MVC CT scans- contrast or no?

This forum made possible through the generous support of SDN members, donors, and sponsors. Thank you.

Aesculapius

Junior Member
15+ Year Member
Joined
Dec 30, 2004
Messages
233
Reaction score
2
Hi, I am starting residency at a tertiary care center where apparently in low-speed MVC (i.e. goes to Fast Track or one of the non-critical/trauma rooms), if the patient needs to get a CT abdomen/pelvis, it is done with PO and IV contrast. There is a radiology residency. The patient that I had looked pretty stable, but he ended up waiting probably at least 3 hours to get his CT. That doesn't strike me as very safe, especially in Fast Track where VS and re-evaluations don't happen as often. I want to know: what is the policy in your shops?

Members don't see this ad.
 
Hi, I am starting residency at a tertiary care center where apparently in low-speed MVC (i.e. goes to Fast Track or one of the non-critical/trauma rooms), if the patient needs to get a CT abdomen/pelvis, it is done with PO and IV contrast. There is a radiology residency. The patient that I had looked pretty stable, but he ended up waiting probably at least 3 hours to get his CT. That doesn't strike me as very safe, especially in Fast Track where VS and re-evaluations don't happen as often. I want to know: what is the policy in your shops?

No role for PO contrast unless patient is needing a repeat scan for some reason. I leave that one up to surgery.
 
IV contrast only - don't wait for Cr should be the standard.
 
Members don't see this ad :)
IV, no PO. eFAST him/her first. Common protocol at my home institution, but we've got this crazy radiologist at one of the ED's where I moonlight that tries to demand PO on almost ANY patient who receives CT. I'm even talking about the SBO that is vomiting every 5 minutes. He always complains about the night ED docs who order IV only on trauma and aspiration risk patients and any CT where PO isn't indicated. Luckily, I work nights there and only have to deal with the nighthawk.
 
IV, no PO. eFAST him/her first. Common protocol at my home institution, but we've got this crazy radiologist at one of the ED's where I moonlight that tries to demand PO on almost ANY patient who receives CT. I'm even talking about the SBO that is vomiting every 5 minutes. He always complains about the night ED docs who order IV only on trauma and aspiration risk patients and any CT where PO isn't indicated. Luckily, I work nights there and only have to deal with the nighthawk.

Unless patient is hypotensive or critically ill, I don't see much need for an eFAST in trauma. There's nothing it will reveal that won't be found on CT. Except if your'e at an academic institute and need to work on your u/s skills.
 
We rarely order any CT with oral contrast at my place. Radiologists never complain about it. Only time we order it is if surgery sees a pt and they request it as an additional test to see something better. I think I ordered PO contrast at my place once or twice in the past year. And that's for CTs for any reason, not just trauma. Seems to help a lot with pt satisfaction and pt turnaround times too. Visits are about 1.5-2 hrs instead of 4 hrs for the work up part to be complete and dispo ready. Another place I've worked had PO contrast for everyone (they had rads residents). It's horrible. No one drinks it quickly and pt times are so much longer.
 
Unless patient is hypotensive or critically ill, I don't see much need for an eFAST in trauma. There's nothing it will reveal that won't be found on CT. Except if your'e at an academic institute and need to work on your u/s skills.

At my place, we do not have an EM residency, but do have a surgical residency... We are a Level 1 Trauma center so we have the standard trauma team of 500 people, everything from RT, students, pharmacists, pgy1-5 GS residents, the trauma att and myself...

I always get a good chuckle when the surgery residents are hollaring "Where is the FAST machine!!" I used to remind them its an Ultrasound, but have given up as they change up every week... *sigh*
 
Sorry for the thread hijack, but what are the firm indications for PO contrast anyway?

There aren't any. Radiology literature shows no difference, but people not trained to read non-contrasted studies aren't as comfortable without it. Thus, it pervades.

Some surgeons like it for SBO. And intraluminal lesions are slighly more easily picked up.
 
I always get a good chuckle when the surgery residents are hollaring "Where is the FAST machine!!" I used to remind them its an Ultrasound, but have given up as they change up every week... *sigh*

One of the Cardiologists here always asks for that "mini-echo" we have :laugh:
 
Dr. McNinja, do you happen to have a source for that by any chance?
 
Couple thoughts. If your considering ct scanning a trauma with abdominal pain in not sure they should be in fast track; just my thoughts
Also whenever a radiologists or surgeon asks for PO contrast for sbo. I point them to radiologists guidelines, the ACR I believe, that recommend against PO contrast bc it might obscure early wall ischemia.
http://www.acr.org/~/media/832F100277004BC69A8C818C7C9BFF33.pdf
 
Members don't see this ad :)
Hi, I am starting residency at a tertiary care center where apparently in low-speed MVC (i.e. goes to Fast Track or one of the non-critical/trauma rooms), if the patient needs to get a CT abdomen/pelvis, it is done with PO and IV contrast. There is a radiology residency. The patient that I had looked pretty stable, but he ended up waiting probably at least 3 hours to get his CT. That doesn't strike me as very safe, especially in Fast Track where VS and re-evaluations don't happen as often. I want to know: what is the policy in your shops?

IV contrast only.
 
Unless patient is hypotensive or critically ill, I don't see much need for an eFAST in trauma. There's nothing it will reveal that won't be found on CT. Except if your'e at an academic institute and need to work on your u/s skills.

I'm biased in that I'll complete residency this year with RDMS certification and am pro US for everything from ocular, regional blocks, MSK, trauma, etc.., but if it's a positive FAST and they are hemodynamically stable (and we've all seen this happen), then they should go to the OR for an emergent ex-lap. If Trauma wants the CT, I'd prefer to let them make that decision than make it myself and have them crump in the scanner.

If I'm not in a tertiary care center and I have U/S available, I'd like to know if the FAST is positive or negative, even if they are stable. Blood in belly? Yes or No is a pretty important answer to have before I send someone out of the ED to CT.

Not to mention knowing if they have an anterior PTX that might only show on the US and not on the portable CXR. The US exam takes less than 2 minutes with critical information.
 
Last edited:
If it's a positive FAST and they are hemodynamically stable (and we've all seen this happen), then they should go to the OR for an emergent ex-lap. If Trauma wants the CT, I'd prefer to let them make that decision than make it myself and have them crump in the scanner.

I've got to completely and vehemently disagree. Positive FAST does not necessarily mean blood, it means fluid. If they are hemodynamically stable, there is absolutely no reason for them to get an e-lap. I have personally done at least two positive FASTs where it turned out to be no bleeding or internal trauma. One was ascites fluid and we never could figure out the second. Two, not all bleeding injuries require exploratory laparotomy. Routinely, solid organ injuries are non-operative management initially. Yes, we've all seen positive FASTs on trauma victims who are initially stable end up needing to go to the OR from the ED. But they end up needing to go to the OR after the CT reveals a high grade lac or after they develop instability.
 
I'll be the second to say that hemodynamically stable patients don't need FAST at all. The indication is for unstable patients, to determine OR vs IR.
Stable with fluid certainly doesn't need OR. Unstable with fluid does, because the presumption is that it is blood.
 
So, let me get this straight... You see no utility in performing a non-invasive, low radiation, FAST (pun intended) diagnostic modality that can give you an enormous amount of information in a hemodynamically stable blunt trauma patient where you might be worried about abdominal injuries or any other injury where ultrasound would be useful? No utility in knowing if there is (fine...fluid or blood) in the belly? Tamponade? Pregnant patient?

I'm not arguing "Not to CT". When it takes 2-3 minutes to complete and gives me a wealth of extra information. I'd like the extra information.

Are you going to tell me that you've never had a trauma patient with positive FAST that was hemodynamically stable that went to the OR and skipped CT? I'm not saying it happens often, but am I the only one?

Blunt abdominal trauma with belly pain and grossly positive FAST that is hemodynamically stable? That's a grade 1 hemorrhage and up to 15% blood loss with rock solid vitals and I sure would like to give that information to the trauma team sooner vs later. How about grade 1 hemorrhage that had positive FAST and then became unstable (Grade II) while awaiting CT and THEN went to OR, bypassing CT altogether. I've seen both. It was also nice being able to compare the amount of fluid from the 1st FAST to the 2nd.

Here's another case I had...

17 yo that got knee'd in the belly on the basketball court, showed up in OSH ED with belly pain, CT was essentially normally with no focal injury identified. Docs there have 0% comfort level with any kid with trauma, auto transfer. Oops, EMS didn't bring the CD's during the hour long ambulance ride. Kid looks great. Says that he feels fine but stomach still aches a little, just not very bad. Essentially benign belly exam. FAST shows sliver of fluid in Morrison's. I'm not saying cases like that happen all the time, but that single bit of information helped make several management decisions in conjunction with the trauma team. The kid did end up having an intra-abdominal injury.

Again, everyone has their own flavor and comfort level but nobody can sit here and claim with 100% veracity that FAST is contraindicated in hemodynamically stable blunt trauma patients.

It doesn't slow me down, it gives me immediate information, and I haven't had any physicians or colleagues fault me for performing one.
 
Last edited:
Are you going to tell me that you've never had a trauma patient with positive FAST that was hemodynamically stable that went to the OR and skipped CT? I'm not saying it happens often, but am I the only one?

I will tell you just that. I have never had a patient with a positive FAST that was hemodynamically stable go to the OR without a CT. Why are they going to the OR when so many blunt trauma patients with real injuries do not require operative management? What injury and what grade lac did that 17yo end up having?

I'm not saying that FAST is a useless test at all, and I'm not saying you shoudln't be doing them on stable patients if you want to do them. I just had to do one yesterday in my own community shop to assess the stability of a pediatric penetrating trauma that I was transferring out. I'm just saying if you are going to be CT'ing a stable patient with blunt abdominal trauma anyway, a positive FAST should not alter management despite giving you a wealth of information, and it is not a mandated test.
 
Last edited:
Some of it is probably institution dependent also... Our trauma team wants and expects FAST exams "most" of the time, even on the hemodynamically stable patients. If you don't do it, and send the pt to CT, they moan about not being told about the positive FAST prior to going to CT. If you do it and they are stable, then again..."most" of the time, they get the CT anyway before making any operative decisions. Either way, from my perspective... more information is never a bad idea although I'm not arguing for a FAST in every patient, but as I said, I think there's always the potential...such as the cases that I mentioned, where it has the ability to change management. My 2 cents, but then again... I'm a proponent of US. I think it's an underused diagnostic modality for the most part.

In your defense, there have been quite a few 2 papers off the top of my head in recent years arguing against the utility of a FAST in exactly the type of cases that you are describing. I don't agree with those papers for reasons beyond the purpose of this thread, but to me, if there's room for argument without a clear consensus, then that's not a reason to stop doing it. Especially when eFAST is obviously being pushed forward in ATLS guidelines as an adjunct to the primary survey.

Of note... there's more than a few studies showing better sensitivity of detecting both PTX and HTX with US vs CXR. With PTX something along the lines of 88% vs 52% in a 20 study meta. If I know they have PTX from my eFAST, but don't have clinical evidence of a severe PTX, I'd probably ask for a cross table lateral along with my portable, knowing that seeing a medium anterior PTX on supine portable is not going to help very much. Would it change my management? It did in ordering the cross table lateral CXR, but from that point? Maybe, maybe not...

Anyway, I hear ya. Just my 2 cents.
 
I too will echo that I have never had a FAST postive but stable patient go to the OR without a CT. In fact, I can't recall a stable patient going to the OR even after a CT.

I have no problems with residents doing FAST exams at any shop (including mine), because they are teaching cases. However, we've gone way past the indications for FAST.

US works great for PTX. I've yet to see a stable patient get a chest tube from an US prior to the CT that quantifies the PTX as well.

Also, many, but not all community shops don't have US machines in the department still. Even at a Level 1 trauma with a surgical residency, but no EM residency, we didn't have an US in the department. Well, there was that Site-Rite 1 for putting in CVLs.
 
We had some terrible machines when I started that looked like they were built in the 70s. Clunky, horrible image, took forever to warm up. Honestly, the US curriculum didn't pick up full swing IMO until we upgraded to a batch of SonoSite machines. World of difference.

Funny side story...

We don't have one at a community ED where I moonlight, and I had a morbidly obese patient that severely needed IV access and the nurses gave up after turning her into a human pincushion. I found the US tech machine (the big ones with 100 knobs, again...built in 1970s) and managed to turn it on and get an image good enough to place a 2" angiocath in a deep brachial. I really didn't want to do a CVL on that lady.

Ever had those patients where you have to tape the pannus up and away and attach the far ends of the surgical tape on the opposite gurney rails to get access to the groin? I pray to God every time that one of those strips doesn't snap...

Anyway, I'm beyond off topic at this point.
 
We had some terrible machines when I started that looked like they were built in the 70s. Clunky, horrible image, took forever to warm up. Honestly, the US curriculum didn't pick up full swing IMO until we upgraded to a batch of SonoSite machines. World of difference.

Funny side story...

We don't have one at a community ED where I moonlight, and I had a morbidly obese patient that severely needed IV access and the nurses gave up after turning her into a human pincushion. I found the US tech machine (the big ones with 100 knobs, again...built in 1970s) and managed to turn it on and get an image good enough to place a 2" angiocath in a deep brachial. I really didn't want to do a CVL on that lady.


Anyway, I'm beyond off topic at this point.

I miss my sonosites :( We've only got one clunky u/s machine, and since I'm one of the few fresh off residency docs at my shop, very little to demand to get a nice small portable machine. I've had to steal the large official u/s machine (that the techs use) in the middle of the night, and have nurses ask if I'm even allowed to use it without calling the tech in, lol.
 
I too have never had a FAST positive yet stable patient go to the OR without a CT.

Although I almost never argue with a surgeon regarding the decision to operate or not (this is FAR outside of our scope), I would very forcefully question a surgeon's decision to take a stable patient with a positive FAST to the OR before CT.

If it was me, I would not consent.

The indications for a traditional FAST (looking for peritoneal fluid -- this does not include eval for HTX, PTX, and maybe pericardial fluid) in my mind are:

1. blunt abdominal trauma and hemodynamic instability
2. triage for CT (multiple patients and only one scanner)
3. education/practice

Also, let's not forget the MANY downsides to a using a test (which the FAST exam essentially is) that is not indicated.

Do you trop every chest pain patient?

That being said, I check for PTX and HTX with the ultrasound on nearly every trauma activation who is going to get a CXR.

HH
 
At my place, we do not have an EM residency, but do have a surgical residency... We are a Level 1 Trauma center so we have the standard trauma team of 500 people, everything from RT, students, pharmacists, pgy1-5 GS residents, the trauma att and myself...

I always get a good chuckle when the surgery residents are hollaring "Where is the FAST machine!!" I used to remind them its an Ultrasound, but have given up as they change up every week... *sigh*


Heard a surgery resident say this yesterday. I was like WTF?
 
I have a sonosite, but at my community non-trauma-center-shop, we just hold the CT scanner for them, IV only, no PO. I ultrasound far more lines and eyeballs than do FAST exams. (um, one in 5 years?)

In fact, we really only use PO contrast in children and skinny females - to increase sensitivity. Otherwise, IV only for pretty much everything.
 
Top