Trauma CT scanning guidance

Whole body CT (WBCT) has assumed a pivotal position in trauma management. UK trauma is typically described as “blunt and blind” i.e. blunt trauma leading to injury patterns that are often occult and impossible to accurately characterise by clinical examination and plain radiographs.

NHS Tayside has recently been identified as one of 4 sites to be developed as Scottish Major Trauma Centres. Current key performance indicators for the Scottish Trauma Network and STAG Quality Indicators include CT within 60 minutes of arrival in ED for the following patient groups:

- severe head injury

- signs of shock and abdominal injury AIS greater than or equal to 3

- Thoracic injury AIS greater than or equal to 2

Provision of a written CT report within 1 hour is an additional identified key performance indicator in patients with severe head injury.

In order to deliver care in line with these standards, clear agreed process to guide appropriate and timely CT requesting, delivery and reporting is required.

WBCT is crucial to the diagnosis and management in particular of haemodynamically unstable patients without a clinically clear cut diagnosis – it is this challenging group that has the greatest potential to benefit from a system that delivers a quick and safe passage to the CT room, if necessary with resuscitation ongoing.

The rapid and safe scanning of the selected patient group utilising a standardised CT protocol to allow diagnosis of life threatening and other significant injury. Specifically:

• to ensure an appropriate and timely alert system for CT radiographer and radiologist.

• to appropriately triage trauma patients, rapidly identifying those patients fulfilling criteria for trauma WBCT.

• to outline an agreed referral process to request and effect timely WBCT

• to establish standard reporting priorities and delivery.

A single positive parameter from any of the three categories leads to the possibility of serious internal injury and WBCT should be initiated.

Mechanism

• Any high speed RTC, e.g.

•     combined speed greater than 30mph
•     roll over
•     ejection
•     concurrent death
•     trapped for longer than 30min

• Car versus pedestrian/cyclist (high energy)
• Fall from greater than 3m (use judgement)
• Significant assault to trunk
• Blast or burn + trauma
• Other high energy mechanism

Apparent injury

• Evidence of blunt thoraco-abdominal trauma
• Evidence of open thoraco-abdominal trauma
• 2 or more long bone #
• Significant CNS trauma
• Requiring intubation
• Unstable vertebral fractures or signs of spinal cord injury
• Unstable pelvic fracture

Vital signs

• GCS less than 14
• Sys BP less than 90mmHg (guide)
• Persistent tachycardia greater than 120
• Respiratory rate less than 10 or greater than 29
• SaO2 lower than 93%

Clinical judgement is still required in the sensible application of this triage scheme, e.g. targeted CT of head and neck will be more appropriate in certain low energy traumas (eg GCS less than 9 following isolated head injury). CT can also easily be extended to include extremities if injury is suspected (avoiding the immediate need for plain radiographs).

The trauma team leader may additionally request WBCT at his/her discretion for any reason falling outside the above.

The trauma team leader will request WBCT as soon as possible for patients fulfilling the above criteria or on receipt of a pre-alert from Scottish Ambulance Service for patients who have potential for fulfilling criteria. Notification of radiology on pre-alert allows for modification of routine work during normal working hours and timely mobilisation of on call teams during the out of hours period. There is an acceptance that ‘stand downs’ may occur following the arrival of a ’pre-alert’ patient in resus.

In-hours notification to CT should occur with a single phone call to inpatient CT (35071), out of hours notification should take place through the on-call radiologist who will subsequently mobilise on-call radiography staff. As soon as patient details are available formal requesting should occur through ICE requesting.

Immediately following the scan the radiologist will complete the following CT primary survey checklist, aiming to include/exclude major life threatening injuries. The checklist will be scanned into RIS then given to the trauma team leader.

Prior to delivering this report the radiologist should be allowed to concentrate on the scan and not disturbed by attending members of the trauma team. Formal written report should be available on ICE reporting within 1 hour of CT scan. If there are anticipated problems with provision of the report within this timeframe, this should be communicated with the Trauma Team Leader.

TRAUMA CT IMMEDIATE REPORT (pdf)

The results of the scan and the patient’s clinical condition guide subsequent action. Decision making should be by the team leader and appropriate senior specialty doctors. A command huddle will take place in CT Control Room and immediate management plan and patient destination will be determined between:

• transfer to theatre or other place of definitive treatment (e.g IR suite).
• admission to ICU/HDU/Trauma ward
• return to resus room for ongoing management, secondary survey and treatment planning and placement. Aim to avoid this if possible.