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CT Whole Body: Major Trauma Protocol

Whole-body CT (the trauma 'pan-scan') is the reference standard for rapid, comprehensive evaluation of the severely injured patient, combining non-contrast head and cervical imaging with contrast-enhanced imaging of the neck, chest, abdomen and pelvis in a single acquisition. It detects life-threatening injuries quickly, informs damage-control decisions and enables injury grading and scoring. In tertiary African trauma centres it is reserved for haemodynamically stabilised patients with high-energy or multi-system injury, balanced against radiation dose and resource use.

Indications

  • Major trauma with high-energy mechanism (high-speed RTC, fall from height, pedestrian/cyclist struck)
  • Clinical or physiological suspicion of multi-system injury (ISS >15)
  • Haemodynamically stabilised patient after initial resuscitation who is too unstable for selective imaging alone
  • Severe head injury (GCS <=13) or clinical signs of intracranial injury
  • Suspected blunt aortic or great-vessel injury, or mediastinal widening on chest radiograph
  • Polytrauma where clinical assessment is unreliable (intubated, obtunded, distracting injuries)
  • Penetrating torso trauma in a stable patient to map trajectory and organ injury

Contraindications & Cautions

  • Haemodynamic instability unresponsive to resuscitation - such patients need theatre or the resuscitation room, not the CT scanner ('do not scan the crashing patient')
  • Known severe contrast reaction: use premedication or a non-contrast/alternative strategy
  • Renal impairment: weigh urgency against contrast-associated nephropathy; in life-threatening trauma the diagnostic benefit usually prevails
  • Pregnancy: justify carefully, shield where feasible, and tailor coverage; maternal stabilisation takes priority and the fetus is not shielded from a torso CT
  • Radiation stewardship: use dose modulation and restrict coverage in children and young adults (ALARA)

Patient Preparation

  • Complete primary survey and resuscitate to transient/stable physiology before transfer to CT
  • Secure airway, ensure adequate IV access (large-bore) for pressure contrast injection, and continue monitoring in the scanner
  • Maintain full spinal precautions until cleared; keep the patient on a trauma board/scoop
  • Remove radio-opaque items from the field where safe without compromising immobilisation
  • Consent is implied in the emergency; document the clinical justification
  • Prepare resuscitation drugs and a trained escort team for transfer, as deterioration in the scanner is common

Technique & Parameters

  • Non-contrast head CT first: axial acquisition, thin sections (0.6-1.25 mm) reconstructed to 3-5 mm, with bone and brain windows
  • Cervical spine: thin-section (<=1 mm) helical acquisition with multiplanar sagittal/coronal reformats and bone/soft-tissue windows
  • Neck/chest/abdomen/pelvis after IV contrast: split-bolus or dual-phase technique (arterial and portal-venous) to detect active haemorrhage and characterise solid-organ injury
  • Typical IV contrast 80-120 mL of iodinated agent at 3-4 mL/s via power injector, with bolus timing/tracking
  • 3-5 mm axial reconstructions plus thin sections for reformats; sagittal/coronal reformats of the whole spine
  • Use automatic tube-current modulation and appropriate kVp (100-120) to minimise dose; consider iterative reconstruction
  • Delayed phase for suspected urinary tract injury (CT cystogram/excretory) or to differentiate active bleeding from pseudoaneurysm
  • Resource-limited adaptation: targeted single-phase portal-venous body CT with selective non-contrast head/C-spine when scanner time or contrast is constrained

Systematic Review

  • Brain: extra-axial collections (extradural, subdural), subarachnoid/intraventricular haemorrhage, contusions, midline shift, herniation and skull fractures
  • Cervical and whole spine: alignment, vertebral body and posterior element fractures, facet dislocation, prevertebral soft-tissue swelling
  • Chest: aortic and great-vessel injury, pneumothorax/haemothorax, pulmonary contusion, tracheobronchial and diaphragmatic injury, rib/sternal fractures
  • Abdominal solid organs: liver, spleen, kidneys, pancreas - lacerations, haematomas, active contrast extravasation, organ injury grade (AAST)
  • Hollow viscus and mesentery: free air, free fluid, bowel-wall/mesenteric injury
  • Retroperitoneum and vasculature: haematoma, active bleeding, vascular contrast blush
  • Pelvis: pelvic ring and acetabular fractures, bladder injury, arterial extravasation
  • Extremities within field, lines/tubes position, and integrate findings into an injury severity assessment

Key Findings & Significance

  • Intracranial: extradural (lentiform, respects sutures), subdural (crescentic, crosses sutures), subarachnoid haemorrhage, contusions and mass effect requiring urgent neurosurgery
  • Cervical spine: Jefferson (C1 burst), hangman (C2 traumatic spondylolisthesis), odontoid, and flexion teardrop fractures with instability
  • Blunt aortic injury: intimal flap, pseudoaneurysm or contour irregularity at the isthmus, and mediastinal haematoma - a time-critical diagnosis
  • Tension/simple pneumothorax, haemothorax and pulmonary contusion
  • Solid-organ injury graded I-V (AAST) with contrast blush indicating active arterial bleeding that may require embolisation
  • Free intraperitoneal air or bowel-wall discontinuity indicating hollow-viscus perforation
  • Pelvic ring disruption with arterial extravasation predicting the need for angio-embolisation or packing
  • Active contrast extravasation (high-attenuation blush that increases on delayed phase) as a marker of ongoing haemorrhage

Differential Considerations

  • Crescentic extra-axial collection -> acute subdural haematoma vs subdural hygroma vs empyema (context)
  • Lentiform extra-axial collection -> extradural haematoma vs atypical subdural
  • Mediastinal widening/haematoma -> aortic injury vs venous/mediastinal small-vessel bleeding vs supine AP magnification artefact
  • High-attenuation focus in a solid organ -> active extravasation vs contained pseudoaneurysm vs AV fistula (compare arterial and delayed phases)
  • Free intraperitoneal fluid without organ injury -> hollow-viscus/mesenteric injury vs physiological fluid vs bladder rupture
  • Perisplenic/perihepatic fluid -> haemoperitoneum vs pre-existing ascites
  • Pelvic haematoma -> arterial (needs embolisation) vs venous/bony bleeding

Pearls & Pitfalls

  • Never scan a persistently unstable patient - resuscitation and haemorrhage control come first
  • Distinguish active arterial extravasation (blush that enlarges/spreads on delayed images) from a contained pseudoaneurysm (blush that follows vessel density and does not spread) - it changes management
  • Review scout and reformats for spinal injuries; axial-only review misses subtle alignment abnormality
  • Aortic injury classically sits at the isthmus - scrutinise this even with subtle mediastinal haematoma
  • Solid-organ injury grade and the presence of a blush, not organ appearance alone, drive operative vs interventional-radiology decisions
  • Beware the 'satisfaction of search' error: a dramatic head injury can distract from a torso or spinal injury - complete the systematic review
  • Streak/beam-hardening artefact from the arms or contrast in the SVC can obscure or mimic pathology - adjust arm position and timing
  • Delayed images are essential for suspected urinary tract and bladder injury

Structured Report

  • Use a structured trauma template covering head, spine, chest, abdomen, pelvis and vasculature
  • State phases acquired, contrast used and technical adequacy/dose considerations
  • Report each region with specific injuries, laterality and organ-injury grade where applicable
  • Highlight time-critical findings first (active bleeding, aortic injury, tension pneumothorax, unstable spine, intracranial mass effect)
  • Comment on lines, tubes and drains position
  • Impression: prioritised list of injuries with management-relevant flags (needs neurosurgery, laparotomy, embolisation, spinal precautions)
  • Communicate critical findings directly and immediately to the trauma team and document the alert

References

  • Royal College of Radiologists / BSTI Standards for Providing a 24-hour Trauma CT Service
  • ATLS (Advanced Trauma Life Support) principles for imaging the injured patient
  • AAST Organ Injury Scaling system
  • ACR Appropriateness Criteria: Major Blunt Trauma
  • RadioGraphics: Whole-Body CT in Polytrauma reviews

Educational clinical decision support only. Protocols vary by institution and equipment; always confirm with a qualified radiologist and local guidelines before clinical use.