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Abstract
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The importance of performing an early primary survey in 'silver trauma' patients in the detection of injuries has been well documented in reducing the associated morbidity and mortality.[1] In the past, when whole body computed tomography (WBCT) was not commonly available, following initial examination patients would undergo chest radiograph and pelvic X-ray and then proceed to selective computed tomography (CT). With the relatively widespread availability of CT, the use of these X-rays has diminished. The reliance on clinical examination alone for the detection of underlying injuries is another matter of debate.
Physical examination of elderly patients has been shown to have a low sensitivity (as low as 0.69) to the detection of injury when compared to WBCT when used as the gold standard.[2] It is also noted that WBCT is more likely to detect further injuries that may not necessarily be detected on clinical examination alone.[2] Routine CT imaging for patients with unreliable physical examination is reported to reveal unsuspected findings in up to 38%, leading to treatment changes in 19%-26%.[3,4] The discussion about the impact of these injuries (if any) if imaging was selected solely based on clinical examination is an ever-important question that needs a rational approach. Since the probability of detecting injuries after major trauma during the clinical course of alert patients might be lowered after WBCT, in-hospital observation might be less valuable.
The main disadvantage of WBCT is the increased radiation exposure, especially in minor injury cases where a selective CT would be sufficient. In trauma patients, the proportion of patients receiving a high radiation dose of > 20 mSv[5] is higher than that of patients undergoing selective CT.
The debate for selective vs. WBCT imaging continues for elderly trauma patients. Currently, there are no specific guidelines for selective CT or WBCT for the initial detection of injuries in elderly patients. Low-energy trauma, including falls from a standing height, has become the most common form of injury. The most common anatomical domains that are injured following these types of falls involve the head and cervical spine.[6] However, this is often associated with increased morbidity and mortality.[7] The balance between excessive radiation and the risk of missing injury is also a matter of debate.[8] While WBCT is more likely to detect additional injuries, the impact of the detection of these injuries and the change in management (if at all) is an important question.
Language: en |