A multicenter, randomized controlled trial of immediate total-body CT scanning in trauma patients (REACT-2)

Contains fulltext : 110874.pdf (publisher's version ) (Open Access)BACKGROUND: Computed tomography (CT) scanning has become essential in the early diagnostic phase of trauma care because of its high diagnostic accuracy. The introduction of multi-slice CT scanners and infrastructural improvements made total-body CT scanning technically feasible and its usage is currently becoming common practice in several trauma centers. However, literature provides limited evidence whether immediate total-body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total-body CT scanning in trauma patients. METHODS/DESIGN: The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. Patients in whom direct scanning will hamper necessary cardiopulmonary resuscitation or who require an immediate operation because of imminent death (both as judged by the trauma team leader) are excluded. Randomization will be computer assisted. The intervention group will receive a contrast-enhanced total-body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness. DISCUSSION: The REACT-2 trial is a multicenter randomized clinical trial that will provide evidence on the value of immediate total-body CT scanning during the primary survey of severely injured trauma patients. If immediate total-body CT scanning is found to be the best imaging strategy in severely injured trauma patients it could replace conventional imaging supplemented with CT in this specific group. TRIAL REGISTRATION: ClinicalTrials.gov: (NCT01523626)

Erratum to: High rates of clinically relevant incidental findings by total-body CT scanning in trauma patients: Results of the REACT-2 trial

A technical error led to incorrect rendering of the author group in this article. The correct authorship is as follows: K. Treskes1, S.A. Bos1, L.F.M. Beenen2, J.C. Sierink1, M.J.R. Edwards3, B.J

Emergency Bleeding Control Interventions After Immediate Total-Body CT Scans in Trauma Patients

Background: Immediate total-body CT (iTBCT) is often used for screening of potential severely injured patients. Patients requiring emergency bleeding control interventions benefit from fast and optimal trauma screening. The aim of this study was to assess whether an initial trauma assessment with iTBCT is associated with lower mortality in patients requiring emergency bleeding control interventions. Methods: In the REACT-2 trial, patients who sustained major trauma were randomized for iTBCT or for conventional imaging and selective CT scanning (standard workup; STWU) in five trauma centers. Patients who underwent emergency bleeding control interventions following their initial trauma assessment with iTBCT were compared for mortality and clinically relevant time intervals to patients that underwent the initial trauma assessment with the STWU. Results: In the REACT-2 trial, 1083 patients were enrolled of which 172

Does repeat Hb measurement within 2 hours after a normal initial Hb in stable trauma patients add value to trauma evaluation?

In our level I trauma center, it is considered common practice to repeat blood haemoglobin measurements in patients within 2 h after admission. However, the rationale behind this procedure is elusive and can be considered labour-intensive, especially in patients in whom haemorrhaging is not to be expected. The aim of this study was to assess the value of the repeated Hb measurement (r-Hb) within 2 h in adult trauma patients without evidence of haemodynamic instability. The local trauma registry was used to identify all trauma patients without evidence of haemodynamic instability from January 2009 to December 2010. Patients in whom no initial blood Hb measurement (i-Hb) was done on admission, referrals, and patients without risk for traumatic injuries or haemorrhage based upon mechanism of injury (e.g. inhalation or drowning injury) were excluded. A total of 1,537 patients were included in the study, 1,246 of which did not present with signs of haemodynamic instability. Median Injury Severity Score (ISS) was 5 (interquartile range (IQR) 1 to 13), 22% of the patients were multitrauma patients (ISS > 15). A normal i-Hb was found in 914 patients (73%). Of the 914 patients with a normal i-Hb, 639 (70%) had a normal r-Hb, while in 127 patients (14%), an abnormal r-Hb was found. In none of these patients, the abnormal r-Hb led to new diagnoses. In 148 patients (16%), no repeated Hb measurement was done without clinical consequences. We conclude that repeated blood Hb measurement within 2 h after admission in stable, adult trauma patients with a normal initial Hb concentration does not add value to a trauma patient's evaluatio

Directe 'total body'-CT-scan bij multitraumapatiënten

Immediate total body computed tomography (CT) scanning has become important in the early diagnostic phase of trauma care because of its high diagnostic accuracy. However, literature provides limited evidence whether immediate total body CT leads to better clinical outcome then conventional radiographic imaging supplemented with selective CT scanning in trauma patients. The aim of the REACT-2 trial is to determine the value of immediate total body CT scanning in trauma patients. The REACT-2 trial is an international, multicenter randomized clinical trial. All participating trauma centers have a multi-slice CT scanner located in the trauma room or at the Emergency Department (ED). All adult, non-pregnant, severely injured trauma patients according to predefined criteria will be included. The intervention group will receive a contrast-enhanced total body CT scan (head to pelvis) during the primary survey. The control group will be evaluated according to local conventional trauma imaging protocols (based on ATLS guidelines) supplemented with selective CT scanning. Primary outcome will be in-hospital mortality. Secondary outcomes are differences in mortality and morbidity during the first year post trauma, several trauma work-up time intervals, radiation exposure, general health and quality of life at 6 and 12 months post trauma and cost-effectiveness. The REACT-2 trial is the first multicenter randomized clinical trial that will provide evidence on the value of immediate total body CT scanning during the primary survey of severely injured trauma patient

Split bolus technique in polytrauma: a prospective study on scan protocols for trauma analysis

For the evaluation of severely injured trauma patients a variety of total body computed tomography (CT) scanning protocols exist. Frequently multiple pass protocols are used. A split bolus contrast protocol can reduce the number of passes through the body, and thereby radiation exposure, in this relatively young and vitally threatened population. To evaluate three protocols for single pass total body scanning in 64-slice multidetector CT (MDCT) on optimal image quality. Three total body CT protocols were prospectively evaluated in three series of 10 consecutive trauma patients. In Group A unenhanced brain and cervical spine CT was followed by chest-abdomen-pelvis CT in portovenous phase after repositioning of the arms. Group B underwent brain CT followed without arm repositioning by a one-volume contrast CT from skull base to the pubic symphysis. Group C was identical to Group A, but the torso was scanned with a split bolus technique. Three radiologists independently evaluated protocol quality scores (5-point Likert scale), parenchymal and vascular enhancement and artifacts. Overall image quality was good (4.10) in Group A, more than satisfactory (3.38) in Group B, and nearly excellent (4.75) in Group C (P  < 0.001). Interfering artifacts were mostly reported in Group B in the liver and spleen. In single pass total body CT scanning a split bolus technique reached the highest overall image quality compared to conventional total body CT and one-volume contrast C

A case-matched series of immediate total-body CT scanning versus the standard radiological work-up in trauma patients

In recent years computed tomography (CT) has become faster and more available in the acute trauma care setting. The aim of the present study was to compare injured patients who underwent immediate total-body CT (TBCT) scanning with patients who underwent the standard radiological work-up with respect to 30-day mortality. Between January 2009 and April 2011, 152 consecutive patients underwent immediate TBCT scanning as part of a prospective pilot study. These patients were case-matched by age, gender, and Injury Severity Score (ISS) category with control patients from a historical cohort (July 2006-November 2007) who had undergone X-rays and focused assessment with sonography for trauma, followed by selective CT scanning. Despite comparable demographics, TBCT patients had a lower median Glasgow Coma Score (GCS) than controls (10 vs. 15; p < 0.001) and on-scene endotracheal intubation was performed more often (33 vs. 19 %; p = 0.004). 30-day mortality was 13 % in the TBCT patient group versus 13 % in the control group (p = 1.000). A generalized linear mixed model analysis showed that a higher in-hospital GCS [odds ratio (OR) 0.8, 95 % confidence interval (CI) 0.745-0.86; p < 0.001] and immediate TBCT scanning (OR 0.46, 95 % CI 0.236-0.895; p = 0.022) were associated with decreased 30-day mortality, while a higher ISS (OR 1.054, 95 % CI 1.028-1.08) p < 0.001) was associated with increased 30-day mortality. Trauma patients who underwent immediate TBCT scanning had similar absolute 30-day mortality rates compared to patients who underwent conventional imaging and selective CT scanning. However, immediate TBCT scanning was associated with a decreased 30-day mortality after correction for the impact of differences in raw ISS and in-hospital GC