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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
   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
   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
                             274
                        total patients


      132 (48 %)                                142 (52%)
    Neuroradiology                              Body CT

   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
 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.
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
Results
                       (132)=48%
                     Neuroradiology



     (39)= 30%                         (91) =70%
      Specific                        Non-specific




                      (142) = 52%
                        Body CT



                                       (58)=41%
  (83)=59%Specific
                                      Non-specific
Results for Neuroradiology CT scans
                39 scans = 30%
                    specific



    43% were                     57% were
     positive                    negative




                91 scans = 70%
                 Non specific


    11% were                     89% were
     positive                    negative
              Specific Diagnosis – Positive Findings




H: New onset right sided              H: worst headache of my life, rule
   weakness , r/o stroke                 out SAH
F: Infarct in the left motor cortex   F: Hemorrhagic infarct in the left
                                         parietal lobe
H: New onset seizures, rule out        H: Dysphagia with fever, r/o
stroke                                 abscess
F: Hemorrhagic stroke in the           F: Right tonsillar abscess
brainstem with decompression into
the fourth ventricle. Incidental old
infarct in the right temporal lobe.
      Non-specific Diagnosis – Positive Findings




H: Mental status changes,
F: embolic stroke in the     Same patient with thrombus
   right motor cortex        in the right carotid artery
Results for Body CT scans
                  83 = 59%
                  specific



    57% were                    43% were
     positive                   negative



                  58 = 41%
                 Non specific


   43% were                     57% were
   significant                  negative
               Specific Diagnosis – Positive Findings




 H: Bowel obstruction                              H: RLQ pain, r/o appendicitis
               High grade SBO                      F: Appendicitis
 F: High grade SBO with ischemia




H: Bowel obstruction                              H: LLQ pain and fever r/o diverticulitis
F: SBO with transition zone in the distal ileum   F: Left hydrosalpinx
H: Fever and pain in the LUQ with rebound   H: APPENDICITIS
   tenderness, r/o abscess                  F: Abscess in rlq
F: Abscess in LUQ



                                             H: Excruciating mid abdominal pain,
                                                r/o pancreatitis
                                             F: Duodenal perforation with free air
               Non-specific History – Positive Findings




H: Diffuse abdominal pain, N/V       History: RUQ pain
Findings – sigmoid diverticulitis    Findings – Non specific colitis




 H: Diffuse abd pain                 H: Diffuse abd pain
 F: acute pancreatitis               F: LLQ abscess
Immunosuppressed pts with diffuse abdominal pain




     Fournier’s gangrene    Necrotic mesenteric nodes
                            and ascites




                                  Acute
                                  appendicitis
                                  with abscess
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
  Neuro CT which helped in decision to discharge patient




H: Old thalamic infarcts, presenting
                                       H: Neck swelling, r/o abscess
with new onset mental status
                                       F: large goiter
changes, r/o acute hemorrhage
F: no hemorrhage
            CT helped in decision to discharge patients




                 H: Post partum, presenting with rlq pain, r/o appendicitis
                 F: Right hydroureter (postpartum)




H: Abdominal distension and pain, r/o SBO        H: Non specific, non localizing abdominal pain
F: Wide neck ventral hernia w/o obstruction      F: Ovarian cysts
                 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 with known ulcerative colitis, no
Patient admitted                                 acute findings; patient discharged
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%)
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.
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.
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