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Three Part Question

In [blunt trauma patients] is [whole-body CT better than conventional diagnostics] in [reducing mortality]?

Clinical Scenario

36 years old patient was transferred to emergency department following a severe blunt trauma in a road traffic accident. When deciding about initial diagnostic investigation, you wonder which one is associated with better survival: whole-body CT or conventional diagnostics.

Search Strategy

MEDLINE using the OVID interface (1946 to February 2014) : [“whole body” OR “total body” OR “pan-ct”] AND [Mesh terms ”tomography OR X-ray computed” OR ”ct scan”] AND [trauma” OR Mesh terms ”wounds and injuries” OR “polytrauma” OR “multiple trauma”].

PubMed (February 2014) : [“total body” OR “whole body”] AND [ “trauma” OR “polytrauma” OR “multiple trauma”] AND [“ct” OR “computed tomography”] AND [ “mortality” OR “survival”]

Search Outcome

178 articles were found in MEDLINE and 167 articles in PubMed.9 studies were relevant to the study question (Table 1).

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Huber-Wagner S et al 2013 Germany	16719 adult blunt major trauma patients, ISS ≥16	Retrospective cohort study	Mortality rate	17.4% in WBCT group vs 21.4% in Non-WBCT group (P value= significant, 95% CI)	Retrospective, Shows association not causality, Residual confounding effect, Lack of information about CT protocols for participating hospitals.
			RISC-Based SMR	0.85 (0.81–0.89) in WBCT group vs 0.98 (0.94–1.02) in non-WBCT group
Huber-Wagner S et al 2009 Germany	4621 blunt trauma patients, ISS ≥16	Retrospective cohort study	Mortality rate	21% in WBCT group vs 22% in Non-WBCT group (P value= Not significant, 95% CI)	Retrospective, Shows association not causality, Residual confounding effect, Lack of information about CT protocols for participating hospitals.
			TRISS –Based SMR	0.745 (0.633–0.859) in WBCT group vs 1.023 (0.909–1.137) in Non-WBCT group
			RISC –Based SMR	0.865 (0.774–0.956) in WBCT group vs 1.034 (0.959–1.109) in Non-WBCT group
Yeguiayan JM et al 2012 France	1950 adult severe blunt trauma patients ICU treatment	Prospective cohort study	Mortality rate	16% in WBCT group vs 22% in Non-WBCT group (P value= significant, 95% CI)	Shows association not causality ,Residual confounding effect ,Lack of information about CT protocols for participating hospitals.
Wada D et al 2013 Japan	152 blunt trauma patients who required emergency bleeding control	Retrospective cohort study	Moratilty rate	18.1% in WBCT group vs 80% in Non-WBCT group (P value= significant, 95% CI)	Retrospective, Shows association not causality, Small sample size in non-WBCT group, Different baseline characteristics between two groups, Residual confounding effect, Lack of pre-defined CT protocol
			TRISS –Based SMR	0.65 (0.41- 0.9) in WBCT group vs 1.15 (0.98-1.31) in Non-WBCT group
Kimura A et al 2013 Japan	5208 blunt trauma patients, Systolic blood pressure >75 mmHg, GCS of 3-12	Retrospective cohort study	Mortality rate	24% in WBCT group vs 28% in Non-WBCT group (P value= significant, 95% CI)	Retrospective, Shows association not causality, Residual confounding effect, Lack of information about CT protocols in participating hospitals
			TRISS–Based SMR	0.83 (0.75-0.91) in WBCT group vs 0.97 (0.91-1.03) in Non-WBCT group
Hutter M et al 2011 Germany	313 blunt major trauma patients	Retrospective cohort study	Mortality rate	8% in WBCT group vs 23% in Non-WBCT group (P value= significant, 95% CI)	Retrospective, Shows association not causality, Limited sample size, Residual confounding effect
Weninger P et al 2007 Austria	370 blunt major trauma patients	Retrospective cohort study	Mortality rate	17% in WBCT group vs 16% in Non-WBCT group (P value= Not significant, 95% CI)	Retrospective, Shows association not causality, Limited sample size, Residual confounding effect
Wurmb TE et al 2010 Germany	318 blunt and penetrating trauma patients	Retrospective cohort study	Mortality rate	8.6% in WBCT group vs 9.0% in Non-WBCT group (P value= Not significant, 95% CI)	Retrospective, Shows association not causality, Limited sample size, Residual confounding effect
Kanz KG et al 2010 Germany	4817 major trauma patients, ISS ≥16 or ICU treatment	Retrospective cohort study	Mortality rate	18.8% in WBCT group vs 22.0% in Non-WBCT group (P value= Not significant, 95% CI)	Retrospective, Shows association not causality, Residual confounding effect, Lack of information about CT protocols in participating hospitals
			TRISS–Based SMR	0.74 (0.40-1.08) in WBCT group vs 0.92 (0.84-1.01) in Non-WBCT group
			RISC-Based SMR	0.69 (0.47-0.92) in WBCT group vs 0.995 (0.94-1.06) in Non-WBCT group

Comment(s)

Based on the available evidences, it can be argued that use of Whole-body CT (WBCT) in trauma patients is associated with better survival outcomes compared to conventional diagnostics. However, most of the available evidences are from retrospective studies with varying quality and there has been only one prospective study. There is a need for high quality randomised controlled trials with (24-h or in-hospital) mortality as outcome of interest to provide more robust evidences about use of WBCT in trauma patients and to describe a causal relationship between WBCT and mortality in trauma patients.

Editor Comment

KMJ

Clinical Bottom Line

Based on available best evidences, use of whole-body CT in management of blunt trauma patients appears to be associated with better survival compared to conventional diagnostics.

References

1. Huber-Wagner S, Biberthaler P, Häberle S, Wierer M, Dobritz M, Rummeny E, et al. Whole-body CT in haemodynamically unstable severely injured patients--a retrospective, multicentre study. PLoS One 2013 Jul 24;8(7):e68880
2. Huber-Wagner S, Lefering R, Qvick LM, Korner M, Kay MV, Pfeifer KJ. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009 Apr;25373(9673):1455-61.
3. Yeguiayan JM, Yap A, Freysz M, Garrigue D, Jacquot C, Martin C et al Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma Crit Care 2012 Jun 11;16(3):R101
4. Wada D, Nakamori Y, Yamakawa K, Yoshikawa Y, Kiguchi T, Ogura H, et al Impact on survival of whole-body computed tomography before emergency bleeding control in patients with severe blunt trauma Crit Care 2013 Aug 27;17(4):R178
5. Kimura A, Tanaka N Whole-body computed tomography is associated with decreased mortality in blunt trauma patients with moderate-to-severe consciousness disturbance: a multicenter, retrospective study. J Trauma Acute Care Surg. 2013 Aug;75(2):202-6.
6. Hutter M, Woltmann A, Hierholzer C, Gartner C,Buhren V, Stengel D. Association between a single-pass whole-body computed tomography policy and survival after blunt major trauma: a retrospective cohort study. Scand J Trauma Resusc Emerg Med 2011 Dec 9;19:73.
7. Weninger P, MauritzW, Fridrich P, Spitaler R, Figl M, Kern B, et al. Emergency room management of patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified by an urban trauma center. J Trauma. 2007 Mar;62(3):584-91.
8. Wurmb T E, Quaisser C, Balling H, Kredel M, Muellenbach R, Kenn W, et al. Whole-body multislice computed tomography (MSCT) improves trauma care in patients requiring surgery after multiple trauma. Emerg Med J. 2011 Apr;28(4):300-4.
9. Kanz KG, Paul AO, Lefering R, Kay MV, Kreimeier U, Linsenmaier U, et al. Trauma management incorporating focused assessment with computed tomography in trauma (FACTT) - potential effect on survival J Trauma Manag Outcomes. 2010 May 10;4:4