Abdominal Scan Conundrum

[UnderwaterDoc]

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We recently had our trauma conference and discussed the following case.

Early 20s girl flips her car at 55 MPH and after a 45 minute extrication is brought in. +LOC. She comes in as a Level 1, vitals WNL, has a few cuts and bruises but otherwise she's fine, abdomen is benign, FAST is negative.

She gets a head and c spine CT, and the usual battery of tests. Stays in the ED for a few hours, during which serial abdominal exams are done by our attending and senior resident. We do not scan the abdomen.

So during Trauma conference the surgeons are arguing that the abdomen should have been scanned, due to the mechanism of injury and prolongued extrication. They are also saying that a negative abdominal exam is basically meaningless in the setting of trauma.

Our argument is that this girl, who had normal vital signs, who had a benign abdomen on SERIAL exams, and who had a negative FAST does not need to be scanned based on clinical judgement.

What do you guys think, agree/disagree?

 

[SoCuteMD]

We recently had our trauma conference and discussed the following case.

Early 20s girl flips her car at 55 MPH and after a 45 minute extrication is brought in. +LOC. She comes in as a Level 1, vitals WNL, has a few cuts and bruises but otherwise she's fine, abdomen is benign, FAST is negative.

She gets a head and c spine CT, and the usual battery of tests. Stays in the ED for a few hours, during which serial abdominal exams are done by our attending and senior resident. We do not scan the abdomen.

So during Trauma conference the surgeons are arguing that the abdomen should have been scanned, due to the mechanism of injury and prolongued extrication. They are also saying that a negative abdominal exam is basically meaningless in the setting of trauma.

Our argument is that this girl, who had normal vital signs, who had a benign abdomen on SERIAL exams, and who had a negative FAST does not need to be scanned based on clinical judgement.

What do you guys think, agree/disagree?

Mental status? Intoxication?

 

[WilcoWorld]

On the one hand, I wouldn't let a negative FAST influence your decision - the sensitivity is just too low.

However, serial abdominal exams (when done well and in a non-intoxicated patient) are more sensitive than a CT scan. If it were my organs in question, I'd prefer serial exams.

There was a study done on pan scanning for mechanism, and if I recall correctly, the only outcome that really improved with the intervention group was a faster disposition.

I think you did the right thing.

 

[UnderwaterDoc]

Mental status? Intoxication?

GCS 15, no EtOH or drugs on board.

 

[EM_Rebuilder]

Mechanism does scare me sometimes into doing scans that are marginally warrented... I've found stuff that I did not expect... I am certain we all have on occasion. My most recent was a fall from standing with no ecchymosis, mild RUQ TTP. She was mid 40s and had HTN and GERD... she had free air with a perforated ulcer! I would have never guessed it and the surgery folks were even shocked at how benign her exam was...

I think we over CT regardless, and I have done similiar to what you did on serial exams and obs in the ED a few hours...have them get up, bathroom, smoke break, whatever...

My big question is how long of time frame are negative serial abdominal exams valid?... in other words 'are a few hours in the ED' ok, or should it really be an obs overnight 23 hour thing (which is back to the dilemma on good luck convincing trauma to admit and do that in lieu of scanning?

The other thing is lets say this 23 year old has a tiny spleen lac, tiny liver lac... so? If they are young and healthy it will probably do fine anyways on its own...

 

[Birdstrike]

.

 

[TysonCook]

...from what I've read so far.
1. FAST is not for ruling out/in abdominal trauma, it basically takes the place of a tap (OR vs Scanner).
2. Any hematuria?
3. Any external abdominal trauma (i.e. seat belt sign)?
4. CT is not very sensitive for blunt abdominal trauma - around 92%, lower for hollow viscus.
5. Ultimately did the girl have an OPERATIVE or NON-op finding? i.e. grade 2 spleen etc.
6. Repeated exams are the MOST sensitive of all tests - stand by that 100%

Sounds like your conference suffers from some serious outcome bias.

I posted a while ago a lecture I did on CT use in Trauma, I'll repost a link if I can find it. Just a FYI, a "pan scan" starts at almost $12,000 for imaging and reads alone, plus radiation, plus incidental findings, plus CIN, plus a million other things 🙂

here is an old link:
http://www.docstoc.com/docs/34636604/Radiology-in-Trauma
I'll see if I can find a server so you don't have to go a commercial site.
Starts around the 30th slide.
Data for the "pan scan" slide noted "denied" as of 2009:
Trauma Pack (Pan Scan):
CT Head w/o $1439.00
CT C-Spine w/o 2056.30
CT Chest w/ 2132.20
CT Abdomen w/ 2085.80
CT Pelvis w/ 1824.60
CT T-Spine w/o 1545.20
CT L-Spine w/o 2031.00
$ 13,114.10


Ask them to put the evidence behind their statement, as you have yours (lots of articles out there, do a search).

 

[southerndoc]

Many trauma surgeons rely on the radiologists to perform their job. Seriously, I've seen many trauma surgeons (and emergency physicians) who don't even examine people and just order CT's for abdominal pain. Not every person needs a CT, and I don't think this patient you presented needed one from the information you've presented.

If I remember correctly, CT head is about 100 x-rays, CT neck is another 100 (and directly over the thyroid), CT chest is 400 and CT of the abdomen/pelvis is another 800. 1400 x-rays is a lot for a "routine pan scan."

 

[EM2BE]

...from what I've read so far.
1. FAST is not for ruling out/in abdominal trauma, it basically takes the place of a tap (OR vs Scanner).
2. Any hematuria?
3. Any external abdominal trauma (i.e. seat belt sign)?
4. CT is not very sensitive for blunt abdominal trauma - around 92%, lower for hollow viscus.
5. Ultimately did the girl have an OPERATIVE or NON-op finding? i.e. grade 2 spleen etc.
6. Repeated exams are the MOST sensitive of all tests - stand by that 100%

Sounds like your conference suffers from some serious outcome bias.

I posted a while ago a lecture I did on CT use in Trauma, I'll repost a link if I can find it. Just a FYI, a "pan scan" starts at almost $12,000 for imaging and reads alone, plus radiation, plus incidental findings, plus CIN, plus a million other things 🙂

here is an old link:
http://www.docstoc.com/docs/34636604/Radiology-in-Trauma
I'll see if I can find a server so you don't have to go a commercial site.
Starts around the 30th slide.
Data for the "pan scan" slide noted "denied" as of 2009:
Trauma Pack (Pan Scan):
CT Head w/o $1439.00
CT C-Spine w/o 2056.30
CT Chest w/ 2132.20
CT Abdomen w/ 2085.80
CT Pelvis w/ 1824.60
CT T-Spine w/o 1545.20
CT L-Spine w/o 2031.00
$ 13,114.10


Ask them to put the evidence behind their statement, as you have yours (lots of articles out there, do a search).

I'm assuming those are the emergency prices (as in much more than routine out patient). If so, I had no idea how much more it was than the outpatient scans.

 

[UnderwaterDoc]

The other thing is lets say this 23 year old has a tiny spleen lac, tiny liver lac... so? If they are young and healthy it will probably do fine anyways on its own...

That was another one of my arguments, I felt that if we were missing something it would not be significant enough for the surgeons to fix.

 

[UnderwaterDoc]

Sounds like your conference suffers from some serious outcome bias.

You can say that again. It was futile trying to reason with some of the surgeons because after hearing about mechanism they automatically went straight to CT, anything else was "undermanagement".

For what it's worth, she ended up staying for obs, and the next day they did scan her, and it was NEGATIVE, Serial exams FTW.

 

[TysonCook]

...once again, you've got everything on your side saying "does not need a scan"....

Mechanism alone for CT of the ABD is not going to cut it, and is a weak way of saying "I don't trust my H+P"...

Pull the articles out, Trauma, Radiology, Annals, etc all say that routine scanning is NOT indicated, and once again, the correct answer is serial exams/obs.

...if they want to scan everyone, ask for justification of ANY sort...

You've got cost
You've got radiation exposure
You've got sensitivity
You've got lit from multiple disciplines
etc.

 

[TysonCook]

Yes, these are the Emergency prices...
I think that EVERY residency should at least once a year go over basic costs.
Yelling out "pan scan" takes 2 seconds and may take the patient 10 years to pay off.

Remember that "first do no harm" is NOT A STATEMENT RESTRICTED TO MEDICAL OUTCOMES... It includes financial, familial, social, and is a multifaceted statement.

Bankrupting a family for life due to irrational "testing" is NOT a benign part of being a doctor.

I'm assuming those are the emergency prices (as in much more than routine out patient). If so, I had no idea how much more it was than the outpatient scans.

 

[ohiovolffemtp]

Quick perspective from someone who used to do the extrications:
1) time of extrication has a lot more to do with type of vehicle and external damage than actual injury to
occupants. Most passenger cars built within the past 5 years crumple extensively on the outside
with minimal damage to the actual passenger compartment. Best way to assess the true mechanism
of injury is from a picture of the interior of the vehicle, 2nd best is the verbal description of it from the
EMS unit. Both are usually part of their report.
2) Presence of roll-over increases the risk of injury, but more important are 2 other things: a) whether
the patient was restrained; b) who and what else bounced around inside the vehicle to hurt the
patient.

I definitely go with the folks who based their decisions to scan/not based on clinical assessment. I've seen death in situations with minimal vehicle damage and minimal injury in situations with massive vehicle damage & prolonged extrication. YMMV.

 

[WilcoWorld]

Yes, these are the Emergency prices...
I think that EVERY residency should at least once a year go over basic costs.
Yelling out "pan scan" takes 2 seconds and may take the patient 10 years to pay off.

Remember that "first do no harm" is NOT A STATEMENT RESTRICTED TO MEDICAL OUTCOMES... It includes financial, familial, social, and is a multifaceted statement.

Bankrupting a family for life due to irrational "testing" is NOT a benign part of being a doctor.

Hmm...I'd never thought of it that way.

 

[Birdstrike]

.

 

[docB]

Great discussion. I wouldn't scan that patient. I wouldn't let one of my daughters get scanned with no symptoms and a benign exam.

That being said every action has its costs. The scan costs. The best approach to this, IMHO, is admit with real serial exams and possibly serial Hcts. That will cost too. Probably as much or more as the CT but it has no radiation associated with it.

The worst situation, and I have seen this more than I care to say, is where the EP says a scan is not necessary but admits for serial exams, the exams stay benign but the trauma attending orders the CT on morning rounds with "d/c if negative." Then you pay for the admit and get the CT anyway. If you are planning to do the admit and avoid the scan route you need to coordinate with trauma.

 

[Janders]

Great discussion. I wouldn't scan that patient. I wouldn't let one of my daughters get scanned with no symptoms and a benign exam.

Good synopsis. I think that we all agree with normal vitals, normal mental status, and truly benign exam there is a relatively low risk of anything serious being inside the belly. However, it is possible there IS something going on...

If it is solid viscus, CT will find out. However, even with modern CT a hollow viscus injury can be hard to find. I think it most reasonable thing to do is to admit for serial exams (or in some settings, obs. in ED for serial exams). However, to be frank, in a community shop with no trauma service, this can be hard!

 

[Rendar5]

You can say that again. It was futile trying to reason with some of the surgeons because after hearing about mechanism they automatically went straight to CT, anything else was "undermanagement".

For what it's worth, she ended up staying for obs, and the next day they did scan her, and it was NEGATIVE, Serial exams FTW.

mind my asking why she stayed for obs even? doesn't sound like she got concussed too bad.

 

[la gringa]

how i was taught:
- mechanism is a reason for a TRAUMA EVAL/transport to a level 1 trauma/trauma activation/whatever you call if where you are... not a reason for a pan scan in an awake/alert pt.
- gcs 15 w/o etoh... CT based on exam. wouldn't even do a FAST w/o cause like funny vitals or labs. waste of time w/o any history, physical, or lab findings...

 

[Apollyon]

how i was taught:
- mechanism is a reason for a TRAUMA EVAL/transport to a level 1 trauma/trauma activation/whatever you call if where you are... not a reason for a pan scan in an awake/alert pt.

New York State had "trauma triage guidelines" for BLS (ALS is regional, but BLS is statewide), and half were mechanism, and half were vital sign/patient based.

However, NYS did away with that after ACS got rid of mechanism-based guidelines. That might be 15 years ago.

 

[BushDoc20]

strip back to field basics..how would you assess the same pt if you were somewhere without a CT, FAST, or anything? sometimes thinking outside the square gives you ideas. personally if it was a long extrication and she was in a compromised position i would scan but other than that i would keep her for 24hrs and if she doesn't complain of abdo tenderness or a 'sore stomach' then i would discharge and tell her to follow up with her GP....seat belt bruising should be taken into consideration when deciding on to scan or not scan

 

[UnderwaterDoc]

mind my asking why she stayed for obs even? doesn't sound like she got concussed too bad.

As DocB said, the idea was to keep her for obs with serial exams and send her out, this was agreed upon with the trauma team that saw the patient that night. However, when the new trauma attending showed in the morning he ordered the scan anyways, quoting mechanism.

It's funny because they are always telling us to use our clinical judgement, not to order scans willy-nilly, but when we do use our judgement the patient gets scanned anyway, and then we get yelled at by the Traumatologists. Can't win.

 

[southerndoc]

Would anyone actually admit this patient for obs? I don't admit patients for obs after brief or unwitnessed LOC ("Yea, I think I passed out") if they have someone at home that can watch them. I instruct them on when to return. This patient wasn't complaining of anything, so I can't justify admitting her for observation status (even in our obs unit where you can admit anything because we run it).

If they live by themselves, it's a different story based on mechanism and suspicion.

 

[BushDoc20]

Would anyone actually admit this patient for obs? I don't admit patients for obs after brief or unwitnessed LOC ("Yea, I think I passed out") if they have someone at home that can watch them. I instruct them on when to return. This patient wasn't complaining of anything, so I can't justify admitting her for observation status (even in our obs unit where you can admit anything because we run it).

If they live by themselves, it's a different story based on mechanism and suspicion.

i would if this same accident had happened in the NT, australia. our native people are uhmm prone to doing some wild and whacky things but also the nearest hospital from alice is darwin soooooo yeah! its a long drive for many its not like its the next district or suburb.

 

[deleted65604]

As DocB said, the idea was to keep her for obs with serial exams and send her out, this was agreed upon with the trauma team that saw the patient that night. However, when the new trauma attending showed in the morning he ordered the scan anyways, quoting mechanism.

It's funny because they are always telling us to use our clinical judgement, not to order scans willy-nilly, but when we do use our judgement the patient gets scanned anyway, and then we get yelled at by the Traumatologists. Can't win.

Wait, you admitted an asymptomatic MVA? Did she have abdominal pain? Tenderness? I wouldn't be able to get a surgeon in to eval said patient at the bedside, let alone admit them. You are in bizarro world, or I don't understand the scenario well enough.

 

[dotcb]

Would keep the patient for a few hrs for serial exams. Would not scan the abdomen. In my training and in the residency I teach in, I generally think the FAST is over-applied for teaching purposes.

I think most would agree - mechanism + abnormal VS (HR, RR, BP, O2) or abnormal lab results (lactate, anemia) - those likely would prompt further investigation (imaging or repeating). But mechanism alone - no.

 

[UnderwaterDoc]

Wait, you admitted an asymptomatic MVA? Did she have abdominal pain? Tenderness? I wouldn't be able to get a surgeon in to eval said patient at the bedside, let alone admit them. You are in bizarro world, or I don't understand the scenario well enough.

Yes, admitted for OBS for serial abdominal exams due to concerning mechanism with +LOC at the scene and to keep her from getting scanned, in the end it didn't work because the morning trauma team scanned her anyways. Surgery was already in on the case because she came in as a level 1, and the evening team agreed with our plan.

 

[deleted65604]

Yes, admitted for OBS for serial abdominal exams due to concerning mechanism with +LOC at the scene and to keep her from getting scanned, in the end it didn't work because the morning trauma team scanned her anyways. Surgery was already in on the case because she came in as a level 1, and the evening team agreed with our plan.

Did she have abdominal pain or tenderness?

 

[UnderwaterDoc]

Did she have abdominal pain or tenderness?

Nope, but we only saw her in the ED for ~3h, as I'm sure you know, blood takes over 6h to develop peritoneal signs. Hence the obs admission with serial exams.

 

[deleted65604]

Give good discharge instructions and out the door. She is more likely to die of a hospital acquired infection than of bleeding out with no abdominal pain, or tenderness on exam, normal vitals and unchanged status after 3 hours. I stand by my original statement...bizarro world.

 

[southerndoc]

Give good discharge instructions and out the door. She is more likely to die of a hospital acquired infection than of bleeding out with no abdominal pain, or tenderness on exam, normal vitals and unchanged status after 3 hours. I stand by my original statement...bizarro world.

That's my vote. I wouldn't even consult surgery on this. That's like saying we should admit a hypertensive, hyperlipidemic, diabetic without chest pain to the chest pain obs unit just because he ate a Big Mac. Mechanism is there to have an MI, so why not admit for serial EKG's and trops?

 

[docB]

Let me point out that the fact we're even having this discussion (which is a good topic and a valid discussion) shows how much the malpractice crisis affects everything we do and that defensive medicine is very real, costly, morbid and insidious.

 

[Birdstrike]

.

 

[UnderwaterDoc]

Just to clarify, the fact that she came in as a Level 1 means that surgery gets the page automatically, it's not like we later decided to consult them on a whim, they were in the trauma bay with us waiting for the patient.

Perhaps I am mistaken, but I feel that the chances that this patient would end up in a community hospital are very low, unless you truly are in the middle of nowhere. A patient like this has no business being in a community setting where 9/10 times she'll get transferred out.

Had she ended up in a community setting I feel that she would have gotten panscanned the second she stepped into the ED and her vitals were checked, because as has been said, there is no backup and you are trying to decide whether to transfer or not. Yes, I agree that admitting her was more for medicolegal purposes than anything else, but that is the world we live in, and we WERE trying to keep her from getting scanned.

Good instructions and out the door sounds to me like a recipe for disaster. Physical exam means squat in blunt abdominal trauma, unless it's done serially for a number of hours (more than 3). Also, this was a young, healthy patient, so her vitals would not show you the signs of blood loss unless she has lost a LOT of blood.

I think admitting her was the best of both worlds, we freed up an ED bed, and we made sure that she was closely checked over the next 24h.

 

[southerndoc]

I'm sorry, when I say community I mean my non-academic center. We see 100,000+ patients per year, and we do routinely get patients like this as they often request to come to our facility. Our sister facility sees 130,000 patients per year and is a trauma center.

 

[Rendar5]

Just to clarify, the fact that she came in as a Level 1 means that surgery gets the page automatically, it's not like we later decided to consult them on a whim, they were in the trauma bay with us waiting for the patient.

Perhaps I am mistaken, but I feel that the chances that this patient would end up in a community hospital are very low, unless you truly are in the middle of nowhere. A patient like this has no business being in a community setting where 9/10 times she'll get transferred out.

Had she ended up in a community setting I feel that she would have gotten panscanned the second she stepped into the ED and her vitals were checked, because as has been said, there is no backup and you are trying to decide whether to transfer or not. Yes, I agree that admitting her was more for medicolegal purposes than anything else, but that is the world we live in, and we WERE trying to keep her from getting scanned.

Good instructions and out the door sounds to me like a recipe for disaster. Physical exam means squat in blunt abdominal trauma, unless it's done serially for a number of hours (more than 3). Also, this was a young, healthy patient, so her vitals would not show you the signs of blood loss unless she has lost a LOT of blood.

I think admitting her was the best of both worlds, we freed up an ED bed, and we made sure that she was closely checked over the next 24h.

You seem to be presenting the case of a patient without any complaints who's completely with it s/p MVC with LOC on scene, but not concussive at the time of exam. In this setting, I still don't get the need for more than 3 hours of serial abdominal exams. There's no complaint of abdominal pain or discomfort, no abdominal tenderness, no abdominal bruising, and nothing even remotely in the history to suggest any sort of abdominal issue. I'm not even sure there's a role for u/s in this patient. Only seems to be a need for head CT. I'm not sure of any abdominal pathology in this setting that would be devoid of both tenderness AND pain (at some point in the history) in this patient. devoid of one or the other, sure, but both?

However, if she was concussed at the time of exam, or even revved up on adrenaline, or had any sort of injury that was occupying her attention, I can see the need for more extensive serial exams.

 

[Birdstrike]

.

 

[UnderwaterDoc]

Let me be clear. You did nothing wrong in this case. It's totally within standard of care. It's above the standard of care, that's all anyone is trying to say.

Abdominal exam IS meaningful in blunt trauma, if someone is awake and alert, without intoxication. It's very meaningful. You CT the patients head (and ok maybe neck), they are stable with no signs of injury whatsoever, so you crush through the next 15 patients that come in. Three hours later the patient taps you on the shoulder and says, "doc, I've got stuff to do, I'm fine, I have no pain". You press on their belly and no pain still, normal vitals still, scans neg, still acting right. Home. Bye bye. At a teaching center, if trauma will admit all these, fine, let them. It's a luxury. Also, I would never transfer a patient like this. Why? For what diagnosis, what injury?

Patients like this absolutely will come to your level 2 or three community hospital, in droves. That's where uninjured trauma patients like this belong.

Also, you'll get WAY better at trauma at a level 2 or 3 where trauma is not hovering: when trauma shows up its "CT. Admit. CT Admit.". Every time.

Lesson: there's multiple ways to work a patient up, and still be within the standard of care. Just because someone did it a little different doesn't mean you were wrong. Next time you admit a patient like this and they FIND something, let's talk.

I couldn't agree more, especially about the CT-admit part, lucky for us we don't call them for the level 2s and 3s that come in so we get to take care of those by ourselves. The really funny/sad part is that this case went to trauma conference because it was "undermanaged", even though she got admitted and scanned the next day.

I think in the future I will be much more willing to discharge, rather than admit, even though I am bound by what the attending on staff wants to do since it is their license on the line.

 

[deleted65604]

Let me be clear. You did nothing wrong in this case. It's totally within standard of care. It's above the standard of care, that's all anyone is trying to say.

Abdominal exam IS meaningful in blunt trauma, if someone is awake and alert, without intoxication. It's very meaningful. You CT the patients head (and ok maybe neck), they are stable with no signs of injury whatsoever, so you crush through the next 15 patients that come in. Three hours later the patient taps you on the shoulder and says, "doc, I've got stuff to do, I'm fine, I have no pain". You press on their belly and no pain still, normal vitals still, scans neg, still acting right. Home. Bye bye. At a teaching center, if trauma will admit all these, fine, let them. It's a luxury. Also, I would never transfer a patient like this. Why? For what diagnosis, what injury?

Patients like this absolutely will come to your level 2 or three community hospital, in droves. That's where uninjured trauma patients like this belong.

Also, you'll get WAY better at trauma at a level 2 or 3 where trauma is not hovering: when trauma shows up its "CT. Admit. CT Admit.". Every time.

Lesson: there's multiple ways to work a patient up, and still be within the standard of care. Just because someone did it a little different doesn't mean you were wrong. Next time you admit a patient like this and they FIND something, let's talk.

I agree with everything birdstrike said.

You don't transfer unless you have a neurosurgical problem, aorta problem, or a stable splenic/liver lac, or polysystem trauma. Heck, I've had trauma surgeons ask me to warn patients that they would get transferred down for a traumatic subarachnoid hemorrhage, CT'd in 6 hours from first CT and sent home if not worsening. By the time I would have arranged transfer, and they would have taken the ride, been processed, and seen the doc, they would have been ready for their second CT and would have incurred a $10,000 in addition to our astronomic bill. Patient opted to stay at our place and get re-CT'd in a couple of hours. Did I feel comfortable with it? No.

The reason I tell you this is that you are obviously practicing with exceedingly conservative trauma surgeons. I didn't think anybody was more conservative than ER doctors. Your experience is not going to be reproduced in the vast majority of hospitals anywhere in the country.

Your trauma surgeons must not have enough to do, and your hospital must have tons of open in-patient beds. They must use these trauma activations to pad their in-patient services with lots of low maintenance patients and increase their billing. Or possibly, there was a bad outcome in somebody with an atypical presentation, who maybe didn't get a great physical exam when they came in. Those are the only explanations for this low threshold to admit patients that I can think of.

 

[crewmaster1]

I teach my patient's how to do their own abdominal exams at home! Just kidding, but seriously. I work in the community and with CT out there, you're not going to wake up a bunch of surgeons in the middle of the night (I work all nights) to ask them to admit every reasonable MVC patient for serial exams. If the patient is a normal, somewhat reliable patient that has a normal exam in the ED with normal vitals and a reassuring repeat exam in a hour or two, they can go home and return back if things get worse. If they have a liver lac that truly needs surgical management (most solid organ injuries don't go to the OR anymore) it is unlikely that they will have a negative exam and normal vitals in the ED. If they are normal and have minimal pain, I discuss the risks and benefits of CT imagaing, make my recommendation, and let the patient buy in to the final decision. If they are not reliable or drunk, they get a scan (if you don't want to be irradiated, don't do stupid things).

 

[Apollyon]

Again, though, just remember that the OP is a resident, and this was called as a level 1 trauma. Even our level 3s got a trauma consult (otherwise, 1s and 2s were trauma's patients).

But, as stated, in the community, do your workup. I agree summarily with crewmaster.

 

[pinipig523]

No scan.

 

[Groove]

Scan. Why not? Fast, definitive, greatest sensitivity and specificity for any injury that you could have missed and given the mechanism, extraction, concussion, etc... The pt most definitely meets obs criteria for any hospital on the planet. That means their going to be most likely admitted to trauma, so if you don't scan, you know they will or will ask for it, so why not?

I think the risks of missing an acute injury in the case "as you've described it" would outweigh radiation risks from a single CT scan.

I get the whole discussion of whether it's definitively needed in certain cases and it's certainly a judgement call, but regardless of X study in X journal, when you back up and think about it, you'd be hard pressed to argue against a superior imaging study such as CT for evaluating "what's in my tummy s/p trauma" vs UTZ and serial belly exams.

Do you really want to take the risk in missing something in a 20yo female who's car just flipped going 50-60mph (she thinks...) and was knocked unconscious and obviously had severe enough damage to the vehicle that it required 45 mins to extract her?

I don't. Neither would I want to be worrying about her for 6 hours in the ED.

Scan, admit for obs, and up she goes out of the ED. You know surgery is going to want it and you know it's going to make you feel warm and fuzzy to have a negative scan.

 

[southerndoc]

Just because surgery wants it doesn't mean it's necessary. If they want it, they can order it.

I wouldn't even consult surgery in an asymptomatic patient just because she had +LOC. As a former paramedic, extrication time doesn't always equate to injury. I've seen some really messed up cars where we've cut people out of them and they've walked around and refused treatment because they were fine. I've seen some firefighters not know what they were doing and take forever to cut a car apart which I could've done in 5 minutes when I was a firefighter.

I don't think this patient "meets obs criteria for any hospital on the planet."

 

[Groove]

Just because surgery wants it doesn't mean it's necessary. If they want it, they can order it.

I wouldn't even consult surgery in an asymptomatic patient just because she had +LOC. As a former paramedic, extrication time doesn't always equate to injury. I've seen some really messed up cars where we've cut people out of them and they've walked around and refused treatment because they were fine. I've seen some firefighters not know what they were doing and take forever to cut a car apart which I could've done in 5 minutes when I was a firefighter.

I don't think this patient "meets obs criteria for any hospital on the planet."

There's a plethora of trauma surgery studies that show pan scanning patients with multi system trauma which includes MVC's with negative exam and lab findings can change management in up to 20% of cases. That's why they generally want pan scans in cases where they probably are not warranted, but there's enough literature out there to support it. Do pt's get over scanned? Yes. Again, it comes down to what's the quickest and most sensitive/specific study to rule out significant injury? If there's +LOC, prolonged extraction, and the vehicle flipped and rolled, that's enough for me to scan them. It really boils down to radiation exposure vs risk of missed critical injury. I understand your perspective, but you weren't the paramedic for this patient, so as valuable as the paramedics information is, I have to take the information as it's given to me and all I hear is +LOC, flip and roll at 50-60mph, and prolonged extraction which all these factors increase the pt's likelihood of critical injury.

Why wouldn't a pt like that not meet hospital obs criteria? You can obs almost any trauma of the nature described. No hospital is going to deny obs for a +LOC, moderate to severe damage to the vehicle and prolonged extraction.

I think these cases can be gray areas but I definitely don't think there's a 100% right or wrong way to manage these people. It's a judgement call. Risks vs benefits. I just happen to side with CT'ing them because I've enough suspicion on mechanism alone to make me nervous. Otherwise they wouldn't be down in the ED for 6 hours while I do serial exams. Pt's shouldn't have to stay in the ED for that long. You never know what's going to come in next and I'd hate to get tied up in 2 more critical cases only to do another serial + UTZ and find blood.

 

[deleted65604]

Scan. Why not? Fast, definitive, greatest sensitivity and specificity for any injury that you could have missed and given the mechanism, extraction, concussion, etc... The pt most definitely meets obs criteria for any hospital on the planet. That means their going to be most likely admitted to trauma, so if you don't scan, you know they will or will ask for it, so why not?

I think the risks of missing an acute injury in the case "as you've described it" would outweigh radiation risks from a single CT scan.

I get the whole discussion of whether it's definitively needed in certain cases and it's certainly a judgement call, but regardless of X study in X journal, when you back up and think about it, you'd be hard pressed to argue against a superior imaging study such as CT for evaluating "what's in my tummy s/p trauma" vs UTZ and serial belly exams.

Do you really want to take the risk in missing something in a 20yo female who's car just flipped going 50-60mph (she thinks...) and was knocked unconscious and obviously had severe enough damage to the vehicle that it required 45 mins to extract her?

I don't. Neither would I want to be worrying about her for 6 hours in the ED.

Scan, admit for obs, and up she goes out of the ED. You know surgery is going to want it and you know it's going to make you feel warm and fuzzy to have a negative scan.

Do you have some literature about scanning asymptomatic people and admitting asymptomatic people? What percent of asymptomatic people end up needing transfusions? I wouldn't worry about her for six hours in the ED. If she were asymptomatic, she would get discharged as soon as I had normal head CT results.

 

[deleted65604]

Why wouldn't a pt like that not meet hospital obs criteria? You can obs almost any trauma of the nature described. No hospital is going to deny obs for a +LOC, moderate to severe damage to the vehicle and prolonged extraction.

My hospital would claim they weren't going to get paid for the admission and would definitely balk. My trauma surgeons would laugh in my face and tell me to observe them myself.

 

[Groove]

http://www.ncbi.nlm.nih.gov/pubmed/16702518

http://www.ncbi.nlm.nih.gov/pubmed/19886129

I'm not arguing to pan scan everyone, and certainly think surgery is over judicious in their usage of CT scanning, but they do have literature to support it.

It all boils down to the fact that there are articles supporting both sides and various sets of guidelines, so I don't think anyone can argue their way of management in this type of patient is unequivocally evidence based.

There are some indications for CT scanning despite a normal FAST examination. One study reported that 28% of patients with a negative initial FAST examination had intraabdominal solid visceral injury without hemoperitoneum.9

Tintinalli, Judith; Stapczynski, J.; Ma, O. John; Cline, David; Cydulka, Rita; Meckler, Garth (2010-10-22).

The abdomen should be examined for signs of injury such as abrasions or contusions. Examination should include the flank, back, lower chest, and the anterior abdomen. A single physical examination is insensitive.5 Serial physical examinations increase the utility of the identification of intraabdominal injury. Examinations should be performed by the same senior level clinician and should occur over at least 16 to 24 hours. The patient must be awake, alert, and reliable. Repeat examinations should be accompanied by serial hematocrit determinations and vital sign measurements.

Tintinalli, Judith; Stapczynski, J.; Ma, O. John; Cline, David; Cydulka, Rita; Meckler, Garth (2010-10-22).

 

[UnderwaterDoc]

My hospital would claim they weren't going to get paid for the admission and would definitely balk. My trauma surgeons would laugh in my face and tell me to observe them myself.

The surgeons are the ones that admitted her, can't keep her in the bay holding up valuable space.