Major trauma — whole-body (pan-scan) versus selective CT

NICE NG39 (major trauma); NICE NG232 (head injury); ACR AC Major Blunt Trauma; REACT-2 2016; WSES spleen 2017 / liver 2020; AUA Urotrauma

Whole-body CT is justified by MECHANISM and PHYSIOLOGY, not by the fact that someone has been injured. The patient with a high-energy transfer, multi-region signs or an examination that cannot be trusted — intubated, obtunded, intoxicated, or distracted by one dominant painful injury — is the patient the pan-scan exists for. The awake, stable, examinable patient who is tender in exactly one place should have that place imaged, and irradiating the rest of them is a real cost for no benefit. And in the patient who does not respond to volume resuscitation the correct answer is not a different protocol: it is theatre or interventional radiology, because a CT that delays haemostasis is the harm.

A trauma call. Blunt or penetrating injury, arriving through the emergency department or transferred from another hospital, where the team is deciding between a single integrated whole-body acquisition and region-directed imaging — or, in the patient who keeps dropping their pressure, whether to image at all before definitive haemostasis.

Referenced decision support — confirm against your local protocol.

Decision support, not a directive. Protocols and timings shown are typical published ones — your local protocol takes precedence, and the vetting radiologist decides.

The request in front of you

Everything is optional. Leave a field alone and the answer assumes nothing — the verdict updates as you go.

Study requested

What the referrer actually asked for. It is evidence of intent, not a constraint on the right answer.

Contrast as written

What the request form says, not what it should say.

Age

Pick a band, or type an exact age if it matters.

years

Pregnancy status

Haemodynamic state

The fact that lets a pathway waive its own requirements. A crashing patient does not wait for a score.

GCS

Renal risk factors

The question a vetter can actually answer from the request. An explicit “none known” is a real answer, and it removes checks rather than deferring them.

Previous contrast reaction

The pathway — tap anything already done

Marking a study complete moves the answer on. A patient arrives partway through a pathway far more often than at the start of one.

Accept as requested

CT Whole-Body Trauma — Single Pass

CT Whole-Body Trauma (Pan-Scan)

What we'd amend, and why

This is the study for the patient in whom the examination cannot be trusted and the mechanism says the injuries could be anywhere: the intubated or obtunded patient, the patient with signs in more than one body region, the high-energy transfer — ejection, entrapment, death of another occupant, fall from height, pedestrian struck at speed — and penetrating truncal injury in a patient stable enough to be scanned, where the track has to be defined. NG39 supports whole-body CT in adults with blunt major trauma and suspected multiple injuries, and supports immediate CT in the patient with suspected haemorrhage who is responding to volume resuscitation or whose haemodynamic status is normal. Two things follow that are easy to get wrong. First, the acquisition is a specific one, not a relabelled CT chest-abdomen-pelvis: unenhanced head and cervical spine acquired before any contrast, because an iodine load degrades the assessment for intracranial haemorrhage, then contrast-enhanced torso coverage carrying both arterial and portal-venous information, as two passes or as a single split-bolus pass, with the thoracolumbar spine and pelvis reformatted from that dataset rather than rescanned. Second, the evidence does not say the pan-scan makes everyone better: the randomised REACT-2 trial found no mortality difference between immediate total-body CT and a selective work-up, which is precisely why the justification has to be the individual patient rather than the trauma call. The patient who does not respond to resuscitation is not on this pathway at all — that patient goes to theatre or to interventional radiology, and a scan that delays haemostasis is the injury.

Nothing needs resolving before this goes ahead. Routine checks below are owned downstream.

How was this decided?

pathwayadult — Adults and young people 16 and over
rulerule-contrast-reaction-premed — Prior contrast reaction and elective premedication; checked by Nurse before the scan
rulerule-metformin — Metformin and iodinated contrast; checked by Radiographer at the scanner
rulerule-paeds-dose — Child-sized technique and contrast dose; checked by Radiographer at the scanner
rulerule-pregnancy-ionising — Pregnancy status before an ionising exposure; checked by Radiographer at the scanner
rulerule-renal-iodinated — Kidney function and intravenous iodinated contrast; checked by Radiographer at the scanner
rulerule-iv-access — Intravenous access adequate for the planned injection; checked by Radiographer at the scanner

Decision support only. Local protocol takes precedence.

Handled at the scanner(4)nothing for you to do

Settled and owned downstream. Each returns to a radiologist only on the stated trigger.

Metformin and iodinated contrast
Confirm whether the patient takes metformin or a metformin-containing combination, and if so whether ACR Category II applies (eGFR below 30, known or suspected AKI, or an arterial catheter study likely to cause renal embolisation). If Category I — that is, no AKI and eGFR at or above 30 — no action of any kind is needed.
Radiographer at the scannerAt the scanner
Flags back if: The patient takes metformin AND meets ACR Category II — eGFR below 30 mL/min/1.73 m2, known or suspected acute kidney injury, or an arterial catheter procedure with likely renal arterial embolisation. Metformin plus a normal or mildly reduced eGFR is explicitly NOT a flag-back: there is no need to stop metformin before or after intravenous iodinated contrast in Category I patients, and no need to re-check creatinine afterwards.
Child-sized technique and contrast dose
Confirm that a size- or weight-based protocol is selected — child-sized kV and mAs against size-based diagnostic reference ranges — and that contrast volume is calculated by weight rather than taken from an adult default. Weight-based iodinated contrast volumes of roughly 1.5–2.0 mL/kg are widely used in paediatric CT.
Radiographer at the scannerAt the scanner
Flags back if: No paediatric or size-based protocol exists on the scanner for the requested examination, or the requested coverage or number of phases exceeds what the clinical question needs — for example a multiphase study where a single phase answers it, or whole-body coverage for a focal question.
For this indication, dose control in a child means child-sized kV and mAs against size-based reference ranges, weight-calculated contrast volume, a single portal-venous torso pass, coverage limited to the regions actually being asked about, and reformatting the spine and pelvis rather than rescanning them. It never means declining or delaying an examination that has been justified — NG39 restricts routine whole-body coverage in children, not indicated imaging.
Pregnancy status before an ionising exposure
Make the pregnancy enquiry immediately before the exposure and record the answer. In the UK this is a statutory operator duty discharged at the time of exposure under the employer’s written procedures required by IR(ME)R 2017 — it is not something the vetting radiologist can perform or pre-empt, and a request is complete without it.
Radiographer at the scannerAt the scanner
Flags back if: The patient states that she is, or may be, pregnant AND the uterus is in or near the primary beam. The exposure is then paused for re-justification by the IR(ME)R practitioner before it proceeds.
Intravenous access adequate for the planned injection
Site and test a cannula that supports the protocol flow rate, preferring an antecubital or large forearm vein, and observe the injection for extravasation. A 20-gauge or larger cannula is preferred for flow rates of 3 mL/s or more.
Radiographer at the scannerAt the scanner
Flags back if: No cannula can be sited that supports the protocol flow rate — for example only a 22-gauge hand or foot cannula for a CT angiogram needing 4–5 mL/s; or the only available access is a central line or port that is not labelled power-injectable; or an extravasation occurs.

Worth asking the referrer (4)

None of these hold the request up. They sharpen the protocol or the plan that follows.

What are the current observations, and is the patient responding to volume and blood product resuscitation?
This is the single fact that decides whether the patient goes to the scanner at all. A transient or non-responder with suspected torso haemorrhage belongs in theatre or the interventional suite, and the radiological contribution at that moment is to say so and to get the IR team activated, not to protocol a scan. State it and this card answers as that patient rather than as a generic trauma call; leave it unstated and the answer is the same one it always gave.
What was the mechanism, and how much energy was transferred — speed, height, ejection, death of another occupant, entrapment, restraint use?
Mechanism is half the justification for whole-body coverage. It is what predicts the injury the examination will not find, and it is the part of the history that most often never reaches the request form.
Is the patient awake, orientated and reliably examinable, or intubated, obtunded, intoxicated, or distracted by one dominant painful injury?
An unreliable examination is the other half of the justification. Selective imaging is only safe when someone can actually clear the regions you are choosing not to scan; where they cannot, the pan-scan is doing the examining.
Has any CT already been performed at the referring hospital, and can the images be transferred?
Repeating an adequate outside study is avoidable dose and avoidable delay. Transfer of the images is almost always faster than rescanning, and where the outside study is genuinely inadequate, naming which part is inadequate turns a whole repeat pan-scan into a single targeted acquisition.

Pathways

Big forks are separate pathways; the first whose conditions match is the one used.

Not responding to resuscitation — haemostasis before imaging

Role	Study & protocol	Why this answers the question
First line	Ultrasound abdomen Ultrasound abdomen — full survey usually appropriate	NG39 frames the decision in both directions, and this is the direction that gets people killed: in the patient with active bleeding who is not responding to volume resuscitation, diagnostic imaging is limited to the minimum. A transient or non-responder with suspected torso haemorrhage belongs in theatre or in the interventional suite, and a CT that delays haemostasis is itself the harm — the highest-consequence error on this card, and a governance failure rather than a protocol one. The useful radiological act at this moment is to activate the interventional radiology team and clear the scanner, not to optimise an acquisition. What imaging does contribute in the resuscitation room is the focused assessment, and its two results mean completely different things. A POSITIVE study — free fluid in a hypotensive patient who is not responding — is not an indication for a CT scan. It is the answer: that patient goes to the operating theatre for laparotomy now, and the correct radiological output is to say so and to stand the scanner down, because the intervening CT buys a grade of splenic injury at the price of the minutes the patient does not have. A NEGATIVE study in the same patient excludes almost nothing and must never be read as reassurance. It says the peritoneal cavity is probably not the source, which redirects rather than reassures: the four remaining places a non-responder is bleeding are the chest, the pelvis and retroperitoneum, the long bones, and the floor. A pelvic binder goes on before anyone argues about imaging, and this is the one situation in which a supine chest and pelvic radiograph in the resuscitation room earn their place — NG39 says not to use them routinely in the primary survey when immediate CT is indicated, which is precisely the point, because in this patient it is not. Its other limits are why it sits on this arm and nowhere else: it is not a screening test for whether CT is needed, it does not exclude solid organ, retroperitoneal, mesenteric or hollow viscus injury, and using a negative one to stand down an indicated scan in a patient who HAS responded is how a delayed splenic or bowel injury is missed.
Second line	CT Whole-Body Trauma (Pan-Scan) CT Whole-Body Trauma — Single Pass	Instability sequences the whole-body study behind haemostasis; it does not cancel it. Once the patient responds to volume and blood products, or once bleeding has been controlled in theatre or by embolisation, this is the study — NG39 supports immediate CT in the patient with suspected haemorrhage who is responding to volume resuscitation or whose haemodynamic status is normal, and the injuries that were never the source of the bleeding still have to be found. It is the specific trauma acquisition rather than a relabelled CT chest-abdomen-pelvis: unenhanced head and cervical spine before any contrast, because an iodine load degrades the assessment for intracranial haemorrhage, then contrast-enhanced torso coverage carrying both arterial and portal-venous information as two passes or a single split-bolus pass, with the thoracolumbar spine and pelvis reformatted from that dataset rather than rescanned.

Nothing here withholds an indicated scan. It sequences it behind the thing that keeps the patient alive, and it says out loud which team should be moving while the scanner waits.
Free fluid plus persistent hypotension is a decision, not a finding. That patient is going to laparotomy, and the scanner is stood down rather than warmed up.
A negative focused assessment in a patient who is still bleeding redirects the search — chest, pelvis and retroperitoneum, long bones, external loss — rather than ending it. Put the pelvic binder on first and argue about imaging second.
The interventional radiology activation is part of the vetting answer, not a consequence of it. Ring while the theatre conversation is happening rather than after it.
A child compensates for hypovolaemia and then decompensates abruptly, so a normal blood pressure in an injured child is much weaker reassurance than in an adult — judge this by tachycardia, perfusion and the trend.
Once the patient responds, the answer becomes the whole-body study on the next rung of this ladder, not a fresh conversation from the beginning.

Pregnant patient

Role	Study & protocol	Why this answers the question
First line	CT Whole-Body Trauma (Pan-Scan) CT Whole-Body Trauma — Single Pass usually appropriate	Pregnancy does not change the indication. The commonest cause of fetal loss in maternal trauma is maternal death, so a pregnant patient who meets the criteria for whole-body CT gets whole-body CT, and the vetting error here is hesitation rather than exposure. The numbers support saying that plainly: conceptus dose from a pan-scan with pelvic coverage is of the order of tens of milligray, below the roughly 100 mGy level at which deterministic fetal effects are discussed at all, and orders of magnitude below the harm of an unrecognised splenic or retroperitoneal haemorrhage. Iodinated contrast is given when the study needs it — it crosses the placenta but has not been shown to cause fetal harm, and neonatal thyroid function is checked after birth in the usual way. What does change is technique and communication: dose-optimise rather than decline, do not place lead over a uterus that is inside the imaged volume because it does nothing about internal scatter and can confuse automatic exposure control, record the estimated conceptus dose, and run the obstetric assessment in parallel rather than instead — CT is poor at placental abruption, which is the diagnosis cardiotocography and targeted ultrasound are for.
Problem solving	Ultrasound abdomen Ultrasound abdomen — full survey	Ultrasound has two quite separate jobs in the injured pregnant patient and neither of them is deciding whether to do the CT. In the resuscitation room a focused assessment answers "is there free fluid in the patient who is too unstable to leave", which is a triage question about which cavity to open. Separately, obstetric ultrasound and cardiotocography assess the fetus and look for abruption, which CT does not reliably show. A negative focused ultrasound has never excluded intra-abdominal injury and must not be used to stand down an indicated CT.
Reasonable alternative	CT Abdomen and Pelvis CT Abdomen and Pelvis — Trauma	The stable, awake, examinable pregnant patient with injury confined to one region is imaged selectively like anyone else — the pregnancy is not a reason to widen the coverage any more than it is a reason to narrow it. Selective does not mean single-phase: a region-directed trauma CT is still a trauma acquisition, carrying arterial as well as portal-venous information, because active arterial extravasation is the finding that sends the patient to interventional radiology and a plain portal-venous study is not designed to show it. Restricting the coverage rather than the phases is the right way to keep conceptus dose down, and the modifiable variables are collimation, tube current modulation and iterative reconstruction, not the diagnostic content of the study.

Treat the mother. Withholding or delaying indicated imaging in pregnancy is a documented cause of missed maternal injury, and the fetus does not survive a missed maternal haemorrhage.
The statutory pregnancy enquiry still happens, and its output here is dose recording and technique optimisation — not a decision about whether the examination goes ahead.
Fetal assessment is a parallel pathway with its own team. Vetting the CT is not the moment to substitute an obstetric ultrasound for it.

Reduced conscious level in an adult — the examination cannot clear anything

Role	Study & protocol	Why this answers the question
First line	CT Whole-Body Trauma (Pan-Scan) CT Whole-Body Trauma — Single Pass usually appropriate	A Glasgow Coma Scale of 12 or less is this card's own definition of the patient whole-body CT exists for: the intubated or obtunded adult whose examination cannot be trusted. Mechanism is half the justification and an unreliable examination is the other half — selective imaging is only safe when someone can actually clear the regions you are choosing not to scan, and in this patient nobody can, so the pan-scan is doing the examining. The acquisition is the specific one, not a relabelled CT chest-abdomen-pelvis: unenhanced head and cervical spine before any contrast, which matters twice over here because an iodine load degrades the assessment for intracranial haemorrhage and because at this conscious level the head is a live question in its own right, then contrast-enhanced torso coverage carrying both arterial and portal-venous information as two passes or a single split-bolus pass, with the thoracolumbar spine and pelvis reformatted from that dataset rather than rescanned. Two things still travel with it. REACT-2 found no mortality difference between immediate total-body CT and a selective work-up, so the justification remains this patient rather than the trauma call. And the pan-scan does not cover the limbs — extremity injury needs dedicated imaging, and an unconscious patient is precisely the one who cannot tell you where it hurts.
Second line	CT Abdomen and Pelvis CT Abdomen and Pelvis — Trauma	Region-directed CT is the right answer for the alert, orientated, haemodynamically normal adult with a reliable and localising examination, and this patient is none of those things. Requesting it instead of the whole-body acquisition here leaves the regions nobody can clear unimaged, which is the under-imaging half of this card and the more dangerous half. It keeps two positions on the ladder: the patient whose conscious level recovers and who can then be examined and cleared, and the targeted repeat after the whole-body study — a delayed acquisition at roughly five to ten minutes for suspected renal collecting system injury, or to separate active arterial extravasation, which grows and persists on the later series, from a contained pseudoaneurysm, which follows the blood pool and washes out. Where it is done as the primary study it is a trauma acquisition rather than a routine portal-venous abdomen: arterial and portal-venous information, as two passes or a split bolus, because active arterial bleeding is what changes the destination.
Second line	CT Head CT Head — Unenhanced	A CT head alone is the right request once the trauma call has resolved into an isolated head injury, and the NICE NG232 rule then owns the question — a conscious level below 13 meets its criteria outright, so the head is being imaged either way. Inside a genuine polytrauma call with an unassessable patient it is the wrong request in both directions: it leaves the torso unimaged in exactly the patient whose examination cannot exclude torso injury, and it duplicates the unenhanced head series the whole-body acquisition already contains.
Problem solving	Ultrasound abdomen Ultrasound abdomen — full survey	Focused assessment keeps its resuscitation-room job of finding free fluid in a patient too unstable to move, and loses any claim to be the test that decides whether this patient needs a CT. NG39 says that directly. In an obtunded patient a negative focused ultrasound is worth even less than usual: it excludes neither solid organ nor retroperitoneal, mesenteric or hollow viscus injury, and there is no reliable examination alongside it to fill the gap.

A conscious level is not the only thing that makes an examination unreliable. Intoxication and one dominant distracting injury do the same job in a patient with a GCS of 15, and this card treats them the same way — the fact the form can carry is the conscious level, so that is what the fork reads.
This arm widens coverage; it does not license a worse acquisition. Contrast timing, the pre-contrast head and cervical spine, and reformatting rather than rescanning the spine and pelvis all still apply.
If the conscious level is not explained by the injury, the trauma team owns that question in parallel — the scan answers what is broken, not why the patient was obtunded when they arrived.

Children and young people under 16

Role	Study & protocol	Why this answers the question
First line	CT Abdomen and Pelvis CT Abdomen and Pelvis — Portal Venous Phase usually appropriate	NICE NG39 is explicit and unusually direct about this: do not routinely use whole-body CT to image children, and use clinical judgement to limit the images to the body areas where assessment is actually needed. The reasoning is not squeamishness about radiation in the abstract — it is that a child has a higher organ radiosensitivity, decades of remaining life for a stochastic effect to express itself, and a much smaller body in which a whole-body acquisition is proportionally a far larger fraction of them. So the paediatric pathway is region-directed by design: a contrast-enhanced abdomen and pelvis where the mechanism, the seat-belt sign, the handlebar, the abdominal tenderness or the deranged transaminases point at the torso, using child-sized kV and mAs against size-based reference ranges and a weight-calculated contrast volume. The phase choice is deliberately different from the adult one, and the difference is not an oversight: a single portal-venous pass is the paediatric standard, because most paediatric solid organ injury is managed non-operatively, the arterial phase changes management far less often than it does in adults, and a routine second pass doubles the dose in exactly the patient this recommendation is written to protect. An arterial phase, or a delayed series at five to ten minutes, is added for a stated reason — suspected active bleeding, a vascular injury, or haematuria raising the collecting system — rather than acquired by default. Where the abdomen genuinely is not the question, this acquisition should not be requested at all.
First line	CT Head CT Head — Unenhanced usually appropriate	Co-equal with the torso study rather than sequenced after it, because in a child the two questions are answered independently and each has its own decision rule. The head is imaged when the NICE NG232 paediatric criteria are met — suspicion of non-accidental injury, post-traumatic seizure, Glasgow Coma Scale below 14 (below 15 in an infant under one year) or failure to reach 15 two hours after injury, suspected open, depressed or basal skull fracture, tense fontanelle, focal neurology, or a bruise, swelling or laceration over 5 cm in a child under one year — with the dangerous-mechanism and loss-of-consciousness criteria requiring a second feature before scanning. Unenhanced, single pass, thin section with bone and soft-tissue reconstructions. Meeting the head criteria says nothing at all about whether the abdomen needs imaging, and that independence is exactly why the whole-body acquisition is not the default in this age group.
Problem solving	CT Whole-Body Trauma (Pan-Scan) CT Whole-Body Trauma — Single Pass	Whole-body CT is not forbidden in children — it is not the routine. It remains the right study for the child with a genuinely unassessable examination and injuries pointing at more than one body region on a high-energy mechanism: the intubated child, the child ejected from a vehicle, the fall from significant height with multi-region signs. That decision should be made by, or immediately escalated to, a consultant in the trauma team and the radiologist together, and recorded as a decision rather than defaulted into. Where it is done, dose control is by child-sized technique, weight-based contrast and reformatting the spine and pelvis from the torso dataset, never by degrading the acquisition that has already been justified.
Problem solving	Ultrasound abdomen Ultrasound abdomen — full survey	Ultrasound occupies a genuinely different position in a child from the one it holds in an adult, and the difference runs in both directions. It is worth more, because the alternative carries a dose that matters more and because most paediatric solid organ injury is managed non-operatively, so the question "does this child need an operation" is often answerable without grading anything. It is also worth less as a rule-out: a negative focused assessment in a child does not exclude solid organ injury and is a poor predictor of who can avoid CT, so it must not be used as the gate. What actually reduces paediatric CT is the combination of a validated clinical decision rule and serial examination — the PECARN intra-abdominal injury rule identifies children at very low risk of clinically important injury, in whom observation with repeated examination is safer than a scan — with contrast-enhanced ultrasound an emerging option in stable children where the expertise exists. Anything short of that, and the answer is the region-directed CT above.

Under-16 is where the guideline stops being a preference and becomes a prohibition on routine practice: NG39 says do not routinely pan-scan children. A request that simply carries the adult trauma protocol across to a child should be turned into a conversation, not a booking.
The cervical spine follows the same logic and NG39 restricts it explicitly: CT of the cervical spine in a child is for a defined set of indications — a conscious level below 13, intubation, focal peripheral neurological signs, an abnormality on plain radiography, or a definitive diagnosis needed urgently — and MRI is otherwise the study. A request that adds a paediatric cervical spine CT to a torso study should say which of those applies.
Serial examination by the same clinician is an imaging decision, not an alternative to one. In a stable child with an equivocal abdomen it is frequently the safest next step, and saying so at vetting is a legitimate radiological answer.
Children compensate for hypovolaemia and then decompensate abruptly. A normal blood pressure in an injured child is much weaker reassurance than in an adult, and the pathway should be driven by tachycardia, perfusion and the trend rather than by the systolic number.
Non-accidental injury is a different pathway with a different imaging set — a skeletal survey and a dedicated protocol — and suspecting it changes what is requested, who is informed and how the images are handled.

Adults and young people 16 and over

Matches your inputsDefault

Role	Study & protocol	Why this answers the question
First line	CT Whole-Body Trauma (Pan-Scan) CT Whole-Body Trauma — Single Pass usually appropriate	This is the study for the patient in whom the examination cannot be trusted and the mechanism says the injuries could be anywhere: the intubated or obtunded patient, the patient with signs in more than one body region, the high-energy transfer — ejection, entrapment, death of another occupant, fall from height, pedestrian struck at speed — and penetrating truncal injury in a patient stable enough to be scanned, where the track has to be defined. NG39 supports whole-body CT in adults with blunt major trauma and suspected multiple injuries, and supports immediate CT in the patient with suspected haemorrhage who is responding to volume resuscitation or whose haemodynamic status is normal. Two things follow that are easy to get wrong. First, the acquisition is a specific one, not a relabelled CT chest-abdomen-pelvis: unenhanced head and cervical spine acquired before any contrast, because an iodine load degrades the assessment for intracranial haemorrhage, then contrast-enhanced torso coverage carrying both arterial and portal-venous information, as two passes or as a single split-bolus pass, with the thoracolumbar spine and pelvis reformatted from that dataset rather than rescanned. Second, the evidence does not say the pan-scan makes everyone better: the randomised REACT-2 trial found no mortality difference between immediate total-body CT and a selective work-up, which is precisely why the justification has to be the individual patient rather than the trauma call. The patient who does not respond to resuscitation is not on this pathway at all — that patient goes to theatre or to interventional radiology, and a scan that delays haemostasis is the injury.
First line	CT Abdomen and Pelvis CT Abdomen and Pelvis — Trauma usually appropriate	Region-directed CT is co-equal here, not a lesser answer, because it is the correct answer for a different patient: the alert, orientated, haemodynamically normal adult with a reliable and localising examination and a mechanism that does not imply energy elsewhere — and the stable patient with a single penetrating truncal wound, where the question is the track and the organs along it rather than the whole body. In that patient adding a head, a cervical spine and a chest because the request said "trauma" is the over-investigation failure this card exists to name: a real radiation cost, a real incidentaloma burden with its own downstream investigations, and no benefit. The discriminator is the patient, never the wording of the request. What narrowing the coverage does NOT license is narrowing the protocol. This is a trauma acquisition — arterial and portal-venous information across the abdomen and pelvis, as two passes or as a single split bolus — and not the routine portal-venous study the same study slug usually means. The arterial information is the point: active arterial extravasation is what sends a patient to interventional radiology, a contained pseudoaneurysm is what makes non-operative management fail two days later, and a single portal-venous pass is not designed to show either. A delayed series at roughly five to ten minutes is added for a stated reason — haematuria or a suspected renal collecting system injury, or to separate active extravasation, which grows and persists, from a pseudoaneurysm, which washes out with the blood pool. No oral contrast. For a flank or back penetrating wound, luminal contrast per rectum is the selective addition some units still use to assess the retroperitoneal colon, and it is a decision to make at vetting rather than at the scanner. Where selective imaging is chosen, someone must be able to clear the regions that are not being scanned, and the decision and the person who made it should be recorded.
Second line	CT Head CT Head — Unenhanced	A CT head alone is the right request when the trauma call has resolved into an isolated head injury, and at that point the question belongs to the NICE NG232 head injury rule rather than to this card. Within a genuine polytrauma call it is the wrong request in both directions: it leaves the torso unimaged in a patient whose examination cannot exclude torso injury, and it duplicates the unenhanced head series that the whole-body acquisition already contains. If the head really is the only question, say so on the request and the head injury pathway will answer it.
Problem solving	Ultrasound abdomen Ultrasound abdomen — full survey	Focused assessment with sonography answers one question in the resuscitation room — is there free fluid in a patient too unstable to move — and it is genuinely useful for deciding which cavity to open in the non-responder. It is not a screening test for whether CT is needed, and NG39 says so directly. A negative focused ultrasound does not exclude solid organ injury, retroperitoneal haemorrhage, hollow viscus injury or mesenteric injury, and using one to stand down an indicated CT is the classic way a delayed splenic or bowel injury is missed.

This is the arm for the patient who is stable, or whose physiology has not been stated. A transient or non-responder with suspected torso haemorrhage is on the arm above: they go to theatre or interventional radiology, and the useful radiological act at that moment is to activate the IR team and clear the scanner, not to optimise a protocol.
Whole-body CT and region-directed CT are both first-line here on purpose. Requesting either is accepted, because the fork between them lives in the patient — mechanism, physiology and whether the examination can be trusted — and a tool that ranked one above the other on a bare request would be wrong roughly half the time. Where the request does state that the examination cannot be trusted, the conscious-level arm above stops treating the two as interchangeable.
Arms up through the torso pass wherever the injury pattern allows; arms down produces streak straight across the upper abdomen, which is where the injuries that change management tend to be.
Split-bolus enhancement does not look like a conventional portal-venous study. Departments that change protocol without briefing their readers see organ enhancement mis-called in both directions.
Add a delayed acquisition selectively, at roughly five to ten minutes, for suspected renal collecting system or ureteric injury and to distinguish active arterial extravasation from a contained pseudoaneurysm — not as a routine fourth series.
A delayed excretory series is NOT a bladder study. Suspected bladder rupture — a pelvic fracture with gross haematuria is the classic combination — needs CT cystography, with the bladder actively filled retrogradely through a catheter to a few hundred millilitres of dilute contrast. Passive filling from an excretory phase is not enough pressure or volume to open a rupture, and an extraperitoneal tear that is managed with a catheter reads exactly like an intraperitoneal one that needs an operation if the study is done badly.
A single penetrating truncal wound in a stable patient is a region-directed question about the track, not a reason to acquire an unenhanced head and cervical spine. Multiple wounds, a transmediastinal track or an unassessable patient are what turn it back into a whole-body study.

Pitfalls

Scanning the patient who is not responding to volume resuscitation. This is the highest-consequence error on the card and it is a governance failure rather than a protocol one: the non-responder with suspected torso haemorrhage belongs in theatre or in interventional radiology, and a CT that delays haemostasis is itself the harm. NG39 is explicit that imaging is limited to the minimum in this group.
Pan-scanning the awake, stable, examinable adult who is tender in exactly one place. The mechanism did not justify it, the examination did not require it, and the cost is a genuine radiation burden plus a crop of incidental findings that generate their own investigations. Selective imaging is the right answer for that patient, and the request form saying "trauma" is not a justification.
Treating a routine CT chest-abdomen-pelvis with "trauma" in the indication box as a trauma protocol. Without the unenhanced head and cervical spine acquired before contrast, and without arterial as well as portal-venous information across the torso, it is a different examination that will miss intracranial haemorrhage assessment, active extravasation and vascular injury.
Giving contrast before the head acquisition. It degrades the assessment for intracranial haemorrhage, and it is an ordering error that cannot be corrected afterwards without rescanning.
Using a negative focused ultrasound to stand down an indicated CT. It is not a screening test for whether CT is needed and does not exclude solid organ, retroperitoneal, mesenteric or hollow viscus injury. In the patient who is still hypotensive it also does not mean the bleeding has stopped — it redirects the search to the chest, the pelvis and retroperitoneum, the long bones and external loss.
Treating free fluid in a non-responder as an indication for CT. It is an indication for laparotomy. The scan that gets done between the positive focused assessment and the operating theatre buys an injury grade at the cost of the minutes that decide the outcome.
Protocolling a region-directed trauma CT as a routine portal-venous abdomen and pelvis. Narrowing the coverage is a justified decision about which regions to image; dropping the arterial information is not. Active arterial extravasation is what sends the patient to interventional radiology and a contained pseudoaneurysm is what makes non-operative management fail on day two, and a single portal-venous pass is not designed to show either.
Answering a suspected bladder injury with a delayed excretory phase. Pelvic fracture with gross haematuria needs CT cystography with the bladder actively distended through a catheter; passive filling from an excretory series misses ruptures, and the intraperitoneal-versus-extraperitoneal distinction it is supposed to make decides between an operation and a catheter.
Accepting a normal early CT as excluding bowel and mesenteric injury. A seat-belt sign, free fluid without a solid organ source, mesenteric stranding or a focally thickened bowel loop are the findings that matter, they are subtle in the first hours, and this is the injury pattern that presents late and kills. Say what is uncertain and ask for the repeat scan or the surgical review rather than reporting a clean study.
Carrying the adult whole-body protocol across to a child. NICE NG39 says do not routinely use whole-body CT in children and to limit imaging to the areas needing assessment; the paediatric decision is region-directed, and a whole-body acquisition in a child should be a recorded consultant-level decision, not a default.
Withholding or delaying indicated imaging in a pregnant trauma patient. Conceptus dose from a pan-scan sits well below the level at which deterministic effects are discussed, the mother is the fetus’s life support, and the documented harm in this group is under-imaging.
Rescanning the thoracolumbar spine or the pelvis instead of reformatting them from the torso dataset. It duplicates exposure in an examination that is already high dose and adds nothing.
Assuming the pan-scan covers the limbs. It does not — extremity injury needs dedicated radiographs or a dedicated CT, and a fracture missed because everyone assumed the whole-body scan had looked is a recurring source of delayed diagnosis.
Repeating a whole-body CT already performed at the referring hospital because the images have not arrived. Chase the transfer; the second scan is dose, delay, and usually a technically inferior answer to a question that has already been answered.
Reading a split-bolus study as though it were a conventional portal-venous one. Organ enhancement looks different by design, and the misreads run in both directions when readers have not been briefed on a protocol change.

Priors — what to pull first

For a transferred patient, pull the referring hospital images before booking anything. A repeat pan-scan on arrival is one of the largest avoidable doses in the whole service, and where the outside study is genuinely inadequate, naming the inadequate part converts a whole repeat into one targeted acquisition.
Any imaging performed earlier in the same admission changes what this scan is for: a second whole-body study a few hours later is almost never the right way to answer a specific new question.
Old cross-sectional imaging is disproportionately valuable in trauma reporting — a splenic contour, a renal cyst, a pre-existing aortic ectasia or an old rib fracture on a scan from two years ago prevents an incidental finding being called an acute injury.

What makes a good request

A true trauma protocol is a specific acquisition, not a routine CT chest-abdomen-pelvis with the word "trauma" typed into the indication box. It is an unenhanced head and cervical spine followed by contrast-enhanced torso coverage with both arterial and portal-venous information — obtained as separate passes, or in many UK major trauma centres as a single split-bolus pass that delivers parenchymal and angiographic enhancement together and roughly halves the torso exposure. Spine and pelvic images are reformatted from the same dataset, never rescanned.
The vetting conversation is with the trauma team leader, and it is about the patient rather than the request form: mechanism and energy transfer, the response to the first units of blood, whether the examination is reliable, and what the surgeon will do with each possible result.
Where this card says ultrasound it means the focused assessment performed in the resuscitation bay — pericardium, hepatorenal and splenorenal recesses and pelvis, with the pleural and anterior lung windows that make it an extended examination — and not a full abdominal survey. The distinction matters at booking: a request that lands in the general ultrasound list as "abdominal ultrasound" for a trauma patient has already gone wrong, because the study is a bedside triage examination performed by the resuscitation team in minutes, not a departmental survey of the solid organs.
A good request states the mechanism, the current observations and their trend, the Glasgow Coma Scale and whether the patient is intubated, the injuries already identified, and whether any imaging was performed at the referring hospital.
NICE NG39 frames the decision the same way in both directions: consider immediate CT in the patient with suspected haemorrhage who is responding to volume resuscitation or whose haemodynamic status is normal, and limit diagnostic imaging to the minimum in the patient with active bleeding who is not responding.
Whole-body CT in the transferred patient is frequently a duplicate. Images from the referring hospital should be pulled and reviewed before anything is rebooked — the second scan is dose, delay and often a worse study because the contrast timing was optimised for a different question.
A region-directed trauma CT is also a specific acquisition. Choosing to image the abdomen and pelvis alone is a decision about coverage; it is not permission to run a routine portal-venous protocol. Arterial as well as portal-venous information belongs in any trauma abdomen, because active arterial extravasation is the finding that changes the destination from the ward to the interventional suite.
Two selective additions are worth naming before the patient is on the table, because both are hard to retrofit: a delayed series at roughly five to ten minutes where haematuria or a pelvic fracture raises the urinary tract, and CT cystography — retrograde filling of the bladder through a catheter — where bladder rupture is the question. A delayed excretory phase does not substitute for the second.

Scoring this once it is done

The classification and risk tools this question ends in.

AAST Spleen Injury Scale AAST Liver Injury Scale AAST Kidney Injury Scale Marshall CT Classification (TBI)eGFR (CKD-EPI 2021 Creatinine)Canadian CT Head Rule (CCHR)PECARN Pediatric Head Injury Rule Rotterdam CT Score (TBI)AO Spine Thoracolumbar Injury Classification TLICS — Thoracolumbar Injury Classification & Severity Score SLICS — Subaxial Injury Classification & Severity Score Denis Three-Column Classification ASIA Impairment Scale (AIS) with Frankel Mapping NEXUS Cervical Spine Criteria

How these studies are acquired

Contrast, phases and timing for every study on the pathways above.

Ultrasound abdomen — full survey CT Whole-Body Trauma — Single Pass CT Abdomen and Pelvis — Trauma CT Head — Unenhanced CT Abdomen and Pelvis — Portal Venous Phase

Confirm locally

CT Whole-Body Trauma — Single Pass: timings are typical — confirm against local protocol.
Timings, contrast volumes and rates above are typical published values. Your department's protocol, scanner and patient population decide the actual numbers.
Safety thresholds and premedication policy follow local policy where it differs from the cited guidance.

References

Implemented from the cited published sources. Educational and workflow support only; confirm against current guidelines and local policy before clinical use.