CT of the chest, abdomen, and pelvis in trauma: rethinking mechanism-based triage criteria in low- and middle-income countries

CT of the chest, abdomen, and pelvis (CT-CAP) is routinely ordered in trauma centers across low- and middle-income countries (LMICs) after road traffic accidents, with mechanism of injury listed as a standalone indication alongside physiological and clinical criteria, a framework derived from Advanced Trauma Life Support guidelines developed in North American resource-abundant settings. Even in well-resourced environments, the evidence base for mechanism-only imaging is weaker than commonly assumed: of established mechanism criteria, only death of another occupant, fall distance, and prolonged extrication time demonstrate meaningful predictive value for serious injury requiring trauma center resources. The landmark REACT-2 randomized controlled trial found no mortality benefit of whole-body CT over selective imaging in 1083 severely injured patients. In resource-constrained LMICs, where CT availability is critically limited and imaging costs fall directly on patients, the case against indiscriminate mechanism-based CT-CAP is even stronger. For isolated extended Focused Assessment with Sonography in Trauma-positive findings in hemodynamically stable patients, targeted regional CT is evidence-supported, with escalation to full CT-CAP reserved for high-grade injury or hemodynamic deterioration. LMICs should move beyond uncritical adoption of high-income country protocols and develop prospective, data-driven local criteria for CT-CAP use calibrated to their patient populations, injury patterns, and resource realities.