Whole-body CT in major trauma — the protocol and the review order

CT

First and second year — the floor first, then every step

A standard protocol (non-contrast head and cervical spine, arterial chest, portal venous abdomen-pelvis or split-bolus) and a fixed review order — primary survey for the life-threatening findings in minutes, then the tertiary read — so nothing is missed under pressure.

Orient first

  • Primary review (hot report): tension pneumothorax, massive haemothorax, aortic injury, active haemorrhage, pneumoperitoneum, unstable spine, extra-axial haematoma with mass effect.
  • Split-bolus protocols reduce dose but can mimic or hide extravasation — know the local protocol.
  • A secondary full report follows within hours; fractures of the extremities are often completed later.

Acquire the study

  • Non-contrast CT head and cervical spine; contrast-enhanced chest (arterial) and abdomen-pelvis (portal venous) or a split-bolus single pass; thin reconstructions with multiplanar and bone/lung windows; delayed phase for the urinary tract when indicated.

The manoeuvre

  • Head, non-contrast series: extra-axial haematoma thickness in mm and midline shift.
  • Chest on lung window: pneumothorax, haemothorax; mediastinum on the arterial phase: aortic injury.
  • Abdomen on the portal venous phase: solid organ injury, active extravasation, free fluid and gas.
  • Spine on sagittal bone-window reformats: unstable fractures.
  • Pelvis on bone window: ring disruption and associated vascular injury.
  • Communicate the critical findings verbally; then complete the tertiary read.

What confirms it

  • A structured primary survey with critical findings communicated.

What licenses you to exclude it

  • A negative whole-body CT does not exclude hollow viscus or diaphragm injury — re-image if the patient deteriorates.

The classic misread

  • Satisfaction of search after the first major injury.

Reporting the injury

Classification to use

  • Injury Severity Score is clinical; the report grades each organ injury by its own system (AAST organ scales, AO/Denis for the spine, Young–Burgess/Tile for the pelvis — verify the versions your trauma team uses).

Measurements — and how to take them

  • Extra-axial haematoma thickness and midline shift in mm; haemoperitoneum as small/moderate/large; aortic injury length in mm.

What to report

  • A primary survey block first (life threats: tension pneumothorax, massive haemothorax, aortic injury, active haemorrhage, pneumoperitoneum, unstable spine, intracranial mass effect); then the full tertiary read by region.

How to report it

  • CT: "PRIMARY SURVEY — Active arterial extravasation from a grade IV splenic laceration with a large haemoperitoneum. Left tension pneumothorax. Communicated to the trauma team leader at 14:32."

What not to report

  • Do not bury a life-threatening finding in the body of a long report.
  • Do not report "no acute injury" before the extremities and spine reformats are reviewed.

Associated injuries to look for

  • Every high-energy injury has a partner: first-rib fracture with aortic/brachial plexus injury, Chance fracture with bowel injury, pelvic fracture with bladder/urethral injury.

What changes management

  • Active extravasation → interventional radiology or theatre.
  • Tension pneumothorax → immediate decompression, before the report is finished.

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