European Journal of Cardiovascular Medicine

Major trauma is a leading cause of mortality worldwide, particularly among individuals under 45 years of age, and is commonly managed in the ED (Emergency Department) setting.^[1-4] These patients often present with multisystem injuries requiring urgent, life-saving interventions. Accurate assessment involves initial evaluation of ABCs (Airway, Breathing, and Circulation), followed by a thorough secondary examination.^[5] However, the complexity of injuries can lead to missed diagnoses, with a reported clinically significant missed injury rate of 8.0%, most commonly involving the head and neck. Risk factors include younger age, severe injury, polytrauma, and absence of soft tissue injuries.

Trauma assessment typically includes protocol-driven use of diagnostic tools such as ultrasound, X-rays, and laboratory tests. Despite their utility, tests like chest X-ray, pelvic X-ray, and FAST ultrasound have limited sensitivity and diagnostic accuracy.^[6-9] CT (Computed Tomography) has emerged as a highly accurate and rapid imaging modality in trauma care, playing a crucial role in early diagnosis.^[10,11] CT use has risen significantly, particularly WBCT (Whole-Body Computed Tomography), which efficiently identifies injuries through multi-detector CT technology.^[12]

WBCT protocols vary by institution but generally include non-contrast CT of the head and C-spine, and contrast-enhanced CT of the neck, chest, abdomen, and pelvis.^[13] The estimated radiation dose is around 20 mSv.^[14] An alternative approach is selective imaging, guided by clinical findings, history, and initial tests.^[5] WBCT is especially valuable in critically injured patients with unreliable histories or examinations, and technological advancements have made WBCT more accessible and common in trauma centers.^[15] However, current literature offers limited evidence that immediate total-body CT improves clinical outcomes over conventional imaging with selective CT.^[16]

Aims and Objectives

To evaluate the impact of immediate WBCT scanning in trauma patients, focusing on its potential benefits in reducing diagnostic time and associated radiation risks and its effect on clinical outcomes. Additionally, to compare the effectiveness of WBCT with the current best imaging strategies recommended by ATLS (Advanced Trauma Life Support) guidelines.

Study Design

This was a retrospective cohort study conducted using data obtained from the case records of patients admitted to the emergency department between January 1, 2017, and December 31, 2018. The study analyzed clinical information documented during this period to evaluate outcomes and diagnostic strategies in trauma patients, based on predefined inclusion and exclusion criteria.

Inclusion and Exclusion Criteria

The study included trauma patients who presented with life-threatening vital signs or clinically suspicious diagnoses, as well as those who had experienced high-risk mechanisms of injury such as falls from a height greater than 3 meters, ejection from a vehicle, or involvement in incidents where a deceased or severely injured occupant was in the same vehicle. Additional inclusion criteria were hemodynamic instability, evidence of chest or abdominal entrapment (wedged or trapped), and patients who had received primary treatment at regional or supra-regional trauma centers. Patients were excluded if they were under 18 years of age, were known to be pregnant, had sustained stab wound injuries, or had incomplete records lacking essential information on their clinical status.

Data Collection Procedure

Data collection was carried out by accessing patient records using unique hospital identification numbers documented in the emergency room and radiology registers. The study population included all trauma patients who underwent whole-body CT scanning prior to being discharged from the emergency department to either an intensive care unit or a ward. The emergency room was staffed 24/7 by consultants, residents, and nurses trained in emergency and critical care, ensuring consistent documentation and management. Relevant clinical and imaging data were retrieved from the hospital's case records for analysis.

Statistical Analysis

For statistical analysis, standard techniques were employed to compare various outcomes. Data were initially collected and organized in a Microsoft Excel worksheet, with each subject identified by their MR (Medical Record) number. The dataset was then transferred to a statistical software package for analysis. Descriptive statistics were used to summarize all categorical variables, while continuous variables were described using mean and standard deviation to assess central tendency and variability.

Table 1 summarizes the baseline demographic data of the trauma patients included in the study, including age, gender, and distribution between selective and pan CT scan groups.

Table 2 compares the hospital length of stay and emergency department diagnostic time between patients undergoing selective CT and pan CT, highlighting a significant reduction in ED time with pan CT.

Table 3 illustrates the diagnostic effectiveness of both CT strategies in detecting injuries, indicating a notable advantage of pan CT only for intra-thoracic injuries.

Table 4 shows mortality outcomes at different time intervals, with no statistically significant difference between patients undergoing pan versus selective CT.

Table 5 presents a comparison of diagnostic time, radiation exposure, and costs between the two CT strategies, showing that pan CT incurs higher radiation but is more cost-effective overall.

Table 6 analyzes gender distribution among patients in each CT group, showing no significant gender-based difference in the type of CT scan used.

Our study showed no statistically significant difference in mortality between WBCT and selective CT, it is important to highlight the clinical trend toward improved outcomes in the WBCT group. Pan CT demonstrated a 16% higher detection rate of intra-thoracic injuries and a significantly shorter emergency department stay, which are crucial in time-sensitive trauma care. These findings suggest reduced morbidity and may lead to better long-term outcomes.

Furthermore, prior studies such as those by Huber-Wagner et al. and Caputo et al. consistently report a mortality benefit with WBCT. While statistical significance in our cohort was not reached, the overall trend supports using WBCT more broadly, particularly in moderate-to-severely injured patients, rather than limiting it strictly to polytrauma or unstable cases.^[17,19]

In this context, WBCT should be seen as a frontline diagnostic strategy in major trauma, balancing the slight increase in radiation exposure with the potentially life-saving diagnostic speed and thoroughness.

This observation is consistent with prior research. Huber-Wagner et al. demonstrated that WBCT during trauma resuscitation significantly reduced mortality, reporting a 6% absolute reduction in a large multicenter cohort.^[17] Similarly, another study by the same group focusing on hemodynamically unstable patients showed improved outcomes with early WBCT.^[18] These findings were further supported by Caputo et al., who conducted a meta-analysis showing that WBCT was associated with improved survival compared to selective scanning.^[19]

Our findings also support the growing consensus that WBCT expedites diagnosis and facilitates early clinical decision-making, particularly in polytrauma patients. Lang et al. emphasized the efficiency of WBCT in critical trauma management, highlighting its role in reducing diagnostic time.^[20] This was echoed by Jiang et al. in their meta-analysis, which found that WBCT led to shorter time to definitive care and was linked with a lower mortality rate.^[21]

However, the evidence is not entirely consistent. A systematic review by Hajibandeh et al. noted that while WBCT may improve survival in certain subgroups, the benefits are not universally observed, and patient selection remains critical.^[22] Wada et al. reported that early WBCT before emergency bleeding control significantly improved outcomes in blunt trauma, suggesting that the timing of WBCT may be a crucial factor.^[23]

Additionally, Kimura and colleagues found WBCT to be particularly beneficial in patients with moderate-to-severe consciousness disturbances, further supporting its utility in select populations.^[24] However, overutilization remains a concern. In our study, a proportion of WBCTs were negative or revealed isolated injuries, echoing the findings of Yeguiayan et al., who warned of unnecessary radiation exposure and advocated for stricter selection protocols.^[14]

The REACT-2 RCT (Randomized Controlled Trial) by Sierink et al. offered a more nuanced view. It found no statistically significant difference in in-hospital mortality between patients who underwent immediate WBCT and those who had conventional imaging plus selective CT.^[25] However, the trial was criticized for its high crossover rates and possibly being underpowered to detect subtle differences in mortality.

Radiation exposure is a persistent concern. WBCT delivers a higher radiation dose (typically 10–20 mSv) compared to selective imaging, raising the risk of long-term malignancies, especially in younger patients. This necessitates a careful risk-benefit analysis when choosing imaging strategies.

Positive Outcomes

In addition to mortality, WBCT was associated with improved morbidity-related outcomes. Patients had shorter stays in the ED and injuries were identified more comprehensively, especially in the thoracic region. These findings may reduce complications from missed injuries and enhance early intervention, underscoring WBCT's clinical value.

Trauma remains a leading cause of death among individuals aged 1 to 45, with rapid diagnosis and intervention being critical to improving outcomes. Conventional methods such as chest and pelvic X-rays, FAST, and selective CT-recommended by ATLS®-may miss serious injuries and delay definitive care. WBCT has clear advantages in trauma care, including faster diagnosis, better injury detection, and potential for improved outcomes. While mortality differences were not statistically significant in our study, the overall clinical trend and previous evidence suggest a survival benefit and reduced morbidity. WBCT should be considered a preferred imaging modality in moderate-to-severe trauma, even in patients who appear clinically stable but are at risk of occult injuries.

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