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Evaluation of CTA of the Chest to Improve Rapid Diagnosis of Pulmonary Embolus Authors: Adam Holbrook, DO Chris Bruner, DO Co-Authors: Jane Daugherty-Luck, DO; Joseph Dougherty, DO, PD Presenter: Joshua Nast, DO PGY2
Introduction • Pulmonary embolus is a potentially life threatening disease process that if not diagnosed early, can lead to significant morbidity and mortality. • Computed Tomographic Angiography (CTA) has emerged as the most commonly used tool in diagnosis of PE. CTA is of great benefit because of the relative ease in obtaining, as well as the high specificity and sensitivity for PE compared to other methods². • In many institutions radiologists are not typically available to read the CTA in the evenings or other off-hour times. Typically, in these facilities, outsourced companies are utilized to cover the gaps of in-house radiologist coverage³ • Studies have shown this process (Teleradiology)can exceed one hour, which can delay diagnosis and treatment of PE4. • When seconds may make a difference in opposing differential diagnoses, such as dissection versus a PE, can ED physicians be trained to identify PE’s on a CTA and therefore not rely on teleradiology?
Materials and Methods • For this study, Internal Medicine and Emergency Medicine residents ranging from PGY1 – PGY5 were utilized in an attempt to determine if a short training course provided by the investigators would improve ability to diagnose clinically significant pulmonary emboli. • The physician subjects were randomly selected into an experimental group and a control group. Both groups were given an initial pretest of various single slice images in a power-point format. • The experimental group will undergo a short training program that will attempt to provide these physician subjects with a quick, easy methodology for evaluating CTAs for Pulmonary Emboli. • Both groups will then receive a post-test, similar to the pretest to see if the teaching protocol was beneficial in improving the physician subject’s ability to identify clinically-significant pulmonary emboli and secondary findings associated with pulmonary emboli. • For this study, a T-test was utilized to evaluate the results between the two groups, assessing the presence of statistical significance between the groups. • Based on calculations, it has been determined that this study will require an N (population) of 20 persons per group or 40 participants in total.
Discussion • The hopes of the investigators are that the training will allow for faster recognition of clinically significant pulmonary emboli, expediting treatment and disposition. • Some of the limitations of our study were the smaller than expected number of participants. The use of solitary slices of CTAs instead of being able to scroll through a full CTA of the chest. • We believe that a continuation of this study and developing a greater sample size and also developing a video of scrolling through the actual CTA would be a worth while consideration for future studies.
Conclusion • After even a short instruction there was some improvement of the teaching group over the control group. The post instruction group had a larger success rate of identifying the smaller PEs that were tested on along with identifying some of the secondary findings of larger PEs. We believe however with more intensive teaching and going through sample CTA s of the chest would greatly improve the teaching groups ability to identify a larger number of significant PEs.
References 1. Ghuysen, A., Ghaye, B., Willems, V., Lambermont, B., Gerard, P., Dondelinger, R. F., D’Orio, V., Computed Tomographic Pulmonary Angiography and Prognostic Significance in Patients with Acute Pulmonary Embolism. Thorax 2005;60:956-961. 2. Garg, K., Sieler, H., Welsh, C.H., Johnston, R.J., Russ, P.D., Clinical Validity of Helical CT Being Interpreted as Negative for Pulmonary Embolism: Implications for Patient Treatment. American Journal of Radiology:172, June 1999. 3. Boland, Giles W.L., Teleradiology Coming of Age: Winners and Losers. American Journal of Radiology:190, May 2008. 4. Lee, JK., Renner, JB., Saunders, BF., Stamford, PP., Bickford, TR., Johnston, RE., Hsaio, HS., Phillips, ML. Effect of real-time teleradiology on the practice of the emergency department physician in a rural setting: initial experience. Academic Radiology: 1998 Aug;5(8):533-8.