Scanning the aged to minimize missed injury: An Eastern Association for the Surgery of Trauma multicenter study

Background: Despite the high incidence of blunt trauma in older adults, there is a lack of evidence-based guidance for computed tomography (CT) imaging in this population. We aimed to identify an algorithm to guide use of a pan-scan (head/cervical spine [C-spine]/torso) or a selective scan (head/C-spine ± torso). We hypothesized that a patient's initial history and examination could be used to guide imaging.

Methods: We prospectively studied blunt trauma patients 65 years or older at 18 Level I/II trauma centers. Patients presenting >24 hours after injury or who died upon arrival were excluded. We collected history and physical elements and final injury diagnoses. Injury diagnoses were categorized into CT body regions of head/C-spine or Torso (chest, abdomen/pelvis, and thoracolumbar spine). Using machine learning and regression modeling as well as a priori clinical algorithms based, we tested various decision rules against our data set. Our priority was to identify a simple rule, which could be applied at the bedside, maximizing sensitivity and negative predictive value (NPV) to minimize missed injuries.

Results: We enrolled 5,498 patients with 3,082 injuries. Nearly half (n = 2,587 [47.1%]) had an injury within the defined CT body regions. No rule to guide a pan-scan could be identified with suitable sensitivity/NPV for clinical use. A clinical algorithm to identify patients for pan-scan, using a combination of physical examination findings and specific high-risk criteria, was identified and had a sensitivity of 0.94 and NPV of 0.86. This rule would have identified injuries in all but 90 patients (1.6%) and would theoretically spare 11.9% (655) of blunt trauma patients a torso CT.

Conclusion: Our findings advocate for head/C-spine CT in all geriatric patients with the addition of torso CT in the setting of positive clinical findings and high-risk criteria. Prospective validation of this rule could lead to streamlined diagnostic care of this growing trauma population.

Level of evidence: Diagnostic Tests or Criteria; Level II.