It’s long been an accepted standard to stay and stabilise or go directly to OR with any unstable trauma patient – and never EVER take them to CT first. And it made sense, as radiology has never been a good place to be with critical patients. But as radiology is getting a central place in trauma care, new thinking is changing all this. Instead of keeping away, lets make the CT lab a safe critical environment.
Donut of life?
These thoughts have been underway for some time. Scott Weingart discussed this in a podcast back in 2009, around the time the first article was published. And other prominent trauma docs, like Karim Brohi, are also advocating pushing the boundaries for when to take patients to CT instead of directly to OR.
Of course, the exsanguinating patient where you can’t keep up with transfusions is still going to OR, but the unstable patient that keeps stable under transfusions is where the debate comes in. If you’re in doubt, you should go to OR, but it is this grey area that’s under debate.
These patients that don|t go directly to OR sometimes stay longer in the trauma bay to get properly stabilised for CT. This stabilisation might be done equally well at the CT lab.
The problem is now viewed more as a logistical problem. As long is you patient isn’t exsanguinating fast, as long as your transfusions can keep up, you should seriously consider CT before OR. But you, your team and your hospital need to be prepared. Your CT lab needs to be as functional and well equipped as your trauma bay. And people need to know how to handle the patient during the transport, transfer and scan. So this isn’t a change you decide to do one dark night on call. This needs to be incorporated in your hospital’s procedures.
And the change might well be worth it. There’s mounting evidence that Whole Body CT, WBCT is good for your trauma patient – even the unstable ones. A German trauma group has done some retrospective statistics based on a trauma registry for 216 centers, and published an article in the Lancet in 2009, finding increased survival in adult blunt multitrauma patients who went to WBCT first. They looked at their database again a few years later and did another analysis which was published in 2013. Here they found numbers that support taking unstable patients to CT, as this was also associated with increased survival. And the more severly shocked, the larger the benefit.
And these were really crook patients, judged by the numbers: 25% in this group received massive transfusions. And even if SBP<90 might not sound like much, this SBP has shown to be an indicator of shock, even severe shock in trauma patients, and increased mortality. This was also reflected here, as this group had a mortality of 42% if they went straight to WBCT, and a mortality of 55% without WBCT! Also, 25% of the patients in severe shock had massive transfusions before getting to ICU!
The latest study released is a meta-analysis on early WBCT vs no CT/partial CT. Although the German articles we list here are by far the largest, this meta-analysis adds more studies that reach the same conclusion: Early WBCT is associated with improved survival and shorter time spent in ED.
Now, these are database studies and not prospective or randomised in any way. There are lots of pitfalls, so no clear conclusions can be made. Patients taken straight to OR was excluded, so there’s no real comparison between going straight to OR vs WBCT first. The no WBCT group also included partial CT’s, which confuses the picture. Go read the paper.
Although the numbers look good, going in-depth it might be hard to find proof that WBCT enhances survival, but at least it doesn’t seem to add to the patient’s risk. As such, I see this as a feasibility study. It’s doable. And the argument is sound: As long as your team and CT lab is set up to handle unstable trauma patients, it should be as safe as your trauma bay. And having information on the injuries before going in will enhance surgery and the general handling of the patient.
The timings also shows that focus on quick WBCT with ongoing resus reduces time in ER: The WBCT group generally got to CT 7-12 mins earlier than the non-WBCT group.
To study this further, a prospective, randomised multicenter study is underway: the REACT-2 trial. It will look at immediate WBCT (performing a primary survey, but ommitting standard x-ray and FAST, then straight to CT), vs standard ATLS-que trauma management with standard x-rays and selective CT scan. We’re looking forward to the results.
CT – the new trauma bay?
Even if your CT is close to ED, it takes time and training to do this right. Don’t rush your unstable trauma patient off to CT on your next shift, but work out good routines for how to do this, and see if it can get incorporated into your hospital’s routines. As many other routines in medicine, it’s not just you, nor just introducing the routine – it is training the whole team to do it well. So adjust ambitions to training: As your hospital and team gets better, and your CT closer, you can take more severely unstable patients to CT if needed. Just remember this is high risk assessment, and patients needing OR should still go straight to OR. With the others, if properly set up, the CT lab may well be this decade’s trauma bay.
Open Access article:
Whole-Body CT in Haemodynamically Unstable Severely Injured Patients – A Retrospective, Multicentre Study, PLOS one, 2013.
Taking these ideas further, you could have trauma patients arrive directly in a purpose-built CT lab and transfered directly onto the CT bench, hook them up to monitoring and do the primary survey there and get CT by just pushing the sliding bench into the machine. That way, you’d finally get rid of standard x-rays for chest and pelvis, and FAST won’t really be necessary either. The result will be significant time savings until definite diagnosis, shaving away non-essential tests, avoid long, dangerous in-hospital transports and several risky stretcher transfers.
Even better would be to receive critical trauma patients directly in a RAPTOR suite with full surgical, radiological and interventional radiological capabilities. But at this point, it seems like a far fetched and very expensive option. But I’ll definitely go have a look at the Shock Trauma Center when they get their first RAPTOR trauma bay.
For now, it seems realistic to focus on organising hospitals so that you can take your unstable patient quickly and safely to CT with ongoing high-quality resuscitation, to make the CT lab this decade’s trauma bay.