The REACT-2 Trial
“Immediate total-body CT scanning versus conventional imaging and selective CT scanning in patients with severe trauma (REACT-2): a randomised control trial.”
Patients who sustain severe trauma receive imaging that is guided by the clinical pattern of injury, and subtle injuries may therefore be missed in the initial workup. Evidence suggests that there may be a mortality benefit for trauma patients who receive immediate total-body CT scanning, but all prior studies have been retrospective and non-randomized. The authors of this study aimed to add higher-quality evidence to the body of literature and determine whether a mortality benefit for total-body CT in trauma patients would be found in a prospective, randomized trial.
This was a multi-center, international, randomized control trial that enrolled patients over the course of nearly three years. 5475 patients were assessed for eligibility, 1403 were randomized into one of two groups (immediate total-body CT scanning or standard workup), and 1083 were included in the primary analysis. Non-pregnant patients over the age of 18 with injuries that were clinically considered severe or life-threatening and with compromised vital signs were included in the study. Randomization was performed by ALEA computer software and stratified by center, and neither physicians nor patients were blinded to randomization. Patients who were randomized to the total-body CT protocol received CT of the head, neck and chest with arms at the sides, followed by CT of the chest, abdomen, and pelvis, immediately after primary survey and medical stabilization; patients randomized to the standard workup group received plain film, ultrasound, and CT imaging directed at assessing their individual injuries.
The primary endpoint was in-hospital mortality. Secondary endpoints included 24 hour mortality, 30 day mortality, time to the end of imaging, time spent in the trauma bay, length of hospital stay, number of ventilator-dependent days, readmission within 6 months, blood transfusions, radiation exposure, and cost of treatment.
541 patients received immediate total-body CT, and 542 received standard work-up. An intention-to-treat analysis was performed, as well as subgroup analyses for patients with polytrauma and patients with traumatic brain injuries. No difference in mortality was found between the groups; 86 (16%) patients in the total-body CT group and 85 (16%) patients in the standard workup group died during initial hospitalization, p = 0.92. There were also no mortality differences found in the subgroup analysis.
There were several statistically significant differences between the groups in analysis of the secondary outcomes. Patients in the total-body CT group received higher doses of radiation (20.9 mSv, IQR 20.6 – 20.9) than the standard imaging group (20.6 mSv, IQR 9.9 – 22.1, p < 0.0001). Patients in the total-body CT group also had decreased time to the end of imaging (30 minutes, IQR 24 – 40) as compared to the standard imaging group (37 minutes, IQR 28 – 52; p < 0.0001). There were no statistically significant differences found for the other secondary outcomes.
Immediate total-body CT is not associated with a mortality benefit in patients with severe trauma, polytrauma, or traumatic brain injury. Patients who received immediate total-body CT scan spent a shorter time overall receiving imaging, but they received higher doses of radiation overall.