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Trauma - Diagnostics and Triage
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences. Akademiska sjukhuset. (Kärlkirurgi)ORCID iD: 0000-0001-8125-4536
2018 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Trauma is a leading cause of death worldwide and it reduces years of productive life and leads to disability. Effective trauma care relies on triage, which aims to ration the use of fine resources to patients with the greatest needs. Imaging is essential in the severely injured patient, but comes at a cost of radiation exposure, which could cause cancer in up to 1/1000 patients examined with whole body computed tomography.

Paper I showed that routine whole-body CT of high-energy trauma patients may lead to excessive radiation exposure without clinical benefit. There were no missed injuries in the low risk group and the mean injury severity score (ISS) was 0.84 in this group (standard deviation SD 1.57). Paper II surveyed radiologists at 93 Nordic and 10 non-Nordic hospitals with 23 questions on usage of whole body CT in trauma. The response rate was 62% and there were several differences in criteria, protocols and radiation dose. Most, 89% consider there is a need for national/international guidelines. Paper III evaluated compliance with trauma alert criteria with the aim to describe how resources may be optimized with sustained low undertriage. The compliance with full trauma alert and no trauma alert was 80% and 79% respectively. Compliance with limited trauma alert was only 54%, and prehospital immobilization was an independent risk factor for mistriage with an odds ratio of 1.78 (95% CI 1.42 - 2.23). Paper IV demonstrated that the newly implemented Swedish trauma team activation (TTA) criteria result in a reduction in limited TTA frequency, indicating an increased efficiency in use of resources. The over- and undertriage is unchanged compared to former criteria, thus upholding patient safety.

In conclusion, whole body CT in trauma should be used only in patients with clinical findings. The routines for use of whole body CT in trauma differ between institutions, and efforts to establish common guidelines are requested. Better compliance with alert criteria may optimize resource allocation, and the newly implemented national TTA criteria in Sweden are safe and resource efficient.  

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2018. , p. 75
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 1431
Keywords [en]
wounds and injuries, trauma, triage, whole body computed tomography in trauma, compliance, radiation exposure, CT, radiation safety
National Category
Surgery
Research subject
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-341763ISBN: 978-91-513-0242-3 (print)OAI: oai:DiVA.org:uu-341763DiVA, id: diva2:1182797
Public defence
2018-04-13, Enghoffsalen, ingång 50bv, Akademiska sjukhuset, 751 85, Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2018-03-23 Created: 2018-02-14 Last updated: 2018-04-24
List of papers
1. Routine whole body CT of high energy trauma patients leads to excessive radiation exposure
Open this publication in new window or tab >>Routine whole body CT of high energy trauma patients leads to excessive radiation exposure
2016 (English)In: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, ISSN 1757-7241, E-ISSN 1757-7241, Vol. 24, no 1Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Whole body computed tomography (WBCT) is an important adjunct in trauma care, which is often part of standard protocol in initial management of trauma patients. However, WBCT exposes patients to a significant dose of radiation. The use of WBCT was assessed in a modern trauma cohort in Sweden.

METHODS: A two-center retrospective cohort study was performed. All consecutive trauma alert patients at a university hospital (July-December 2008), and a rural county hospital (January 2009- December 2010) were included. Patients were stratified into three groups (high, intermediate and low risk) based on documented suspected injuries at primary survey at the site of accident or at the emergency department. Injury severity score (ISS) was calculated. Case records were reviewed for clinical and radiological findings at the time of trauma, and during a ≥36 months of follow-up period to identify possible missed injuries.

RESULTS: A total of 523 patients were included in the study (university hospital n = 273; rural county hospital n = 250), out of which 475 patients (91.0 %) underwent radiological examinations, 290 patients (55.4 %) underwent WBCT, which identified trauma related findings in 125 patients (43.1 % of those examined). The high-risk group (n = 62) had a mean age of 38.5 years (21.1 SD). Mean ISS was 16.48 (18.14 SD). In this group, WBCT resulted in a positive finding in 38 (74.5 %) patients. In the intermediate-risk group (n = 322; mean age 37.66, 20.24 SD) ISS was 4.42 (6.30 SD). A positive finding on WBCT was found in 87 of the intermediate group patients (44.8 %). The low-risk group (n = 139; mean age 32.5 years; 21.4 SD) had a mean ISS of 0.84 (1.57 SD) with no positive findings on WBCT and no missed injuries in medical records at ≥36 months.

DISCUSSION: The risk of developing radiation induced cancer is significant for young people if exposed to relatively high dose radiation as is the case in WBCT. WBCT in high-energy trauma is important for planning of treatment in severely injured patients while it can be questioned in the seemingly not injured where it is used mainly to permit early discharge from the ED.

CONCLUSIONS: Risk stratification criteria could in this retrospective study identify high energy trauma patients not in need of radiological imaging. WBCT in high-energy trauma does not affect patient care if the patient is mentally alert, not intoxicated nor shows signs of other than minor injuries when evaluated by a trauma-team. The risk of missing important traumatic findings in these patients is very low. Observation of the patient with reexamination instead of imaging may be considered in this group of often young patients where radiation dose is an issue.

National Category
Anesthesiology and Intensive Care
Identifiers
urn:nbn:se:uu:diva-278958 (URN)10.1186/s13049-016-0199-2 (DOI)000370592500001 ()26817669 (PubMedID)
Available from: 2016-02-26 Created: 2016-02-26 Last updated: 2018-02-14Bibliographically approved
2. Whole body computed tomography for trauma patients in the Nordic countries 2014: survey shows significant differences and a need for common guidelines
Open this publication in new window or tab >>Whole body computed tomography for trauma patients in the Nordic countries 2014: survey shows significant differences and a need for common guidelines
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2016 (English)In: Acta Radiologica, ISSN 0284-1851, E-ISSN 1600-0455, Vol. 57, no 6, p. 750-757Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Whole body computed tomography in trauma (WBCTT) is a standardized CT examination of trauma patients. It has a relatively high radiation dose. Therefore, well-defined clinical indications and imaging protocols are needed. This information regarding Nordic countries is limited.

PURPOSE: To identify Nordic countries' WBCTT imaging protocols, radiation dose, and integration in trauma care, and to inquire about the need for common Nordic guidelines.

MATERIAL AND METHODS: A survey with 23 multiple choice questions or free text responses was sent to 95 hospitals and 10 trauma centers in and outside the Nordic region, respectively. The questions were defined and the hospitals selected in collaboration with board members of "Nordic Forum for Trauma and Emergency Radiology" (www.nordictraumarad.com).

RESULTS: Two Nordic hospitals declined to take part in the survey. Out of the remaining 93 Nordic hospitals, 56 completed the questionnaire. Arterial visualization is routine in major trauma centers but only in 50% of the Nordic hospitals. The CT scanner is located within 50 m of the emergency department in all non-Nordic trauma centers but only in 60% of Nordic hospitals. Radiation dose for WBCTT is in the range of 900-3600 mGy × cm. Of the 56 responding Nordic hospitals, 84% have official guidelines for WBCTT. Eighty-nine percent of the responders state there is a need for common guidelines.

CONCLUSION: Scanning protocols, radiation doses, and routines differ significantly between hospitals and trauma centers. Guideline for WBCTT is presently defined locally in most Nordic hospitals. There is an interest in most Nordic hospitals to endorse new and common guidelines for WBCTT.

Keywords
CT; adults; trauma; radiation safety; equipment; contrast agents - intravenous
National Category
Radiology, Nuclear Medicine and Medical Imaging
Identifiers
urn:nbn:se:uu:diva-282885 (URN)10.1177/0284185115597718 (DOI)000375726300018 ()26271124 (PubMedID)
Available from: 2016-04-07 Created: 2016-04-07 Last updated: 2018-02-14Bibliographically approved
3. Better compliance with triage criteria in trauma would reduce costs with maintained patient safety
Open this publication in new window or tab >>Better compliance with triage criteria in trauma would reduce costs with maintained patient safety
Show others...
2018 (English)In: European journal of emergency medicine, ISSN 0969-9546, E-ISSN 1473-5695, Vol. FebArticle in journal (Other academic) Epub ahead of print
National Category
Surgery
Research subject
Surgery
Identifiers
urn:nbn:se:uu:diva-341445 (URN)10.1097 (DOI)
Available from: 2018-02-08 Created: 2018-02-08 Last updated: 2018-03-02
4. A prospective stepped wedge cohort evaluation of the new national trauma team activation criteria in Sweden – the TRAUMALERT study
Open this publication in new window or tab >>A prospective stepped wedge cohort evaluation of the new national trauma team activation criteria in Sweden – the TRAUMALERT study
(English)Manuscript (preprint) (Other academic)
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-341446 (URN)
Available from: 2018-02-08 Created: 2018-02-08 Last updated: 2018-02-14

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