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Non –Trauma Emergency CT Imaging: How Relevant is it to Patient Care?. Lavanya Kalla, M. D., Jessica S. Conn, M. D., Teresita L. Angtuaco, M. D., Ernest J. Ferris, M. D. Background.

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non trauma emergency ct imaging how relevant is it to patient care

Non –Trauma Emergency CT Imaging:How Relevant is it to Patient Care?

Lavanya Kalla, M. D.,

Jessica S. Conn, M. D.,

Teresita L. Angtuaco, M. D.,

Ernest J. Ferris, M. D.

background
Background
  • Research project performed by two first year residents (Drs. Kalla and Conn) as part of ACGME residency competency requirement for practice-based learning
  • Choice of topic was prompted by concern for “overutilization” of Radiology imaging resources
  • Question: are radiology residents asked to perform “electronic physical examinations on call”
purpose
Purpose
  • The purpose of our study was to investigate whether CT examinations requested for non trauma related emergencies on-call made an impact in patient care.
subjects
Subjects
  • charts of 274 patients undergoing emergency CT scans for non trauma related reasons (January-February 2003)
  • 132 scans were neuroradiology CT scans (head, spine and neck)
  • 142 were body CT scans (chest, abdomen and pelvis)
  • Follow-up was available on 271, 3 patients left AMA
methods
Methods
  • Post imaging diagnoses were compared to the pre-imaging referral diagnoses
  • The impact of initial imaging on further patient management was determined after retrospectively reviewing the discharge summaries
  • Outcome was determined based upon whether our diagnoses led to patients’ admission or discharge.
methods6
Methods
  • CT scans were classified according to the type of diagnosis provided at the time they were ordered
    • Specific diagnosis (i.e. stroke, SAH, diverticulitis, appendicitis, renal stones)
    • Non specific diagnosis (i.e. generalized abdominal pain, mental status change)
  • Yield of positive findings was determined based on the type of diagnosis and how the findings impacted patient management
slide9

Specific Diagnosis – Positive Findings

H: New onset right sided

weakness , r/o stroke

F: Infarct in the left motor cortex

H: worst headache of my life, rule

out SAH

F: Hemorrhagic infarct in the left

parietal lobe

slide10

H: Dysphagia with fever, r/o abscess

F: Right tonsillar abscess

H: New onset seizures, rule out stroke

F: Hemorrhagic stroke in the brainstem with decompression into the fourth ventricle. Incidental old infarct in the right temporal lobe.

slide11

Non-specific Diagnosis – Positive Findings

H: Mental status changes,

F: embolic stroke in the

right motor cortex

Same patient with thrombus in the right carotid artery

slide13

Specific Diagnosis – Positive Findings

H: RLQ pain, r/o appendicitis

F: Appendicitis

H: Bowel obstruction

F: High grade SBO with ischemia

High grade SBO

H: Bowel obstruction

F: SBO with transition zone in the distal ileum

H: LLQ pain and fever r/o diverticulitis

F: Left hydrosalpinx

slide14

H: APPENDICITIS

F: Abscess in rlq

H: Fever and pain in the LUQ with rebound

tenderness, r/o abscess

F: Abscess in LUQ

H: Excruciating mid abdominal pain,

r/o pancreatitis

F: Duodenal perforation with free air

slide15

Non-specific History – Positive Findings

H: Diffuse abdominal pain, N/V

Findings – sigmoid diverticulitis

History: RUQ pain

Findings – Non specific colitis

H: Diffuse abd pain

F: LLQ abscess

H: Diffuse abd pain

F: acute pancreatitis

slide16

Immunosuppressed pts with diffuse abdominal pain

Fournier’s gangrene

Necrotic mesenteric nodes and ascites

Acute appendicitis

with abscess

slide17

Clinically positive findings – Initially negative CT

H:Patient was admitted based on clinical symptoms.

F: acute left basal ganglia stroke diagnosed after

admission on MRI

slide18

Neuro CT which helped in decision to discharge patient

H: Old thalamic infarcts, presenting with new onset mental status changes, r/o acute hemorrhage

F: no hemorrhage

H: Neck swelling, r/o abscess

F: large goiter

slide19

CT helped in decision to discharge patients

H: Post partum, presenting with rlq pain, r/o appendicitis

F: Right hydroureter (postpartum)

H: Non specific, non localizing abdominal pain

F: Ovarian cysts

H: Abdominal distension and pain, r/o SBO

F: Wide neck ventral hernia w/o obstruction

slide20

CT role in patient management

Known hernia with acute abdominal pain

F: Pneumonia , no bowel obstruction – patient discharged

Acute exacerbation of Crohn’s disease

Patient admitted

Patient with known ulcerative colitis, no acute findings; patient discharged

conclusions
CONCLUSIONS
  • CT imaging plays a pivotal role with respect to patient admission and discharge in the acute setting.
  • For neurological studies the yield of positive findings was higher when a specific diagnosis was sought (43 % vs. 11 %).
  • For body imaging, there was no significant difference in the results of the scans whether they were performed based on specific or non specific diagnosis (57% vs. 43%)
conclusions22
CONCLUSIONS
  • NEURORADIOLOGY – For neurological studies the yield of positive findings was higher when a specific diagnosis was sought (43 % vs. 11 %).
  • However even when a specific dx was not sought , we helped triage the patients and it was imperative to rule out life threatening conditions.
conclusions23
CONCLUSIONS
  • BODY CT - For body imaging, there was no significant difference in the results of the scans whether they were performed based on specific or non specific diagnosis (57% vs. 43%)
  • In both categories we found findings which were significant and helped in further patient management.