What imaging should be ordered for a 65-year-old female restrained driver presenting to the emergency department after a rollover motor vehicle collision with airbag deployment?

Whole-Body CT Imaging Should Be Performed

For a 65-year-old restrained female driver involved in a rollover motor vehicle collision with airbag deployment, whole-body CT (WBCT) is the recommended imaging approach, assuming hemodynamic stability. This mechanism meets established high-risk criteria that warrant comprehensive imaging 1.

Rationale for Whole-Body CT

Your patient meets multiple ACR Appropriateness Criteria indications for WBCT 1:

• Rollover mechanism - explicitly listed as a WBCT indication
• Airbag deployment - suggests significant force of impact
• Age 65 years - older adults have increased injury severity and hospital admission rates after MVC 2, and elderly drivers with airbag deployment face elevated risk of cervical spine injury 3

The ACR guidelines specifically state that indications warranting WBCT include "MVC resulting in rollover or passenger ejection" along with consideration of "patient age and functional status" 1.

Specific WBCT Protocol

The imaging should consist of 1:

• CT head and cervical spine without IV contrast
• CT chest, abdomen, and pelvis WITH IV contrast (portal venous phase at 70 seconds)
  • Contrast-enhanced imaging has significantly greater sensitivity for detecting visceral organ and vascular injuries compared to noncontrast CT
  • Should be performed unless absolutely contraindicated

Initial Triage Imaging (If Not Proceeding Directly to CT)

If there is any delay in obtaining WBCT, initial trauma series should include 1:

• Portable AP chest radiograph - screens for tension pneumothorax, mediastinal injury, confirms line placement
• Portable AP pelvis radiograph - evaluates for unstable pelvic fractures and hip dislocation
• FAST examination - primarily for triage; positive FAST with hemodynamic instability would necessitate immediate surgical intervention rather than CT

Critical Age-Related Considerations

Your patient's age of 65 years creates specific vulnerabilities 3:

• Restrained drivers with airbag deployment who sustain cervical spine injuries are significantly older than those without injuries (mean age 65.2 vs. 44.8 years, p=0.002)
• All cervical spine injuries in airbag-deployed, restrained drivers were hyperextension injuries, with 50% having concomitant spinal cord injuries from dislocation
• Airbag deployment is independently associated with increased risk of blunt cerebrovascular injury (BCVI), even without cervical spine injury 4

Hemodynamic Status Caveat

If the patient is hemodynamically unstable despite resuscitation attempts 1:

• Proceed directly to the operating room if FAST is positive for abdominal trauma
• Defer CT imaging until after operative intervention
• Limited literature supports WBCT in truly unstable patients

Evidence Quality Note

While the 2024 ACEP Clinical Policy 5 found no high-quality studies (Class I-III) specifically addressing WBCT versus selective CT in hemodynamically stable blunt trauma patients, the ACR Appropriateness Criteria [1-1] provide the most comprehensive and recent guideline-based framework. The ACR guidelines acknowledge that meta-analyses show conflicting mortality benefits, but emphasize that clinical judgment incorporating mechanism, age, and hemodynamic status should guide the decision—all of which favor WBCT in your patient.

Additional Imaging Considerations

Do not obtain 1:

• MRI in the acute setting (too time-consuming)
• Oral contrast (delays diagnosis without improving sensitivity for blunt abdominal injuries)
• Standalone noncontrast CT of chest/abdomen/pelvis (inferior to contrast-enhanced imaging)

Consider adding if clinically indicated during the same acquisition:

• CT angiography of extremities if vascular injury suspected 1
• CT maxillofacial (often reconstructed from head/c-spine data) if facial injuries present 1