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In that case I would like to shout "sober, alert patient with normal vital signs, no complaints and a normal abdominal exam".
The "pan scan" is far from a benign intervention.
Abdominal Scan Conundrum
- Thread starter UnderwaterDoc
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In that case I would like to shout "sober, alert patient with normal vital signs, no complaints and a normal abdominal exam".
The "pan scan" is far from a benign intervention.
http://www.youtube.com/watch?v=YzYxz_uvtSI
The one with the mechanism of injury
The one with the mechanism of injury
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Same here. The trauma team would laugh at me if I tried to admit an entirely asymptomatic MVA (if no drugs/etoh on board)... Then they'd recomend a pan scan and sign off on the patient.
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...in response to groove:
-------------------------
http://thermoclineventures.com/yahoo_site_admin/assets/docs/PanScanArticleSnyder.71115557.pdf
"
Whole-Body Imaging in Blunt Multisystem Trauma Patients
Who Were Never Examined" - this is a response to your AJT article.
-annals 2008
-------------------------
http://www.ajronline.org/content/197/6/1393.short
Appropriateness of CT of the Chest, Abdomen, and Pelvis in Motorized Blunt Force Trauma Patients Without Signs of Significant Injury
-AJR 2011
I'm not saying sometimes you don't do pan scans, I'm just saying that sometimes you don't NEED to...
-------------------------
http://thermoclineventures.com/yahoo_site_admin/assets/docs/PanScanArticleSnyder.71115557.pdf
"
Whole-Body Imaging in Blunt Multisystem Trauma Patients
Who Were Never Examined" - this is a response to your AJT article.
-annals 2008
-------------------------
http://www.ajronline.org/content/197/6/1393.short
Appropriateness of CT of the Chest, Abdomen, and Pelvis in Motorized Blunt Force Trauma Patients Without Signs of Significant Injury
-AJR 2011
I'm not saying sometimes you don't do pan scans, I'm just saying that sometimes you don't NEED to...
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Ok, I'm obviously getting slammed by the Hiroshima nazis, but seriously...
I don't think you can take anything I'm saying as an excuse to pan scan every MVA that comes in, but there IS a gray zone. That gray zone unfortunately, whether you like it or not, includes mechanism of injury. We can all grab as many journal articles as we can to boost our argument, but the fact remains that it's not algorithmic and there is an element of clinical judgement involved. There is also no definitive rule of thumb for just how long is long enough to obs someone in the ED for serial belly exams.
My personal take is that if the pt lost consciousness, the vehicle suffered enough damage (intrusion, etc..) that resulted in a prolonged extraction, and the vehicle flipped and rolled, I would err towards a pan scan unless they just looked virtually untouched. The fact remains though... how long is long enough to obs them in the ED? Should the ED be a holding place for pt's such as this where you've got a surgery/trauma service that won't admit for observation? I would argue no. The ED is not a holding area and I don't want to get really busy 1 hour later with ED resources diverted elsewhere and lose track of the patient.
Our own text argues an even more conservative approach such as serial belly exams by the SAME senior clinician for 16-24 hours. Do we actually do this? Of course not. Does anyone feel like doing this? I sure don't.
Yes, there is radiation exposure. Yes, negative scans make you feel bad for exposing the patient, but honestly... if the majority of my scans are positive, I'm not doing enough of them.
We can all sit here and argue that one particular way is the right way, but there is currently no unified evidence based approach to how to handle those gray area patients. There are multiple guidelines and mechanism of injury should most definitely play a role in the management process of trauma patients IMO.
Personally, I get no push back at all by trauma for observing these patients. Def not in my teaching institution and def not out moonlighting...yet.
Also, I think we all are prone to develop bias based on adverse outcomes. Maybe I'm more sensitive to it but I'll never forget a case where a young adult who was transferred from another hospital for a mechanism even less than this one and had a faint finding on CT A/P (that probably I wouldn't have even done). Looked so well that trauma at this particular place even elected to not re-scan the belly. Serial belly exams normal during obs. Discharged and guy shows up in an ED within the next 12 hours with belly full of blood and dies. Unavoidable? Perhaps. Repeat CT would have probably showed new findings I would think, but again...lots of radiation for a minor finding. We sure aren't perfect, but CT can pick up a lot of stuff that we miss. Radiation or not, it's still the best and fastest imaging study we have in acute trauma. Again, that doesn't mean pan scan everyone but it's not all black and white. As posted above, even the experts are still arguing over how to properly stratify patients for pan CT's.
I don't think you can take anything I'm saying as an excuse to pan scan every MVA that comes in, but there IS a gray zone. That gray zone unfortunately, whether you like it or not, includes mechanism of injury. We can all grab as many journal articles as we can to boost our argument, but the fact remains that it's not algorithmic and there is an element of clinical judgement involved. There is also no definitive rule of thumb for just how long is long enough to obs someone in the ED for serial belly exams.
My personal take is that if the pt lost consciousness, the vehicle suffered enough damage (intrusion, etc..) that resulted in a prolonged extraction, and the vehicle flipped and rolled, I would err towards a pan scan unless they just looked virtually untouched. The fact remains though... how long is long enough to obs them in the ED? Should the ED be a holding place for pt's such as this where you've got a surgery/trauma service that won't admit for observation? I would argue no. The ED is not a holding area and I don't want to get really busy 1 hour later with ED resources diverted elsewhere and lose track of the patient.
Our own text argues an even more conservative approach such as serial belly exams by the SAME senior clinician for 16-24 hours. Do we actually do this? Of course not. Does anyone feel like doing this? I sure don't.
Yes, there is radiation exposure. Yes, negative scans make you feel bad for exposing the patient, but honestly... if the majority of my scans are positive, I'm not doing enough of them.
We can all sit here and argue that one particular way is the right way, but there is currently no unified evidence based approach to how to handle those gray area patients. There are multiple guidelines and mechanism of injury should most definitely play a role in the management process of trauma patients IMO.
Personally, I get no push back at all by trauma for observing these patients. Def not in my teaching institution and def not out moonlighting...yet.
Also, I think we all are prone to develop bias based on adverse outcomes. Maybe I'm more sensitive to it but I'll never forget a case where a young adult who was transferred from another hospital for a mechanism even less than this one and had a faint finding on CT A/P (that probably I wouldn't have even done). Looked so well that trauma at this particular place even elected to not re-scan the belly. Serial belly exams normal during obs. Discharged and guy shows up in an ED within the next 12 hours with belly full of blood and dies. Unavoidable? Perhaps. Repeat CT would have probably showed new findings I would think, but again...lots of radiation for a minor finding. We sure aren't perfect, but CT can pick up a lot of stuff that we miss. Radiation or not, it's still the best and fastest imaging study we have in acute trauma. Again, that doesn't mean pan scan everyone but it's not all black and white. As posted above, even the experts are still arguing over how to properly stratify patients for pan CT's.
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deleted65604
Wow. I admit I haven't seen these studies. I'd like to know what each and every of the 8 patients that got operated on had on exam, and whether or not there was an actual repair. Case by case, what was missed? Could the 1 in several hundred cancers caused by CT's equal out the number of lives saved? Is this one of those studies that screws us over like chest pain studies that basically force us to feel obligated to admit every chest pain even when we would go home if we were the patient, and we don't think we are doing the right thing?
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deleted65604
Great counter-points. I esepecially like the Snyder article. I makes you want to have actually been present and observed the actual physical exam performed by the clinicians on the 8 missed injuries. In a study that big, there have got to be the occasional physician who is irritated by the logistics of the study and says, "Who cares what my physical exam is, they are going to get pan-scanned, so let me fill out this stupid form so I can go catch up on the tidal wave of medical patients that is potentially dying because I'm wasting time examining a patient with normal vitals and no complaints."
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The primary criticism I have of the first article is that much of his critique is based on subjective physical examination along with a single study of cancer risk based on a well known study by Brenner who studied cancer risk based on survivors from Hiroshima atomic survivors. It's a decent study, but isn't a study on pt's who've undergone CT's and that resulted in cancer. It attempts to validate itself by saying that the levels are roughly the same, but with Hiroshima, we're talking long term low level whole body radiation exposure in a single ethnic group. There have been plenty of critiques of this study and just as many supporters. The fact is that we don't really know yet...what the definite risk of cancer is for people who say have had 5 whole body CT's in their life. CT radiation intensity is not even standardized among all the machines, nor are the exact protocols, length of time during exposure, etc.. So, he uses one article to use as his premise that CT is "very bad" and states a liberal estimate that it causes "X" incidence of cancer as his primary supporting argument for opposing the use of judicious CT scanning. That's the biggest weakness in my opinion. We just don't have enough information yet. We know radiation is bad, but "how bad?" is the question. Not bad enough to outweigh the risk of missing critical injury in stratified patients at the moment but maybe in the future.
The second article is a Canadian study entirely. That's like arguing Canadian C-spine rules vs Nexus criteria. Everyone knows that most socialist healthcare systems have an invested interest in studies that provide evidence to use the most financially conservative method of management. I'm not saying it makes the study bad. I haven't analyzed it yet, but that immediately crossed my mind when I saw where it was performed.
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deleted65604
You are right, this totally refutes it.
You can't say it better than Weird Al-
http://www.youtube.com/watch?v=W_fOttyeq3M
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...my favorite was Robin Williams along the lines of "Canadians are angry because they're like the apartment over a really great party..."
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lol...I'm just sayin....
F'ING CRAZY CANADIANS
F'ING CRAZY CANADIANS
