Typical order: “chest CT with and without contrast”
A review of Medicare claims from 2008 showed that 5.4% of patients received double CT scans of the chest. Although the median was about 2% across 3,094 hospitals, 618 hospitals performed double scans on more than 10% of their patients. And 94 did it on more that half! One of the outliers was a small hospital in Michigan that double scanned 89% of Medicare patients! As expected, there was wide variation from hospital to hospital, and from region to region around the US.
Time for some editorial comment.
This practice is very outdated and shows a lack of understanding of the information provided by CT. Furthermore, it demonstrates a lack of concern for radiation exposure by both the ordering physician and the radiologist, who should know better.
Some officials at hospitals that had high scan rates related that radiologists ordered or okayed the extra scan because they believed that “more information was better.” There are two problems with this thinking.
Information for information’s sake is worthless. It is only important if it changes decision making and ultimately makes a difference in outcome.
As with every test we do, there may be false positives. But we don’t know they are false, so we investigate with other tests, most of which have known complications.
The solution is to do only what is clinically necessary and safe. The tests ordered should be based on the best evidence available, which demands familiarity with current literature.
In trauma, there are a few instances where repeat scanning of an area is required. Examples include solid organ lesions which may represent an injury or a hemangioma, and CT cystogram to exclude bladder trauma. In both cases, only a selected area needs to be re-scanned, not the entire torso.
Bottom line: Physicians and hospitals need to take the lead and rapidly adopt or develop guidelines which are literature-based. State or national benchmarking is essential so that we do not continue to jeopardize our patient’s safety and drive up health care costs.
Tomorrow I’ll share the blunt trauma imaging protocol we use which has decreased trauma CT use significantly at Regions Hospital.
Trauma professionals worry about radiation exposure in our patients. A lot. There are a growing number of papers dealing with this topic in the journals every month. The risk of dying from cancer due to CT scanning is negligible compared to the risk from acute injuries in severely injured patients. However, it gets a bit fuzzier when you are looking at risk vs benefit in patients with less severe injuries. Is it possible to quantify this risk to help guide our use of CT scanning in trauma?
A nice paper from the Mayo clinic looked at their scan practices in 642 adult patients (age > 14) over a one year period. They developed dose estimates using a detailed algorithm, and combined them with data from the Biological Effects of Ionizing Radiation VII data. The risk level for injury was estimated using their trauma team activation criteria. High risk patients met their highest level activation criteria, and intermediate risk patients met their intermediate level activation criteria.
Key points in this article were:
Average radiation dose was fairly consistent across all age groups (~25mSv)
High ISS patients had a significantly higher dose
Cumulative risk of cancer death from CT radiation averaged 0.1%
This risk decreased with age. It was highest in young patients (< 20 yrs) at 0.2%, and decreased to 0.05% in the elderly (> 60 yrs)
Bottom line: Appropriate CT scan use in trauma evaluation is challenging. It’s use is widespread, and although it changes management it has not decreased trauma mortality. This paper shows that the risk of death from trauma in the elderly outweighs the risk of death from CT scan radiation. However, this gap narrows in younger patients with less serious injuries because of their very low mortality rates. Therefore, we need to focus our efforts to reduce radiation exposure on our young patients with minor injuries.
The traditional gold standard for diagnosis of vascular injury to the extremities has been a good physical exam plus conventional catheter angiography. However, using angiography always adds a layer of complexity and risk to patient care. The interventional team may not be immediately available after hours, there is typically a road trip within the hospital to deliver the patient for the study, and overall it is quite expensive.
With the advancements we have seen in CT angio techniques and scanner technology, some centers have been using computed tomography to evaluate for vascular injury. A few small retrospective studies have been done, but this month a larger prospective study was published.
Over a 20 month period, 635 patients with extremity trauma and a suspicion for vascular injury were entered into the study. A structured physical exam was performed, and any patient with “hard signs” of vascular injury were taken to the OR. 527 patients had no signs of vascular injury and were observed and released. The remaining 73 (most had soft signs of vascular injury) underwent CT angiography of the extremity.
The sensitivity and specificity of this test were 82% and 92%, respectively. Positive and negative results were nearly perfectly predictive. However, approximately 10% were inconclusive, usually due to bullet artifact or reformatting errors. These patients either underwent confirmatory conventional angiography or operation.
Bottom line: Angiography using multi-detector CT scanners is an excellent tool for evaluating potential extremity vascular trauma from penetrating trauma. The technology is available around the clock without a wait, and usually does not involve lengthy trips through the hospital. A good physical exam is imperative so patients with hard signs of injury can go straight to the OR. Equivocal studies must be evaluated further by conventional angio or an operation.
CT scan is a valuable tool for initial screening and diagnosis of trauma patients. However, more attention is being paid to radiation exposure and dosing. Besides selecting patients carefully and striving for ALARA radiation dosing (as low as reasonably achievable) by adjusting technique, what else can be done? Obviously, shielding parts of the body that do not need imaging is simple and effective. But what about simply changing body position?
One simple item to consider is arm positioning in torso scanning. There are no consistent recommendations for use in trauma scanning. Patients with arm and shoulder injuries generally keep the affected upper extremity at their side. Radiologists prefer to have the arms up if possible to reduce scatter and provide clearer imaging.
A recently published article looked at arm positioning and its effect on radiation dose. A retrospective review of 690 patients used dose information computed by the CT software and displayed on the console. Radiation exposure was estimated using this data and was stratified by arm positioning. Even though there are some issues with study design, the results were impressive.
The dose results were as follows:
Both arms up: 19.2 mSv (p<0.0000001)
Left arm up: 22.5 mSv
Right arm up: 23.5 mSv
Arms down: 24.7 mSv
Bottom line: Do everything you can to reduce radiation exposure:
Be selective with your imaging. Do you really need it?
Work with your radiologists and physicists to use techniques that reduce dose yet retain image quality
Shield everything that’s not being imaged.
Think hard about getting CT scans in children
Raise both arms up during torso scanning unless injuries preclude it.
Reference: Influence of arm positioning on radiation dose for whole body computed tomography in trauma patients. J Trauma 70(4):900-905, 2011.
This injury is likely to occur in patients who have a full bladder and sustain anterior pelvic trauma that typically leads to fractures. They generally present with gross hematuria upon placement of the bladder catheter. This should prompt an abdominal CT scan with cystogram technique.
CT cystogram involves pressurizing the bladder with contrast prior to the study. This differs from the usual method of clamping the catheter and allowing the bladder to passively fill. The literature here is clear: failure to use cysto technique will miss 50% of these injuries.
The majority of extraperitoneal bladder injuries can be treated nonoperatively, and probably do not need Urology involvement. The bladder catheter is left in place 10-14 days (we do 10 days), and a repeat cystogram is obtained. If there is no leak, the catheter can be removed. If there is still some leakage, Urology consultation should then be obtained.
There are a few cases where operative management is required:
There is some intraperitoneal component of bladder injury
Fixation of the pubic rami is required (bathing the orthopedic hardware with urine is frowned upon)
Failure of conservative management
Arrows in the photo show extraperitoneal extravasation of cystogram contrast.