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Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients

  1. Raoul Van Vugt1,*,
  2. Frederik Keus2,
  3. Digna Kool3,
  4. Jaap Deunk4,
  5. Michael Edwards1

Editorial Group: Cochrane Injuries Group

Published Online: 23 DEC 2013

Assessed as up-to-date: 9 MAY 2013

DOI: 10.1002/14651858.CD009743.pub2


How to Cite

Van Vugt R, Keus F, Kool D, Deunk J, Edwards M. Selective computed tomography (CT) versus routine thoracoabdominal CT for high-energy blunt-trauma patients. Cochrane Database of Systematic Reviews 2013, Issue 12. Art. No.: CD009743. DOI: 10.1002/14651858.CD009743.pub2.

Author Information

  1. 1

    Radboud University Nijmegen Medical Center, Department of Surgery and Trauma, Nijmegen, Netherlands

  2. 2

    University of Groningen, University Medical Center Groningen, Department of Critical Care, Groningen, Netherlands

  3. 3

    Canisius Wilhelmina Hospital, Department of Radiology, Nijmegen, Netherlands

  4. 4

    VU Medical Center, Department of Surgery, Amsterdam, Brabant, Netherlands

*Raoul Van Vugt, Department of Surgery and Trauma, Radboud University Nijmegen Medical Center, PO Box 9101, Nijmegen, 6500 HB, Netherlands. Raoul.vanVugt@gmail.com. R.vanvugt@chir.umcn.nl.

Publication History

  1. Publication Status: New
  2. Published Online: 23 DEC 2013

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms

Trauma is the fifth leading cause of death in the world, and in people younger than 40 years of age, it is the leading cause of death. Incidents causing blunt injuries result in a worldwide mortality of 9%, which is equivalent to five million deaths each year (WHO 2008). In Europe, injuries account for approximately 800,000 deaths each year (10% of all deaths) (WHO Eur 2008; WHO 2012), and are an important source of health-related costs. During initial resuscitation of blunt-trauma patients, timely and accurate diagnoses are essential for planning further therapy. To guide the primary analysis and treatment of trauma patients, the Advanced Trauma Life Support (ATLS®) is predominantly used worldwide (ATLS 2012). Because physical examination alone is not sufficiently accurate, additional radiological examinations are performed. According to the ATLS® guidelines, conventional diagnostics are performed first, for example, conventional radiography (CR) and focused abdominal sonography in trauma (FAST), followed by selective use of computed tomography (CT) of specific body regions, if indicated.

Since the 2000s, CT has been increasingly used in the trauma bay (Deunk 2007; Trupka 1997). CT has higher sensitivity and specificity compared with CR and FAST (Brink 2008; Deunk 2009). In the 2010s, with technical and infrastructural improvements, CT has evolved into a reliable and important method of diagnostic imaging in trauma. Both organ and osseous injuries can be diagnosed and (potentially life-threatening) bleeding sites may be identified. In addition to the diagnostic value of CT in imaging patients presenting with traumatic injury to individual organs (Pal 2002; Rhee 2002), CT has been reported to be a valuable modality for imaging in terms of better patient management and diagnostic accuracy (Huber-Wagner 2009). However, there are several disadvantages such as radiation exposure, extra costs and the need for transport to the CT room if the scanner is not located in the trauma bay (Devine 2010; Inaba 2011).

As a consequence of these developments, currently applied imaging guidelines may be outdated. The use of routine thoracoabdominal CT is currently rapidly implemented in trauma protocols worldwide (Maurer 2008). Most studies focus on the additional diagnostic value of CT, but there are few studies that address additional value with respect to patient outcome. It is assumed that improved diagnostics will lead to improved survival, which will lead to an increasing use of thoracoabdominal CT. However, the question is if there is sufficient evidence to justify the implementation of routine thoracoabdominal CT after blunt high-energy trauma.

 

Description of the condition

Blunt injury may occur during a motor vehicle, bicycle or pedestrian crash or a fall from a height, resulting in a direct impact (e.g. forced against a steering wheel or floor) or an indirect impact (acceleration-deceleration). Blunt-injury patients need a different type of physical examination than patients with penetrating injuries. In blunt injury, it may be difficult to identify which part of the body is injured. During initial evaluation of blunt-trauma patients, timely and accurate diagnoses are essential, as inappropriate or delayed diagnoses may result in unnecessary morbidity and mortality (Davis 1992; Fakhry 2000). Worldwide, the ATLS®, developed by the American College of Surgeons, is the most commonly used approach during the initial evaluation of blunt-trauma patients (ATLS 2012). These guidelines are based upon the principle 'treat first that kills first'. A systematic approach involving clinical examination and use of diagnostics recognises the most life-threatening injuries that should be treated first. Since it is known that physical examination alone is not sufficiently accurate, additional (radiological) examinations are needed. According to the ATLS® principles, conventional diagnostic imaging is performed first (e.g. X-rays and focused abdominal sonography), followed by selective use of CT of specific body regions if indicated.

 

Description of the intervention

CT, with technical and infrastructure improvements, along with high specificity and accuracy, has evolved into a reliable and important method of diagnostic imaging in trauma. CT enables fast and detailed diagnoses for well-founded planning of therapy. As a consequence, current guidelines following the ATLS® may no longer represent the optimal primary imaging algorithm (Kool 2007). In many hospitals around the world, rapid CT scanning is available and it is possible that routine thoracoabdominal CT scanning may result in more appropriate care than treatment according to ATLS®.

 

How the intervention might work

With the use of routine thoracoabdominal CT, decisions can be made based on detailed anatomical information rather than clinical suspicion. With the use of selective CT, scanning can be performed based on aberrant findings during physical examination and CR. It is known that the performance of physical examination and CR alone have a low sensitivity. When these examinations are the trigger for performing additional CT, this might lead to a greater chance of underdiagnosis and missing injuries. The use of routine thoracoabdominal CT may lead to quicker and more accurate assessment of injuries, and, consequently, outcomes may be improved.

 

Why it is important to do this review

There are two different commonly used diagnostic strategies: 1. the use of physical examination and conventional diagnostic imaging, potentially followed by selective use of CT if indicated; 2. the use of physical examination and conventional diagnostics, followed by a routine (instead of selective) use of thoracoabdominal CT. It is unclear which of the current diagnostic strategies used in blunt high-energy trauma patients is the most appropriate. The aim of this systematic review was to evaluate mortality using the two different diagnostic strategies in patients with blunt high-energy trauma.

To 2013, there are data available from cohort studies, but these mostly consider prospective observational and retrospective cohort studies with a before-and-after design (see Characteristics of excluded studies table). The results of non-randomised studies frequently differ from results of randomised studies of the same intervention. Non-randomised studies may still give seriously misleading results when treated and control groups appear similar in key prognostic factors and, in some situations, adjusted results may appear more biased than unadjusted results. There are instances in which observational data can be useful and randomised controlled trials (RCTs) unnecessary. This can be reasonable, but such instances are rare (Deeks 2003; Ioannidis 2001; Jakobsen 2013; Papanikolaou 2006). Before observational data can be used for assessing benefits, a bias risk assessment has to be conducted. The risk of systematic errors (bias) is one dimension of internal validity and the risk of random errors ('the play of chance') is another, and these two should not be confused (Keus 2010). Therefore, although the studies cumulatively have a high number of participants, this does not compensate for a higher risk of bias. We believe that randomised trials considering this issue are feasible, and there is currently a randomised trial recruiting in the Netherlands which confirms that the scientific community is uncertain (REACT-2). Data from this study may be included into this review in the future.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms

To assess the effects of routine thoracoabdominal CT compared with selective thoracoabdominal CT on mortality in blunt high-energy trauma patients.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We included data from RCTs that compared blunt-trauma resuscitation algorithms using routine thoracoabdominal CT versus algorithms using selective thoracoabdominal CT. We included RCTs irrespective of blinding, number of participants randomised and the language of the study report. We also included cluster-randomised trials.

 

Types of participants

We included randomised trials that evaluated people who had sustained all types of blunt high-energy trauma (including blast or barotrauma). We excluded trials that evaluated people with penetrating injuries, such as gunshot or stab wounds. We excluded trials that evaluated pregnant women.  

 

Types of interventions

We considered diagnostic strategies that used routine thoracoabdominal CT as the experimental intervention. We considered usual care to be the control intervention and may have included physical examination followed by conventional radiological examination (X-rays of the pelvis/thorax and FAST), followed by selective use of thoracoabdominal CT.

 

Types of outcome measures

 

Primary outcomes

  • Overall mortality (30-day survival).

 

Secondary outcomes

  • Adverse events:
    • non-therapeutic laparotomy (i.e. performed for false-positive findings of index tests or misclassification of organ injury);
    • morbidity until discharge (i.e. systemic inflammatory response syndrome, sepsis, nosocomial pneumonia, abdominal compartment syndrome, acute respiratory distress syndrome);
    • rates of missed injuries irrespective of therapeutic consequences (findings of unplanned laparotomy/laparoscopy, autopsy, follow-up during hospital stay or readmission following discharge due to false-negative findings).

Adverse events as total numbers.

  • Time spent at the trauma bay (emergency department) until surgery, admission to intensive care unit (ICU), peripheral wards or ambulation.
  • Length of hospital and ICU stays (days) among people who survived until discharge.

 

Search methods for identification of studies

We did not restrict searches by date, language or publication status.

 

Electronic searches

The Cochrane Injuries Group Trials Search Co-ordinator searched the following electronic databases:

  • Cochrane Injuries Group's Specialised Register (9 May 2013);
  • Cochrane Central Register of Controlled Trials (Issue 4, 2013);
  • MEDLINE (OvidSP) (1946 to May week 1 2013);
  • Embase Classic + Embase (OvidSP) (1947 to 8 May 2013);
  • CINAHL Plus (EBSCO) (1937 to May 2013).

Details of the search strategies can be found in Appendix 1.

 

Searching other resources

We checked the reference lists of all relevant studies retrieved from our search and from relevant, published systematic reviews to identify other possibly relevant studies for inclusion. We conducted an Internet search for grey literature and other information on the topic. In addition, we contacted the authors of included trials by letter or email to request further information and to ascertain whether they have knowledge of any further published, unpublished or ongoing trials.

 

Data collection and analysis

We conducted the review according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011). We used Review Manager 5 to conduct the review (RevMan 2012).

 

Selection of studies

Two review authors (RvV, DK) independently performed the study selection process. A third review author (ME) would have arbitrated in case of any disagreement on study inclusion. We perfomred the first selection based on the titles and abstracts identified from the searches and selected potentially relevant articles. In case of any uncertainty, we would have included the article. We based further selection on the full text. Publications selected for full-text analysis are listed with their reasons for inclusion (Characteristics of included studies) or exclusion (Characteristics of excluded studies) according to the criteria for considering studies for this review.

 

Data extraction and management

We found no studies meeting our inclusion criteria. However, two review authors (RvV, DK) would have independently extracted all relevant data. The following information would have been extracted for each included study: number of people in each group; age; gender; mechanism of injury; Glasgow Coma Scale score (on scene and on arrival at the emergency department); Revised Trauma Score; study design; sample size information; inclusion and exclusion criteria of the study; follow-up period; loss to follow-up; and information regarding the (missed) diagnosis, rates of non-therapeutic interventions, morbidity, time spent on trauma bay, time of admission to ICU/hospital, data needed for methodological quality assessment of the study, and primary and secondary outcomes.

 

Assessment of risk of bias in included studies

We found no RCTs meeting our criteria. However, based on the available empirical evidence and the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions the methodological quality of (cluster-) RCTs would have been assessed using the tool for assessing risk of bias (Higgins 2011). The following definitions would have been used.

 

Random sequence generation

  • Low risk: if the allocation sequence was generated by a computer or random number table. We would have considered drawing of lots, tossing of a coin, shuffling of cards or throwing dice as adequate if a person who was not otherwise involved in the recruitment of participants performed the procedure.
  • Unclear: if the trial was described as randomised, but the method used for generation of the allocation sequence was not described.
  • High risk: if a system involving dates, names or alternating allocation was used for the allocation of participants.

 

Allocation concealment

  • Low risk: if the allocation of participants involved a central independent unit, on-site locked computer or sealed opaque envelopes.
  • Unclear: if the trial was described as randomised, but the method used to conceal the allocation was not described.
  • High risk: if the allocation sequence was known to the investigators who assigned participants.

 

Blinding of outcome assessment (mortality)

Blinding in the resuscitation of trauma patients is in many instances impossible. In this review, with the diagnostic strategy considered as an intervention in this research question, blinding was considered impossible.

 

Incomplete outcome data assessed

  • Low risk: if the percentage of dropouts did not exceed 20%, and numbers and reasons for dropouts and withdrawals in all intervention groups were described.
  • Unclear: if the report gave the impression that there had been no dropouts or withdrawals, but this was not specifically stated.
  • High risk: if the percentage of dropouts exceeded 20%, or the numbers and reasons for dropouts and withdrawals were not described.

 

Selective outcome reporting

  • Low risk: if it was clear that the published report included all expected outcomes, including those that were prespecified in the study protocol.
  • Unclear: if insufficient information was provided to permit clear judgement of this aspect.
  • High risk: if not all relevant outcomes and all the study's prespecified outcomes were reported, or if they were incompletely reported.

 

Other sources of bias

  • Low risk: if the study appeared to be free of other sources of bias.
  • Unclear: if a risk of potentially important bias existed, but sufficient information to assess this bias was lacking.
  • High risk: if one or more sources of potentially important biases could be identified in the study (e.g. extreme baseline imbalances or other imbalances in study design).

Particular biases considered in cluster-randomised trials were related to recruitment bias: participants may have differed due to the differences that may have existed between the participating clusters.

 

Measures of treatment effect

In the future, if studies are included in an update of the review, we will present dichotomous data in proportions. We will present normally distributed continuous data as means with their standard deviations (SD). We will present non-normally distributed numerical data as medians with ranges and interquartile range (IQR), where appropriate.

For dichotomous data, we will use risk ratios as the summary statistic. For continuous outcomes, we will use mean differences as the summary statistic. However, study authors often present their results in medians with ranges due to suspicion of skewed data, while means with their SDs are needed for meta-analysis. In these cases, we will first contact study authors for additional data. If we cannot retrieve the means, we will also perform a sensitivity analysis, imputing data for missing means and SDs (Hozo 2005).

 

Unit of analysis issues

In the study reports, the number of observations in the analysis should match the number of participants that were randomised. Participants should be individually randomised to one of two intervention groups. A single measurement for each outcome from each participant should be collected and analysed.

If we identify RCTs when this review is updated, we will consider data analysis from cluster-randomised trials in the primary analysis. If the randomisation was performed on clusters rather than individuals, we will perform approximately correct analysis with the use of effective sample size (Rao 1992), in order to prevent a unit of analysis error (Whiting-O'Keefe 1984). We will carry out this analysis when the following data can be extracted: number of clusters randomised to each intervention group (or mean size of each cluster), outcome data ignoring the cluster design for the total number of individuals and an estimate of the intracluster correlation coefficient (Donner 1980).

 

Dealing with missing data

If outcome or summary data are missing from a study identified when this review is updated, we will try to retrieve these data by contacting the authors of the article concerned.

 

Assessment of heterogeneity

Considerable variation in results, particularly inconsistency in the direction of effect, may represent clinical heterogeneity. We found no RCTs meeting the criteria for inclusion in this review. However, if substantial clinical heterogeneity is present in RCTs identified in an update of this review, we will not perform a meta-analysis. We will calculate statistical heterogeneity using the Higgins Chi2 test and quantify the inconsistency in study effects using the I2 statistic (Higgins 2002). We will consider a Chi2 test with a P value < 0.10 to indicate the presence of heterogeneity, while we will consider an I2 statistic greater than 50% to suggest a marked inconsistency in effect between studies.

 

Assessment of reporting biases

If we identify RCTs in a future update of this review, we will use a funnel plot if there are 10 or more studies included in an analysis. This may help identify the presence of publication or other types of biases (Macaskill 2001).

 

Data synthesis

We aimed to compare routine thoracoabdominal CT versus selective CT in the resuscitation of high-energy blunt-trauma patients through meta-analysis. If we identify RCTs in a future update of this review, for the meta-analysis, we will use a fixed-effect model first and then a random-effects model if the fixed-effect model is inappropriate based on a value of the I2 statistic greater than 50% (Higgins 2011). We will conduct statistical analysis using the statistical package Review Manager 5 provided by The Cochrane Collaboration (RevMan 2012). We will consider differences to be significant when the P value is less than 0.05.

 

Subgroup analysis and investigation of heterogeneity

If heterogeneity greater than 50% is present based on the I2 statistic, we will re-checked the data first. If heterogeneity persists, we will excluded extreme outliers if appropriate. In the event of missing data, we will impute median or mean values.

We will perform subgroup analysis based on gender, age and differences in the severity of trauma.

 

Sensitivity analysis

If sufficient data are available for a future update of this review, we will perform sensitivity analyses based on allocation concealment.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms
 

Description of studies

 

Results of the search

We identified 396 studies using the search strategy. The study selection process is summarised in the PRISMA flow diagram (Figure 1).

 FigureFigure 1. Study flow diagram.

 

Included studies

We found no randomised or cluster-randomised studies comparing routine thoracoabdominal CT versus selective thoracoabdominal CT in blunt high-energy trauma patients.

 

Excluded studies

We excluded 396 studies because they were irrelevant to the topic of the review. Of the 396, 381 were excluded based on the abstract and title, because these studies did not compare routine versus selective thoracoabdominal CT. We assessed 15 articles for eligibility. Of these, we subsequently excluded six studies because they were prospective observational studies (Deunk 2009; Rieger 2009; Salim 2006; Sampson 2006; Tillou 2009; Yeguiayan 2012), seven were retrospective cohort studies (Huber-Wagner 2009; Hutter 2011; Self 2013; Smith 2011; Weninger 2007; Wurmb 2009; Wurmb 2011), one was an overview (Stengel 2009), and one was a technical CT study (Okamoto 2002). See the Characteristics of excluded studies table.

 

Risk of bias in included studies

We included no studies in this review.

 

Effects of interventions

We included no studies in this review.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms

We found one report of an RCT comparing routine versus selective thoracoabdominal CT in blunt high-energy trauma patients, which is currently recruiting in the Netherlands. As no data are currently available from completed RCTs, the current practice of using routine thoracoabdominal CT is based on non-randomised, observational and retrospective studies.

Due to the paucity of RCTs, evidence to support one of the diagnostic strategies is limited. RCTs with low risks of systematic and random error comparing routine versus selective (thoracoabdominal) CT are needed and it is possible to evaluate the benefits and harms of this diagnostic strategy as an intervention. The results may guide the evidence base of further implementation of CT in blunt high-energy trauma patients. One ongoing international multicentre RCT in the Netherlands is aiming to provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group (REACT-2).

 

Summary of main results

We included no studies in this review.

 

Potential biases in the review process

Although a specialist information scientist composed as extensive and sensitive search, which was run on different databases, it is possible that articles were missed by the search.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms

 

Implications for practice

Patients sustaining blunt high-energy trauma need an accurate and rapid evaluation to optimise their management with the goal of increasing survival. Routine thoracoabdominal computed tomography (CT) has the potential to have an important role during the resuscitation of a trauma patient. While the diagnostic value of CT seems clear, its benefits on mortality cannot be established as no randomised trials have been conducted. Randomised controlled trials with low risks of bias are needed to guide recommendations.

 
Implications for research

Good-quality randomised controlled trials comparing routine versus selective (thoracoabdominal) CT for patients with blunt high-energy trauma are needed. These prospective trials should focus on mortality as a primary outcome measure, but should also assess adverse events such as non-therapeutic laparotomies, morbidity, costs, and rates and consequences of missed injuries.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms

The authors thank Emma Sydenham, Deirdre Beecher, Karen Blackhall and the staff of the Cochrane Injuries Group editorial base.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms

This review has no analyses.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms
 

Appendix 1. Search strategies

Cochrane Injuries Group Specialised Register

1 ((blunt or non-penetrat*) AND (trauma* or injur* or wound*)) AND ( INREGISTER) [REFERENCE] [STANDARD]
#2 ((spleen or splenic or liver or hepatic or abdomen or abdominal or stomach or thorax or thoracic) AND (trauma* or injur* or ruptur* or bleed*)) AND ( INREGISTER) [REFERENCE] [STANDARD]
#3 #1 OR #2 [REFERENCE] [STANDARD]
#4 ((x-ray or xray or tomography or ct)) AND ( INREGISTER) [REFERENCE] [STANDARD]
#5 #3 AND #4 [REFERENCE] [STANDARD]

Cochrane Central Register of Controlled Trials (The Cochrane Library)

#1 MeSH descriptor Tomography, X-Ray Computed explode all trees
#2 (CT near3 (cine or scan* or x?ray* or xray*)):ti,ab,kw
#3 (CT or MDCT):ti
#4 ((electron?beam* or comput* or axial) near3 tomography):ti,ab,kw
#5 (tomodensitometry):ti,ab,kw
#6 (#1 OR #2 OR #3 OR #4 OR #5)
#7 MeSH descriptor Wounds, Nonpenetrating explode all trees
#8 MeSH descriptor Thoracic Injuries explode all trees
#9 MeSH descriptor Abdominal Injuries explode all trees
#10 ((Nonpenetrating or blunt) near3 (wound* or injur*)):ti,ab,kw
#11 MeSH descriptor Liver explode all trees with qualifier: IN
#12 MeSH descriptor Diaphragm explode all trees
#13 MeSH descriptor Intestine, Small explode all trees with qualifier: IN
#14 MeSH descriptor Intestine, Large explode all trees with qualifier: IN
#15 MeSH descriptor Colon explode all trees with qualifier: IN
#16 MeSH descriptor Spleen explode all trees with qualifier: IN
#17 MeSH descriptor Aorta, Thoracic explode all trees with qualifier: IN
#18 MeSH descriptor Urinary Bladder explode all trees with qualifier: IN
#19 MeSH descriptor Heart Injuries explode all trees
#20 MeSH descriptor Ribs explode all trees
#21 MeSH descriptor Sternum explode all trees with qualifier: IN
#22 MeSH descriptor Lung Injury explode all trees
#23 MeSH descriptor Shock, Traumatic explode all trees
#24 MeSH descriptor Splenic Rupture explode all trees
#25 MeSH descriptor Aorta, Abdominal explode all trees
#26 (#7 OR #8 OR #9 OR #10 OR #11 OR #12 OR #13 OR #14 OR #15 OR #16 OR #17 OR #18 OR #19 OR #20 OR #21 OR #22 OR #23 OR #24 OR #25)
#27 (#26 AND #6)

MEDLINE (OvidSP)

1. (CT adj3 (cine or scan* or x?ray* or xray*)).ab,ti.
2. CT or MDCT.ti.
3. ((electron?beam* or comput* or axial) adj3 tomography).ab,ti.
4. tomodensitometry.ab,ti.
5. exp Tomography, X-Ray Computed/
6. 1 or 3 or 4 or 5
7. exp Wounds, Nonpenetrating/
8. exp Thoracic Injuries/
9. exp Abdominal Injuries/
10. exp Hernia, Diaphragmatic, Traumatic/
11. ((Nonpenetrating or blunt) adj3 (wound* or injur*)).ab,ti.
12. exp Liver/in [Injuries]
13. exp Diaphragm/in [Injuries]
14. exp Intestine, Small/in [Injuries]
15. exp Intestine, Large/in [Injuries]
16. exp Colon/in [Injuries]
17. exp Spleen/in [Injuries]
18. exp Splenic Rupture/
19. exp Aorta, Abdominal/in [Injuries]
20. exp Aorta, Thoracic/in [Injuries]
21. exp Urinary Bladder/in [Injuries]
22. exp Heart Injuries/
23. exp Ribs/in [Injuries]
24. exp Sternum/in [Injuries]
25. exp Lung Injury/
26. exp Shock, Traumatic/
27. ((Injur* or trauma* or blunt or non?penetrat*) adj5 (abdom* or liver or spleen or splenic or diaphragm* or aorta or thorax or thorac* or bowel or intestine* or colon* or bladder* or heart or rib* or lung*)).ti.
28. 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27
29. 6 and 28
30. randomi?ed.ab,ti.
31. randomized controlled trial.pt.
32. controlled clinical trial.pt.
33. placebo.ab.
34. clinical trials as topic.sh.
35. randomly.ab.
36. trial.ti.
37. 30 or 31 or 32 or 33 or 34 or 35 or 36
38. (animals not (humans and animals)).sh.
39. 37 not 38
40. 29 and 39

EMBASE Classic + EMBASE (OvidSP)
1. exp computer assisted tomography/
2. (CT adj3 (cine or scan* or x?ray* or xray*)).ab,ti.
3. ((electron?beam* or comput* or axial) adj3 tomography).ab,ti.
4. tomodensitometry.ab,ti.
5. CT.mp. or MDCT.mp.
6. 1 or 2 or 3 or 4 or 5
7. exp blunt trauma/
8. exp thorax injury/
9. exp abdominal injury/
10. exp diaphragm hernia/
11. ((Nonpenetrating or blunt) adj3 (wound* or injur*)).ab,ti.
12. exp liver injury/
13. exp diaphragm injury/
14. exp intestine injury/
15. exp large intestine/
16. exp colon injury/
17. exp spleen injury/
18. exp spleen rupture/
19. exp abdominal aorta/
20. exp thoracic aorta/
21. exp bladder injury/
22. exp heart injury/
23. exp rib fracture/
24. sternum/
25. exp lung injury/
26. exp traumatic shock/
27. ((Injur* or trauma* or blunt or non?penetrat*) adj5 (abdom* or liver or spleen or splenic or diaphragm* or aorta or thorax or thorac* or bowel or intestine* or colon* or bladder* or heart or rib* or lung*)).ti.
28. 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16 or 17 or 18 or 19 or 20 or 21 or 22 or 23 or 24 or 25 or 26 or 27
29. 6 and 28
30. randomi?ed.ab,ti.
31. (randomised or randomized or randomly or random order or random sequence or random allocation or randomly allocated or at random or controlled clinical trial$).tw,hw.
32. clinical trial/
33. 30 or 31 or 32
34. human/
35. exp animal/
36. exp experimental animal/
37. animal experiment/
38. 35 or 36 or 37
39. 38 not 34
40. 33 not 39
41. 29 and 40
42. limit 41 to exclude medline journals

CINAHL Plus (EBSCO)
S1 (MH "Clinical Trial+")
S2 PT Clinical trial
S3 TX clinic* n1 trial*
S4 TX ( (ingl* n1 blind*) or (ingl* n1 mak*) ) or TX ( (doubl* n1 blind*) or (doubl* n1 mak*) ) or TX ((tripl* n1 blind*) or (tripl* n1 mak*) ) or TX ( (trebl* n1 blind*) or (trebl* n1 mak*) )
S5 TX randomi* control* trial*
S6 (MH "Random Assignment")
S7 TX random* allocat*
S8 TX placebo*
S9 (MH "Placebo")
S10 (MH "Quantitative studie")
S11 TX allocat* random*
S12 S1 or S2 or S3 or S4 or S5 or S6 or S7 or S8 or S9 or S10 or S11
S13 (MH "Tomography, X-Ray Computed+")
S14 TI (ct or mdct)
S15 AB (tomodenitometry)
S16 AB (electron?beam* or comput* or axial) n3 AB (tomography)
S17 AB (cine or can* or xray* or xray*) n3 (ct)
S18 S13 or S14 or S15 or S16 or S17
S19 (MH "Wound, Nonpenetrating+")
S20 (MH "Thoracic Injurie+")
S21 (MH "Abdominal Injurie+")
S22 (MH "Hernia, Diaphragmatic+")
S23 AB (Nonpenetrating or blunt) n3 (wound* or injur*)
S24 (MH "Liver/IN")
S25 (MH "Diaphragm/IN")
S26 (MH "Intestine, mall+/IN")
S27 (MH "Intestine, Large+/IN")
S28 (MH "Colon+/IN")
S29 (MH "Spleen/IN")
S30 (MH "Splenic Rupture")
S31 (MH "Aorta, Abdominal/IN")
S32 (MH "Aorta, Thoracic/IN")
S33 (MH "Urogenital system+/IN")
S34 (MH "Heart Injurie+")
S35 (MH "Rib/IN")
S36 (MH "Sternum/IN")
S37 (MH "Lung Injury+")
S38 (MH "Shock, Traumatic+")
S39 TI (Injur* or trauma* or blunt or non?penetrat*) n5 (abdom* or liver or spleen or splenic or diaphragm* or aorta or thorax or thorac* or bowel or intestine* or colon* or bladder* or heart or rib* or lung*)
S40 S19 or S20 or S21 or S22 or S23 or S24 or S25 or S26 or S27 or S28 or S29 or S30 or S31 or S32 or S33 or S34 or S35 or S36 or S37 or S38 or S39
S41 S12 and S18 and S40

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms

RvV and DK reviewed the study references. All authors contributed to writing the review.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms

None known.

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. Contributions of authors
  12. Declarations of interest
  13. Differences between protocol and review
  14. Index terms

None.

References

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Differences between protocol and review
  15. Characteristics of studies
  16. References to studies excluded from this review
  17. References to ongoing studies
  18. Additional references
Deunk 2009 {published data only}
  • Deunk J, Brink M, Dekker HM, Kool DR, Blickman JG, van Vugt AB, et al. Routine versus selective multidetector-row computed tomography (MDCT) in blunt trauma patients: level of agreement on the influence of additional findings on management. Journal of Trauma 2009;67(5):1080-6.
Huber-Wagner 2009 {published data only}
  • Huber-Wagner S, Lefering R, Qvick LM, Körner M, Kay MV, Pfeifer KJ, et al. Effect of whole-body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009;373(9673):1455-61.
Hutter 2011 {published data only}
  • Hutter M, Woltmann A, Hierholzer C, Gärtner C, Bühren V, Stengel D. Association between a single-pass whole-body computed tomography policy and survival after blunt major trauma: a retrospective cohort study. Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2011;19:73.
Okamoto 2002 {published data only}
  • Okamoto K, Norio H, Kaneko N, Sakamoto T, Kaji T, Okada Y. Use of early-phase dynamic spiral computed tomography for the primary screening of multiple trauma. American Journal of Emergency Medicine 2002;20(6):528-34.
Rieger 2009 {published data only}
  • Rieger M, Czermak B, El Attal R, Sumann G, Jaschke W, Freund M. Initial clinical experience with a 64-MDCT whole-body scanner in an emergency department: better time management and diagnostic quality?. Journal of Trauma 2009;66(3):648-57.
Salim 2006 {published data only}
  • Salim A, Sangthong B, Martin M, Brown C, Plurad D, Demetriades D. Whole body imaging in blunt multisystem trauma patients without obvious signs of injury: results of a prospective study. Archives of Surgery 2006;141(5):468-75.
Sampson 2006 {published data only}
Self 2013 {published data only}
  • Self ML, Blake AM, Whitley M, Nadalo L, Dunn E. The benefit of routine thoracic, abdominal, and pelvic computed tomography to evaluate trauma patients with closed head injuries. American Journal of Surgery 2003;186(6):609-14.
Smith 2011 {published data only}
  • Smith CM, Woolrich-Burt L, Wellings R, Costa ML. Major trauma CT scanning: the experience of a regional trauma centre in the UK. Emergency Medicine Journal 2011;28(5):378-82.
Stengel 2009 {published data only}
  • Stengel D, Frank M, Matthes G, Schmucker U, Seifert J, Mutze S, et al. Primary pan-computed tomography for blunt multiple trauma: can the whole be better than its parts?. Injury 2009;40 (Suppl 4):S36-46.
Tillou 2009 {published data only}
  • Tillou A, Gupta M, Baraff LJ, Schriger DL, Hoffman JR, Hiatt JR, et al. Is the use of pan-computed tomography for blunt trauma justified? A prospective evaluation. Journal of Trauma 2009;67(4):779-87.
Weninger 2007 {published data only}
  • Weninger P, Mauritz W, Fridrich P, Spitaler R, Figl M, Kern B, et al. Emergency room management of patients with blunt major trauma: evaluation of the multislice computed tomography protocol exemplified by an urban trauma center. Journal of Trauma 2007;62(3):584-91.
Wurmb 2009 {published data only}
  • Wurmb TE, Frühwald P, Hopfner W, Keil T, Kredel M, Brederlau J, et al. Whole-body multislice computed tomography as the first line diagnostic tool in patients with multiple injuries: the focus on time. Journal of Trauma 2009;66(3):658-65.
Wurmb 2011 {published data only}
  • Wurmb TE, Quaisser C, Balling H, Kredel M, Muellenbach R, Kenn W, et al. Whole-body multislice computed tomography (MSCT) improves trauma care in patients requiring surgery after multiple trauma. Emergency Medicine Journal 2011;28(4):300-4.
Yeguiayan 2012 {published data only}
  • Yeguiayan JM, Yap A, Freysz M, Garrigue D, Jacquot C, Martin C, et al. Impact of whole-body computed tomography on mortality and surgical management of severe blunt trauma. Critical Care 2012;16(3):R101.

References to ongoing studies

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Differences between protocol and review
  15. Characteristics of studies
  16. References to studies excluded from this review
  17. References to ongoing studies
  18. Additional references
REACT-2 {published data only}
  • Sierink JC, Saltzherr TP, Beenen LF, Luitse JS, Hollmann MW, Reitsma JB, et al. A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2). BMC Emergency Medicine 2012;12:4.

Additional references

  1. Top of page
  2. AbstractRésumé scientifique
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. Contributions of authors
  13. Declarations of interest
  14. Differences between protocol and review
  15. Characteristics of studies
  16. References to studies excluded from this review
  17. References to ongoing studies
  18. Additional references
ATLS 2012
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Brink 2008
  • Brink M, Deunk J, Dekker HM, Kool DR, Edwards MJ, van Vugt AB, et al. Added value of routine chest MDCT after blunt trauma: evaluation of additional findings and impact on patient management. American Journal of Roentgenology 2008;190(6):1591-8.
Davis 1992
  • Davis JW, Hoyt DB, McArdle MS, Mackersie RC, Eastman AB, Virgilio RW, et al. An analysis of errors causing morbidity and mortality in a trauma system: a guide for quality improvement. Journal of Trauma 1992;32(5):660-5.
Deeks 2003
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Deunk 2007
  • Deunk J, Dekker HM, Brink M, van Vugt R, Edwards MJ, van Vugt AB. The value of indicated computed tomography scan of the chest and abdomen in addition to the conventional radiologic work-up for blunt trauma patients. Journal of Trauma 2007;63(4):757-63.
Devine 2010
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Donner 1980
Fakhry 2000
  • Fakhry SM, Brownstein M, Watts DD, Baker CC, Oller D. Relatively short diagnostic delays (<8 hours) produce morbidity and mortality in blunt small bowel injury: an analysis of time to operative intervention in 198 patients from a multicenter experience. Journal of Trauma 2000;48(3):408-14.
Higgins 2002
Higgins 2011
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Hozo 2005
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Inaba 2011
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Ioannidis 2001
Jakobsen 2013
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Keus 2010
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Trupka 1997
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