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Emergency Medicine

Association of Low-Dose Whole-Body Computed Tomography With Missed Injury Diagnoses and Radiation Exposure in Patients With Blunt Multiple Trauma

Educational Objective
To identify the extent to which low-dose whole-body computed tomography with statistical image reconstruction is associated with similar rates of missed injuries and accuracy but reduced radiation exposure compared with standard-dose whole-body computed tomography in the primary diagnostic workup of blunt multiple trauma.
1 Credit CME
JAMA Surgery
March 1, 2020
Original Investigation
Dirk Stengel, MD, PhD, MSc1,2,3;
Sven Mutze, MD, PhD4,5;
Claas Güthoff, PhD1;
Moritz Weigeldt, MD1;
Konrad von Kottwitz, MD2;
Domenique Runge, MD1;
Filip Razny, MD4;
Anna Lücke, MD4;
Dirk Müller, PhD6;
Axel Ekkernkamp, MD, PhD2,3,7;
Thomas Kahl, MD4
Author Affiliations
  • 1Center for Clinical Research, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
  • 2Department of Trauma and Orthopaedic Surgery, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
  • 3BG Kliniken–Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Berlin, Germany
  • 4Institute of Radiology, BG Klinikum Unfallkrankenhaus Berlin gGmbH, Berlin, Germany
  • 5Institute for Diagnostic Radiology and Neuroradiology, Universitätsmedizin Greifswald, Greifswald, Germany
  • 6Consultant in radiation physics, Hamburg, Germany
  • 7Department of Trauma, Reconstructive Surgery and Rehabilitation Medicine, Universitätsmedizin Greifswald, Greifswald, Germany
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Key Points

Question  Is low-dose whole-body computed tomography with statistical image reconstruction associated with similar rates of missed injuries and accuracy but reduced radiation exposure compared with standard-dose whole-body computed tomography in the primary diagnostic workup of blunt multiple trauma?

Findings  In this quasi-experimental cohort study of 971 patients with suspected blunt multiple trauma, participants in the standard-dose and low-dose whole-body computed tomography groups had the same risk of missed injury diagnoses. Low-dose scanning markedly reduced exposure to radiation, improved the contrast-to-noise ratio, and showed similar diagnostic accuracy among the investigated anatomical areas and organs when compared with standard-dose scanning.

Meaning  These findings suggest that low-dose whole-body computed tomography may safely replace standard-dose scanning in the primary diagnostic workup of blunt multiple trauma.

Abstract

Importance  Initial whole-body computed tomography (WBCT) for screening patients with suspected blunt multiple trauma remains controversial and a source of excess radiation exposure.

Objective  To determine whether low-dose WBCT scanning using an iterative reconstruction algorithm does not increase the rate of missed injury diagnoses at the point of care compared with standard-dose WBCT with the benefit of less radiation exposure.

Design, Setting, and Participants  This quasi-experimental, prospective time-series cohort study recruited 1074 consecutive patients admitted for suspected blunt multiple trauma to an academic metropolitan trauma center in Germany from September 3, 2014, through July 26, 2015, for the standard-dose protocol, and from August 7, 2015, through August 20, 2016, for the low-dose protocol. Five hundred sixty-five patients with suspected blunt multiple trauma prospectively received standard-dose WBCT, followed by 509 patients who underwent low-dose WBCT. Confounding was controlled by segmented regression analysis and a secondary multivariate logistic regression model. Data were analyzed from January 16, 2017, through October 14, 2019.

Interventions  Standard- or low-dose WBCT.

Main Outcomes and Measures  The primary outcome was the incidence of missed injury diagnoses at the point of care, using a synopsis of clinical, surgical, and radiological findings as an independent reference test. The secondary outcome was radiation exposure with either imaging strategy.

Results  Of 1074 eligible patients, 971 (mean [SD] age, 52.7 [19.5] years; 649 men [66.8%]) completed the study. A total of 114 patients (11.7%) had multiple trauma, as defined by an Injury Severity Score of 16 or greater. The proportion of patients with any missed injury diagnosis at the point of care was 109 of 468 (23.3%) in the standard-dose and 107 of 503 (21.3%) in the low-dose WBCT groups (risk difference, −2.0% [95% CI, −7.3% to 3.2%]; unadjusted odds ratio, 0.89 [95% CI, 0.66-1.20]; P = .45). Adjustments for autocorrelation and multiple confounding variables did not alter the results. Radiation exposure, measured by the volume computed tomography dose index, was lowered from a median of 11.7 (interquartile range, 11.7-17.6) mGy in the standard-dose WBCT group to 5.9 (interquartile range, 5.9-8.8) mGy in the low-dose WBCT group (P < .001).

Conclusions and Relevance  Low-dose WBCT using iterative image reconstruction does not appear to increase the risk of missed injury diagnoses at the point of care compared with standard-dose protocols while almost halving the exposure to diagnostic radiation.

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Emergency Medicine Surgery Radiology Trauma and Injury
Article Information

Accepted for Publication: October 26, 2019.

Published Online: January 15, 2020. doi:10.1001/jamasurg.2019.5468

Correction: This article was corrected on April 1, 2020, to add missing affiliations for Drs Mutze and Ekkernkamp and to add a missing data point in eTable 4 in the Supplement.

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2020 Stengel D et al. JAMA Surgery.

Corresponding Author: Dirk Stengel, MD, PhD, MSc, BG Kliniken–Klinikverbund der Gesetzlichen Unfallversicherung gGmbH, Leipziger Platz 1, 10117 Berlin, Germany (dirk.stengel@bg-kliniken.de).

Author Contributions: Dr Stengel had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Stengel, Mutze, Güthoff, Weigeldt, Müller, Ekkernkamp, Kahl.

Acquisition, analysis, or interpretation of data: Stengel, Mutze, Güthoff, Weigeldt, von Kottwitz, Runge, Razny, Müller, Kahl.

Drafting of the manuscript: Stengel, Mutze, Güthoff, Müller, Kahl.

Critical revision of the manuscript for important intellectual content: Stengel, Mutze, Güthoff, Weigeldt, von Kottwitz, Razny, Müller, Ekkernkamp, Kahl.

Statistical analysis: Stengel, Güthoff.

Obtained funding: Stengel, Mutze, Ekkernkamp.

Administrative, technical, or material support: Stengel, Mutze, Weigeldt, Razny, Lücke, Kahl.

Supervision: Stengel, Mutze, Razny, Ekkernkamp, Kahl.

Other - Objective image quality analysis: Müller.

Conflict of Interest Disclosures: Dr Stengel reported occasional contracted expert statements and work (ie, scientific presentations and summaries) for Philips, Siemens, ZimmerBiomet, Johnson & Johnson, Aesculap, and other industrial partners. Dr Mutze reported scientific collaboration with Philips Healthcare. Dr Müller reported being a former employee of Philips Healthcare. Dr Ekkernkamp reported scientific collaboration with Philips Healthcare. No other disclosures were reported.

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