Imaging prior to transfer to a trauma center has been the subject of debate for years. The focus has primarily been on the necessity of these scans, and the sheer numbers that are done. For the most part, the discussion has been driven by the potential for radiation exposure.
This paper, from the University of Oklahoma, takes a different approach. The authors looked at the accuracy and adequacy of imaging performed prior to transfer to their Level I trauma center.
Patients were enrolled prospectively over an 8 month period in 2012. Outside images were interpreted by a single radiologist who was blinded to the outside interpretation. If images were repeated, they were compared to the first scan, and the reason for the redo was noted.
Here are the factoids:
- 235 consecutive transfer patients were enrolled, and 203 who had at least one CT scan were included in the final dataset
- 76% of these patients had additional imaging performed once they arrived at the trauma center
- Reasons for additional images were insufficient workup (76%) and technical inadequacy (31%)
- Missed injuries were detected on outside CT scans 49% of the time, and the majority of them (90%) were deemed clinically significant
- Missed injuries on a repeated scan were present in 54% of patients, and 76% were clinically significant
- Overall, 73% of images (either outside or repeat) contained additional injuries
Bottom line: This is a new approach to assessing the value of outside imaging prior to transfer to a trauma center. I have always recommended that trauma centers work with their referral partners to assure them we don’t need them to do the workup for us. I encourage them to obtain only what they need to decide if they can keep the patient. But once they find anything that they cannot treat, stop all workup and prepare to transfer.
Questions/comments for the authors/presenters:
- Why did you use such an old dataset?
- Is this a prospective enrollment/retrospective analysis study designed to use an existing, old dataset?
- How did you decide that outside imaging represented an inadequate workup? Do you have a diagnostic imaging guideline that you follow?
- What are the credentials for your trauma radiologist?
- How did you determine that a missed injury was clinically significant? Be sure to provide a list and explanation during your presentation.
- Be sure to separate out missed injuries seen on the original CT from new missed injuries seen on the repeat scan.
- Congratulations on looking at an old problem in a new way!
- Pediatric CT scans before transfer to a trauma center
- Repeat CT and image sharing systems
- How often are images repeated after transfer?
Reference: Adequacy and accuracy of non-tertiary trauma center computed tomography: what are we missing? Paper #7, EAST 2017.