When to Pan-Scan vs. Selectively CT Elderly Patients

August 16, 2024

Written by Rebecca DiFabio and Ketan Patel

Spoon Feed
Based on key history and physical examination findings, the Eastern Association for the Surgery of Trauma (EAST) developed an algorithm for the evaluation of blunt trauma patients ≥65 years.

History and examination are key in determining imaging needs
This multicenter, prospective observational EAST study reviewed the charts of 5,498 blunt trauma patients aged 65 years and above, from 18 Level I/II Trauma Centers, with the goal of developing a simple algorithm to determine if this population should undergo a pan-scan (head/c-spine & torso – chest/abd/pelvis with T/L-spine reconstructions) or a selective scan (head/s-spine +/- torso). Only patients who triggered a full or limited trauma activation or required a formal trauma consultation were included. Patients who presented >24 hours after the injury, were pronounced dead upon arrival, had penetrating or burn-related trauma, or were never seen by a trauma surgeon were excluded.

Authors developed an algorithm based on the patient’s examination (i.e. normal, tenderness, or deformity) and history (i.e. presence or absence of “high-risk factors”) that had a sensitivity of 0.97 and NPV of 0.86. When applied to the study population, it would have missed 90 patients’ injuries and spared 955 individuals a torso CT. Of note, all patients in this population were recommended to receive head and c-spine CT scans.

How will this change my practice?
Algorithms are the best friend of many emergency medicine physicians. Having a flowchart that we can use to support our work-up is awesome. Though this algorithm hasn’t been validated, I think it has potential and, in the future, may help guide the work-up of this high-risk population. However, I don’t think it will change my practice, as I already pan-scan any geriatric blunt trauma patient meeting these criteria. That said, in an ED that doesn’t see a high volume of geriatric trauma, this could serve as a valuable decision-making tool, once further validated.

Editor’s note: To make this rule, they 1) tested patients against existing rules (i.e. Canadian CT Head); they 2) used machine learning to derive and test high-risk variables, and they then 3) used their experience and expertise to craft the simple, common sense algorithm above. It’s not perfect and needs external validation, but it performs fairly well, makes sense, and GRANDE is catchy. ~Clay Smith

Source
Scanning the aged to minimize missed injury: An EAST multicenter study. J Trauma Acute Care Surg. 2024 May 27. doi: 10.1097/TA.0000000000004390. Online ahead of print. PMID: 38797882