What type of imaging is recommended for a patient who fell from a porch?

Imaging Recommendations for Patients Who Fell From a Porch

For patients who fell from a porch, a CT whole body (WBCT) scan is recommended as the primary imaging modality, especially if the fall was from a height of >15 feet or if there are signs of significant trauma. 1

Initial Assessment and Imaging Algorithm

Hemodynamically Unstable Patients

• Begin with portable trauma series radiographs (chest and pelvis) to quickly identify life-threatening conditions such as tension pneumothorax, significant mediastinal injury, or unstable pelvic injuries 1
• Perform Extended Focused Assessment with Sonography in Trauma (E-FAST) to rapidly assess for free fluid in the chest, abdomen, and pelvis 1
• If the patient remains unstable despite resuscitation efforts and has positive signs of abdominal trauma on E-FAST, proceed directly to exploratory laparotomy rather than CT imaging 1
• For unstable patients with suspected pelvic fractures, obtain a pelvic X-ray upon arrival to the trauma center 1

Hemodynamically Stable Patients

• Proceed directly to CT whole body (WBCT) with IV contrast, which includes:
  • CT head without IV contrast 1
  • CT cervical spine without IV contrast 1
  • CT chest, abdomen, and pelvis with IV contrast 1
• Skip the initial pelvic X-ray for stable patients and proceed directly to CT scan 1
• For patients with suspected maxillofacial injuries, include CT maxillofacial (often reconstructed from head and cervical spine source data) 1

Rationale for WBCT in Fall Patients

• Falls from heights >15 feet are considered high-energy mechanisms that warrant comprehensive imaging 1
• WBCT provides rapid and accurate assessment of multiple potential injury sites in a single session 2
• CT with IV contrast has greater sensitivity for detecting visceral organ and vascular injuries compared to non-contrast CT 1
• Studies show that 38% of trauma patients have unexpected findings on body scans that weren't clinically apparent 3
• Management changes occur in approximately 19% of patients based on CT findings that weren't clinically suspected 2

Special Considerations

Head Trauma Assessment

• CT is the first-line imaging technique for head trauma evaluation 4
• For patients with Glasgow Coma Score <13, non-contrast CT of the head is essential 1
• If CT doesn't explain the clinical state, consider MRI for more sensitive detection of parenchymal injuries 4

Abdominal Trauma Assessment

• CT with IV contrast in the portal venous phase (70 seconds after contrast administration) is optimal for characterizing solid organ injuries 1
• Oral contrast is not recommended as it can delay diagnosis without improving sensitivity or specificity 1
• E-FAST has high specificity but lower sensitivity compared to CT for detecting intra-abdominal injuries 1

Chest Trauma Assessment

• Contrast-enhanced CT of the chest is preferred over non-contrast CT for comprehensive evaluation 1
• CT is significantly more sensitive and specific than conventional radiographs for detecting chest trauma 1
• Patients with abnormal chest radiographs have clinically significant rates of major injury on chest CT 1

Common Pitfalls to Avoid

• Don't rely solely on E-FAST to exclude injuries, as it has relatively lower specificity compared to CT 1
• Don't delay imaging for patients with significant mechanism of injury even if they appear stable and have no obvious external injuries 2
• Don't administer oral contrast for abdominal CT in trauma as it delays diagnosis without improving accuracy 1
• Don't forget that FAST has a high false-negative rate in patients with pelvic fractures 1
• Don't underestimate the importance of clinical judgment in determining the need for WBCT versus selective CT 1