Results from the first year as a major trauma radiology unit in the UK.

Clinical Radiology xxx (2014) 1e10

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Results from the first year as a major trauma radiology unit in the UK A. Adiotomre a, A. Chopra a, A. Kirwadi, N. Kotnis* Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield S5 7AU, UK

art icl e i nformat ion Article history: Received 8 January 2014 Received in revised form 15 March 2014 Accepted 20 March 2014

AIM: To record and analyse data from all facets of practice in the first year as a newly set-up major trauma centre radiology department. MATERIALS & METHODS: Retrospective analysis of all patients who underwent whole-body computed tomography (WBCT) for suspected polytrauma over a 1 year period was performed. The mechanism, the time of day, the number of body parts injured, the type of injuries, and resulting surgical or radiological interventions were recorded. Also recorded was the time from the CT examination to the formal report. Where applicable, the consultant-verified reports were cross-referenced with the out-of-hours registrar reports to assess for discrepancies. RESULTS: Two hundred and one patients underwent WBCT for suspected polytrauma. Sixtyfour percent (128/201) of WBCT examinations were performed “out-of-hours”. Fifty-seven percent (115/201) were road traffic accidents (RTAs), 33% (66/201) were falls, and 6% (12/ 201) were assaults. At WBCT, 31% (63/201) had no injuries; 27% (54/201) had injury to one body area; 21% (43/201) had injury to two areas; and 20% (41/201) had injury to three or more areas. Nineteen percent (39/201) required urgent radiological or surgical intervention. The mean time from end-of-CT to a formal report was 27 min. There were discrepancies between consultant reports and registrar reports in 7% (31/142) of cases; 1% (2/142) led to a change in acute management. CONCLUSION: Based on our early experiences, nearly one-third of patients who undergo a WBCT scan for suspected polytrauma, will have no acute injury at WBCT. One-fifth of patients in our study required emergency surgical or radiological intervention for acute injuries found on WBCT. A low discrepancy rate was found between on-call registrar reports and the consultant-verified reports. Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved.

Introduction In a government-led initiative to improve the care of patients, the National Health Service (NHS) set up major trauma centres (MTC). This followed a report from the * Guarantor and correspondent: N. Kotnis, Northern General Hospital, Sheffield Teaching Hospitals NHS Foundation Trust, Herries Road, Sheffield S5 7AU, UK. Tel.: þ44 (0) 114 2714339; fax: þ44 (0) 114 2714388. E-mail address: [email protected] (N. Kotnis). a Dr Adiotomre and Dr Chopra have contributed equally to the preparation of this manuscript and should be considered joint first authors.

National Audit Office in 2010 that described an unacceptable level of variation in the care of trauma patients between different hospitals.1 With the advent of MTCs, the care of trauma patients should be standardized so that upon arrival they are immediately assessed by a designated trauma team in the emergency department (ED). Patients should be promptly referred for whole-body computed tomography (WBCT), if clinically indicated, to facilitate early detection of serious injuries within one centre with a full range of trauma specialists. Multidetector CT has revolutionized the care of polytrauma patients and cemented the pivotal role of radiology

0009-9260/$ e see front matter Ó 2014 The Royal College of Radiologists. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.crad.2014.03.015

Please cite this article in press as: Adiotomre A, et al., Results from the first year as a major trauma radiology unit in the UK, Clinical Radiology (2014), http://dx.doi.org/10.1016/j.crad.2014.03.015

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A. Adiotomre et al. / Clinical Radiology xxx (2014) 1e10

in directing treatment and specialist referral. Advances in technology and marked improvement in access has led to CT being considered as an essential tool for guiding the immediate management of trauma patients.2 Improvement in image quality has allowed detection of serious injuries that are unexpected clinically. A network of 22 centres, specializing in treating patients who suffer from major trauma, opened across England in April 2012. Sheffield Teaching Hospitals was one of those designated as an MTC. The aim of the present observational study was to record and analyse data from all facets of practice in the first year as a newly set-up MTC radiology department. As the polytrauma imaging pathway was aligned closely to guidelines issued by the Royal college of Radiologists (RCR),3 the aim was to assess how manageable this framework was for everyday practice within a newly set-up MTC.

Materials and methods The study was conducted as a retrospective analysis of major trauma imaging over a 1 year period, from April 2012 to April 2013. Institutional review board approval was obtained. Retrospective review of the trauma-imaging database was performed to identify patients who underwent WBCT as a result of trauma during the first year as an MTC. A major trauma-imaging protocol was set up in advance of the start date, with agreement between the Traumaimaging Lead and the ED Major Trauma Lead. It was based largely on RCR guidelines.3 Some adaptations were made to this framework based on the experiences of the present authors regarding trauma imaging, and in order to make it a workable protocol for staffing levels within the department. A polytrauma CT request card, similar to the template provided in the RCR guidelines, was used for all polytrauma cases (Fig 1). Two protocols for trauma WBCT were established from these guidelines depending on whether the patient was considered haemodynamically stable or unstable by the clinical team. All examinations were performed on a 64 section VCT Phillips scanner (Milwaukee, Wisconsin, USA). Both protocols involved a unenhanced CT examination of the head and cervical spine. In the stable protocol, the arterial phase of the chest/abdomen/pelvis and a portal venous phase abdomen/pelvis were then performed. For the unstable patient, the protocol comprised the above phases and an additional delayed (100 s) abdomen/pelvis phase. The arterial phase abdomen/pelvis was omitted from the stable protocol following a clinicoradiological review of all injuries detected after 3 months. The location and mechanism for each incident, the time of day, and whether the incident occurred on a weekday or at the weekend were recorded. Data on the number of body parts injured, the type of injuries, and resulting surgical or radiological interventions were collected for each case. Where applicable, the consultant-verified report was crossreferenced with the registrar secondary report to assess for discrepancies. Where discrepancies were found, the CT examinations were reviewed by both a consultant radiologist

and a radiology registrar. A consensus decision was reached as to the significance of the discrepancy. Discrepancies were graded using the following scale: 0, no significant discrepancy; 1, missed incidental finding; 2, missed injury but no potential for acute clinical deterioration; 3, missed injury with potential for acute clinical deterioration; FP1, false positive with no clinical significance; FP2, false positive with clinical significance; Consultant miss, injury reported on the registrar secondary report but not on the consultant-verified report. The performance in specific areas was recorded: the arrival time in the ED to CT examination; the time from endof-CT to a primary survey report; and the time from end-ofCT to a formal report were all recorded. A primary survey proforma was filled out in the CT control room as the scan was being performed and then handed to the Trauma Team Lead, typically before the patient returned to the ED (Fig 2). A detailed secondary report was either provided as a final consultant-approved report available on the radiology information service (RIS) system or as a secondary survey proforma filled in by a post-FRCR radiologist for out-ofhours examinations (Fig 3). Both proformas were based on RCR templates.3 The radiation dose, measured in terms of doseelength product (DLP; in mGycm2), was recorded for each MTC CT examination. Statistical analyses of the data were expressed as frequencies (with percentages) or mean values.

Results A total of 201 polytrauma WBCT examinations were performed over the 1 year period. Patient demographics are listed in Table 1. One hundred and sixty-five patients were classed as stable and 36 patients unstable. One hundred and seventy-one patients were admitted, 26 were discharged on the same day of the examination, and four patients died on the same day of the WBCT. The majority of patients were brought into the ED by the ambulance service. Two patients self-referred to the ED. Thirty-six percent (73/201) of patients were examined during “daytime weekday” working hours and 64% (128/201) of examinations were performed in the evenings, overnight, or over the weekend by the on-call radiology team. Seventytwo percent of (145/201) examinations were performed during weekdays and 28% (56/201) at the weekends. Fifty-seven percent (114/201) of patients were involved in RTAs, the majority of which were high-speed impacts with injury to more than one body region. Thirty-three percent (66/201) suffered a fall. Six percent (12/201) were victims of an assault. In the remainder of cases, the mechanism was either a “miscellaneous” cause or not documented in the notes (Table 1). Thirty-one percent (63/201) of patients had no injuries at WBCT. Twenty-seven percent (54/201) had an injury to one body area, 21% (43/201) had an injury to two body areas, and 20% (41/201) had an injury to three or more body areas (Fig 4). Chest injuries were most common, seen in 43% (87/ 201) of patients, with rib fractures accounting for most. This



3

Figure 1 Major trauma WBCT request card.

was followed by vertebral (29%), head (23%), abdominal (10%), and pelvic bone injuries (10%). The areas injured and types of injuries are detailed in Table 2. Three patients were confirmed to have cord injury at a magnetic resonance imaging (MRI) examination performed within 48 h of the WBCT examination. In one of these cases, there was a T10 fracture with retropulsed bone fragments at WBCT. In the other two cases, no fractures were demonstrated at WBCT, but prevertebral soft-tissue swelling suggested ligamentous injury in one of these cases. Six CT examinations showed active abdominal haemorrhage: five within solid abdominal viscera and one from a

rectus sheath injury. Two percent (5/201) of patients required emergency endovascular procedures. Seventeen percent (34/201) of patients underwent emergency surgery for findings reported on the WBCT examinations. The emergency interventions are listed in detail in Table 3. The average time-to-CT from arrival in the ED was 48 min in the 193 patients where times were clearly recorded. The average time-to-CT was 39 min for unstable patients and 50 min for stable patients. Only 46% (86/193) of patients underwent CT within 30 min of arrival. Sixty-nine percent (139/201) of patients had plain radiographs prior to CT. Of these, only four patients had plain film findings that


4


Figure 2 Primary survey polytrauma CT report.

required immediate action prior to CT. These included a misplaced endotracheal tube (ET), bilateral pneumothoraces in an intubated patient, large bilateral pneumothorax, and a tension pneumothorax. In the 122 patients where data were recorded, the primary survey report was completed on average 12 min before the entire CT examination was completed and sent to the picture archiving and communication system (PACS). A time was not recorded in 46 of the primary surveys and 33 primary surveys were not entered into the RIS system and could not be found with the notes. For the detailed report, there were available data for 169 patients. Of 127 secondary surveys filled out by registrars,

the mean time from end-of-CT to the report being recorded was 22 min. Of 42 formal reports provided directly by consultants within hours, the average time from end-of-CT to the report being available on the RIS system was 1 h 22 min. The overall (combined in and out-of-hours data) mean time from end-of-CT to a detailed formal report was thus 27 min. Eighty-two percent of cases (138/169) had a detailed formal report provided within 1 h. In 18 cases, no report time was recorded, and in 14 cases, the report was not entered into the RIS system. Eighty-nine percent (178/201) of WBCT examinations had a formal, verified consultant report available on the RIS system within 24 h of the examination. The average time for



5

Figure 3 Secondary survey polytrauma CT report.

a formal, verified RIS report was 13 h and 52 min. Twentythree examinations did not have a consultant-verified RIS report available within 24 h. Fifteen occurred at the weekend and 15 were within the first 6 months of the MTC service. All senior registrars’ secondary reports were compared against the consultant-verified formal report as demonstrated in Table 4. There were discrepancies between these reports in 22% (31/142) of cases. These comprised six (grade 1) missed incidental findings; 16 (grade 2) missed injuries that had no potential for acute clinical deterioration; two (grade 3) missed injuries with potential for acute clinical deterioration; four (FP1) false positives that had no clinical consequence; and three (consultant miss) injuries that were

correctly reported by registrars but were omitted in the formal consultant-verified report. The grade 3 discrepancies comprised a teardrop cervical spine fracture that was missed in a patient with severe head trauma and a small subdural haemorrhage in a patient with other complex injuries. The average DLP dose for a polytrauma CT was 2458 mGycm2. The highest dose was 5222 mGycm2 and lowest dose was 605 mGycm2.

Discussion The potential implications of running an MTC service for radiology departments in the UK have previously been


6


Figure 3 (continued).

discussed in great detail.4 To the authors’ knowledge, however, this is the first paper to publish data based on direct experiences of a newly set-up MTC radiology service in the UK. The use of WBCT in early trauma care significantly increases the probability of survival in polytrauma patients.5 Trauma patients commenced CT examinations within 30 min of arrival to ED in 46% of cases in the present study, with an average time to CT of 48 min. The London Trauma Network has included time from ED admission to CT as one

of its performance markers.6 The acceptable time by which CT acquisition should have begun has not been specifically defined. However, it has been shown that patients with a primary diagnosis achieved within 50 min of arrival are hospitalized significantly longer than those with a primary diagnosis achieved within 40 min.7 To help reduce time to CT, the RCR state that CT machines should be adjacent to or in the ED. In addition, it is stated that if there is an early decision to request WBCT, FAST scans or plain films should not cause delay. At Northern General Hospital, the resident


A. Adiotomre et al. / Clinical Radiology xxx (2014) 1e10 Table 1 Demographic and admission characteristics. Characteristics Age 15e20 21e30 31e40 41e50 51e60 61e70 71e80 81e90 91e100 Male Mechanism Road traffic accident Fall Assault Miscellaneous Unknown Time of ED admission Week day 9ame5pm Out of hours Incident location Within region Bypass Unknown Self-referred Haemodynamic status Stable Unstable Outcome from ED Admitted Discharged Died

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Table 2 Summary of injuries. No.

(%)

19 43 30 29 19 17 29 12 3 152

9.5 21.4 14.9 14.4 9.5 8.5 14.4 6.0 1.5 75.6

114 66 12 6 3

56.7 32.8 6.0 3.0 1.5

73 128

36.3 63.7

114 43 42 2

56.7 21.4 20.9 1.0

165 36

82.1 17.9

171 26 4

85.1 12.9 2.0

ED, emergency department.

on-call radiology registrar and radiographer are included in the major trauma bleep cascade and, therefore, are on standby if WBCT is required. In addition, the CT rooms at Northern General Hospital are adjacent to ED to allow immediate access. However, the majority of patients (139/201) had plain films prior to their CT. Most plain films taken prior to WBCT did not add to immediate patient management and were a factor in delaying admission-to-CT time. In a study of 245 patients with major trauma who underwent WBCT, Hudson et al.8 concluded that plain films could safely be omitted during the primary survey of selected major

Figure 4 Graph to illustrate the number of body areas injured/case at polytrauma CT.

Injuries CT head Normal Abnormal Intracranial haemorrhage Contusion Skull vault fracture CT spine Normal Abnormal Fracture Unstable fracture Dislocation CT chest Normal Abnormal Pneumothorax/haemothorax Lung contusion Vessel injury Aortic Rib fractures Flail segment CT abdomen/pelvis Normal Abnormal Solid-organ injury Active bleeding Free fluid Bowel injury/perforation CT bony pelvis Normal Abnormal Multiple pelvic fractures Single pelvic fracture Fracture dislocation Hip dislocation

No.

%

155 46 35 25 24

77.1 22.9 17.4 12.4 11.9

143 58 40 9 1

71.1 28.9 19.9 4.5 0.5

114 87 46 41 4 2 65 3

56.7 43.3 22.9 20.4 2.0 1.0 32.3 1.5

180 21 14 5 10 2

89.6 10.4 7.0 2.5 5.0 1.0

181 20 16 3 1 1

90.0 10.0 8.0 1.5 0.5 0.5

CT, computed tomography.

trauma patients and found that the addition of plain films significantly delays time to WBCT. Some clinicians still feel uncomfortable without a radiographic trauma series as part of their initial assessment even when a WBCT is clearly indicated and readily accessible. This is something that is regularly discussed with ED clinicians at trauma radiology audit meetings at Northern General Hospital. In a study of 4000 trauma victims, Laupland et al.9 found that 78% of patients were admitted during the “after hours” (evening/nights or weekends). This is similar to the present study whereby, in the first year of being an MTC, 64% patients were admitted “after-hours” (evening/nights or weekends). The referral criteria for WBCT for polytrauma patients at Northern General Hospital were based on RCR guidance and set out in the WBCT request card proforma. Minor adaptions to the RCR request card were made following consultation with ED department colleagues. This involved ensuring that patients with obvious signs of significant spinal or vascular injury were clearly identified to the reporting radiologist and CT staff. In particular, it was necessary to formalize the need for alerting the on-call vascular radiologist before WBCT was performed in unstable patients, to ensure an early specialist assessment of the imaging (Fig 1). At


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Table 3 Summary of interventions from whole-body computed tomography findings. Injury Brain (10) SAH þ SDH þ Skull # SAH SAH þ SDH SAH and skull # EDH þ SDH þ SAH SAH þ parenchymal contusion þ skull # SAH þ SDH þ skull # EDH þ SDH þ parenchymal contusions þ skull # SDH þ Skull # SAH þ SDH þ EDH Abdomen (10) Splenic laceration Splenic laceration Shattered spleen Splenic lacerations Traumatic abdominal wall hernia Large bowel perforation Small bowel Injury Stomach perforation Right renal injury Anterior abdominal wound Pelvic fractures (6) Pubis & acetabulum # Complex multiple pelvic # Pubis, ilium &acetabular # Sacral & pubis # Sacral, pubis &acetabular # Sacral, ilium &acetabular # Chest (6) Traumatic aortic dissectiona Traumatic aortic dissection Chest stab wound Chest stab wound Oesophageal perforation with post-traumatic tracheo-oesophageal fistula Spine (3) Unstable T5, T6 and T7 #s with cord injury Unstable T7 and T8 #s with stable T11 # Unstable C7 #a Miscellaneous (5) Clavicle # (3) Open reduction and fixation Foreign body in buttock Active pelvic bleeding Obturator artery embolization

Surgery Bifrontalcraniectomy Craniectomy Craniotomy Craniectomy þ ICP bolt Craniotomy Craniotomy Craniotomy Bilateral burr holes Craniectomy and ICP bolt Craniotomy Splenic artery embolization Splenic artery embolization Splenectomy Splenectomy Hernia Repair Right Hemicolectomy Small bowel resection Stomach suture Renal stent Wound exploration and washout All treated with external fixation for immediate stabilization prior to definitive fixation

Endovascular stent procedurea Endovascular stent procedure Exploration & washout Exploration & washout Tracheo-oesophageal repair

Posterior instrumental fixation and decompression Posterior instrumental fixation and decompression Spinal stabilizationa

Foreign body removal

SAH, subarachnoid haemorrhage; SDH, subdural haemorrhage; EDH, extradural haemorrhage; #, fracture; ICP bolt, intracranial pressure bolt. a This is the same patient.

Northern General Hospital, the mechanism of trauma, clinical signs of significant injury, and the patient’s vital signs are all used to triage patients for WBCT. Using the current criteria, 31% of patients who underwent WBCT had a normal examination. Other centres have published a similar rate of normal trauma WBCT examinations.10,11 Attempts to use clinical judgement from experienced ED consultants have failed to safely reduce the proportion of normal patients being scanned resulting in significant missed injuries.12 Bearing in mind the young demographic of many trauma patients, methods of avoiding unnecessary radiation exposure have to be examined. There is also the expense, increase to workload and delay to other urgent scans that need to be considered. It has been suggested that mechanism alone may not be a useful referral criterion, as it has a low sensitivity as an indicator of serious injury

resulting in an over-triage rate of up to 75%.13,14 Based on the current literature available, WBCT indications for trauma will continue to capture a proportion of completely normal scans. However, CT in major trauma has been shown to detect clinically unexpected findings that can lead to significant changes in management.15 It is thus easy to understand why many clinicians see WBCT as a vital screening tool for all major trauma patients, particularly when distracting injuries or a reduced Glasgow Coma Scale (GCS) can mask clinical signs of significant injury elsewhere. Sixty percent of patients in the present study had either no injury or injury to one body region only. Only 19% (38/ 201) patients required emergency interventions. Only one patient required emergency intervention to more than one body area. This does call into question whether WBCT is really required in all major trauma patients and whether


A. Adiotomre et al. / Clinical Radiology xxx (2014) 1e10 Table 4 Summary of discrepancies between registrar secondary reports and consultant verified reports. Discrepancies

No.

%

No Yes Grades 1 2 3 FP1 FP2 Consultant miss

111 31

78.2 21.8

6 16 2 4 0 3

4.2 11.3 1.4 2.8 0.0 2.1

0, No significant discrepancy; 1, incidental finding; 2, acute injury but no clinical consequence; 3, acute injury with significant clinical consequence; FP1, false positive with no clinical significance; FP2, false positive with clinical significance; Consultant miss, injury reported on registrar secondary report but not on consultant-verified report.

more focused scanning, after a period of observation, could be used in the stable patient. The average DLP dose for a polytrauma CT examination was 2458 mGycm2, Some of the individual higher WBCT doses were attributable to either the examination being performed with arms down or due to patient body habitus. Raising both patient’s arms above the level of shoulders after the head and cervical spine images have been acquired may reduce the effective radiation dose of WBCT by up to 45%, with the added benefit of increased image resolution.16,17 Understandably, this is not always possible with trauma patients. WBCT is a high-radiation-dose examination and is often performed on patients who are young healthy adults with a high proportion of resulting “normal” scans. A single fullbody CT examination in a 45-year-old adult would result in an estimated lifetime attributable cancer mortality risk of around 0.08%.18 This is clearly not of immediate concern to emergency clinicians. However, opportunities should be taken regularly to raise awareness of the radiation risk when requesting WBCT on seemingly well patients purely due to the mechanisms of injury, which, as previously discussed, has a poor sensitivity for prediction of serious injury. The primary and secondary reporting frameworks were based on RCR recommendations.3 In the present study, the average primary report was issued 12 min before the completion time of the CT examination. The primary reports are completed by the reporting radiologist in the CT control room as the images are being acquired. This was found to be quicker than waiting for the images to be sent to the PACS. In addition, it brings the reporting radiologist into direct contact with the trauma team. The present primary report proforma was structured around the RCR guidance3 and focused purely on severe, sometimes life-threatening injuries paralleling the clinical Advanced Trauma Life Support primary survey. The secondary/formal report was issued within an hour from the end of the CT examination in 82% of cases. These reports were issued by either senior radiology registrars or consultants. RCR guidance states that all formal/secondary reports should be issued within an hour by a consultant

9

radiologist.3 Due to the potential impact on daily consultant working patterns and the absence of teleradiology facilities at present, this was not possible at Northern General Hospital. Therefore, the majority of secondary reports out-ofhours were issued by senior registrars, although a consultant on-call is available to report these examinations within the first hour if required. In addition, all secondary reports issued by registrars are double reported by a consultant radiologist within 24 h at Northern General Hospital d a standard that was met 89% of the time. Registrar secondary reports were compared with the consultant-verified report and acute missed injuries were found in 13% of registrar reports. In less than 2% (2/142) of cases was it felt that there was potential for immediate clinical deterioration as a result of missed injuries. No patients suffered untoward clinical consequences as a result of the missed injuries. This was in concordance with several previous studies including that published by Briggs et al.10 who found the incidence of major discrepancies between the registrar provisional and consultant final report in polytrauma CT was low (4%) and did not lead to any significant clinical deterioration.10,19,20 The suboptimal recording of data was a weakness of the present study. This usually occurred due to a failure to record times on the primary and secondary survey report cards or the cards not being scanned into the RIS system. Most of these “missing” reports were not filed in the medical notes. The secondary survey report template has recently been embedded into the PACS system for all polytrauma cases so that these reports are always permanently recorded in the system. In addition, staff within the department are constantly reminded about the importance of complete documentation at regular MTC radiology meetings. Another weakness is the retrospective nature of the study. As certain parts of the protocol were adapted during the first year as an MTC centre, there were some inconsistencies, particularly with regard to CT protocols and doses. In conclusion, the RCR guidelines for the severely injured patient were found to be a good framework within which to work for a newly set-up MTC radiology centre. A consultant-verified report within 1 h for every out-of-hours examination is not feasible in all UK MTCs at this time; however, a low discrepancy rate was found between on-call registrar reports and the consultant-verified reports. Based on our early experiences, nearly one-third of patients who undergo a WBCT scan for suspected polytrauma, will have no acute injury at WBCT. One-fifth of patients in our study required emergency surgical or radiological intervention for acute injuries found on WBCT.

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A. Adiotomre et al. / Clinical Radiology xxx (2014) 1e10 Radiologists; 2011. Available at: http://www.rcr.ac.uk/docs/radiology/ pdf/BFCR(11)3_trauma.pdf [accessed 10.12.13]. Harvey JJ, West ATH. The right scan, for the right patient, at the right time: the reorganization of major trauma service provision in England and its implications for radiologists. Clin Radiol 2013;68:871e86. Huber-Wagner S, Lefering R, Qvick LM, et al. Effect of whole body CT during trauma resuscitation on survival: a retrospective, multicentre study. Lancet 2009;2009(373):1455e61. NHS London Trauma Office. Mid-year report for the period april-september 2010. London: NHS London Trauma Office; 2012. Available at: http://www. londontraumaoffice.nhs.uk/silo/files/london-trauma-office-midyear-report. pdf [accessed 10.12.13]. Prokop A, Hotte H, Kruger K, et al. Multislice CT in diagnostic work-up of polytrauma. Unfallchirurg 2006;109:545e50. Hudson S, Boyle A, Wiltshire S, et al. Plain radiography may be safely omitted for selected major trauma patients undergoing whole body CT: database study. Emerg Med Int:432537. Available at: http://dx.doi.org/10. 1155/2012/432537; 2012 [accessed 10.12.13]. Laupland KB, Ball CG, Kirkpatrick AW. Hospital mortality among major trauma victims admitted on weekends and evenings: a cohort study. J Trauma Manag Outcomes 2009;3:8. Briggs RH, Rowbotham E, Johnstone AL, et al. Provisional reporting of polytrauma CT by on-call radiology registrars. Is it safe? Clin Radiol 2010;65:616e22. Smith CM, Woolrich-Burt L, Wellings R, et al. Major trauma CT scanning: the experience of a regional trauma centre in the UK. Emerg Med J 2011;28:378e82.

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