009 Mar 24; [e-pub]). These authors randomized 1403 Dutch and Swiss patients with severe trauma to immediate whole-body CT (non-contrast exam of head and neck, followed by split-bolus, contrast-enhanced CT of the chest, abdomen, and pelvis) or standard imaging (focused assessment with sonography in trauma [FAST] exam plus plain films of the chest and pelvis, followed by targeted CT at the discretion of the trauma team, which included trauma surgeons but no emergency physicians).

Among 1083 patients included in the primary analysis, there was no statistically significant difference between groups in the main outcome measure of in-hospital mortality (16% for both groups). There were small differences in secondary outcomes, such as median time in the trauma room (63 minutes for whole-body CT vs. 72 minutes for standard imaging) and median radiation exposure (20.9 mSv vs. 20.6 mSv, respectively).

Comment Even in this carefully conducted trial, there was substantial creep in the practice of whole-body CT. Investigators mistakenly enrolled more than 100 patients with less severe trauma who were subsequently excluded, and 46% of “standard imaging” patients ended up getting the equivalent of a whole-body CT. If whole-body CT is beneficial to anyone, it is the severely traumatized patient at high risk of death. Use your clinical assessment, know the evidence, and resist the urge to “just pan-scan” everyone.