Correspondence / American Journal of Emergency Medicine 35 (2017) 1012-1030 1015

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The screening criteria for whole-body computed tomography in trauma patients is required

To the Editor:

We read with great interest with the article entitled “Introduction of a pan-scan protocol for blunt Trauma activations: what are the conse- quences?” [1]. The aim of this study was to investigate the effects of whole-body computed tomography (WBCT) on trauma patients, and the endpoints included incidence of missed injuries and incidental find- ings, treatment times, radiation exposure dose, and cost. Finally, the au- thors concluded that the application of a WBCT protocol significantly decreased the incidence of missed injuries, reduced the time in the emergency department, and shortened the time to initiation of the first operation. Meanwhile, the authors reported it increased the fixed computed tomography (CT) costs and was associated with a higher ra- diation exposure. We really appreciate this comprehensive work, how- ever, several concerns should be noted.

Firstly, in section of “characters of subjects”, the authors reported the median injury severity scale (ISS) score of included trauma patients was 4 (interquartile range 1-9) [1]. In addition, according to the Tables 1, 88.4% of included trauma patients in the WBCT period had an ISS score b 15, and 70.4% of these patients had an ISS score b 8 [1]. Thus it can be seen that the severity of injuries of included trauma patients in this study, either in the pre-WBCT period or WBCT period was much slighter than those de- scribed in most of previous studies [2]. In a previous meta-analysis, Zhang and his colleagues retrospectively reviewed studies that assessed the effect of WBCT in Multiple trauma patients. And one of inclusion criteria of included studies in this meta-analysis was ISS score not b 16 [2]. As in the previous randomized controlled study, REACT-2 trial, 67% of patients in the WBCT group had an ISS score higher than 16, and the percentage in the control group was 61% [3]. All the above data indicated that the injury severity of patients in this study was much slighter and these slightly injured patients may not benefit from WBCT. Thus, who will benefit from the WBCT or who should receive the diagnostic model of WBCT? Up to now, the majority held the opinion that major multiple trauma patients will benefit from the WBCT. And in the favorable situa- tion, the benefits of WBCT will outweigh the disadvantages of WBCT in- cluding the increased risk of cancer associated with radiation exposure [1]. How to define major multiple trauma in initial evaluation period? In most studies, patients with severe injuries (ISS >= 16) were identified retrospectively. Only after the trauma evaluation completed, can we ob- tain an accurate ISS score. So, in the period of initial trauma assessment, ISS score cannot be used to select patients for WBCT. In most studies, in- cluding the REACT-2 trial [3], a three-dimensional selection scheme in- cluding injury mechanism (like falls N 5 m,ejection from the vehicle, passenger died in the same compartment etc.), vital signs (like blood pressure b 90 mm Hg, respiratory rate b 10 or N 29, Glasgow score b 8 etc.), and some special injuries (like flail chest, pelvic fracture, open chest or abdominal injuries etc.) [4], was used to identify potential candi- dates for WBCT. However, the above WBCT protocol also resulted in a 30% over-triage rate, meaning 30% of selected trauma based on this protocol would receive unnecessary radiation exposure [4]. One of reasons which may account for the high over-triage rate is the equivalent weight of each dimension. The aim of further studies should focus on the combi- nation of different predictive factors or constructing an electronic deci- sion tree through Bayes statistics based on the various predictive factors.

One of the disadvantages of the WBCT is higher radiation dose. In this study, the authors reported that patients in the WBCT period re- ceived average 8.2 mSv radiation exposure greater than those in the pre-WBCT period [1]. However, it has been reported that the effective dose of WBCT has decreased from 10 to 20 mSv to 5-10 mSv, due to the application of iterative reconstruction techniques [5]. Wedegartner et al. conducted a research comparing the dose of radiation exposure between trauma patients in the WBCT group and patients in the con- ventional group (patients in this group received conventional film radi- ography and/or organ-specific CT). Five different diagnostic models were used in this study, that was WBCT, conventional film radiograph, conventional film radiograph in combination with head and cervical spine CT, conventional film radiograph in combination with head, cervi- cal spine and chest CT, and conventional film radiograph in combination with head, cervical spine and abdominal CT. Finally, the authors found that the effective doses were 20 mSv, 2 mSv, 6.8 mSv, 10.3 mSv, and 18 mSv for the above mentioned five diagnostic models separately and concluded that if in the “right” situation, WBCT would not increase the dose of radiation exposure, whereas it would increase the dose of ra- diation exposure by 3 fold in the “false” situation [6]. In addition, a re- cent study performed by Sierink et al. reported that trauma patients with severe injuries (ISS >= 16) experienced a higher radiation exposure in the trauma bay, however these patients experienced less radiation exposure during the following hospital admission. So the authors con- cluded that the total dose of radiation exposure between the WBCT group and the control group was similar [7].

Competing interests

None.

Funding

None.

Xiuqin Feng

Division of Nursing, Second Affiliated Hospital, School of Medicine, Zhejiang

University, Jiefang Road 88, Hangzhou, China E-mail address:[email protected]

Libing Jiang Mao Zhang*

Department of Emergency Medicine, Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Jiefang

Road 88, Hangzhou, China

*Corresponding author at: Department of Emergency Medicine Second Affiliated Hospital, School of Medicine & Institute of Emergency Medicine, Zhejiang University, Jiefang Road

88, 310009 Hangzhou, China

E-mail addresses:[email protected] (L. Jiang)

[email protected](M. Zhang) http://dx.doi.org/10.1016/j.ajem.2017.01.041

References

1. James MK, Schubl SD, Francois MP, et al. Introduction of a pan-scan protocol for blunt trauma activations: what are the consequences? Am J Emerg Med 2017;35(1):13-9.
2. Jiang L, Ma Y, Jiang S, et al. Comparison of whole-body computed tomography vs se- lective radiological imaging on outcomes in major trauma patients: a meta-analysis. Scand J Trauma Resusc Emerg Med 2014;22(1):1-11.
3. Sierink JC, Treskes K, Edwards MJ, et al. Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised controlled trial. Lancet 2016;388(10045):673-83.
4. Wurmb TE, Fruhwald P, Hopfner W, et al. Whole-body multislice computed tomogra- phy as the primary and sole diagnostic tool in patients with blunt trauma: searching for its appropriate indication. Am J Emerg Med 2007;25(9):1057-62.
5. Huberwagner S, Biberthaler P, Haberle S, et al. Whole-body CT in haemodynamically unstable severely injured patients-a retrospective, multicentre study. PLoS One 2013; 8(7):e68880.

1016 Correspondence / American Journal of Emergency Medicine 35 (2017) 1012-1030

1. Wedegartner U, Lorenzen M, Nagel HD, et al. Diagnostic imaging in polytrauma: com-

Shi-Wen Lee, DO

parison of radiation exposure from whole-body MSCT and conventional radiography with organ-specific CT, 176(7); 2004 1039-44.

1. Sierink JC, Saltzherr TP, Wirtz MR, et al. Radiation exposure before and after the introductionof a dedicated total-body CT protocolin multitrauma patients. Emerg Radiol 2013;20(6):507-12.

Author’s response to: “The screening criteria for whole-body computed tomography in trauma patients is required”

To the Editor:

We thank Dr. Zhang for his comments on our manuscript. The aim of our study was to determine the effect of switching from selective scan- ning as our standard of care to whole body CT (WBCT), for all blunt trau- ma activation patients. Therefore, patients were prospectively enrolled into the study and the injury severity score (ISS) was unknown prior to study inclusion. As the authors mentioned, most of the studies that examined the use of WBCT, retrospectively identified patients for inclu- sion and thus, controlled for ISS. At our institution there are three differ- ent tiers of trauma activations; tier 1 (highest) and tier 2 (intermediate) trauma activations were included in the study. There were no selection criteria for WBCT; inclusion in the study was based on criteria for tier ac- tivations, which is similar to the selection scheme in the REACT-2 trial [1]. During the study period, there were significantly more tier 2 activa- tions. As a result, our study included less severely injured patients as compared to other studies; 88.1% of our patients had an ISS b 16 before the introduction of a WBCT protocol and 88.4% of patients had an ISS b 16 after the introduction of the protocol. However, despite this fact, introduction of a WBCT protocol decreased the incidence of missed injuries, reduced the time spent in the emergency room, and the time to the first operating room visit. WBCT was beneficial to less severely in- jured patients. Moreover, when we excluded patients with an ISS b 8, treatment times decreased further, indicating that WBCT would have an even greater benefit to more severely injured patients. It is important to note, unlike some studies, we did not include penetrating trauma pa- tients, which would have increased the average ISS of our study popula- tion. We acknowledged that during the WBCT period, a significant number of scans did not detect any trauma injuries or relevant inciden- tal findings and that WBCT may not be appropriate for all blunt trauma patients. Therefore, as the authors suggested criteria for determining when a WBCT is required is needed and future studies should address how to determine injury severity in the trauma bay. With regards to ra- diation, the WBCT protocol was not a single-pass protocol; therefore, ra- diation exposure increased during the WBCT period. The average effective dose for a WBCT using our protocol was 23.8 mSv. If a single- pass WBCT was utilized, it is possible that radiation exposure would have been less during the WBCT period. With the development of new reconstruction techniques, increased radiation exposure may not be an issue when implementing a WBCT protocol [2].

Conflict of interest

All authors declare no conflict of interest and have no financial ties to disclose.

Melissa K. James, PhD

Department of Surgery, Jamaica Hospital Medical Center

Jamaica, New York Corresponding author at: Department of Surgery, Trauma Suite Jamaica Hospital Medical Center, 8900 Van Wyck Expressway

Jamaica, NY 11418

E-mail address: [email protected]

Department of Emergency Medicine, Jamaica Hospital Medical Center,

Jamaica, New York E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2017.01.042

References

1. Sierink JC, Treskes K, Edwards MJ, Beuker BJ, den Hartog D, Hohmann J, et al. Imme- diate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomized controlled trial. Lancet 2016;388(10045):673-83.
2. Padole A, Ali Khawaja RD, Kalra MK, Singh S. CT radiation dose and iterative recon- struction techniques. Am J Roentgenol 2015;204(4):W384-92.

Nursemaid’s elbow?

Dear Editor,

Bexkens and colleagues have published a very helpful meta-analysis of studies comparing the hyperpronation and supination-flexion methods to treat nursemaid’s elbow. Their paper was carefully studied in the Rwandan Emergency Medicine residents’ journal club, and we agreed with their overall conclusions.

However, there appears to be a mistake in the calculation of the ab- solute risk reduction (ARR), stated to be 26.4%, and the number needed to treat (NNT), 3.8. In the supination-flexion group, the risk of failure on first attempt was 96/351 (27%), and 32/350 (9%) in the hyperpronation group. This is an ARR of 18% and NNT of 5.5.

While the overall message that hyperpronation was more effective than supination-flexion is true, we think it’s important that the difference should not be exaggerated, and errors corrected.

Faithfully yours,

Dr Vincent Ndebwanimana, Dr Amelia Y Pousson, Dr Giles N Cattermole. Emergency Department, Centre Hospitalier Universitaire de Kigali, University of Rwanda.

Vincent Ndebwanimana Amelia Y. Pousson Giles N. Cattermole*

Emergency Department, University of Rwanda, Centre Hospitalier

Universitaire de Kigali, Kigali, Rwanda

*Corresponding author.

E-mail addresses: [email protected] (V. Ndebwanimana)

[email protected] (A.Y. Pousson) [email protected] (G.N. Cattermole)

http://dx.doi.org/10.1016/j.ajem.2017.02.009

? Bexkens R. et al. Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis. Am J Emerg Med 2017 Jan; 35(1): 159-163.

Response to effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis

In the study “Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: A systematic review and meta-analysis”, the stated absolute Risk difference and number needed to treat are incorrect. The absolute risk difference is 18.2% and the number needed to treat is 5.5. This signifies that for every 6 children treated with