EM Nerd - February 13, 2016 - By Rory Spiegel
"It is not uncommon for the standard of care to be dictated by those who speak the loudest rather than a representative sample of best medical practice. This is certainly the case with the inclusion of whole-body CT scans in the initial management of patients presenting to the Emergency Department with traumatic complaints. Known colloquially as the trauma pan-scan, this global irradiation has become a significant part of the primary survey in many trauma centers across the US. For critically ill trauma patients in whom the clinical exam is unreliable, the introduction of the CT scan has been invaluable. What benefits do total body radiological evaluations provide for the clinically stable, cognitively present patient with minor injuries?...
...The implication when reviewing this literature is that well appearing, evaluable patients presenting to the Emergency Department may be harboring clinically occult, life threatening injuries undetectable by a standard physical exam. And yet this interpretation is based off methodologically flawed retrospective analyses and prospective data sets in which the physical exam was all but neglected. More importantly this ignores the multitude of clinical decision instruments, derived and validated from high quality prospective data, demonstrating that imaging can be avoided using simple components from a history and physical exam. Randomized data is required to truly assess whether the whole-body CT is beneficial in the workup of the undiagnosed trauma patient. One such trial is underway and its results are urgently needed. But even if it shows a small benefit in detecting clinically meaningless injuries we must ask ourselves, what is the cost? How many patients do we have to expose to harmful radiation to find one additional rib fracture? What portion of these injuries would remain occult during a reasonable period of observation? How does this overzealous imaging strategy affect the flow of the rest of the department? What about the remainder of our patients, the ones who may truly require an emergent CT who are continually bumped in favor of the endless trauma alerts? There is a cost to all our actions and it behooves us to consider them carefully. No matter who is yelling the loudest."
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