When should a computed tomography (CT) scan of the head, neck, thorax, abdomen, and pelvis be performed in an elderly patient following trauma?

From the Guidelines

Elderly patients following trauma should undergo a computed tomography (CT) scan of the head, neck, thorax, abdomen, and pelvis when there are concerning clinical features or mechanism of injury, regardless of the severity of the trauma, due to their reduced physiological reserve and higher mortality risk. This approach is supported by the most recent guidelines, including the American College of Radiology's (ACR) appropriateness criteria for penetrating torso trauma 1 and major blunt trauma 1.

Key Indications for CT Scan

The following clinical features and mechanisms of injury should prompt a CT scan in elderly patients:

• Falls from standing height or greater
• Any head injury with loss of consciousness or amnesia
• Chest or abdominal pain following trauma
• Suspected fractures of the ribs or pelvis
• Neurological deficits
• Anticoagulant use
• Hemodynamic instability (even if mild)
• Multiple comorbidities, confusion, or inability to provide a clear history

Rationale for Lower Threshold

Elderly patients often have blunted pain responses and may not exhibit typical signs of serious injury, while their reduced physiological reserve means they can decompensate rapidly 1. Early identification of injuries through appropriate imaging can significantly improve outcomes and reduce mortality in this vulnerable population. The use of whole-body CT or CT with IV contrast can help determine the optimal surgical approach and prevent delay of definitive management, even in hemodynamically unstable patients 1.

Considerations for Imaging

When deciding on the use of CT imaging, considerations should include the degree of hemodynamic instability, distance to the CT scanner, and the potential benefits of early identification of injuries 1. However, given the potential for significant morbidity and mortality in elderly patients following trauma, a lower threshold for comprehensive imaging is recommended to ensure timely and appropriate management.

From the Research

Computed Tomography (CT) Scan Indications for Elderly Patients Following Trauma

• A CT scan of the head, neck, thorax, abdomen, and pelvis should be performed in elderly patients following trauma when specific clinical variables are present, as identified in studies 2, 3, 4.
• These clinical variables include:
  • High-risk mechanisms of injury
  • Vomiting
  • Witnessed loss of consciousness
  • Anterograde amnesia
  • Focal neurological deficit
  • History of traumatic intracranial haemorrhagic lesion (tICH) on a previous CT scan
• The presence of at least one of these risk factors is associated with the occurrence of traumatic intracranial haemorrhagic lesion (tICH) 5.
• A decision-tree based on these objective clinical severity criteria can detect the majority of tICH requiring surgical intervention 5.
• Physical exam alone is not sensitive enough to detect all traumatic injuries in elderly patients, and a pan-scan (head/cervical spine/torso) may be necessary to optimize care 4.
• A clinical algorithm to identify patients for pan-scan, using a combination of physical examination findings and specific high-risk criteria, can have a sensitivity of 0.94 and a negative predictive value (NPV) of 0.86 3.

CT Scan Body Regions

• The most commonly injured CT body regions in elderly patients following trauma are:
  • Head (52%) 2
  • Chest (42%) 2
• Injuries to the abdomen/pelvis and thoracolumbar spine are also common 3.
• A CT scan of the head, neck, thorax, abdomen, and pelvis can help identify these injuries and guide treatment.

Imaging Criteria

• Current decision tools to guide trauma CT imaging were not validated for use in older patients 2.
• Studies have identified groupings of clinical variables that are predictive of injury to guide CT imaging after geriatric blunt trauma 2, 3.
• Further study is needed to refine and validate these models 2, 3.