Pan Scan Instead of Clinical Exam? David A. Spain, MD

Transcription

1 Pan Scan Instead of Clinical Exam? David A. Spain, MD

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3 Granted, some patients don t t need CT scan

4 Platinum Package Stanford Special CT Scan Head Neck Chest Abdomen Pelvis Takes about 20 minutes to do

5 LightSpeed The Power to Scan. Finer. Faster. Further.

6 The New ABCs Admit Begin CT T scan Only exam pt if CT doesn t t tell you what s s wrong

7 Everybody loves CT scan Often times, resuscitation seems like a race to CT scan I have seen pts taken to CT without completing primary survey, let alone the secondary portion

8 Death begins in X-ray

9 Real Case 22 year old man Restrained passenger Side impact on his side Intubated in field (mental status)? Right chest crepitance Being wheeled to CT scan when surgery R4 stopped and insisted on reviewing CXR

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11 Dilemma What s s the cost of a CT scan Real dollars Versus Cost of missed or delayed injuries Faster thru put (double-edge) edge) Peace of mind Can you accurately predict who needs or doesn t t need a CT scan?

12 Injuries distracting from IAI after blunt trauma Prospective study, GCS 15 and CT of abdomen or DPL Presence of pain and/or tenderness sensitivity 82% specificity 45% positive predictive value 21% negative predictive value 93% Abdominal pain and/or tenderness incidence of IAI, but lack of these findings did not preclude IAI Am J Emerg Med 1998;16:145-9

13 CT for blunt abdominal trauma in the ED: a prospective study. 196 patients were evaluated Abdominal tenderness present in patients had IAI (11%) Abnormal abdomen examination and hematuria sensitivity of 64% specificity of 94% positive predictive value of 56% negative predictive value of 95% Am J Emerg Med 1998;16:338-42

14 Absence of intraabdominal injury predicted with sensitivity of 100% and specificity of 87%

15 Surgery 2002;132, p

16 Abd CT with increased AST in the era of FAST HD stable, FAST negative and an AST > 200 IU/L 42 (63%) had AST level < 360 IU/L and 25 (37%) had an AST > 360 IU/L AST level > 360 IU/L 88% chance any hepatic injury 44% were > grade III AST level < 360 IU/L 14% chance any liver injury no chance of injury > grade III or greater Surgery. 2002;132:642-6

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18 Admit or obs is not necessary after a negative Abd CT: results of a prospective, multi-institutional institutional trial 22 months at four Level I trauma centers All patients with blunt abdominal trauma suspected by either PE or mechanism were evaluated by protocol PE in the ED Abdominal CT scan Hospitalization for observation Standardized PE was repeated between 4 and 8 hours J Trauma 1998;44:273-80

19 Admit or obs is not necessary after a negative Abd CT 2299 fulfilled the entire study protocol 21% were positive 19% patients with a positive CT scan had no tenderness Negative predictive power of abd CT scan based on prelim reading and need for a laparotomy was 99.63%

20 Can we omit head CT?? Loss of consciousness: when to perform computed tomography? Kids w/ LOC or amnesia and GCS should have a head CT to avoid missing an intracranial injury Minor head trauma: Is computed tomography always necessary? Routine head CT in pts with LOC/amnesia but no Sx/signs of depressed skull fracture has minimal value and not warranted NEXUS

21 Value of repeat cranial CT in patients with minimal head injury MHI and a positive cranial CAT scan 151 had a persistently normal or improved neurological examination none required after the repeat cranial CAT scan? Value repeat CAT scan in this setting J Trauma 2004;56:475-80

22 Do we really need CT in primary evaluation of blunt chest trauma in patients with "normal" CXR? 93 consecutive patients 76% MVC > 10 mph 24% after fall > 5 ft 25 had normal CXR and 13 (52%) CT scan showed multiple injuries 2 (8%)aortic lacerations 3 pleural effusions 1 pericardial effusion J Trauma 2001;51:1173-6

23 Reevaluation of diagnostic procedures for transmediastinal gunshot wounds 22 stable patients CT scans were positive in 7 Directed further diagnostic evaluation 2 operations 68% had negative CT scans and were observed without further evaluation No missed injuries Hospital charges generated with CT-based protocol were significantly less J Trauma 2002;53:635-8

24 Reformatted visceral protocol HCT vs. conventional radiographs of T and L spine in blunt trauma patients prospective evaluation of consecutive patients with thoracic and lumbar spine fractures Screening sensitivity Reformatted HCT: 97% (T) and 95% (L) Conventional Xray:62% (T) and 86% (L) J Trauma 2003;55:665-9

25 It s s always good to exam the patients Restrained rear seat passenger with seatbelt, c/o some abd pain

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27 Reliability of clinical exam in detecting pelvic fx in blunt trauma 12 studies with 5454 patients 49 false neg cases fx majority had either altered consciousness or minor pelvic fracture only Only 3 clinically relevant pelvic fractures were missed among 441 pts with fracture within a total population > 5000 In stable and alert trauma pts, thorough exam will detect pelvic fractures with nearly 100% sensitivity

28 Selective management of penetrating neck trauma based on level of injury 312 pts over 18 years 75% stab, 25% GSW Zone I=13%, Zone II=67%, Zone III=20% 34% early exploration (16% non- therapeutic) 66% observed (0.5% delayed exploration) Am J Surg 1997;174:

29 Selective Management Unstable Hard signs OR Penetrating Neck Injury Symptoms or Signs Zone I Zone II Zone III study OR angio Zone I study Asymptomatic Zone II/III observe

30 Start with Assessment of Skin Temperature to Identify Hypoperfusion in ICU Trauma or Septic pts w/o obvious low flow Examined distal extremities and measured serum HCO - 3 Either abnormal - check lactate If lactate - resuscitate ± invasive monitor J Trauma 2001;50:620-7

31 You can t t get it back in

32 Not an either/or question CT scan technology will continue to improve Faster More accurate Supplanting other invasive modalities CT is complimentary to good initial assessment and serial examinations

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