C26 Trauma Protocols and their Correlation with Radiation Dose

Introduction Recent studies have shown that trauma imaging standards have increased radiation dose to patients which has nearly doubled due to the increase in performing CT scans over plain films. Studies have also shown that although CT image quality has improved, the overall statistics of injury such as Injury Severity Score (ISS) and hospital length of stay (LOS) has remained the same. The information provided goes through the various benefits along with the consequences of whole-body CT, plain x-rays, and ultrasound while providing suggestions as to how trauma facilities can lower radiation doses while maintaining prompt and accurate diagnoses. 1

Objectives Review current trauma imaging guidelines along with the advantages and disadvantages of each imaging modality. Increased radiation doses and unintended consequences Compare a WI Level 1 Trauma imaging protocol to ATLS imaging guidelines Improvements that can be made for Level I Trauma hospitals

Current Trauma Guidelines Advanced Trauma Life Support (ATLS) 1 AP Chest X-ray AP Pelvis X-ray X-Table Lateral Cervical Spine X-ray Enhanced Focused Assessment with Sonography in Trauma (eFAST) 2 Identifies intraperitoneal fluid Whole-Body Computed Tomography (WBCT) 2 Simultaneous inclusions of head, cervical spine, thorax, abdomen, and pelvis Rapid Imaging Protocol in Trauma (RIPIT) 3 Standardized trauma imaging protocol Non-contrast CT Head CTA from vertex to pelvis Portovenous CT abdomen to pelvis

Advantages of Imaging Modalities X-Ray 2 Least amount of radiation exposure Fairly inexpensive, most cost effective resource in trauma scenario Can be performed in patient’s bed and room eFAST 1 Conducted in trauma room without delay or interruption of resuscitation Useful in unstable patient where quick identification of major pathology required No ionizing radiation High repeatability rate WBCT Post processing can be patient specific Minimizes unnoticed injuries 2 Takes a quarter of the time and avoids one-half of the patient transfers 2 Gold standard for diagnosis of solid organ, retroperitoneal, and orthopedic injuries of pelvis and spine 4 Reduces mortality 4 RIPIT Reads at the scanner console 1 Increased findings of trauma injuries, reduces mortality 3

Disadvantages of Imaging Modalities X-ray 2 Can cause patient discomfort due to placement of IR beneath the patient Not as fast, takes more time to set up for the imaging eFAST exam 1 Operator dependent and make take longer to complete depending on experience Low sensitivity and high specificity WBCT & RIPIT Significant dose increase 3 More expensive 2 Patient age considered due to high radiation dose

Radiation Doses of Imaging Procedures EfD AP Chest X-Ray 0.054 mSv 5 AP Pelvis X-Ray 0.675 mSv 5 X-Table Lateral C-Spine X-Ray 0.107 mSv 5 eFAST N/A WBCT 29.5 mSv 5

Radiation Dose Comparisons The average number of chest x-rays performed on trauma patients decreased by approximately 2 x-rays over a 5 year period. CT scans, on average, doubled in frequency in a 5 year period. Between the two level 1 trauma centers, the radiation dose at the very least doubled over a 5 year period. 6

Unintended Consequences Studies show that there is a significant increase in ionizing radiation exposure to trauma patients with the use of CT and plain radiographs. CT gives the patient the highest dose but radiography accounts for the most of the exams. 7

Comparison of ATLS Guidelines to a WI Level I Hospital Trauma Protocol Advanced Trauma Life Support (ATLS) - AP Chest X-ray, Lateral C-spine X-ray, AP Pelvis X-ray, and eFAST 1 WI Level 1 Trauma Hospital Protocol - AP Chest X-ray, AP Pelvis X-ray, C-Spine CT Integrating eFAST with a physical examination safely provided information necessary to complete WBCT scan in stable patients without a CXR or PXR. 6 When imaging studies were performed without x-rays in stable trauma patients, the lack of x-rays did not lead to any undiagnosed life-threatening injuries and provided little decision making information.6 X-rays have little clinical value and causes unnecessary delay to diagnosis. 8

Conclusion Trauma patients need immediate diagnosis and treatment to prevent permanent damage and possibly death. Current guidelines provided by the ATLS should be updated to include current developments in imaging technology which can improve treatment. Due to advancements in computed tomography (CT) and ultrasound (US), plain film x-rays do not provide as much diagnostic information to aid with detecting pathologies as well as the other two modalities. X-rays increase radiation dose, delay time for a definitive diagnosis through CT or US, and can increase mortality because of delayed diagnosis and treatment. Diagnostic x-rays provide a minimum radiation dose compared to CT, but the cumulated dose can lead to unwanted stochastic or deterministic effects. An important factor that should be considered with patient exposure in x-ray is the “dose creep” phenomenon. Dose creep occurs when technologists use higher technical factors to improve image quality which inherently leads to an increase in patient dose. This increase in patient exposure from dose creep adds to the cumulated dose, which heightens the patient’s chance of stochastic or deterministic effects of radiation exposure. We conclude that AP chest and pelvis x-rays can be safely excluded from trauma guidelines by replacing them with eFAST and WBCT which inevitably decreases overall patient dose.

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