Accepted Manuscript

Whole body computed tomography versus selective radiological

imaging strategy in trauma: An evidence-based clinical review

Brit Long, Michael D. April, Shane Summers, Alex Koyfman

PII: S0735-6757(17)30215-2
DOI: doi: 10.1016/j.ajem.2017.03.048
Reference: YAJEM 56566
To appear in:
Received date: 23 February 2017
Revised date: 19 March 2017
Accepted date: 21 March 2017

Please cite this article as: Brit Long, Michael D. April, Shane Summers, Alex Koyfman
, Whole body computed tomography versus selective radiological imaging strategy in
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Title: Whole Body Computed Tomography Versus Selective Radiological Imaging

Strategy in Trauma: An Evidence-Based Clinical Review

Authors:

Brit Long, MD1

1
San Antonio Military Medical Center
Department of Emergency Medicine
3841 Roger Brooke Dr, Fort Sam Houston, TX, United States, 78234
Email: brit.long@yahoo.com

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Michael D. April, MD, DPhil, MSc2
2
San Antonio Military Medical Center

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Department of Emergency Medicine
3841 Roger Brooke Dr, Fort Sam Houston, TX, United States, 78234
Email: Michael.D.April@post.harvard.edu

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Shane Summers, MD FACEP3
Maj (P) USA MC
3
Residency Director, Emergency Medicine, SAUSHEC Associate Professor of
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Emergency Medicine, USUHS
Email: shanesummers1@gmail.com
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Alex Koyfman, MD4

4
The University of Texas Southwestern Medical Center
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Department of Emergency Medicine

5323 Harry Hines Boulevard, Dallas, TX, United States, 75390
Email: akoyfman8@gmail.com
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Corresponding Author:
Brit Long, MD
Present Address:
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3841 Roger Brooke Dr

Fort Sam Houston, TX 78234
Email: brit.long@yahoo.com
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Keywords: trauma, imaging, computed tomography, pan scan, whole-body computed

tomography

Conflicts of Interest: NONE

Acknowledgements: This manuscript did not utilize any grants, and it has not been
presented in abstract form. This clinical review has not been published, it is not under
consideration for publication elsewhere, its publication is approved by all authors and
tacitly or explicitly by the responsible authorities where the work was carried out, and
that, if accepted, it will not be published elsewhere in the same form, in English or in any
 ACCEPTED MANUSCRIPT

other language, including electronically without the written consent of the copyright-
holder. This review does not reflect the views or opinions of the U.S. government,
Department of Defense, U.S. Army, U.S. Air Force, or SAUSHEC EM Residency
Program.

Author Involvement:
BL, MDA, SS, and AK conceived the idea for this review. BL, MDA, SS, and AK
contributed significant content and editing. Figure design was completed by MDA. BL
produced the tables for the manuscript.

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Whole Body Computed Tomography Versus Selective Radiological Imaging

Strategy in Trauma: An Evidence-Based Clinical Review

1. ABSTRACT

1.1 Background: Trauma patients often present with injuries requiring resuscitation and

further evaluation. Many providers advocate for whole body computed tomography

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(WBCT) for rapid and comprehensive diagnosis of life-threatening injuries.

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1.2 Objective: Evaluate the literature concerning mortality effect, emergency department

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(ED) length of stay, radiation, and incidental findings associated with WBCT.

1.3 Discussion: Physicians have historically relied upon history and physical

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examination to diagnose life-threatening injuries in trauma. Diagnostic imaging
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modalities including radiographs, ultrasound, and computed tomography have

demonstrated utility in injury detection. Many centers routinely utilize WBCT based on
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the premise this test will improve mortality. However, WBCT may increase radiation and
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incidental findings when used without considering pre-test probability of actionable

traumatic injuries. Studies supporting WBCT are predominantly retrospective and

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incorporate trauma scoring systems, which have significant design weaknesses. The
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recent REACT-2 trial randomized trauma patients with high index of suspicion for

actionable injuries to WBCT versus selective imaging and found no mortality difference.
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Additional prospective trials evaluating WBCT in specific trauma subgroups (e.g.

polytrauma) are needed to evaluate benefit. In the interim, the available data suggests

clinicians should adopt a selective imaging strategy driven by history and physical

examination.
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1.4 Conclusions: While observational data suggests an association between WBCT and a

benefit in mortality and ED length of stay, randomized controlled data suggests no

mortality benefit to this diagnostic tool. The literature would benefit from confirmatory

studies of the use of WBCT in trauma sub-groups to clarify its impact on mortality for

patients with specific injury patterns.

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Keywords: trauma, imaging, computed tomography, pan scan, whole-body computed

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tomography

2. INTRODUCTION
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Trauma is the number one cause of death in patients under 45 years and accounts for 10%

of global mortality.in both high and low income countries.1-5 In addition, the economic
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impact is severe due to the predominance of working age patients within this group.3-5
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Trauma patients regularly present to the emergency department (ED) with multisystem

injuries that may require lifesaving interventions. Initial assessment of these patients is
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often highly protocol driven, as rapid identification of imminent life threats is paramount
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before systematically evaluating for other injuries.6 Such protocols often include

ultrasonography, plain film radiography, and laboratory testing which may take
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precedence over a thorough history and physical examination. Conventional initial

imaging strategies include plain radiography of the chest and pelvis along with Focused

Assessment with Sonography for Trauma (FAST).6-8 Although these tests can be

performed rapidly at the bedside and are relatively low cost, they have significant

limitations in terms of diagnostic accuracy. For example, plain radiography of the chest
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is poorly sensitive for pneumothorax and may miss other significant thoracic injuries.8-14

Furthermore, the sensitivity of pelvic radiography for fracture detection ranges from 50-

70%.11-13 FAST examination is poorly sensitive for solid organ injury and may miss

hemoperitoneum 6-8

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Given these limitations, providers frequently rely upon more advanced imaging

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modalities to rule out life-threatening injuries in trauma patients. Computed tomography

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(CT) is one such advanced imaging modality that provides a highly sensitive and rapid

test for detecting injuries.6,15-19 As one example, CT will reveal more extensive injuries in

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over 8% of patients with a completely normal chest radiograph; however, the clinical
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utility of detecting these injuries is unclear as these additional findings change

management in less than 10% of these patients.15-19 Nevertheless, use of advanced

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imaging in trauma patients has drastically increased over the last decade since the
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integration of multi-detector CT imaging into trauma evaluation and management.20

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Whole-body CT scanning (WBCT), or “pan scan”, is commonly used in trauma centers

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as a single-pass primary assessment for traumatic injuries. This diagnostic study became

technically feasible after the introduction of multi-detector CT with its speed, diagnostic
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accuracy, and feasibility.16-18,21-36 Although the specific imaging protocol varies across

institutions, WBCT usually entails CT of the head and cervical spine without contrast

combined with contrasted CT of the chest, abdomen, and pelvis.35-42 Radiation for WBCT

can approach over 20 mSv based on the CT utilized.42-46 The alternative to WBCT is

selective imaging based on the history of injury, mechanism, examination, and other
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evaluation results including radiographs, ultrasound, and laboratory assessment.16,27-35

This imaging modality is potentially indispensable in critically ill trauma patients in

whom clinical history and examination is not possible or reliable. However, physicians

are increasingly relying upon this imaging modality in patients for whom history and

physical examination might facilitate a more selective imaging approach. What does the

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literature tell us about the differences in patient outcomes using these two modalities?

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This review will begin with an overview of the risks and benefits of WBCT, followed by

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an evaluation of the observational data related to this question. Finally, the review will

conclude with a discussion of the single RCT on the point: the REACT-2 Trial.35

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3. DISCUSSION

Supporters of WBCT argue this strategy provides more rapid diagnosis and earlier
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treatment, improves outcomes, and shortens ED and hospital stays, while leading to
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fewer missed injuries. However, this imaging modality is not without cost as it can delay

critical interventions, may increase radiation exposure, and may increase costs.16,27-36
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Proponents of WBCT argue this strategy is associated with decreased mortality,

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decreased time to diagnosis, decreased time to treatment, and decreased length of stay.

However, those who support a selective imaging strategy state WBCT may increase
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radiation exposure, increase the incidence of incidental findings, increase patient testing,

and increase patient anxiety over these incidental findings.16,27-36 We will begin our

discussion by exploring further some of these potential harms of WBCT and then discuss

the evidence base for its potential benefits.

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3.1 WBCT Potential Harms

3.1.1 Radiation Exposure

A major potential disadvantage to WBCT imaging is increased radiation exposure. While

the association between radiation exposure and malignancy risk is generally accepted, the

specific nature of that relationship remains unclear. Most studies accept the linear no-

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threshold model of ionization; this model assumes that any radiation exposure increases

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cancer risk in a linear fashion.47 This model is an extrapolation of cancer data and

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radiation exposure estimates in over 120,000 atomic bomb survivors as part of the Life

Span Study.48 The strength of this association is variable across studies, all of which may

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make different assumptions and calculations regarding timeline of exposure, age of
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patient (pediatric patients display increased risk), type of CT performed, and technology

utilized.43-49 Indeed, studies estimating the numbers of WBCT scans required to result in
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one lethal cancer range from 32245 to 1,250 WBCTs.46-51 Regardless, studies demonstrate
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that WBCT results in a significantly higher radiation dose than individual scans (Table

1).46-52 To the extent that one accepts the linear no-threshold model, this translates to a
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significant increase in malignancy risk. This is an important consequence of this imaging

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modality about which emergency physicians must be cognizant.

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Table 151,52
Examination Average Effective Dose (mSv)
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WBCT 24
Brain 1.8
CTA brain 2.5
Sinuses 0.6
Cervical spine 3
CTA carotids 4.4
Chest 5.1
CTA chest 2.4
Thoracic spine 12
Abdomen 11

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Kidney 11

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Lumbar spine 12
Pelvis (dedicated) 4.5

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3.1.2 Incidental Findings

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Another significant consequence of WBCT is an increase in incidental radiographic

findings of unclear clinical importance.51-61 The total proportion of trauma patients with
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incidental findings ranges from 34-45% in trauma patients receiving selective CT

imaging, versus 53% in patients undergoing WBCT.53-57 The proportion of these findings
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requiring additional diagnostic work-up is similarly variable, ranging from 48-68%.54-58

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Unfortunately, these studies generally do not describe any clinical outcomes or clarify

what proportion of findings yielded actionable pathology.53-61 Consequently, it is

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difficult to know how many of these findings were tantamount to over-diagnosis resulting
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in increased cost, patient anxiety, and further radiation exposure due to additional

required workup.59-61
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Though WBCT has the potential to identify injuries not discovered on history and

physical examination, the question of whether injuries found on this scanning are

clinically important and actionable is important. Rizzo et al. in 1995 enrolled 1,609

patients with 2,047 scans.61 Approximately 38% of scans demonstrated injury, but 6% of
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these were falsely positive. Close to 29% of these scans affected patient management,

and authors state that 11% of scans were unnecessary, as the injuries discovered were

apparent by other means (examination, radiographs).61 Investigators concluded that heavy

reliance on CT in excess may increase wait times, radiation exposure, and costs with little

benefit. However, they state under-utilization could result in missed, dangerous injuries.

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Responsible and focused imaging is necessary through history, physical examination, and

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consideration of injury mechanism.57-61

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3.2 WBCT Potential Benefits: Observational Data

3.2.1 Trauma Scoring Systems

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We turn now to the observational data relating to the potential benefits of WBCT. The

primary analyses for many of these studies are not comparisons of mortality between
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patients undergoing WBCT versus selective imaging. Instead, these studies commonly
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compare differences between measured mortality and mortality as predicted by trauma

scores. 62-68 Understanding these scoring systems is a pre-requisite to understanding this

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observational literature. Of note, these systems were created before the use of
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multidetector CT scanners were available.

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There are multiple scales in use, all of which utilize different components including

physiologic and anatomic variables. One of the most common is the Trauma and Injury

Severity Score (TRISS), comprised of the Revised Trauma Score (RTS) and the Injury

Severity Score (ISS).62-68 This system incorporates physiologic variables, anatomic

injuries, and age. The Revised Trauma Score (RTS) measures physiologic variables, and
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the Injury Severity Score (ISS) evaluates anatomic injuries.62-68 Many WBCT studies use

the ISS, which will be the primary score reviewed. The ISS divides the body into 6

regions, ranks the severity of each injury on a 6-point scale, and then scores from the 3

regions with the highest scores are squared and added. Points range from 0 to 72 on the

ISS, and the score was originally proposed in 1971 for automotive injuries. However,

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ISS relies on anatomical injuries, creating a conundrum.62-68 Patients undergoing WBCT

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will display more anatomic injuries, whether the patient is symptomatic or not. Simply by

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undergoing WBCT, the patient has greater injury severity based on the ISS. 35,69-73 Figure

1 is a graphic representation demonstrating trauma score relationship with bias, true

effects, and confounding.

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Figure 1 – Trauma Score Predicted Mortality Interactions
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Several studies have evaluated use of these scoring systems, primarily ISS, in trauma

patients. Gupta et al. performed a post hoc analysis of data from a study of 701 study
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subjects undergoing WBCT in whom physicians indicated which component scans they
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did not desire.69,70 Of the scans undesired by either the Emergency Physician or Trauma

Surgeon, there were findings of non-critical injuries (defined a priori as not requiring a
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critical action) in 92 patients. The median ISS in these patients with the WBCT result

was 10. When excluding the anatomic information provided by the undesired scans

which did not require any critical actions, the median ISS in these patients decreased to 5

(50% reduction).69,70 These studies nicely demonstrate the bias inherent in measuring

WBCT effectiveness as a proportional reduction in mortality as predicted by ISS.

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Whereas many studies attribute the gap in ISS-predicted versus actual mortality to

therapeutic advantage extending from a WBCT diagnostic strategy, in fact much or all of

this gap may merely reflect an artificial elevation in the ISS-predicted mortality.

3.2.2 WBCT Effect on Mortality

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The central question for the management of trauma patients is whether WBCT improves

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mortality. Several predominantly observational studies report associations between

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WBCT and survival.16,27-34 Salim et al. in 2006 evaluated the utility of WBCT in

evaluable trauma patients.15 They prospectively enrolled 592 trauma patients with a

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significant mechanism of injury (e.g., motor vehicle crash at greater than 35 miles per
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hour) with no visible evidence of external injury, stable vital signs, and who were

clinically evaluable. The authors found WBCT changed management in 18.9% of

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patients.15 However, authors did not utilize a comparator group, and the details of their
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abdominal examination techniques are unclear and may have been limited secondary to

efforts to obtain expeditious imaging given the severe mechanisms of injury. A complete
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history and physical examination may lead to different results, and the absence of a
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comparator group makes it impossible to infer the superiority of WBCT over selective

imaging.
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One of the most prominent studies by Huber-Wagner et al., released in 2009,

retrospectively evaluated 4,621 patients enrolled in a trauma registry over two years, with

comparison of mortality in patients who underwent WBCT versus selective scanning.27

The primary analysis comprised a comparison of mortality as predicted by trauma and

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injury severity scale (TRISS) and the revised injury severity classification (RISC) score.

This study reported that among patients undergoing WBCT, mortality was 25% less than

that predicted by TRISS scores (17.3% actual mortality versus 23.2% predicted

mortality).27 In comparison, patients undergoing select CT imaging had a slightly higher

actual mortality compared to TRISS-predicted mortality (17.5% versus 17.1%). Similar

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analyses based on RISC yielded comparable results.26-28 However, overall mortality was

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similar regardless of diagnostic modality: 21% and 22% in the WBCT and selective

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scanning groups, respectively. As discussed above, the fact that the apparent advantage of

WBCT when utilizing a TRISS-based predicted mortality outcome measure evaporates

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when comparing simple mortality rates suggests that the use of WBCT may artificially
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inflate TRISS.69,70 Figure 1 displays the interaction among mortality, confounders, bias,

and trauma scoring systems. The RISC score is a prognostic score for mortality in
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trauma and incorporates ISS.

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A subsequent retrospective study by Huber-Wagner released in 2013 included 16,719

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patients, with 9,233 receiving WBCT.28 Per this study, patients receiving WBCT
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demonstrate overall lower mortality in the WBCT groups, 17.4%, when compared to the

selective scanning group, 21.4% (p < 0.001).28 This study is more suggestive of a
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mortality benefit associated with WBCT than their earlier study. Nevertheless, the results

are observational and therefore subject to confounding and bias. In particular, some have

noted concerns regarding “time immortal” bias: because the authors excluded patients

who died within 30 minutes of imaging completion, patients surviving the lengthier

WBCT are arguably a healthier cohort than patients surviving more abbreviated selective
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CT imaging protocols.69-73 Moreover, it is possible that WBCT is more likely to be used

at trauma centers which are better manned and equipped to treat trauma patients.

There have been multiple other observational WBCT investigations in trauma.15,16,27-35 A

published meta-analysis sought to collate these observational data to achieve greater

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clarity regarding the impact of WBCT on patient mortality. This study included 7 studies

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with 25,782 patients undergoing CT scans due to trauma.71 Of these patients, 52%

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underwent WBCT, while 48% underwent selective scans. As suggested with other studies,

overall ISS was higher in WBCT patients, though mortality was lower, with a pooled

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odds ratio for mortality 0.75 (95% CI 0.7-0.79) in support of WBCT.71 Time to diagnosis
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and treatment was improved based on results on included studies. Several of the

prospective studies included in the meta-analyses have high risk of bias, as the groups
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undergoing selective scanning versus WBCT had significant differences in baseline

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characteristics, such as the percentage of patients suffering polytrauma. These

weaknesses create difficulties in determining the true outcomes on mortality.71

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Another recent systematic review and meta-analysis published in 2014 included 11

studies with 26,371 patients.73 Unfortunately, many of the included studies demonstrate
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varying quality in terms of the cohort representation, comparability in the study arms

utilized, and outcome. Investigators suggest WBCT decreases mortality (OR 0.66, 95%

CI 0.52-0.85) and ED length of stay (27.58 minute difference, 95% CI 12.12-43.04

min).73 This study finds no effect on hospital or ICU length of stay, though it did find

improved time to diagnosis and ED length of stay. Though these meta-analyses suggest
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mortality benefit, all included studies were observational and non-randomized. Groups

receiving select imaging and WBCT were not well matched in baseline characteristics in

several of the observational studies, including ISS, with few studies matching groups

appropriately.16,27-35,71-73

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Surrendran et al. conducted a systematic review, finding the data too heterogeneous to

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complete a meta-analysis.72 Investigators state the studies included suffer from multiple

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confounders, including on the hospital and patient levels, with many of the same potential

biases which plagued the Huber-Wagner studies (e.g., time immortal bias). Authors of

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this systematic review also raise the concern of bias in many of observational studies of
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WBCT insofar as patients undergoing selective CT may represent a sicker population too

hemodynamically unstable to undergo WBCT. The authors call for prospective,

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randomized studies for outcome clarification.72

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3.3 REACT-2: A Multicenter Randomized Controlled Trial

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As discussed, the prior studies and meta-analyses suggesting improved mortality with
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WBCT are observational and predominantly retrospective in nature. Few prospective

observational studies have evaluated WBCT.31,32,35 Those that exist suffer from design
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flaws in patient selection and analysis and have not met criteria for inclusion into

systematic reviews and meta-analyses, which themselves suffer from inclusion of

retrospective studies with design flaws.71-73

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However, in 2016 Sierink et al. conducted a prospective, multi-center randomized trial on

the point with a modified intention to treat analysis (investigators excluded patients post

randomization if they did not fulfill inclusion/exclusion criteria, declined participation, or

a language barrier was present). Investigators randomized 1,403 patients to either

selective imaging or WBCT in 5 different hospitals, all level 1 trauma centers.35 The

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intervention group included CT from vertex to pubic symphysis without prior

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conventional imaging. The control group consisted of selective scanning, which entailed

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chest and pelvic X-ray with FAST during primary survey, followed by selective CT

scanning. The study utilized a randomization stratification protocol that sought to ensure

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cohorts were equivalent in patient characteristics, treatments, and prior probability of
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survival, with strict inclusion criteria. The study included 1,083 high acuity trauma

patients, with inclusion and exclusion criteria shown in Table 2.

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Table 235
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WBCT Criteria in trauma used in REACT-2

Trauma patients with one of the following: Respiratory rate > 29/min or < 10/min,
pulse > 120/min, SBP < 100mmHg, estimated exterior blood loss > 500 mL, GCS < 13,
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abnormal pupillary reaction on site

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OR
Patients with suspected diagnoses: Fractures from at least two long bones; flail chest,
open chest, or multiple rib fractures; pelvic fracture; unstable vertebral fractures; spinal
cord compression
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OR
Severe mechanism of injury: Fall from height (> 3 meters), ejection from vehicle, death
of occupant in same vehicle, severely injured patient in same vehicle, wedged or trapped
chest/abdomen
Trauma patients not receiving WBCT: Age < 18years, known pregnancy, referred
from another hospital, any patient too unstable to undergo CT and requires resuscitation
or immediate operation
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Investigators found no difference in 24-hr mortality (intervention group 8% versus

control group 6%, p = 0.23), 30-day mortality (intervention group 17% versus control

group 16%, p = 0.69), or all patient mortality (intervention group 15.9% versus control

group 15.7%, p = 0.92). Subgroup analysis of patients with polytrauma did not

demonstrate differences in mortality (44% versus 38%, p = 0.46), or traumatic brain

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injury (44% versus 38%, p = 0.46). REACT-2 also suggests a decreased time to diagnosis

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or treatment of 7 minutes, with 11 minutes among polytrauma patients.35 Though this

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may seem clinically insignificant, 7 minutes comprised 10% of the median time spent in

the trauma room for patients (approximately 69 minutes).35

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Of note, 46% of patients randomized to selective scanning underwent CT scans of all

body regions, essentially comprising a WBCT. Of note, investigators utilized an intention

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to treat analysis, so these patients originally randomized to the selective scanning group
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were analyzed in this group. This sequential imaging did not result in delay in diagnosis

of life-threatening disease. However, this means 54% of patients avoided WBCT,

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decreasing radiation exposure. In fact, median radiation exposure was higher in the
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WBCT group than those in the selective scanning group in the ED and during admission

per subgroup analysis. The selective imaging group received less radiation overall. A
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larger percentage of polytrauma patients underwent randomization to WBCT (67%

versus 61%).35 This data is the strongest to date due to study design, which was

prospective and multicenter with strict randomization and inclusion criteria. Table 3

summarizes several of the studies discussed, including REACT-2, the study with the most

rigorous design to date.

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Table 316,27-35
Study Year Patients Design Mortality – Mortality – Odds Ratio
WBCT Selective (OR)
Weninger et al. 2007 370 Retrospective 17.3 (12.5-23.4) 16.7 (12-22.8) 1.03 (0.6-1.7)
Huber-Wagner et al. 2009 4,621 Retrospective 20.4 (18.5-22.6) 22.1 (20.6-23.5) 0.91 (0.78-1.05)
Wurmb et al. 2011 318 Retrospective 8.5 (5.1-13.9) 9 (5.4-14.5) 0.95 (0.43-2.0)
Hutter et al. 2011 1,144 Retrospective 7.8 (6-10.3) 19.7 (16.6-23.3) 0.35 (0.24-0.50)
Yeguiayan et al.* 2012 1,950 Prospective 16.3 (14.6-18.1) 22 (17.3-27.5) 0.69 (0.49-0.95)
Hsiao et al.* 2013 660 Prospective 3 (1-8.6) 1.25 (0.6-2.5) 2.5 (0.63-9.8)

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Huber-Wagner et al. 2013 16,719 Retrospective 17.4 (16.6-18.2) 21.4 (20.5-22.3) 0.77 (0.71-0.83)
Sierink et al.* 2016 1,083 Prospective 15.9 15.7 1.02 (0.73-1.41)

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*Note: Sierink et al. 2016 REACT-2 study is prospective and randomized, with higher quality design when
compared to other prospective studies listed.

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3.4 How does this change management?

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As discussed, a significant proportion of studies comparing WBCT to select imaging
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utilized retrospective, non-randomized designs. The study by Huber-Wagner et al.

utilized a risk-adjusted approach with multivariate analysis to adjust for possible

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confounders, and their study suggests a mortality benefit with WBCT, along with several
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other studies and reviews.27,28 Yet it is unclear whether their analysis techniques

adequately controlled for confounders given their observational design. For example,
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WBCT may be more readily available in dedicated trauma centers; thus the mortality
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differences noted may actually be a result of provider experience and protocol-driven

care within trauma teams.71-74 Furthermore, critically ill patients may be too unstable to
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undergo CT, increasing the number of patients with mortality in the non-WBCT

groups.35,71-74 As noted above, the measurement of mortality benefit as the difference

between ISS-predicted and actual mortality may exaggerate the benefits of WBCT by

inflating the ISS in patients undergoing this comprehensive anatomic assessment.69,70

There is currently only one prospective, well-designed study involving REACT-2, which

shows no mortality benefit with selective imaging versus WBCT.35 This evidence casts
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serious doubt upon the conclusion that WBCT leads to better trauma patient outcomes.

Given these findings, it is unclear whether the consequences of WBCT in terms of

radiation exposure and over-diagnosis of incidental findings warrant the possibility of

detecting additional actionable injuries.

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Based on the evidence currently available, WBCT likely decreases time to diagnosis and

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may improve management decisions in unevaluable patients but may not otherwise have

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a material impact on definitive patient outcomes including mortality. Nevertheless,

WBCT may be beneficial in certain sub-group populations, such as patients with multi-

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system injuries, severe mechanism of injury, and who are clinically unevaluable
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(intoxication, head trauma, or unresponsive).
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3.5 Recommendations for WBCT use

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Several studies report protocols or algorithms for use of WBCT which providers may

utilize to guide their diagnostic imaging choices.16,27-29,35,74-76 The majority of WBCT

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protocols incorporate mechanism of injury, patient injuries, patient mental and

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hemodynamic status, and several other aspects. 16,27-29,35,74-76 Most protocols state that

any suspicion of critical injury, alteration in hemodynamic status, abnormal mental status,
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and severe mechanism of injury warrants WBCT.

One study published in Injury in 2015 identified predictors of polytrauma through

regression analysis, which were clinical signs of trauma in greater than one body region,

decreased GCS (< 14), hemodynamic abnormality (SBP < 100 mmHg or HR > 100
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beats/min), respiratory abnormality (oxygen saturation < 93% or RR > 24 breaths/min),

and mechanism of injury.74 Following this, investigators constructed a decision-making

model from analysis of these predictors, producing the Manchester Trauma Imaging

Score (ManTIS), which providers may use for imaging in multitrauma patients.74

However, investigators state the protocol should not trump physician gestalt.74,75 This

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protocol recommends WBCT if the patient is unconscious or has signs of spinal injury. If

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not, mechanism of injury is considered. Falls < 1 m require use of dedicated trauma

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radiographs, and if positive or a respiratory abnormality is found, these require focused

CT including all suspected regions of injury. If the patient fell > 1 m, patients with

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trauma score elevation require WBCT.74 This trauma score includes the initial predictors
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outlined previously with mechanism. Another option for WBCT use is available through

examination of the REACT-2 protocol, which utilized specific criteria (Table 2).35 If
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concerned for severe injury in multiple systems, WBCT may be warranted. Patients who
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are evaluable likely should undergo history and physical examination for selective

imaging.
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Ultimately, the physician at the bedside should complete a focused history and physical

examination, followed by ultrasound. One unifying theme across all these protocols is
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deference to physician judgment. Even proponents repeatedly caution that mindless

adherence to protocol-driven imaging is no substitute for a careful clinical evaluation. In

light of the existing evidence at the time of writing, we encourage providers to generally

pursue select imaging based on history and physical examination while simultaneously

recognizing the potential role of WBCT for those patients in whom pre-test probability of
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severe multi-system trauma is high and the patient is not clinically evaluable (i.e. altered

mental status or requiring endotracheal intubation). Other clinical decision rules such as

NEXUS Chest CT Decision Instrument for CT Imaging,77 Canadian CT Head

Injury/Trauma Rule,78 Canadian C-Spine Rule,79 and NEXUS Criteria for C-spine

Imaging80 may be utilized in conjunction with serial FAST examinations and laboratory

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studies for evaluation of the polytrauma patient.

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4. CONCLUSIONS

Trauma is a major cause of morbidity and mortality in the world, and patients often

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present with critical injuries requiring resuscitation and further evaluation. Diagnostic
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modalities such as radiograph, ultrasound, and CT offer tools for rapidly diagnosing these

injuries. Many centers now use WBCT, which has displayed mortality benefit and
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decreased time to diagnosis and ED length of stay in observational studies. However,

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these studies suffer from myriad potential confounders and potentially biased analyses.

REACT-2, the only randomized controlled trial comparing WBCT to select imaging in
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trauma patients, found no difference in mortality between these two strategies. On the
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basis of REACT-2, WBCT does appear to decrease time to diagnosis and length of stay

in the ED. However, increased radiation exposure and incidental findings can occur with
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WBCT. We argue that most patients should undergo history and physical examination to

drive CT-imaging decisions with WBCT reserved for those patients in whom clinicians

have a high index of suspicion for extensive polytrauma. Future randomized controlled

trials should focus on the evaluation of WBCT in specific trauma sub-groups such as

intoxicated or unconscious patients in whom clinical evaluation is impractical.

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