Evaluation and comparison of the efficacy of three clinical decision tools in patients who received full body computed tomography due to trauma in the emergency department

Introduction: The whole-body computed tomography (WBCT) scanning has been used in multiple trauma patients since 1997. No standard approach has not yet been established in the practice of medicine for which multiple trauma patients undergo the WBCT as a diagnostic tool. There are three attempts to establish clinical decision rules to demonstrate the necessity of the WBCT. These are Manchester Trauma Imaging Protocol (ManTIS), Chanta et al. WBCT Clinical Decision Rules in Trauma Patients and Vittel Criteria. In our study, we aimed to compare these three clinical decision rule trials with each other and physicians' physical examination and clinical gestalt and to evaluate their effectiveness. Method: In this cross-sectional study, 369 patients over the age of 18 who were admitted to Emergency Medicine Department, Dokuz Eylul University between 01.08.2019-01.03.2020 and who was undergone the WBCT. Demographic data, physiological findings, trauma mechanisms, physical examination findings, resuscitation needs, reasons of physicians' decision to undergo the WBCT, and the findings expected by the WBCT were recorded. The recommendations of the clinical decision rules for patients undergoing the WBCT were determined. Afterwards, the findings detected in the WBCT, patient outcomes were followed and Abbreviated Injury Score (AIS) was calculated. Primary outcome for comparison was presence of polytrauma on WBCT. We defined polytrauma as a CT scan demonstrating injuries were detected in at least two body areas or demonstrating major injury in one body area or demonstrating AIS>2 in whole body. Results: 248 (67.2%) of the 369 patients included in the study were male. The median age was 44.0 (IQR: 31.0-64.0; range: 18-98). The most frequent trauma mechanism was road traffic accident (out of vehicle) (n = 131 (35%)). WBCT results showed no positive findings in 184 (49.9%) patients, while 65 (17.6%) had positive findings in more than one body region. 129 (35%) patients' AIS was higher than 2 point. ManTIS suggested that 83 (22.5%) patients should have WBCT. Chanta et al. clinical decision rule suggested that 180 (48.8%) patients should have WBCT and Vittel criteria suggested that 233 (63.1%) patients should have WBCT. For the detection of pathology in more than one body region, their sensitivity were 56.9%, 81.5% and 72.3% respectively, and their specificity were 84.9%, 58.2% and 38.8% respectively. For the detection AIS>2 injuries were 43.4%, 67.4% and 62.8% respectively, and their specificity were 88.8%, 61.3% and 36.7% respectively. The sensitivity of physicians to detect pathology in more than one body region was 76.9%, and selectivity was 66.8%. The sensitivity of physicians to detect AIS>2 injuries was 61.2%, and selectivity was 70.0%. WBCT did not detect injury in more than one body part in any patient whose physical examination suspected injury at most in one body part. As the result of WBCT, AIS> 2 injuries were detected in only 1 patient whose physical examination suspected injury in only one body part. Conclusion: The sensitivity and specificity of the three clinical decision rules were similar and close to the physician clinical gestalt. The most sensitive clinical decision rule was Chanta et al. Clinical Decision Rule and the most selective clinical decision rule was ManTIS. On the other hand, physical examination findings had higher sensitivity than the three clinical decision rules. It is likely that the use of clinical decision alone was insufficient to change the current practice in order to request the WBCT in trauma patients. Keywords: multiple trauma, whole-body computed tomography, Manchester Trauma Imaging Protocol (ManTIS), Chanta et al. WBCT Clinical Decision Rules in Trauma Patients, Vittel Criteria, clinical gestalt, physical examination, clinical protocols, traumatology