Benefit of the Vittel criteria to determine the need for whole body scanning in a severe trauma patient.

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ORIGINAL ARTICLE / Technical

Beneﬁt of the Vittel criteria to determine the need for whole body scanning in a severe trauma patient

J. Babaud

^a

, C. Ridereau-Zins

^a^,∗

, G. Bouhours

^b

, J. Lebigot

^a

, R. Le Gall

^b

, S. Bertrais

^c

, P.M. Roy

^d

, C. Aubé

^a^,^c

aDepartmentofRadiology,CHUAngers,4,rueLarrey,49990Angerscedex,France

bDepartmentofAnesthesiaandCriticalCare,CHUAngers,4,rueLarrey,49990Angerscedex, France

cLaboratoryHIFIH,UPRES3859,IFR132Université,Angers,France

dAdmissionsandEmergencyDepartment,CHUAngers,4,rueLarrey,49990Angerscedex, France

KEYWORDS CTscan;

Multipletrauma;

Emergency;

Vittelcriteria

Abstract

Objective:ToevaluatetheuseoftheVittelcriteriainadditiontoaclinicalexaminationto determinetheneedforawholebodyscan(WBS)inaseveretraumapatient.

Materials and methods:Between December 2008 and November 2009, 339 severe trauma patientswithatleastoneVittelcriterionwereprospectivelyevaluatedwithaWBS.Thefollow- ingdatawerecollected:theVittelcriteriapresent,circumstancesoftheaccident,traumatic injuryontheWBS,andirradiation.Theoriginalintent toprescribeacomputedtomography (CT)scan(wholebodyoratargetedregion),basedsolelyonclinicalsigns,wasspeciﬁed.

Results:Injurieswerediagnosedin55.75%oftheWBS(n=189).ThemostcommonVittelcriteria were‘‘globalassessment’’(n=266),‘‘thrown,runover’’(n=116),and‘‘ejectedfromvehicle’’

(n=94).Themultivariate analysis usedthe followingas independent criteriafor predicting severetraumaticinjuryontheWBS:Glasgowscorelessthan13,penetratingtrauma,andcolloid resuscitationgreaterthan11.Basedsolelyonclinicalfactors,164patientswouldnothavehad anyscanor(only)atargetedscan.Inthatcase,15%ofthesevereinjurieswouldhavebeen missed.

Conclusion:UsingtheVittelcriteriatodeterminetheneedforaWBSinaseveretraumapatient makesitpossibletoﬁndseriousinjuriesnotsuspectedontheclinicalexamination,butatthe costofanincreasednumberofnormalscans.

∗Correspondingauthor.

E-mailaddress:caridereauzins@chu-angers.fr(C.Ridereau-Zins).

doi:10.1016/j.diii.2012.02.007

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InFrance,severe traumais theleadingcauseof death in adults under 40 years of age [1]. Its management is a real socioeconomic challenge. Usually performed by a trained,multidisciplinary medicaland paramedical team, it requires a fast and thorough injury workup. Imaging is its foundation and consists of a whole body scan (WBS) [2—11].However,theclinicalcriteriaforperformingaWBS havenotbeenclearlyestablished.Forexample,whileitis mandatoryforanunconsciouspatientwithmultipletrauma to undergo a WBS, a fully conscious patient with focal symptomssometimeshasonlyatargetedstudyofthesymp- tomaticanatomicalarea,regardlessoftheseverityofthe trauma.Thisisallthemorecommonwhenthepatientissent toanon-specializeddepartment,wheretheinitialworkup maybeincompleteordelayed.

Similarly,thepre-admissionclinicalevaluationoftrauma patientsis well established andrelies onseverity criteria basedonareviewofﬁvecategoriesofparameters:physio- logicalvariables,kineticcomponents,anatomicalinjuries, resuscitationpriortoadmission,andpredisposition(Table1) [12].Theexistenceofoneormoreofthesecriteria,known asVittelcriteria,deﬁnesaseveretraumapatient.Ourinitial hypothesiswasthatthesecriteriacouldbeusedtodeter- minetheneedforaWBS.

Thustheprimaryobjectiveofyourstudywastoassessthe beneﬁtof usingtheVittelcriteriainadditiontoaclinical examinationtodetermine theneedfor aWBSin asevere traumapatient.

Materials and methods Study design

This was a prospective, single-center study. Between December 2008 and November 2009, 339 severe trauma patients,referredeitherbythesurgicalresuscitationroom or by the emergency department, were prospectively enrolledonan ongoing basis. The inclusioncriteriawere:

traumapatientwithatleastoneVittelcriterion(otherthan thepredispositionfactor).Theexclusioncriteriawere:less than15yearsofage,pregnancy,andfocaltraumawithout potentialmultiple traumaor severe kineticcomponent as deﬁnedintheVittelcriteria.

Technique

Traumapatientswereinitiallytreatedinthesurgicalresus- citationroomoremergencydepartment.Somepatientswho hadnoorfewsymptomscouldbereferredbyanotherhos- pitalizationdepartment.

Hemodynamicallyunstablepatientsweretreatedinthe resuscitation room. The team consisted of an anesthe- sia/criticalcareresident,asenioranesthesiologist/critical care specialist, and a nurse. An access port was always placed in the femoral veins and arteries, and a Focused AssessmentwithSonographyforTrauma(FAST)wasalways done toﬁnd any effusion in the pleura, pericardium,the pouchofDouglas,andMorrison’sspace,along withexplo- ration of the splenorenal space. The radiological workup wascompletedbyastandardx-rayofthechestandpelvis.

Then, patients who had become hemodynamically stable

Table1 ListoftheVittelcriteria.

Evaluation Severitycriteria Physiological

variables

Glasgowscore<13

Systolicbloodpressure<90mmHg O2saturation<90%

Kineticelements Ejectionfromavehicle

Otherpassengerdiedinthesame accident

Fall>6m

Victimthrownorrunover Globalassessment(vehicle deformation,estimatedspeed,no helmet,noseatbelt)

Blast Anatomical

injuries

Penetratingtrauma:head,neck, chest,abdomen,pelvis,arm, thigh

Flailchest

Severeburn,smokeinhalation Smashedpelvis

Suspectedspinalcordinjury Amputationatthewrist,ankle,or above

Acuteischemiaofalimb Resuscitation

priorto admission

Assistedventilation Colloidﬂuids>1000mL Catecholamines

Inﬂatedantishocktrousers Predisposition(to

bedetermined)

Age>65years

Heartorcoronaryfailure Respiratoryfailure Pregnancy(secondorthird trimester)

Dyscrasia

Thepresenceofasinglecriterionissufﬁcienttocharacterize the severity of thetrauma, except for predisposition, which mustbeevaluatedcasebycase.Furthermore,extremeseverity criteriaweredeﬁned,sincetheseareassociatedwithveryhigh mortality:systolicbloodpressurelessthan65mmHg(mortality:

65%),Glasgowscore—3(mortality:62%),andO2saturationless than80%orunreadable(mortality76%).

wereexaminedbyWBS.Patientswhowerestillhemodynam- ically unstablepatients weretransferred totheoperating roomforsurgicalexploration.

Patients who were initially hemodynamically stable patientscouldbetreatedintheresuscitation roomor the emergencydepartment.Afterclinicalassessmentandplace- mentofvenousaccessports,theywereexploredbyWBS.

All studies were performed with the same scanner, a PHMSBrilliancecomputedtomography(CT)16-slicemulti- detectorsystem(PhilipsNetherlands)usingastandardized protocolthatincludedseveralacquisitions.

Acquisitions without injection of contrast product, exploring the skull (120kV, 300mAs) reconstructed with bone and parenchymal windows, then the cervical spine (120kV, 250mAs) reconstructed witha bone window, and

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thentheabdominalandpelviccavity(AP)(120kV,220mAs) reconstructedwithanabdominalwindow.

AfterIVinjectionofiodinatedcontrast,acquisitionfocus- ing on the chest, abdomen, and pelvis (CAP) (120kV, 240mAs), reconstructedwithapulmonary windowfor the chest, and abdominal and bone windows for the entire CAP. The acquisition began with the chest and was per- formed60secondsafterstartingtheinjectionof130mLof Xenetix^® 350mg/mL(Guerbet,Roissy,France)at arateof 3mL/sec.

Based on the clinical guidelines and interpreting data fromthenon-injected seriesexploringthe abdominaland pelviccavity,anadditionalspiralscanwasdoneinthearte- rialphasefor25to30seconds(dependingonthepatient’s heartfunction)tolookforactivehemorrhagingand/orinthe latesecretoryphaseforatleast10minutes(ifthepatient’s conditionallowed)ifinjuriestotheurinarytractweresus- pected.

Thesupra-aorticvesselswereexploredbasedontheclin- ical and traumatic context, after reinjection of 40mL of contrast at 3mL/sec. The WBS series were immediately interpretedontheworkstationbytheradiologistonduty oroncall.Ahandwrittenprovisionalreportwasissuedafter thestudy.AsecondreadingwasalwaysdoneonaPACSwork stationby aradiologist specializing in emergencyimaging aftertheﬁrstreportwasissued.

Criteria collected

Clinicalcriteria

Thefollowingwerecollected:theVittelcriterionorcriteria present (Table 1),the circumstances of theaccident, the patient’s initial hemodynamic condition and any changes.

Finally, clinicians were asked what they would have pre- scribedoutsidethecontextofthisstudy,i.e.,awholebody scan,ascanofatargetedanatomicalarea,ornoscan.That itemwascalled‘‘originalprescribingintent’’.

Scancriteria

The radiologist completeda readingchartfor each study, classifying the injuries by system. Also entered were the time the WBSwas performed, the timeelapsed between theaccidentandtheWBS,andthetimeofthereading.The DLPontheskull/spineandCAPwerecollected.

Endpoints

Theinjuriesthatwouldnothavebeenfoundbythetargeted scanprescribedbytheclinician(item:originalprescribing intent)wereenteredforeachpatient.Thoseinjurieswere called‘‘unsuspectedinjuries’’.

For each unsuspected injury, we assessed its severity, rating as severe any potentially life-threatening or dis- abling injuries (immediate ordelayed) and injurieswhose existence affected the management or monitoring of the patient.

Statistical analysis

Firstly,weperformedadescriptiveanalysisofthedata.Dis- tributions forcategoricalvariables arepresented interms

of numbers and percentages while quantitative variables areexpressed as a mean±standard deviation (minimum, maximum).Comparisonsbetweenpatientswithandwithout injuries(determinedbyanabnormalornormalwholebody scan,respectively)wereperformedforcategoricalvariables withachisquaretest,oraFisher’sexacttestwhenthecon- ditionsforusingachisquaretestwerenotmet.Student’st testwasusedtotestthemeanagedifferencesbetweenthe twogroups.

We then determined the effectiveness of each Vittel criterion for diagnosing the presence of an injury. The following are reported for each Vittel criterion: diagnos- ticeffectiveness,sensitivity,speciﬁcity,positivepredictive value,negativepredictivevalue,andpositiveandnegative likelihoodratios. To determine which Vittel criteriawere independently associatedwiththe existence of an injury, weperformedamultivariatelogisticregression.Allanaly- ses wereperformed usingSAS^® softwareVersion 9.2 (SAS Inc.,Cary,NC).Thesigniﬁcancethresholdwassetto5%;all testsweretwo-tailed.

Results

Population characteristics

Threehundredandthirty-ninepatientswereenrolled,71.4%

men(n=242)and28.6%women(n=97).Themeanagewas 35.06 years (range: 15—88 years). Age and sex were not statisticallypredictiveoftraumaticinjuries.

Injurieswerediagnosedin55.75% oftheWBS(n=189), witharelatively proportionate distributionover the main anatomicalregions(Table2).

The mean WBS reading time was estimated at 20.48minutes (range: 8—60minutes). The mean time between the accident and performance of the WBS was 4hoursand15minutes(range:10minutesto24hours).

Description of injuries by type of accident

Trauma circumstances were dominated by automobile (51.03%, n=173) and motorcycle/bike (30.97%, n=105) accidents. The existence of injuries (all combined) was not signiﬁcantly different based on the type of accident (P<0.1138)(Table3).

Thestudyoftheanatomicalregionsaffectedbyinjuries by type of accident showed the following relationships (Table 3):injuries of theskull and/orcervical spine were more common withpedestrian and bicycle accidents and

Table2 Numberandpercentageofinjuriesbylocation.

Injuries n Percentagebased

onNo.ofpatients

Skull 63 18.6

Cervicalspine 86 25.36

Chest 103 30.38

Abdomen-pelvis 74 21.82

Vascular 4 1.17

Bone 92 27.13

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Table3 Locationofinjuriesbytypeofaccident.

Injuries Pedestrian

n/%

Car n/%

Bicycle n/%

Motorcycle/bike n/%

Fall n/%

Other n/%

Fisher’s test

Allcombined 15/75 87/50.29 7/70 53/55.21 18/69.23 6/75 0.1138

Skull/Cervicalspine 10/50 39/22.54 5/50 18/18.75 10/38.46 2/25 0.0102

Chest 9/45 47/27.17 2/20 34/35.42 7/26.92 2/25 0.4643

Abdominal 5/25 35/20.23 2/20 27/28.13 3/11.54 2/25 0.5040

Vascular 0/0 2/1.16 0/0 2/2.08 0/0 0/0 0.8382

Bone 9/45 40/23.12 0/0 29/30.21 11/42.31 3/37.50 0.0239

falls; bone injuries (other than cervical spine) were less commonwithautomobileandbicycleaccidents.

Effectiveness of original intent to prescribe a computed tomography (CT) scan for detecting traumatic injuries

When clinicians were asked about their original intent to prescribe a CT scan (whole body or targeted anatomical region),aWBSwouldhavebeenorderedin50.74%ofcases (n=172), while the others were predominantly targeted brainandcervicalspinescans.Thedistributionofscantype byanatomicalregionisreportedinTable4.

Ofthe339WBSperformed,44.2%werenormal(n=150).

Of the 172 WBS that would have performed in the con- textof an original prescribing intent, 26.7% were normal (n=46)and73.3%wereabnormal(n=126).Ofthe164WBS performed basedsolelyonthe Vittel criteria, 32.3%were abnormal(n=53)and67.7%werenormal(n=111).Thepro- portion of abnormal WBS was signiﬁcantly higher in the originalprescribingintentWBSgroupthanintheVittelcri- teriaonlyWBSgroup(P<0.0001).

Dosimetry study

The mean DLP was 1231.77 mGy.cm in the head-neck region,476.92mGy.cm inthe chest,1566 mGy.cmonthe abdominopelvicregion,and2051.54mGy.cminthecumula- tivedataonthechest/abdomen/pelvisregion.

Table4 Originalprescribingintent.

Originalprescribingintent n Percentagebased onNo.ofpatients

WBS 172 50.74

Noscan 32 9.44

Skull-cervicalspine 63 18.6

Chest 11 3.25

Abdomen-pelvis 18 5.3

Skull-cervicalspineand chest

23 6.8 Skull-cervicalspineand

abdomen-pelvis

13 3.8 ChestandAbdomen-pelvis 4 1.17

Missingdata 3 0.9

Analysis of the Vittel criteria based on traumatic injuries detected by WBS:

DistributionoftheVittelcriteria

The proportion of the various Vittel criteria present is reportedinFig.1.Themostcommoncriteriapresentwere the‘‘global assessment’’criterion(n=266),the ‘‘thrown, runover’’criterion(n=116),andthe‘‘ejectedfromvehicle’’criterion(n=94).

Theeffectivenessofthevariouscriteriafordiagnosisof traumaticinjuriesisreportedinTable5.Thecriteriawith the bestpositivepredictive value andsufﬁcientlypresent inourseveretraumapopulationwerehemodynamiccriteria andresuscitationpriortoadmission.However,thesecriteria oftenhavelowsensitivity.The‘‘global assessment’’criterion,which wasthe mostcommon (n=266), wasthe only Vittelcriterionpresentin117patients.Injurieswerefound in42ofthe117WBS(35.9%)wheretheonlyVittelcriterion presentwasthe‘‘globalassessment’’criterion.

The‘‘thrown,runover’’criterionwasthesecond most commoncriterion(n=116).Itwasassociatedwithamotor- cycle accident in 50% of cases (n=54), an automobile accidentin25.9%ofcases(n=28),andanaccidentinvolv- ingapedestrianin16.6% ofcases(n=18).Itwastheonly criterionpresentin5motorcyclists.Asanoriginalprescrib- ing intent, only two motorcyclists wouldhave hada WBS and atargeted scan. The presence of thiscriterion alone wasthe reason for performinga WBSin threecases, one ofwhichhadinjuries.Theinjurythatwasfound(peritoneal effusionwithnoassociatedparenchymalinjury)waslocated in theareathat wouldhave been exploredaspartof the initialprescribingintent(targetedscan)anddidnotaffect treatment.

The‘‘ejectedfromvehicle’’criterionwasthethirdmost commoncriterion(n=94).Itwastheonlycriterionpresent in 13motorcyclists.As an originalprescribingintent, only ﬁvemotorcyclistswouldhavehadaWBS.The presenceof thiscriterionalonewasthereasonforperformingaWBSin eightcases,threeofwhichhadinjuries.Inallthreecases, noserioustraumaticinjurywouldhavebeenmissed,sincea CTscanfocusingontheareawheretheabnormalitywasdis- coveredhadbeenorderedaspartoftheoriginalprescribing intent.

MultivariateanalysisoftheVittelcriteriafor discoveryoftraumaticinjuries

The ascending or descending step-wise multivariate logis- ticregression modelsresultedin threeindependentVittel

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Figure1. Vittelcriteriapresentinpatientsincludedinthestudyandnumberofnormalandabnormalwholebodyscan(WBS)percriterion.

Table5 EffectivenessoftheVittelcriteriafordiscoveryoftraumaticinjury.

Vittelcriteria n % PD Se Sp RV+ RV— PPV NPV

Glasgowscore<13 56 16.5 55.5 24.9 94.0 4.14 0.80 83.9 49.8

Syst.BP<90mmHg 29 8.6 51.0 13.8 98.0 6.88 0.88 89.7 47.4

SaO2<90% 16 4.7 47.2 6.9 98.0 3.44 0.95 81.3 45.5

Ejectionfromavehicle 94 27.7 50.7 30.7 76 1.28 0.91 61.7 46.5

Otherpassengerdied 6 1.8 44.8 2.1 98.7 1.59 0.99 66.7 44.4

Fall>6m 15 4.4 46.3 5.8 97.3 2.18 0.97 73.3 45.1

Victimthrown/runover 116 34.2 51.3 37.0 69.3 1.21 0.91 60.3 46.6

Globalassessmentofvehiclecondition 266 78.5 50.7 76.2 18.7 0.94 1.28 54.1 38.4

Blast 4 1.2 45.4 2.1 100 — 0.98 100 44.8

Penetratingtrauma 21 6.2 49.3 10.1 98.7 7.54 0.91 90.5 46.5

Flailchest 6 1.8 45.4 2.6 99.3 3.97 0.98 83.3 44.7

Severeburn/Smokeinhalation 0 0.0 — — — — — — —

Smashedpelvis 12 3.5 45.4 4.2 97.3 1.59 0.98 66.7 44.6

Suspectedspinalcordinjury 34 10.0 50.1 14.3 95.3 3.06 0.90 79.4 46.9

Amputationupperlimb 1 0.3 44.5 0.5 100 — 0.99 100 44.4

Acuteischemiaofalimb 7 2.1 46.3 3.7 100 — 0.96 100 45.2

Assistedventilation 39 11.5 54.0 19.0 98.0 .52 0.83 92.3 49.0

Colloidﬂuids>1000mL 39 11.5 54.6 19.6 98.7 14.68 0.81 94.9 49.3

Catecholamines 18 5.3 49.0 9.0 99.3 13.49 0.92 94.4 46.4

Inﬂatedantishocktrousers 1 0.3 44.5 0.5 100 — 0.99 100 44.4

Age>65years 20 5.9 46.0 6.9 95.3 1.47 0.98 65 44.8

Heartorcoronaryfailure 4 1.2 45.4 2.1 100 — 0.98 100 44.8

Respiratoryfailure 3 0.9 44.5 1.1 99.3 1.59 1.00 66.7 44.3

2ndor3rdtrimesterofpregnancy 0 0.0 — — — — — — —

Dyscrasia 5 1.5 45.7 2.6 100 — 0.97 100 44.9

criteriafordiscoveryoftraumaticinjuries.Thethreeinde- pendent criteria were: a Glasgow score less than 13, penetrating trauma, and resuscitation with greater than 1000mLofcolloids.Interpretationoftheseresultsislimited bytheweakrepresentationofthesecriteria.

Analysis of unsuspected injuries (clinician original prescribing intent)

Basedonclinical originalprescribingintent,only172 WBS wouldhavebeenperformed.ThususeoftheVittelcriteria

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wasresponsiblefortheperformanceof164additionalWBS.

Of those164 WBS, 49 unsuspected injuries, asdeﬁned in theMaterialsand Methodssection, werediscoveredin 35 patients(Table6andFigs.2—5).

These were: four skull injuries (one temporal fracture and three intraparenchymal hemorrhages); 18 chest injuries(oneruptureofthediaphragmaticdome,twopneu- mothorax, eight costal fractures, and seven pulmonary contusions); 18 abdominopelvic injuries (one liver fracture,threerenalinjuries[onefracture,onevenouswound, and one ischemia], four splenic injuries [one fracture, onecontusion,andtwohematomas],onecontusionofthe mesosigmoidwithnoassociatedGIperforation,oneadrenal hematoma, one hemoperitoneum, and seven peritoneal effusions).Inaddition,threeclavicularfractures,twoster- nal fractures,threevertebralfractures,and onescapular fracturewerediscovered.Ofthose49injuries,29injuries in25patients (excludingthe eightcostalfractures,seven

peritonealeffusions,oneadrenalhematoma,threeclavicularfractures,andonescapularfracture)wereconsidered severe,asdeﬁnedintheMaterialandMethodssection.This represented15%ofthe164WBSwhoseonlyjustiﬁcationwas thepresenceofaVittelcriterion.

Discussion

TheVittelcriteria[12]arepartofatriagealgorithmusedby SAMU(emergencymedicalservice)physiciansinFrancefor managing traumapatients prior toadmission.The trauma severitydiagnosisismadebasedonthepresenceofasingle criterion(otherthanpredisposition),whichallowsthemost criticalpatientstobedirectedtowardaspecializedtrauma- tologycenter.Thedeﬁnitionofseveretramapatientreﬂects theVittelcriteriaandcorrespondstoapatientwithatleast onepotentiallylife-threatening ordisablinginjury,orwho

Table6 Number ofinjuriesdiagnosed inandoutsideofregions whenatargetedscan(ornoscan) wouldhavebeen prescribed(originalprescribingintent).

Prescribingintent Targetedregion(s)

n Injury(ies)inregion(s) Injury(ies)outsideofregion(s)

Noscan 32 0 15

Skull-cervicalspine 63 10 13

Chest 11 4 8

Abdomen-pelvis 18 4 2

Skull-cervicalspine andchest

23 15 6

Skull-cervicalspine andabdomen-pelvis

13 5 5

Chestand abdomen-pelvis

4 0 0

Figure2. Clinicallyunsuspectedsternalinjury(originalprescribingintent:noscan): axialslice(a)andsagittalreconstruction(b)of thechestinbonewindowshowinganon-displacedmanubrialfracture(whitearrow).Discoveryofsuchinjuriessystematicallyleadsto performanceofanechocardiogramtosearchforassociatedmyocardialinjuries.

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Figure3. Clinicallyunsuspectedrenalinjury(originalprescribing intent:noabdominalscan):axial sliceofabdomeninabdominal window,inportalphase,showingafractureoftheposteriorlipof therightkidney(hollowarrow),associatedwitharightperirenal hematoma(shortsolidarrow) andperitoneal effusion(longsolid arrow).

sustained trauma whose mechanism or violence suggests thatsuch lesionsmayexist.Timetotreatment oftrauma patients is oneof the main factors inpreventable deaths of multiple trauma victims [13,14] and negatively corre- lateswithpatientsurvival[15,16].Atthe sametime,12%

ofpatientdeathsduemultipletraumaswerepreventable, eitherbecausejustiﬁcationforsurgerywasnotestablished orbecauseinjurieswentunnoticedontheclinicalexamina- tion[17,18].NumerousstudieshaveshownthatWBSshould bethepreferredmethodofexploringseveretrauma[2—11].

However,theclinicalexaminationcansometimesbeinsuf- ﬁcient tojustify sucha study [19]or the beneﬁtof using probabilistic criteria, such as the Vittel criteria, for the presenceofseveretrauma.

In our study, 15% of 164 patients for whom the Vit- telcriterialedtoperformanceof aWBShadunsuspected severe injuries. These results conﬁrm ourinitial hypothe- sis,i.e.,thebeneﬁtofusingtheVittelcriteriatodetermine

Figure4. Clinicallyunsuspected hepatic injuries(originalprescribing intent: no abdominal scan): axial slice of abdomen in abdominalwindow,inportalphase,showinghypodenselesionsof hepaticsegments VIIand VIII,corresponding tomultiple hepatic fracturesoftherightlobe(arrows).

Figure5. Clinicallyunsuspectedpulmonaryinjuries(originalprescribingintent:noscan):axialsliceofchestinparenchymalwindow showingrightanteriorpleuraldetachmentcorrespondingtoaright pneumothorax(longsolidarrows),pulmonarycondensationatsite ofairbronchogramscorrespondingtopulmonarycontusions(short solidarrows),andsubpleuralaircystscorrespondingtopneumato- celes(hollowarrow).

theneed for aWBSin asevere trauma patient.However, thisincreasedeffectivenessisassociatedwithasigniﬁcant increase in the number of WBS performed, as well as an increase inthe proportion of normalWBS. This has three implications:

• ﬁrstly,inordertodecreasetheproportionofnormalWBS, it wouldbeuseful toidentify themost pertinentVittel criteria.Individually,theVittelcriteriaarenotveryeffec- tive for discovery of serious injuries The most speciﬁc onesarethemostrareandthereforehavelowsensitivity.

Threecriteriamaygiverisetocomments:

◦ theﬁrst,the‘‘globalassessment’’criterion,isthemost common.Itresultsintheperformanceofalargenum- ber of normal WBS. This criterionis very subjective.

Whileitisamongthemostsensitivecriteria,itisthe least speciﬁc. However,the goal of managing severe traumapatientsistonotmissanyinjuries.Inourstudy, injurieswerefoundin42patientsinwhomthe‘‘global assessment’’ criterionwastheonly criterionpresent.

Itcanthereforenotbeexcluded.Itcouldhoweverbe studied toisolate itsmost pertinentsub-criteria.For example,itisprobablethatrolloversandextractionare moresigniﬁcantaccidentseverityfactorsthansubjec- tiveinterpretationofvehicledeformation.Thenotion ofspeedcouldalsobeamoreselectiveelement,

◦ the twoothers arethe‘‘Victim thrown or run over’’

and‘‘Ejectedfromavehicle’’criteria.Thesetwocrite- riawereoftenusedformotorcycle/bikeaccidents,but didnotidentifyseriousinjuries.Inthoseaccidents,the driverwasalways‘‘ejectedfromavehicle’’or‘‘thrown or runover’’. It therefore seemsjustiﬁednot touse thosetwocriteriainmotorcycle/bikeaccidents;

• thebeneﬁtofincreasingthe numberofWBSperformed cannotbeexpressedsolelyinpositivediagnosesofunsus- pectedinjuries.Infact,anormalWBSisakeyelementin managingtraumapatients,whocouldeitherbeobserved in a non-specialized unit or discharged. This is therefore important information from a medical economic

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perspective, which can reduce longer and more costly hospitalizations;

• ﬁnally,thisincreaseinthenumberofWBSraisestheprob- lem of scanner utilization time.These are long studies (approximately 20 to 30minutes per study in our center) in patients whoare difﬁcult to move. Interpreting thesestudies takes time(themean interpretation time inourstudywas20.48minutes)andradiologistsspecial- izinginemergencyimaging.Alloftheseelementsimplya needfortraumacentersequippedwithimagingunitsfor emergencyuse.

Ourstudyhascertainlimitations.Firstly,atourcenter, wewerealreadyusingtheVittelcriteriatodeterminethe needforaWBS.The purposeofourstudywastoevaluate thispractice.Duetothismodeofoperation,itwasethically difficult to change that approach and form two separate groups:agroupwheretheWBSwasjustifiedbytheVittelcri- teriaandagroupwheretheWBSwasjustifiedbytheclinical examination.Infact,inourstudy,allpatientshadatleast oneVittelcriterion,soitwasnotpossibletocalculatethe effectivenessoftheVittelcriteriaasawhole.Finally,the verysubjectivenatureofthe‘‘globalassessment’’criterion isaclearrecruitmentbias.

The choice of an exploratory protocol remains open.

OncethejustificationforperformingaWBSisestablished, theexploratoryprotocolshouldbestandardizedtoenable rapid management. It should also be brief while provid- ingsufficientimagequalityforathoroughdiagnosis.Inour study,weusedastandardizedprotocol comprisingsucces- siveacquisitionsoftheskull,thenthecervicalspin,thenthe abdomenandpelvisallwithoutcontrast,followedbyacqui- sition of the chest, performed 60seconds after injection ofiodinatedcontrast.Performance ofa spiralscanofthe abdomenandpelviswithout contrastisdiscussed bysome authors[20]whobelievethattheinjuriesdiagnosedbythat typeofacquisitionarebestvisualizedonalatephasespiral scanperformed3to5minutesafterinjection.Accordingto someauthors,eliminatingthatacquisitionwithspontaneous contrast enabled a 42.5% time saving with no difference in imaging effectiveness while maintaining high diagnos- ticquality[21]. However,fromour point of view,certain hemorrhagicinjuriesofthemesenteriumthatappearspon- taneouslymoderatelyhyperdensearesometimesdifficultto seeafterinjectionofiodinatedcontrast.

Decreasingtheradiationisalsooneofthechallengesfor exploringtraumapatients.Theseareoftenpatientswhowill haverepeatedradiologicalexaminations[22].Inourstudy, radiation was consistent with the reference levels established by the French Radioprotection and Nuclear Safety Institute (IRSN), with a mean DLP of 1231.77 mGy.cm to theskullandneck,476.92mGy.cmtothechest,and1566 mGy.cmtotheAP,i.e.,ameancumulativedoseof2051.54 mGy.cmtotheCAP.However,basedontheALARA(AsLow As Reasonably Achievable) principal, the protocol should beadjusted to decreasethe radiation. In a study usinga protocolcomposedofalateralscanogramfollowedbyacqui- sitionimmediately afterinjection of contrast,Ptaketal.

[23]founda17%decreaseinDLPcomparedwithaprotocol performingsuccessiveacquisitionsinthedifferentanatom- ical regions. That decrease in radiation was attributed to the elimination of redundant images acquired due to

overlapbetweenseries[21,23—25].Mostcurrentequipment allowstheuseofdosereducingtechniquesandsoftwarethat shouldbeusedwhenavailable.Suchsoftware,whichdidnot existonourdeviceatthetimeofthestudy,isnowavailable andusedsystematically,providingasubstantialdosereduc- tion.Similarly,eventhoughitwasnotitsoriginalpurpose, thisstudyledustomodifyouracquisitionprotocols.Apro- tocol wasestablishedlimiting thenumberof acquisitions.

It includes a single scanogram, a spiral scanof the skull without contrast,then an exploration ofthe neck, chest, abdomenandpelvis,immediatelywithIVcontrastinjection.

However,theinformationsuppliedbytheclinicianisessen- tialforadjustingtheprotocol,andasuspectedabdominal injurycanleadtoanacquisitionbeforecontrastinjectionso asnottomissanyhemorrhagicinjuriestothemesenterium.

Conclusion

TheuseofprobabilisticcriteriasuchastheVittelcriteriato determinetheneed foraWBSmakesitpossibletodetect injuriesthatwouldhaveinitiallybeenmissed.However,the resultingincreaseinthenumberofscansrequiresreﬂection aboutthetechnicalimplementationoftheseexaminations and about the infrastructure necessary to perform them.

Finally,thesecriteria,divertedfromtheiroriginalfunction, needtobereﬁnedinordertodecreasethenumberofnormal examinationsperformed.

Disclosure of interest

Theauthorsdeclarethattheyhavenoconﬂictsofinterest concerningthisarticle.

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