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

1. 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.

2. 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”

3. 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.

4. 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

5. 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.

6. 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

7. Results

8. Results for Neuroradiology CT scans

9. 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

10. 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.

11. 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

12. Results for Body CT scans

13. 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

14. 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

15. 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

16. Immunosuppressed pts with diffuse abdominal pain Fournier’s gangrene Necrotic mesenteric nodes and ascites Acute appendicitis with abscess

17. 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

18. 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

19. 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

20. 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

21. 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%)

22. 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.

23. 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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