Background

Total body CT scanning is increasingly being utilized as part of the initial survey of trauma patients in trauma centers. The belief is that initial total body scan provides a comprehensive evaluation of life threatening traumatic injuries, requires fewer trips to the CT scanner, and mitigates the necessity for other imaging modalities such as x-ray and ultrasound. 

Several studies have shown benefits to pan scanning, claiming increased probability of survival with as well as decreased time in the ER.  However these studies have been retrospective and plagued with selection bias.  The REACT-2 Trial is the first randomized controlled trial that seeks to determine if a mortality benefit exists for those who receive a total body scan versus selective CT scanning based on the clinical picture.

Clinical Question

Is there an in-hospital mortality benefit conferred to severe trauma patients who receive immediate total body CT scanning versus standard conventional imaging supplemented by selective CT scanning?

Population

Trauma patients >/= 18 years of age with compromised vital parameters, clinical suspicion of life-threatening injuries or severe injury. Participants must have presented with at least one of the following: respiratory rate >30 or <10, pulse >120, SBP< 100, GCS<14, estimated blood loss of >/= 500 mL, abnormal pupillary reaction, or “high risk” mechanism. They were similarly included if there was clinical suspicion for flail chest, open chest, or multiple rib fractures, severe abdominal injury, pelvic fracture, unstable vertebral fractures or spinal cord compression, fractures of at least two long bones.

Intervention

Immediate “total body” CT scan of the head, neck, chest, abdomen, and pelvis

Control

Conventional imaging in accordance with ATLS guidelines (CXR, pelvic XR, FAST), then selective CT scans for individual body regions based on clinical picture

Outcomes

Primary: In-hospital mortality
Secondary: 24 hour and 30 day mortality, clinically relevant time intervals during trauma survey, duration of stay, number of ventilation days for patients admitted to ICU, readmission in 6 months, radiation exposure, serious adverse events, necessity of at least 1 blood transfusion, hospital cost

Design

Multicenter international non-blinded randomized, controlled trial

Excluded

Age <18, pregnancy, referred from another hospital, low energy trauma with blunt injury mechanism, isolated penetrating injury to 1 body region (not including gunshot wounds), any patient too unstable to undergo CT scan or required CPR or immediate operation due to risk of imminent death

Primary Results

  • 5475 patients were assessed for eligibility
  • 1403 patients were randomized to either intervention or control groups
  • 1083 patients were included in the primary analysis

Critical Results

  • Primary Outcome (In-hospital mortality)
    • Immediate total body CT group: 16%
    • Standard work-up with selective CT group: 16%
  • Secondary measures
    • No difference in 24hr mortality
    • No difference in 30 day mortality
    • Median radiation exposure was higher in patients with total body scan:  20.9 mSv in total body scan group vs. 20.6mSv in selective imaging group
    • Median time to end of imaging was less in total body scan group:  30 min in total body scan group vs. 37 min in selective imaging group
    • Median time to diagnosis was less in total body scan group:  50 min in total body scan group vs. 58 min in selective imaging group
    • Time in trauma slot (including CT scanner) was shorter for patients in the total body scan group: 69 min versus 82 min
    • Hospital cost was pretty much the same between the two groups: 25-27,000 Euros, but this was only calculated in the Netherlands
    • Readmission within 6 months higher in total body scan group:  17% vs. 11%
    • Adverse events occurring in CT scanner were greater in the total body scan group: 3 in total body scan group, 1 in standard group

Strengths

  • First prospective large scale randomized controlled trial to evaluate the utility of immediate total body scanning in trauma
  • Multicenter and international
  • The authors performed an intention to treat analysis
  • Achieved power of 80% to detect a minimum of 5% mortality difference

Limitations

  • 46% of patients in the standard group ended up getting the equivalent of a total body scan
  • Number of total body scans done in the standard care (control) group may have been artificially inflated over the course of the study due to trauma team members gaining experience from the study
  • Included a substantial number of patients with Injury Severity Score <16.  36% of cases were not considered major trauma
  • Medical costs were calculated for Dutch hospitals only and cannot be extrapolated to other countries
  • Some subjectivity in regards to inclusion versus exclusion criteria (i.e. determining high or low mechanism of injury, variations in witnesses and EMS reports)
  • Non-blinded study

Author's Conclusions

“Diagnosing patients with an immediate total-body CT scan does not reduce in-hospital mortality compared with the standard radiological work-up. Because of the increased radiation dose, future research should focus on the selection of patients who will benefit from immediate total-body CT.”

Our Conclusions

This well-designed, large study effectively refutes the theory of a mortality benefit in trauma patients who automatically receive total body scanning compared to those patients who receive selective imaging based on clinical picture. Those patients who received total body CT scans were exposed to a slightly higher level of radiation, however the increased amount of radiation is of minimal clinical significance (equivalent of approximately 1 chest x-ray). Patients who receive initial total body scan may, however, benefit from faster time to diagnosis and speedier initial trauma evaluation.

Potential Impact To Current Practice

The results of this study should discourage providers from assuming that total body CT scanning improves overall mortality during initial survey of trauma patients. While decreased time during trauma evaluation may be a benefit of the total body scan, it is unclear how this may effect overall Emergency Department flow and resource utilization.

Bottom Line

Mortality rates in trauma patients with major injuries are not improved by utilizing total body CT scans as standard protocol during initial trauma survey.

Read More

EMNerd: The Case of the Anatomic Injury Part II

St. Emlyn’s: JC: Do We Always Need a Whole Body CT in Trauma?